Were CCBHCs able to Sustain These Practices? One client had been coming to the clinic for quite a while, and had been really engaged in services, and was pregnant and put on bed rest. Officials in Oklahoma, for example, noted that, even though clinics have been able to incorporate the components needed to deliver an IOP level of services for SUD, including MAT and recovery-focused services, persuading clients to make use of such services posed a challenge. Almost one-fourth of clinics (n = 15 in each year) reported making "other changes" to their physical space in DY1 or DY2. As one provider noted, "I don't need to know everything about diabetes, I have a team I can connect you to. The PPS-2 model also requires bonus payments for clinics that meet defined quality metrics. One official noted that "one of the CCBHCs had been able to be more successful because they finally realized that they had to pay more. One CCBHC in Oklahoma has distributed more than 1,000 tablet computers (iPads) with built-in communication systems to consumers for use in their homes, to on-call psychiatrists, to sheriffs and police departments in several counties surrounding the CCBHC, and to emergency departments, with the goal of overcoming traditional transportation barriers to accessing care in rural communities. In September 2016, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica and its subcontractor, the RAND Corporation, to conduct a comprehensive national evaluation of the demonstration. State officials in New Jersey and Oregon reported in DY1 that, based on the lower-than-expected number of consumers that CCBHCs served in the first two quarters of the demonstration, the number of consumers served during the demonstration's first year would likely be lower than originally envisioned. Officials in the state speculated that the law could encourage some CCBHCs to begin participating in AOT but they also noted that the law was not specific to CCBHCs. Biological diversity means the variability among living organisms from all sources including, inter alia, terrestrial . The Department of Health and Human Services (HHS) has developed criteria for CCBHC certification. All CCBHCs provided crisis behavioral health services in both years of the demonstration (Figure III.6). The interview guides for each staff type appear in Appendix D. We asked interviewees' permission to audio record the discussions to facilitate our analysis. Under the demonstration, each nurse partners with a psychiatrist in the clinic to collect labs and complete nursing assessments to collect clients' vitals and history when clients attend psychiatric appointments. We conducted the second round from February to March 2018 and the third round from February to April 2019. CCBHC Expansion grantees can access free training and technical assistance support through the CCBHC E- National TTA Center. The CCBHC is responsible for all care coordination, whether it involves coordination within the CCBHC, with a designated collaborating organization (DCO), or with another entity identified in the statutory language related to care coordination. In contrast, officials in other states suggested that the CCBHC model had significantly reduced turnover by allowing clinics to offer improved benefits and salaries. As described earlier, some states initially experienced challenges in recruiting and hiring certain types of staff. Working with these federal partners, Mathematica and RAND designed a mixed-methods evaluation to examine the implementation and outcomes of the demonstration and to provide information for HHS to include in its reports to Congress. Total reflects both Medicaid and non-Medicaid. Clinic leadership reported that the PPS reimbursement model allowed the clinic to hire additional nursing staff, and remarked that adding nurses to the care team was "one of the biggest successes of the CCBHC demonstration.". Both PPS models aim to enhance Medicaid reimbursement by ensuring that reimbursement rates more closely reflect the cost of providing an enhanced scope of services. CCBHCs that engage DCOs maintain clinical and financial responsibility for services provided by a DCO to CCBHC consumers, and DCOs provide services under the same requirements as CCBHCs and are reimbursed for these services directly by the CCBHC. For example, one official commented that "we still have some clinics that have competition with other health care systems or industries in the area and have trouble filling positions. Older adult services (2 percent of CCBHs, n = 1). In Nevada, for example, rural and frontier CCBHCs use telehealth tools, as needed, to deliver MAT services, specialty medical care, and child psychiatry. Officials in New Jersey, for instance, indicated that a more prescriptive approach to certain services at the beginning of the demonstration could perhaps have engendered the more widespread availability and use of those services. It offers the capability to assess, stratify and define quality metrics. An official in Minnesota, for instance, reported that initial evaluations occurring within ten days as required by the demonstration are simply "earth-shattering in the mental health world" and facilitate consumer engagement from the outset. One consumer representative noted, for example, that "the wait-times in CCBHCs are down. Officials in other states noted that while some CCBHCs use telehealth, it does not account for a large share of service provision. People with law enforcement/corrections contact, which was a new finding for 2019: 20 percent of these clinics (n = 7) reported targeting outreach to this population as of the DY2 progress report, whereas only 4 percent of these clinics (n = 1) did so of the DY1 progress report. Are CCBHCs in the State Providing CCBHC Services in Collateral Agencies such as Schools and Shelters? Timeline for Reporting Future Evaluation Findings, TABLE A.2. CCBHCs adopted several of the following services as a result of certification, as reported in the DY1 progress report (Appendix Table A.11). CCBHC Designated Collaborating Organizations (DCO) Requirements All or nearly all clinics in both DY1 and DY2 reported that they provided crisis behavioral health services; screening, assessment, and diagnosis services; person-centered and family-centered treatment planning services; outpatient mental health and/or SUD services; psychiatric rehabilitation services; peer support services; and TCM either directly or through DCOs (Figure III.6). 