Integrated Care for Adults with Behavioral and Physical Health Needs: Issues & Options

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Integrated Care for adults wIth BehavIoral and

PhysICal health needs: Issues & oPtIons

By: Dennis L. Kodner*

November 2011

SUMMARY

The integration o behavioral and physical health is viewed as the most logical way to provide com-prehensive, whole person care in a quality, cost-eective manner. The need or integrated care is aparticular concern or individuals with serious and complex behavioral health disorders; the popula-tion nds itsel in ragmented systems o care with little or no coordination across providers. This otenresults in poor quality and higher costs. Medicaid, which is the biggest payer o behavioral healthservices and also covers a large share o publicly unded beneciaries with mental disorders, chronicillness and physical disabilities, has the most to gain rom pursuing integrated care solutions.

The ollowing paper presents the powerul rationale or integrating behavioral and physical health

services and the important role o the primary care sector in this process. It also examines the variousintegrated care options available to the states to organize the nancing and delivery o comprehensiveservices or Medicaid beneciaries and dual eligible individuals at the highest levels o need. Finally,the requirements to achieve truly integrated care on the all-important clinical level are explored.

This is the ourth in a series o papers that critically examine key policy and service delivery issues andoptions related to various special populations. The rst paper looked at New York States People FirstWaiver or people with developmental disabilities rom the perspective o Medicaid managed care.1The second paper in the series ocused on the dual eligible dilemma and the strategic implications orintegrated models o care which bring together Medicare and Medicaid.2 The third paper examinedthe medical home model and its t with various special needs populations.3

1 Kodner, D., New York States People First Waiver: Concept Paper on Strategic Issues and Options Related to theDevelopment o Innovative Medicaid Managed Care Models or Developmentally Disabled Adults, Arthur Webb Group,Inc., n.d.2 Kodner, D., Dual Eligibles: Understanding this Special Needs Population and Options to Improve Quality andCost-Eectiveness o Care Through Integrated Solutions, Arthur Webb Group, Inc., September 20103 Kodner, D., The Medical Home: Improving Its Fit with the Frail Elderly and Other Special Needs Populations,

Arthur Webb Group, Inc., October 2011.


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IntRodUctIon And BAckgRoUnd

The historical practice o separating the provision o mental health and substance abuse services rom pical health care is now considered misguided.4 This split, which is historic in its application, is especiaproblem or people with chronic and severe behavioral health problems who require an array o coordinaservices rom both sides o the health system. The lack o integrated care with close links to primary csettings oten leads to poor quality, higher costs, and other societal problems. As the ederal governmthe states, and leading-edge providers are seeking to transorm health care and achieve more cost-eecpublicly-unded care, more and more attention is being ocused on developing managed and integracare models or this complex population. This paper examines the issues and options related to this new important direction against the backdrop o the enormous epidemiological, clinical, organizational, serdelivery, nancing, and policy challenges involved.

Behavioral Health Challenges

Behavioral health5 conditions not only impose a substantial burden on individuals and society, but are

highly prevalent and disabling. About one in our adultsan estimated 26 percent o Americans agedand oldersuer rom these disorders.6 Although 60 million adults are aficted with mental illness andsubstance abuse, the main illness burden is concentrated in the 6 percent o the population with seriouschronic mental health problems.7

Adults with so-called serious mental illness (SMI) and severe and persistent mental illness (SPMI)8

moderately to severely impaired. They experience a wide range o problems in areas such as eeling, moand aect; thinking; turbulent amily and interpersonal relationships; disruption in role perormance; solegal problems; and, inability to care or themselves.

