When thinking about behavioral and clinical health coverage on a state level, the National Council for Community Behavioral Healthcare (NCCBH) uses a simple question and answer tool to help determine the appropriate policy for each state. This tool is intended to help state level agencies as well as health care providers to review and reconfigure state policy appropriately. The tool works to consider state financing and the extent to which a state is providing for the integration of behavioral and clinical healthcare.

The integration of behavior and primary healthcare can be defined in many different ways. One of the most important ways is through financial and structural integration. This requires looking at benefit packages, "cave-ins," shared risk pools and other incentives used to help those requiring integrated healthcare. Also, structural integration is assessed by looking at the different services offered by one organization and behavioral healthcare services being offered along with primary care. Such structural and financial integration is necessary to achieve clinical integration.

Clinical integration is understood as the goal of integrated healthcare. This is the actual experience between the patient and healthcare providers. It is debated whether behavioral healthcare should be added or subtracted when states make financial policy decisions. The NCCBH's assessment tool sees both of these options as neutral when making a decision about clinical integration policy. What is important is that the models used must show how the different services are financed through the plan. Using the NCCBH's assessment tool will allows policy makers to dig deeper into state policy, including finance issues. Doing so gives a more complete picture of the many parts involved in implementing clinical integration.

Before creating integrated clinical and behavioral healthcare programs, it is important to look at the population that will be served by these programs. After the 1998 consensus document for mental health and substance abuse/addiction service integration was created, a Four Quadrant Model was formed for use by state mental health and substance abuse directors building on the principles of the document. This model shows the different level of mental health and substance abuse integration and clinical competencies based on the model

Quadrant I: Low Mental Health (MH)-low Substance Abuse (SA), served in primary care

Quadrant II: High MH-low SA, served in the MH system by staff who have SA competency

Quadrant III: Low MH-high SA, served in the SA system by staff who have MH competency

Quadrant IV: High MH-high SA, served by a fully integrated MH/SA program

The NCCBH's assessment tool uses the Four Quadrant Model as a basis for showing the different levels of behavioral/primary care integration needed in a given state.

Quadrant I: Low Behavioral Health (BH)-low physical health complexity/risk, served in primary care with BH staff on site; very low/low individuals served by the Primary Care Personnel (PCP), with the BH staff serving those with slightly elevated health or BH risk.

Quadrant II: High BH-low physical health complexity/risk, served in a specialty BH system that coordinates with the PC

Quadrant III: Low BH-high physical health complexity/risk, served in the primary care/medical specialty system with BH staff on site in primary or medical specialty care, coordinating with all medical care providers including disease managers.

Quadrant IV: High BH-high physical health complexity/risk, served in both the specialty BH and primary care/medical specialty systems; in addition to the BH case manager, there may be a disease manager, in which case the two managers work at a high level of coordination with one another and other members of the team.

In order to find more information about the assessment tool as well as information on the different populations found in the Four Quadrant Model, visit the NCCBH Behavioral Health/Primary Care Integration Background Paper, found on the NCCBH website.