2. Working with these federal partners, Mathematica and RAND designed a mixed-methods evaluation to examine the implementation and outcomes of the demonstration and to provide information for HHS to include in its reports to Congress. Designated Affiliate means any Affiliate selected by the Administrator as eligible to participate in the Non-423 Component. (These findings were similar to findings from the DY1 progress reports.) PDF SAMHSA CCBHC Criteria and Texas Reviewer Checklist Crosswalk Engaging the state's credentialing board to share job announcements with all credentialed providers in the state. Behavioral health providers and clinic leadership value the nurses in that they provide access to physical health services for clients who otherwise might not have considered engaging in physical health care. In Nevada, for example, officials described efforts aimed at better integrating psychiatrists into treatment planning and treatment teams as required under the demonstration. The update includes data from additional interviews with state officials and consumer and family organizations, site visits to CCBHCs, and progress reports submitted by CCBHCs. In a write-in question in the progress report, clinics listed a range of such strategies that were similar in DY1 and DY2, including suicide assessments (for example, the Columbia Scale), relapse prevention and planning, critical/crisis intervention planning, and working with external partners and stakeholders to provide patient-centered services in the area of crisis planning. I can walk to a nurse and tell them I am worried about this person. As of the DY1 progress report, CCBHCs most frequently relied on DCOs for the provision of suicide/crisis services; otherwise, DCO relationships were not common (Table III.8). CCBHCs have used a variety of strategies to improve care coordination, including the addition of various provider types to treatment teams and the expansion of targeted care coordination strategies to different populations and service lines. The chapter presents findings on implementation progress, successes, and challenges with respect to CCBHC staffing (Chapter III.A), access to care (Chapter III.B), scope of required services (Chapter III.C), and care coordination (Chapter III.D). Whether your organization's path there started with an original SAMHSA demonstration grant, a subsequent expansion grant, or a State Plan Amendment, the CCBHC services framework requires an EHR that supports data sharing with partner organizations, treatment plans aligned with evidence-based practices, new payment . Accordingly, as of March 2018 (DY1 Progress Report), the majority of clinics reported employing staff to fulfill the following positions, which are required or recommended in the certification criteria: Ninety-nine percent of clinics (n = 66) reported employing a CCBHC medical director compared to 82 percent (n = 55) before certification (Figure III.1). In Pennsylvania, for example, officials mentioned that "some clinics went from paper records to a new EHR, other clinics were changing an EHR vendor, or staying with EHR but needing to modify the system to work for the CCBHC." This section of the report summarizes: (1) the types of staff that clinics hired; (2) the challenges that clinics encountered in maintaining the required staff during the demonstration; and (3) the types of training that CCBHC staff received since the demonstration's outset. Officials in Missouri also mentioned growth in school-based services throughout the demonstration. CCBHCs have established and maintained formal (non-DCO) and informal relationships with a wide variety of external providers, with some variation over time (Table III.9). One state official remarked, for example, that the "CCBHC model in the state was a launching point for clinics to embed EBPs into their clinic models and all clinics have grown their trainings and monitoring processes for EBPs in the second year." For instance, in Nevada, the clinics that became CCBHCs were previously SUD treatment clinics. . At the same time, 27 percent of clinics (n = 18) provided crisis stabilization through a DCO relationship in DY2 compared with 21 percent (n = 14) in DY1. Currently there are 142 NICs in 112 countries around the world and 7 WHO collaborating centers. In addition, to enhance care coordination across the service landscape, CCBHC staff members collaborate with internal and external providers who serve the same clients. In August 2019, we will submit a separate report that summarizes states' and clinics' experiences with the required quality measures (based on interview and site visit data) and costs (using data from the CCBHC cost-reporting template).