Generally speaking, people with behavioral health problems requently do not receive treatment. 9 Fe

than 50 percent o all adults with such disorders do not receive the care they need.10 Moreover, behavhealth disorders oten co-occur with other physical illnesses such as cardiovascular or pulmonary disediabetes, or arthritis; this complicates treatment and management, increases the level o disability, netively aects outcomes, and raises the overall costs o medical care.11 Indeed, these mind-body exacetions are a two-way street. Not only are behavioral health conditions oten accompanied by physical morbidities, but people suering rom chronic physical conditions like diabetes, stroke, and HIV/AIDS experience relatively signicant levels o depression and anxiety. This pattern leads to higher medical c

4 Agency or Healthcare Research and Quality (AHRQ), Integration o Mental Health/Substance Abuse and PriCare, Evidence Report/Technology Assessment, AHRQ Publication No. 09-E003, October 2008.

5 The terms mental health and behavioral health are oten used interchangeably. In this paper, we use the term beioral health, which encompasses mental illness and substance abuse disorders.6 Institute o Medicine, Improving the Quality o Health Care or Mental and Substance-Use Conditions: Quality ChSeries, November 1, 2005. Available online at: http://www.iom.edu/Reports/2005?Improving-the-Quality-o-Health-CareMental-and-Substance-Use-Conditions-Quality-Chasm-Series.aspx.7 Statistics, National Institute o Mental Health (NIMH). Available online at: http://www.nimh.nih.gov/health/topicstistics/index.shtml8 The SPMI category includes schizophrenia, bipolar disorder, other severe orms o depression, panic disorder, andsessive-compulsive disorder.9 AHRQ, 2008, op cit.10 Russell, L., Mental Health Services in Primary Care: Tracking the Issue in the Context o Health Reorm, WashinDC: Center or American Progress, October 2010.11 AHRQ, 2008, op cit.


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utilization and health care costs and ultimately aects patient outcomes.12 Overall, however, it the SMIand SPMI populations that are greatest risk o serious medical problems and shorter lie spans. 13 This isdue, in large part, to the lack o access to preventive and primary care and the negative impact most o theeective psychotropic drugs have on physical health.14

It should be sel-evident that people with chronic and serious behavioral health problems not only needexcellent primary care, but also coordinated access to a wide range o mental health and substance abuseclinical services and supports.

Financing of Behavioral Health Disorders

The Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that $100 billionwas spent on behavioral health disorders in 2003.15 Publicly-unded outlays actually reached $58 bil-lion in 2006.16 That is, public programs, including Medicaid, Medicare, and other ederal, state and localsources, covered 58 percent o total costs. In 2008, the total economic costs or behavioral health wereestimated at $317 billion or the equivalent o $1,000/year or every American.17 Medicaid is the largest

payer o behavioral health services in the United States.18

In 2003, Medicaid paid 45 percent o all publicexpenditures.19

The Integrated Care Resource Center (ICRC), an initiative o the Centers or Medicare & Medicaid Services(CMS), recently presented the ollowing prole o Medicaid and dual eligible beneciaries with behavioralhealth conditions, including mental health and substance abuse disorders20:

X Over hal o Medicaid beneciaries with disabilities have been diagnosed with a mental illness;

X For those with common chronic conditions, health care costs are as much as 75 percent higher or thosewith a mental illness as compared to those without a mental illness, and the addition o a co-occurringsubstance abuse disorder results in a two- to three-old increase in health care costs;

X Among dual eligible individuals (i.e., those beneciaries covered by both Medicaid and Medicare), 44percent have at least one mental health diagnosis;

12 Kathol, R. et al., Epidemiologic Trends and Costs o Fragmentation, Medical Clinics o North America 2006; 90(4):549-72.13 AHRQ, 2008, op cit.14 For example, metabolic syndrome (e.g., obesity, elevated cholesterol, and high blood pressure) is associated with the

