(Melinda) Hello, everyone.
I'm Melinda Lehman with The Joint Commission's
Behavioral Health and Human Services program.
Welcome to today's webinar,
CCBHCs: New Horizons in Integrated Care.
Before we get started, I'd like to go over a few items,
so you know how to participate in today's event.
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We are so excited to bring together David DeVoursney from SAMHSA
and Rebecca Farley David
from the National Council to discuss CCBHCs today.
With that, I'd now like to introduce Colette Bukowski, Associate Director
with the Behavioral Health and Human Services Accreditation program
at The Joint Commission.
Colette?
(Colette) Thank you, Melinda,
and thank you, everyone, for joining us today.
As Melinda said, it is our pleasure
to have the opportunity to present to you today.
My name's Colette Bukowski.
I am the Associate Director
of Behavioral Health Care and Human Services
at The Joint Commission.
I'm a licensed professional clinical counselor
with supervisory endorsement in the state of Ohio.
I've been in the behavioral health care field
for over 25 years.
I've worked in a variety of settings and organizations
as a clinician and a leader,
and I surveyed in the Behavioral Health Care and Human Services cadre
for over two years before assuming this role.
I am pleased to facilitate today's webinar,
Certified Community Behavioral Health Clinics:
New Horizons in Integrated Care.
Next slide.
The views,
opinions, and content expressed in this presentation
do not necessarily reflect the views, opinions, or policies
of the Center for Mental Health Services,
the Substance Abuse and Mental Health Services Administration,
or the US Department of Health and Human Services.
Next slide.
As we often like to do at The Joint Commission
is we'd like to start our webinars off with a poll
to get an idea of who's with us,
and today we would like to get a better idea
of where your organization is on the CCBHC continuum.
If you could take a few moments and provide us a response,
that would be great.
All right, let's see what our results tell us.
We have a bunch who've joined us who are currently a CCBHC
and then some who are working towards becoming a CCBHC,
and other people who still haven't made a decision yet.
That's a good mix of people who joined us.
Thank you for participating in our poll.
Today's agenda,
We, again, are pleased to have some visitors with us.
David DeVoursney from SAMHSA
will be providing us with an overview of the CCBHC.
Then Rebecca Farley David
from the National Council for Mental Wellbeing
will be talking to us about the emerging CCBHC model.
Our own Stacey Paul
from our Health Care Standards Development area
will be talking to you about accreditations for CCBHC.
Next slide.
I would like to, first, introduce David.
He is the Director of the Division of Service and Systems Improvement
within the Center for Mental Health Services
at SAMHSA.
Over the past decade and a half,
David has also worked as a Branch Chief,
Policy Analyst,
and Government Project Officer within SAMHSA;
as a Policy Analyst
within the Office of the Assistant Secretary
for Planning and Evaluation
in the Office of the Secretary of Health and Human Services;
and as a consultant,
helping states develop their Medicaid and behavioral health systems.
David, thank you so much for joining us today.
You have the floor.
(David) Thank you so much. I really appreciate it.
Happy to be here.
Just always happy to go out and talk about CCBHCs.
I appreciate the work that everybody on the webinar is doing.
It sounds like a lot of you already are CCBHCs.
You're probably already working with us.
Thank you to those of you who are considering the CCBHC model.
Thanks to The Joint Commission and to the National Council
for their work in this area too.
As you said, my name is David DeVoursney.
I'm the Director of the Division of Service
and Systems Improvement at SAMHSA.
We have the CCBHC Initiative for SAMHSA
working with our Federal partners
at the Centers for Medicare and Medicaid Services,
and then also the Office of the Assistant Secretary
for Planning and Evaluation.
Our division also manage
SAMHSA's Behavioral Health and Primary Care Integration portfolio.
Our work around adults with serious mental illness
and supports for them in the community
and then our suicide prevention grant programs.
But today, we're here to talk about CCBHCs.
If you could jump to the next slide, that'd be great.
I'm going to provide an overview of the CCBHC model,
talk a little bit about the Federal partnership
that I just mentioned,
go through a bit of the history of CCBHCs,
talk a little bit about the types of CCBHCs,
provide a really broad overview of the certification criteria
that really define what it means to be a CCBHC,
and in the end, talk a little bit about CCBHCs and accreditation,
which is more of a recent development in the program.
The disclaimers are all my fault.
I asked them for that disclaimer at the beginning.