[4]. In spring 2018 (Demonstration Year 1 [DY1]), clinics submitted an online progress report that included information about their staffing, training, accessibility of services, scope of services, electronic health record (EHR)/health information technology (HIT) capabilities, care coordination activities, and relationships with other providers. However, readers should interpret state-level variation in the findings cautiously, given that some states such as Nevada and Oklahoma account for a small number of clinics participating in the demonstration (n = 3 each), whereas others, such as New York and Missouri, have over a dozen clinics. The criteria require CCBHCs to provide integrated and coordinated care that is person-centered and family-centered and addresses all aspects of a person's health. We drive policy, social and practice changes that use integrated health as a proven solution to closing the mortality gap and expanding access to comprehensive, coordinated care. CCBHC Spotlight: Scope of Services: Expansion of Therapeutic Group Services. When the clinic became a CCBHC, it hired four RNs and one licensed practical nurse, and restructured and expand the nurse role to provide primary care screening and monitoring (CCBHC Requirement 4.a.1), on-site primary care services, and to coordinate physical health care with external providers. In DY1, officials in all but two of the demonstration states expected that, during the demonstration's first year, CCBHCs would serve the number of consumers as originally projected. Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2019, Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration, Preliminary Cost and Quality Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration. Designated organization Definition | Law Insider ), Peer support services for consumers/clients, Intensive community-based MH services for armed forces and veterans. As one official noted, "For many years all there was [for SUD treatment] were residential and 12-step programs. Community mental health liaisons, who are employed by clinics (including CCBHCs), work closely with the criminal justice system (including courts, police) to help direct consumers into behavioral health care. Although the clinic perceived that the groups were successful, the clinic faced some challenges in expanding its group services. Interpreters or linguistic counselors (30 percent in DY2 versus 43 percent in DY1) and community health workers (35 percent in DY2 versus 40 percent in DY1). In March 2018, that CCBHC withdrew from the demonstration after Nevada revoked its certification. Oklahoma, for example, developed a "most in need" list of consumers who account for the most crisis center and inpatient stays, distributed a clinic-specific list to each CMHC with a state contract that identified the clinic's consumers who are on the state's "most in need" list, and asked the clinics to prioritize stabilization of these individuals. The findings underscore the importance of these various provider types in CCBHCs' delivery of services, which seems to have grown as the demonstration progressed. Almost all CCBHCs provided transportation services or transportation vouchers in DY1 and DY2 (n = 60), representing about 90 percent of clinics in each year. For example, one CCBHC has started to use a one-page CCBHC consumer "report card," accessible to staff, that shows laboratory results, medication compliance, the number of services received, and screenings for a given consumer. State credentialing and licensure requirements. Other, less common locations where CCBHCs provided services included primary care offices and FQHCs, in public spaces, or even on the street (not included in Figure III.2); these locations were similar in DY1 and DY2. Ninety-eight percent of clinics (n = 65) accepted referrals from courts for individuals with involuntary treatment or AOT orders as of the DY2 progress report, an increase from 91 percent of clinics (n = 61) in DY1. Working With a Designated Collaborating Organization (DCO) Consequently, Nevada's CCBHCs had relatively few mental health providers on staff before the demonstration, whereas New York's CCBHCs employed a broad range of mental health providers but fewer substance use treatment providers. For example, case managers and peer specialists meet with clients in their homes or at community locations. Telehealth and Remote Services, TABLE A.7. CCBHC Notification about Consumers' Care Transitions for Physical and Behavioral Health Conditions, TABLE A.19. This report does not contain findings based on data from these cost reports, but, where noted, some of the definitions and terminology used in this report align with definitions and terms from the CMS cost-reporting template. 1. However, the proportion of clinics that reported the inclusion of consumers or clients on treatment teams decreased by 10 percentage points from DY1 to DY2. In DY1, 76 percent of clinics (n = 51) reported a change in the membership of their treatment teams as a result of the certification process; in DY2, 58 percent (n = 38) reported that members of their treatment teams changed in the last 12 months. Behavioral Health Service Advisory Council, Contact Your Local Mental Hygiene Department, Help people improve their health by making it easier to get into treatment, Keep people from going into the hospital when they dont need hospital care, Build better relationships between hospitals and community health care providers, Pay community providers working in underserved areas more money through enhanced Medicaid payments, Blend mental health, substance use disorder, and physical health treatment services, Crisis mental health services including 24-hour mobile crisis teams, emergency crisis intervention, and crisis stabilization, Screening, assessment, and diagnosis including risk assessment, Patient-Centered treatment planning or similar processes, including risk assessment and crisis planning, Outpatient mental health and substance use services, Outpatient clinic primary care screening and monitoring of key health indicators and health risk, Peer