intensive drug therapy used with these populations.15 National Institute o Mental Health (NIMH), Distribution o Public Mental Health Expenditures by Public Payer (2003).Available online at: http://www.nimh.nih.gov/statitics/4DIS_PAYER2003.shtml.16 AHRQ, Medical Expenditure Panel Survey, Statistical Brie No. 248, 2009. Available online at: http://www.meps.ahrq.gov/mepsweb/data_les/publications/st248/stat248.pd.17 Insel, T., Assessing the Economic Costs o Serious Mental Illness, American Journal o Psychiatry 2008; 165: 663-5.Although a huge sum, this does not include the costs o comorbid physical conditions, homelessness, incarceration, and earlymortality.18 Shirk, C., Medicaid and Mental Health Services, Background Paper No. 66, National Health Policy Forum, The GeorgeWashington University, October 23, 200819 NIMH, op cit.20 Integrated Care Resource Center (ICRC), State Options or Integrating Physical and Behavioral Health Care, Techni-cal Assistance Brie, October 2011.


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X For the 20 percent o dual eligibles with more than one mental health diagnosis, annual spendingaverages $38,000, which is twice as high as average annual spending or the dual eligible popula-tions;

X The prevalence o serious mental illness is especially high among dual eligible individuals underage 65, which is three times higher than dual eligibles who are age 65 plus; and,

X Substance abuse disorder, with or without co-occurring mental illness, is also more commonamong dual eligible individuals than among Medicare-only beneciaries.

While behavioral health problems afict all Americans, the cost and quality o care implications orMedicaid and dual eligible beneciaries represent a marked challenge or the states and CMS.

ESSEntIAl RolE of PRIMARY cARE

The argument or connecting, coordinating, or otherwise integrating behavioral health with primary

health care is to improve the treatment o the whole person, enhance clinical outcomes, and reduceutilization and costs. Because o the dening eatures o primary carecomprehensiveness, conti-nuity, and coordinationit is designed to play an important bridging role in the care o people withchronic physical and behavioral health conditions.21 Quality o health and quality o lie or patientswith behavioral health problems, especially those with serious disorders, are not possible withoutprimary care and mental health-related providers working in tandem.

According to the Minnesota Evidence-Based Practice Center22 , there are eight main reasonssomealready touched on earlieror redesigning health systems and clinical practices to orge closer col-laborations and connections between primary care and behavioral health:

1) People with mental health problems oten do not receive treatment;

2) People with mental health problems are as likely to be seen in the general medicine sector thanin the mental health sector; 23

3) Patients with less serious mental health problems are more likely to see a primary care physician(PCP) each year than a mental health specialist;24

4) Many people with mental health problems experience co-morbid physical health problems;25

5) Mental health problems can exacerbate disabilities associated with physical illness;26

21 Rothman, A. and Wagner, E., Chronic Illness Management: What is the Role o Primary Care, Annals o InternalMedicine, 138(3):256-61, 2003.22 See AHRQ, 2008, op cit.23 Rothman, A. and Wagner, E., op cit.24 Wang, P. et al., Twelve-Month Use o Mental Health Services in the United States: Results From the NationalComorbidity Survey Replication, Archives o General Psychiatry, 62(6):629-40, 2005.25 National Center or Health Statistics (NCHS), Chartbook on Trends in the Health o Americans. Hyattsville, MD,2007.26 Kessler, R. et al., Comorbid Mental Disorders Account or the Role Impairment o Commonly Occurring ChronicPhysical Disorders: Results From the National Comorbidity Survey, Journal o Occupational & Environmental Medicine,45(12):1257-66.


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6) Evidence suggests that primary care physicians can eectively treat common mental health prob-lems, such as depression and anxiety;27

7) Patients with SMI and SPMI oten do not address their general medical needs, and are at highermedical risk than others without behavioral health disorders;28 and,

8) Certain drug therapies or mental health conditions can have deleterious eects on physical health.

Given the above, integration can work in two directions to meet patients mental health needs: 1)specialty behavioral health services could be introduced into primary care settings; or, 2) primaryhealth care could be introduced into specialty behavioral health settings.29 Nonetheless, it is impor-tant to recognize that the primary care setting may not be the best or most logical medical home oradults with chronic and unstable behavioral health problems which prove dicult to treat and man-age; this population includes a signicant number o individuals with SMI and SPMI.

The rest o this paper ocuses on person-centered organizational/service delivery and clinical op-

tions or integrating physical and behavioral health care or Medicaid beneciaries and dual eligiblesthat all into this narrowly-dened, but very challenging special needs group.

IntEgRAtEd cARE oPtIonS foR MEdIcAId And dUAl ElIgIBlE BEnEfIcIARIES30

This section examines the options available to the states to integrate the organization, managementand nancing o behavioral and physical health services or Medicaid beneciaries and dual eligibleindividuals with SMI and SPMI. 31

There are our (4) possible integrated care models: 1) managed care organizations (MCOs); 2) pri-mary care case management programs (PCCMs); 3) behavioral health organizations (BHOs); and,4) partnerships between MCOs/PPCMs and BHOs. While these models dier somewhat, they sharethe ollowing characteristics:

X Aligned nancial incentives across the physical and behavioral health systems

X Multidisciplinary care teams responsible or coordinating the entire range o physical health, be-havioral health, and long term care services and supports on an as-needed basis

X Use o a range o clinical integration tools32

27 Stein, M. et al., Quality o Care or Primary Care Patients with Anxiety Disorders, American Journal o Psy-chiatry, 161(12):2230-7; While PCPs are capable o identiying and treating depression and anxiety, they requently allbelow standard.28 AHRQ, 2008, op cit.29 Links between primary care and specialized addiction services have also been shown to be eective; see, orexample, Druss, B. and von Essenwein, S., Improving General Medical Care or Persons with Mental and Addictive Dis-orders: Systematic Review, General Hospital Psychiatry, 28(2):145-53, 2006.30 This discussion is based, in part, on the October 2011 technical assistance brie prepared by ICRC; see ICRC, opcit.31 AHRQ, 2008, op cit.32 Tools include comprehensive physical and behavioral health screening/assessment, joint care planning (bene-ciary, caregivers, and providers), care coordination/case management, and navigation support.


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X Specialized provider networks

X Real-time inormation-sharing with all members o the care team

X Mechanisms or evaluating and rewarding quality care

States will have to determine which o the above integrated care option(s) best suit their needs.

States will have to determine which o the above integrated care option(s) best suit their needs. Inmaking this decision, consideration should be given whether to: 1) leverage the existing Medicaidservice delivery inrastructure or build new capacity; 2) make an MCO or BHO the lead integratingentity; 3) develop a single integrated care model, or specialized systems or subsets o the popula-tion; and, 4) implement dierent approaches in dierent regions o the state.

These integrated care options are sketched below:

Option #1Managed Care Organization (MCO)

Medicaid MCOs have typically managed beneciaries physical health care needs on a risk basis. Tra-

ditionally, MCOs have covered beneciaries with limited behavioral health problems and/or stateshave carved out behavioral health care rom MCO contracts. This option, on the other hand, creates acomprehensive managed care arrangement ocusing on the totality o physical and behavioral healthneeds o enrollees; examples can be ound in Minnesota, Tennessee, and Washington,

Integration can be achieved through the integration o behavioral health benets within the main-stream MCO33 or via contracting between mainstream MCOs and more specialized behavioral healthMCOs.34 To accommodate dual eligibles, the integrated MCO should be a Medicare Special NeedsPlan (SNP)35. Or at the very least, the state must obtain access to Medicare data or dual eligiblesthrough CMSs Medicare-Medicaid Coordination Oce.36

Option #1 more or less represents the most integrated, cost-ecient and accountable approachto bringing together and managing a broad package o physical and behavioral health services. Itprovides seamless access to needed benets and goes a long way to achieving true clinical integra-tion.37 However, strong oversight will be needed to ensure that enrollees receive the behavioralhealth care they need within the context o a mainstream MCO.38 Moreover, arrangements shouldbe put in place to ensure that subcontracting, i employed, does not undermine the integrated natureo the model.