support, counselor services, and family support services, Intensive community-based mental health care for members of the armed forces & veterans. In addition, as indicated below, state officials maintained throughout both demonstration years that CCBHCs rarely engaged DCOs and instead preferred to provide CCBHC services directly. While the certification criteria allowed for some services to be provided by DCOs, officials suggested that CCBHCs preferred to provide services directly because they wished to embrace the model fully and were reluctant to assume oversight responsibility for another provider's services. In preparation for and throughout the demonstration's implementation, all states developed structured networks for regular communication with their CCBHCs to identify gaps in knowledge and provide formal and informal training and support activities. Switch to Chrome, Edge, Firefox or Safari. Officials in several states, including Minnesota, New Jersey, and New York, noted particular challenges in hiring peer support staff in rural areas. People who identify as sexual or gender minorities, especially youth: 14 percent (n = 5) of these clinics in DY2 and 14 percent (n = 4) in DY1. CCBHC Notification about Consumers' Care Transitions for Behavioral Health Conditions, by State, 2019, TABLE A.20. Concerns about the effects of uncertainty on staff appeared most acute in states that have not developed a plan to sustain components of the demonstration, although state officials nearly unanimously voiced the same concern. Table III.3 summarizes states' projections at the beginning of the demonstration, the projected changes at the demonstration's mid-point (2018), and, drawing on interviews with state officials in 2019, actual beneficiaries served in the first demonstration year. Have CCBHCs Maintained Required Staffing? As of the DY2 progress report, 97 percent of clinics (n = 64) reported that they offered services outside CCBHCs' physical buildings, in similar locations as reported the previous year. Other than suicide/crisis services, the variety of facility/provider types with which CCBHCs established DCO partnerships as of the DY2 progress report increased from the previous year (Table III.8). People seeking services must have freedom of choice of providers. Before the demonstration, the clinic opened Monday through Friday during business hours. Program staff and leadership reported on the several benefits of the risk-stratification process. The organization operates two locations for the delivery of behavioral health services (one for adults and one for children and families), as well as operates several additional locations for residential addiction recovery services. The CCBHC retains responsibility for care coordination. More specifically, among these clinics, they wrote in similar "other" services as in the previous year, but at lower rates: 20 percent (n = 3) provided emergency room enhancement services (compared to 41 percent [n = 9] in DY1); 13 percent (n = 2) provided withdrawal management services (compared to 14 percent [n = 3] in DY1); and 7 percent (n = 1) provided community mental health liaisons (compared to 41 percent (n = 9) in DY1). State officials highlighted some of these efforts; for example, officials in Oklahoma and Minnesota reported on clinics deploying clinical staff such as LCSWs in tandem with emergency responders, such as police or emergency medical service teams, to provide care wherever it is required. The findings in this report are based on: (1) responses to progress reports each clinic completed in spring 2018 and 2019; (2) three rounds of interviews with state Medicaid and behavioral health officials; and (3) site visits to clinics in four demonstration states. Telephone interviews. The demonstration also aims to provide coordinated care that addresses both behavioral and physical health conditions. Officials in three states echoed the issue of competition. Officials in two states noted that, even though EBPs have been an important component of the CCBHC service array, states have found it necessary to grant CCBHCs some flexibility to adjust their offerings to ensure that their services reflected the needs of their client populations as those needs came into focus during the first demonstration year. Fifty-five percent of clinics (n = 37) reported reliance on some "other" strategy to facilitate crisis planning in DY1, increasing to 64 percent (n = 42) in DY2 (Table III.5). It draws on qualitative findings gathered from interviews at the state level and data from surveys of CCBHCs. For these clients, the nurse obtains permission from the client and calls the external provider's office to discuss plans for behavioral and physical health care and to review labs. More than one DCO can be used. Additional information about the CCBHC demonstration can be found at The National Council for Mental Wellbeing. The PPS-1 model also includes a state option to provide quality bonus payments (QBPs) to CCBHCs that meet defined quality metrics. In DY2, DCOs providing suicide/crisis services were still by far the most common type of DCO; 30 percent of CCBHCs (n = 20) reported a relationship with a DCO to provide suicide/crisis hotlines or warmlines compared with 28 percent (n = 19) in DY1. To ensure the availability of the full scope of CCBHC services, service delivery could involve the participation of Designated Collaborating Organizations (DCO), which are entities not under the direct supervision of a CCBHC but that are engaged in a formal, contractual relationship with a CCBHC to provide selected services. Officials in most states indicated that, even though individual CCBHCs may have added a few new practices, clinics, in general, have consistently implemented the EBPs required by states across demonstration years. Hillsides | Implementation Success - Qualifacts The .gov means its official. For example, the clinic developed care teams charged with specializing in and treating specific conditions and addressing specific needs such as SMI, SUD, and medical complexities. Clinic leadership credited the PPS with facilitating these changes. 