33 I subcontracting is permitted or behavioral health services, rigorous perormance standards will be necessaryto acilitate and support service access, coordination, and quality.34 This arrangement is particularly well suited or Medicaid beneciaries with SMI and SPMI.35 For an overview o issues related to integrated care or dual eligible beneciaries with special needs, see Kod-ner, D., September 2010, op cit.; A major drawback rom the dual eligible point o view is that enrollment in SNPs isvoluntary, thereby potentially aecting the nancial viability o this approach.36 For details on this initiative, see Centers or Medicare & Medicaid Services (CMS), Financial Models to Sup-port State Eorts to Integrate Care or Medicare-Medicaid Enrollees, August 9, 2011. Available online at: https://www.cms.gov/medicare-medicaid-coordination/08_FinancialModelstoSupportStatesEortsinCareCoordination.asp#TopOPage.37 Issues related to clinical integration are addressed in the next section o the paper.38 This is o particular concern, given the act that individuals with chronic conditions are not always well served

by MCOs and enrollees with special needs have also been known to experience problems with accessing specializedsupport services.


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John Iglehart in an introduction to a recent Health Aairs journal39 reerences the Lewin Group reportthat was prepared or the Americas Health Insurance Plans (AHIP), which concludes that studiesstrongly suggest that the Medicaid managed care model typically yields cost savings.However, Iglehart goes on to say that there are surprisingly ew data available to indicate what heoverall quality managed Medicaid will produce. He also quotes Diane Rowland o the Medicaid andCHIP Payment and Access Commission (MACPAC) who says we need to learn more about how

these plans handle long-term care and chronic illness.

Option #2Primary Care Case Management Program (PCCM)

Under this option, the state could contract directly with providers or procure services through aPCCM contractor (operating either statewide or in one or more o its regions) in order to ensurethe coordinated delivery o behavioral health services; versions o this model can be ound in NorthCarolina and Vermont.

The PCCM provides comprehensive primary care services to its enrollees on either a ee-or-service

(FFS) or capitated basis40; in essence, it is the patients medical home.41 It would also connect themwith needed behavioral health care, and maintains ongoing links with these specialized providers.Collaboration between primary and behavioral health care could be achieved through a variety omechanisms and approaches, oten in combination: 1) paying primary care physicians (PCPs) anenhanced ee to support care coordination/care management activities; 2) supporting the develop-ment o community-based care teams to reach out to patients and extend oce-based practice42; 3)health inormation technology (IT) to support clinical inormation exchange, population health man-agement, and perormance measurement; 4) use o best practices in behavioral health screeningand psychopharmacology; and, 5) ormal linkages with the behavioral health system.

Medicaid and Medicare unding streams are not blended. Thus, the fexibilities o a capitated modelare not available. Nonetheless, i the PCCM is properly designed, it can move toward nancial align-ment between the two programs and also potentially provide the state with access to Medicare sav-ings resulting rom this integrated care option through the CMS Medicare-Medicare CoordinationOce.43

Option #2 would be an excellent model or states to begin integrating physical and behavioral healthservices where PCCMs already provide the existing inrastructure o primary care. I capitation orother orms o global payment is not easible, the option could still be implemented as a FFS pro-gram. PCCM also places the PCP in the rontline o behavioral health care, a much vaunted role.However, the fexibilities that come with the pooling o Medicaid and Medicare nancing are not

possible. And many challenges and much time are involved in developing ongoing relationships andcollaborations with behavioral health providers.

39 Iglehart, J.Desperately Seeking Savings: States shit More Medicaid Enrollees to Managed Care, Health A-airs. September 2011, Vol. 30, No.940 Providers participate in both the Medicaid and Medicare programs.41 PCCMs are beginning to organize themselves around the medical home model. Moreover, Medicaid-undedhealth homes, where they exist, are building close, complementary relationships with medical homes; the latter ocus onthe coordination o services and supports beyond the package o medical services. For a compact analysis o the medicalhome concept and its implications or special needs populations, see Kodner, D., October 2011, op cit;

42 The team could include behavioral health consultants, coordinators, counselors, and coaches.43 See ootnote 33.


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Option #3Behavioral Health Organization (BHO)

Behavioral health organizations (BHOs) are well disposed to manage behavioral health services,especially those aimed at complex, high-need individuals in the SMI and SPMI cohort. In this option,the statethrough a partnership with the Medicaid agency, mental health agency, and county pur-chaserswould contract with one or more BHOs to manage a package o comprehensive behavioraland physical health benets or a dened population, and the provider networks involved in deliver-ing requisite services.44 Iowa is currently piloting this option; Arizona and Massachusetts are alsopursuing the model.45

There are three (3) approaches that the model can take: 1) ull-risk46 or behavioral health and physi-cal health (Arizona); 2) ull-risk or behavioral health and managed FFS or physical health (Massa-chusetts); and, 3) ull-risk or behavioral health and FFS or physical health (Iowa). In order to servedual eligibles, a population with a high concentration o individuals with chronic and serious behav-ioral health problems, the BHO would have to qualiy as a Medicare SNP.

An additional model is the one being pursued by the State o New Yorks Oces o Mental Health(OMH) and Alcoholism and Substance Abuse Services (OASAS) are jointly contracting with Behav-ioral Health Organizations (BHO) to monitor inpatient behavioral health services or ee-or-serviceMedicaid individuals and services or children with a serious emotional disturbance (SED) who re-ceive care in OMH-licensed clinics.In New York, BHOs are entities with experience and demonstrated expertise managing behavioralhealth services or individuals with substance use and serious mental illness. In Phase 1 BHOs willmonitor inpatient behavioral health services or Medicaid-enrolled individuals whose inpatient be-havioral health services are not covered by (i.e., carved out o) a Medicaid Managed Care plan andwho also are not enrolled in Medicare. In most cases, Phase I BHOs will begin operations in the all o2011 and will be ully implemented by January 2012. BHOs will be responsible or:

X Concurrent review o behavioral health inpatient length o stay

X Reducing behavioral health inpatient readmission rates

X Improving rates o engagement in outpatient treatment post discharge

X Gathering inormation on the clinical conditions o children with a Serious Emotional Disturbancewho are covered by Medicaid Managed Care and receiving treatment in an OMH licensed spe-cialty clinic

X Proling provider perormance and testing perormance metricsX Facilitating cross-systems linkage

44 These provider networks could include individual provider/provider agency contractors and MCOs. Dependingon the state design, Medicaid-authorized health homes could also be connected to the BHO to implement care coordina-tion/management and related services and supports; or a discussion o newly authorized Medicaid health homes, seeKodner, D., op cit.45 This should not be conused with a New York initiative which contracts with BHOs to perorm utilization man-agement unctions, rather than the coordination o care.46 Full-risk or behavioral health services may or may not include the cost o related prescription medication.Nonetheless, BMOs would be expected to develop clinical pharmacy management capacity.


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Option #3 makes sense or Medicaid and dual eligible individuals with SMI and SPMI, especiallywhere such organizations exist and already contract with the state. While there is very limited expe-rience with the model, it can clearly serve as an important step to achieving ull system integrationbetween behavioral and physical health. While BHOs have managed care-like capabilities (e.g., carecoordination/care management, inormation systems, and quality management), developing the ca-pacity to also manage physical health services could be challenging47; qualiying as a Medicare SNPwould be dicult, though not impossible. Finally, state oversight authority, including relationshipsbetween the Medicaid and mental health agencies, would have to be claried.

Option #4MCO/PCCM and BHO Partnership

As pointed out in our earlier discussion o Option #1, states tend to limit the coverage o behavioralhealth services or Medicaid beneciaries enrolled in MCOs or carve-out these benets to a BHO; thisalso applies to PCCMs. Under this option, the state retains the separation between medical (physicalhealth) and behavioral health care, but creates aligned nancial incentives, including shared savingsarrangements, or other perormance-based approaches, to encourage closer coordination between

the two systems.48

This model currently operates in Pennsylvania.