3. Types of "Other" Providers or Partners that Participated in CCBHC Treatment Teams, FIGURE III.9. There were some shifts over time in the proportion of clinics that provided individual crisis behavioral health services directly versus through a DCO relationship (Appendix Table A.12): Ninety-five percent (n = 63) of clinics directly provided emergency crisis intervention services in DY2 compared with 88 percent (n = 59) in DY1. The report cards assign a grade to the agency on how well the services provided to each CCBHC consumer are coordinated, with those results also available to all staff involved in the individual's care. In DY2, all clinics (n = 66) had provided training in the past 12 months in risk assessment, suicide prevention, and suicide response, and nearly all had provided training in evidence-based and trauma-informed care (95 percent, n = 63) and cultural competency (91 percent, n = 60) (Table III.1). In general, social and human service providers such as schools; criminal justice agencies; and employment, older adult, and peer service providers seemed to be emerging as increasingly important for DCO relationships, whereas inpatient behavioral health-related facilities were the only type of DCO to decrease in number from DY1 to DY2. However, at the time of the second round of interviews, officials in most states noted that CCBHCs and states had resolved most challenges. We summarize findings across all clinics and within each state. The DCO must be part of the CCBHCs health IT system, The CCBHC must arrange for DHS to access data about the DCO where access to data outside the CCBHC is required (such as claims data), and. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. This requirement will especially benefit high-acuity individuals . One clinic provided translation services through DCO contracts in DY2, a change from DY1, when no translation services were provided through DCOs. And because of the PPS, they did." State officials pointed to several other positive effects of open-access scheduling, such as the elimination of wait lists and a reduction in the burden on other external community resources. Site visits. One state official in Nevada noted that CCBHCs instituted open-access scheduling because "the clinics acknowledge that it is important to meet the client in a moment of need and be able to start to establish services so that the client doesn't leave and never come back." Have CCBHCs and DCOs Sustained the Delivery of Required Services in the Second Year of the Demonstration? In both years, CCBHCs more often received notifications about consumers' treatment at external facilities for behavioral health conditions than for physical health conditions (Figure III.9 and Figure III.10). Therapy or counseling, offered by 39 percent of clinics (n = 18) compared to 24 percent (n = 11) in DY1. DCOs may also provide ambulatory and medical detoxification in American Society of Addiction Medicine categories 3.2-WM and 3.7-WM. Through the demonstration, the following services must be offered and will be paid for even if they are not included in a state's Medicaid plans: In June 2018, Mathematica and RAND submitted to ASPE a report titled "Interim Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration," which described--through April 2018--the progress that states and CCBHCs made in implementing the demonstration and their successes and challenges. This finding was generally consistent across states (state-level findings appear in Appendix Table A.3). As of the DY1 progress report, 97 percent of clinics (n = 65) reported that they altered their EHR or HIT systems to meet CCBHC certification, and 33 percent (n = 22) adopted a new EHR or HIT system as part of the CCBHC certification process. Nearly all CCBHCs in both DY1 and DY2 reported that they provided the required services, with the exception of intensive community-based mental health services for members of the armed forces and veterans; about 70 percent of clinics provided those services in both years. In Nevada, for example, state officials mentioned that they initially asked CCBHCs to provide specific EBPs; however, the state later recognized that requiring clinics to expend significant resources to provide a service used by only a small percentage of consumers was not a judicious use of funds for CCBHCs, particularly when other less resource-intensive services were available to meet the same need. To meet the certification criteria, most clinics made changes to their physical space as a result of the demonstration (in the DY1 progress report) and/or in the past 12 months (in the DY2 progress report). We are your trusted friends "at work" with whom you can brainstorm, find encouragement, and ask for accountability. Fifty-five percent of CCBHCs (n = 36) provided on-site primary care during the second year of the demonstration (Figure III.7), the same proportion of CCBHCs that reported provision of this service in DY1 (Appendix Table A.14). Staff reported that they introduced existing clients to the groups through internal referrals; any staff member could suggest a group to a client who might benefit or be interested. To meet certification criteria, the clinics had to add the full range of specialty mental health services, including psychiatric rehabilitation and child/adolescent services.
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