To bring Medicare and Medicaid together, MCOs/ PCCMs operating in this model would have toshare Medicare and Medicaid data with BHOs49, or the partners would have to access these datathrough the Medicare-Medicaid Coordination Oce. In addition, states could pursue Medicare sav-ings through CMSs recently launched nancial alignment initiative.

Option #4 enables states to pursue the integration o behavioral and physical health services withoutundertaking a major system overhaul. As such, this is the least powerul integrated care option avail-able. Although Medicaid beneciaries would gain better access to needed behavioral health care,the biurcated system nonetheless stays in place; ragmentation at some level would likely remain an

ongoing concern.

Toward True Clinical Integration

Financing, organizational and provider alignment in the models sketched above do not in and othemselves ensure clinical integration, that is, the coordination o patient level inter-proessionalteamwork, clinical decision support, and service delivery in a single process across time, setting, anddiscipline.50 Collins and associates, in their major Milbank Memorial Fund report on the integrationo behavioral health in primary care, makes this abundantly clear.51

47 Especially i the BHO is not allowed to contract or physical health services and must, thereore, build this capac-ity internally.48 Savings between MCO/PCCM providers, BHOs and the state can be shared on a capitated basis through reduc-tions in per member per month (PMPM) costs or through back-end FFS calculations. Perormance-based incentives areoten associated with savings achieved rom reductions in avoidable hospitalizations and emergency room visits.49 While data-sharing is essential, the state will have to set clear privacy guidelines or the exchange o patient-level inormation across both systems within the context o existing legal/regulatory constraints.50 Kodner, D., Integration o Health Systems, Services and CareWhat Works and How?, Keynote presentationat the Inaugural Asian Conerence on Integrated Care, Agency or Integrated Care, Singapore, February 25, 2011.51 Collins, C. et al., Evolving Models o Behavioral Health Integration in Primary Care, Milbank Memorial Fund,2010.


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In order to better understand what is actually needed to achieve true clinical integration or behav-ioral health patients, a brie review o the four quadrants of clinical integration would be helpul. Thisconcept52, which is summarized in Table 1 on the next page, is used to match services, clinical ap-proaches, and settings with the characteristics and needs o our (4) patient population types.

This Four Quadrant Model is not diagnosis-specic; it considers the degree o clinical complexity,BH/PH risks involved, and level o unctioning. When taken into consideration or each o the abovepopulation subsets, we can better understand the essential elements needed to achieve clinicalintegration:53

See below.

52 See Mauer, B., Behavioral Health/Primary Care Integration: The Four Quadrant Model and Evidence-BasedPractices.53 See Parks, J., Bartels, S., and Mauer, B., Integrating Behavioral Health and Primary Care Services: Opportuni-ties and Challenges or State Mental Health Authorities, National Association o State Mental Health Directors, January2005.

Table 1: Four Quadrants of Clinical Integration Based on Patient Needs

Quadrant II

BH PH

Patients with high behavioral health (BH)

and low physical health (PH) needs

(Example: Bipolar disorder andchronic pain)

Served in BH setting or primary care

(when mental health needs are stable)

Quadrant IV

BH PH

Patients with high behavioral health (BH)

and high physical health (PH) needs

(Example: Schizophrenia and metabolicdisorder or hepatitis C)

Served in BH setting or primary care

(when mental health needs are stable)

Quadrant I

BH PH

Patients with low behavioral health (BH)

and low physical health (PH) needs

(Example: Moderate alcohol abuse and

fibromyalgia)

Served in primary care setting

Quadrant III

BH PH

Patients with low behavioral health (BH)

and high physical health (PH) needs

(Example: Moderate depression and

uncontrolled diabetes)

Served in primary care setting


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X Quadrant I Primary care-based BH Primary care physician (PCP) with standardized screening tools/BH practice guidelines

X Quadrant II54

BH case manager with responsibility or coordination with PCP PCP with standardized screening tools/BH practice guidelines Specialty BH Residential BH Crisis/ER BH/inpatient (IP) Other community supports

X Quadrant III PCP with standardized screening tools/BH practice guidelines Care/disease manager Specialty medical/surgical ER Medical/surgical/IP SNF/home-based care Other community supports

X Quadrant IV55 PCP with standardized screening tools/BH practice guidelines BH case manager with responsibility or coordinating with PCP and Care/disease manager Care/disease manager Specialty medical/surgical Specialty BH Residential BH Crisis/ER BH and medical/surgical/IP Other community supports

In summary, the Four Quadrant Model is not meant to be prescriptive. It is a template designed toassist in local BH system planning. Thereore, it should be very useul to integrated care entities andtheir partners in the design and development o clinical systems and strategies.Summary

Behavioral health is a major health care concern. Despite improvements over the past ty years interms o how me treat and manage mental health and substance abuse disorders, the system stillaces considerable challenges. The ragmentation o care at the system and clinical levels remains animportant barrier to quality, cost-eective behavioral health care.

54 Includes patients with SMI and SPMI.55 Ibid.


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*This paper was authored by Dr. Dennis L. Kodner and prepared with the support of the Author Webb Group, Inc.

Dennis Kodner, PhD, FGSA is a global thought leader on health systems/services integration. He is an expert on coordinated care and managed caresystems for people with chronic, disabling, medically complex, and high-risk conditions, including the frail elderly and those whose needs cut across thehealth, long term care, mental health, and social service systems.

Arthur Y. WebbMr. Webb has extensive experience in the policy and practice areas of serving high needs, high cost individuals. See www.arthurwebbgroup.com

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Since mental and physical health problems are interwoven, comprehensive, integrated solutions aredemanded. This idea is supported by public payers, especially Medicaid, which pays the lions shareo costs, as well as advocates and providers alike. Integrated care models, which are designed tolink and coordinate the behavioral health system with primary care settings and providers, are beingincreasingly pursued by the states and CMS to address the needs o Medicaid and dual eligible ben-eciaries. For the most part, the emphasis is being placed on the serious, complex and costly needso individuals with and SPMI; these individuals would benet the most rom integrated care.

In this paper, we have explored the rationale or bringing behavioral and physical health servicestogether, as well as the critical role that primary care plays in bridging these two systems in orderdeliver quality, eective, holistic care to people with mental health and substance abuse disorders.

We also examined our more or less integrated models o behavioral and physical health care or theadult Medicaid population. Also touched on was how these options could be retrotted to serve dualeligible individuals. In making their decision about which option(s) to ollow, the states will have to

consider how such models t with the existing inrastructure o Medicaid-unded behavioral healthand primary care services. Other important considerations include whether to develop specializedbehavioral health plans and whether BHOs should be made the lead integrating entity.

Finally, even the most organizationally and nancially integrated model sketched here does not guar-antee the delivery o clinically integrated care. In orging clinical systems and strategies to meet theneeds o patients with a combination o behavioral and physical health needs, the lead integratingagency and its partners must rst careully examine the clinical complexity, BH/PH risks, and levelo unctioning or each o the patient subgroups in the target population. Only then can they denethe services, methods and tools needed to achieve clinical integration. The Four Quadrant Modeldescribed in this paper oers an important planning ramework in this regard.

One last point bears mentioning: State legislators, advocates and citizens will need to be convincedthat integrated care solutions or behavioral health care is a good thing, particularly managed caremodels that combine the two systems under one roo. Since mental health and substance abuseservices are largely unded with state dollars, the states must use their authority to establish clearclinical guidelines, quality standards and outcome measures or integrated care programs; they mustalso put in place strong oversight. Only then can the transormation o behavioral health into a high-quality, cost-eective system move orward under the banner o integrated care.

Integrated Care for Adults with Behavioral and Physical Health Needs: Issues & Options

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