This is another one, but I will just say that disclaimer at the beginning
really applies to other people's presentations,
not to my presentation.
I am talking on behalf of SAMHSA.
This disclaimer is just that our participation in this webinar
is not an endorsement of any product or accreditation scheme.
We're supportive of developing accreditation systems,
but we aren't endorsing any specific accrediting body or approach.
I just want to make sure that people know
that my participation in this webinar
doesn't mean that we're choosing
any certain accreditation model over another one,
but we are proudly supportive of trying to build capacity across the country
for accreditation of CCBHCs.
With that, next slide, please.
What is a CCBHC?
It sounds like a lot of people on the webinar today
are already familiar with the model,
but at the basic level, a CCBHC is supposed to be
a one-stop-shop for comprehensive behavioral health services.
They bring together a comprehensive range of services--
behavioral services--
incorporating evidence-based practices
and other supports based on the needs of the community that the CCBHC serves.
They're supposed to provide for improved access to mental
and substance use disorder services,
including capacity to respond to people
who are experiencing mental health or substance use-related crises.
CCBHCs are required to serve anybody who walks through the door.
Across the lifespan, they're supposed to provide
developmentally appropriate care
to children, youth, adults,
older adults.
They do have to serve anybody regardless of their ability to pay
or place of residence.
Really importantly, CCBHCs must meet the CCBHC certification criteria,
which is, really, if you want to understand what the CCBHCs model is,
I think the best thing to do is to read through those criteria,
which I'll get into a little bit more detail about later.
Next slide, please.
There are three Federal agency partners
who are involved in the CCBHC Initiative.
There's us at SAMHSA.
Not to get into too much detail,
but we operate Planning Grants
that are a part of the CCBHC Initiative
to prepare states to join the CCBHC Demonstration.
We also work on maintaining and providing technical assistance
around the certification criteria and programmatic issues of the CCBHCs.
Then we also administer the CCBHC Expansion grant programs.
CMS, our partner,
works on the development and oversight of the CCBHC prospective payment roles,
cost reporting, and related issues.
Then the Office of the Assistant Secretary for Planning and Evaluation at HHS,
they handle the National Evaluation of the CCBHC Demonstration.
While we do all have these individual roles,
we really work together on everything,
spend a lot of time on the phone together, really working out issues
across our respective areas of responsibility.
We really work on managing this initiative together.
Next slide, please.
CCBHC started in-- the concept originally born in 2014
with the Protecting Access to Medicare Act of 2014.
That act basically created the CCBHC model.
It created the framework for the model,
and it directed the Federal government through HHS
to develop certification criteria for CCBHCs' prospective payment roles
and to award Planning Grants to prepare states
to join a CCBHC Demonstration program
to be run through a subset of states through Medicaid.
As a result of that same legislation,
we've released this certification criteria.
We created the prospective payment guidance.
We awarded 24 Planning Grants in 2015.
We admitted eight states into the CCBHC Demonstration.
You can see those states here in 2017.
That Medicaid Demonstration,
I'll talk a little bit more about what that entails in a second.
Separate from the demonstration,
we started supporting CCBHCs
through a separate funding mechanism
in 2018 through Expansion grants
with that first $100 million in appropriations.
We now have more than 450 active grantees
across the country,
and that is now a $385-million-a-year program.
We've been lucky to see growth in the appropriations
for that program every year since 2018.
Two additional states were added to the CCBHC Demonstration
in 2020 and 2021
as a result of the CARES Act:
Kentucky and Michigan.
The demonstration grew in size there.
Then, most recently, we got very exciting news in 2022
with the passage of the Bipartisan Safer Communities Act,
which authorized the addition of ten states every two years
to the demonstration starting July 1st, 2024.
It also authorized us to release another round of Planning Grants.
We just awarded in March a set of 15 Planning Grants
to 15 new states
to prepare them to potentially join the demonstration.
In 2024, we will be selecting ten states to join the demonstration by July 1st,
but we're going to be repeating this process again in 2025,
awarding 15 more Planning Grants
to bring ten more states into the demonstration in 2026.
That authority to bring additional states in the demonstration doesn't end,
but theoretically, we can bring in ten more states to the demonstration
every two years thereafter
until, I think, we run out of states.
Next slide, please.
There's three main payment sources for CCBHCs from the Federal level.
There's the CCBHC Medicaid Demonstration that I mentioned on the last slide.
This was authorized, as I said,
under the Protecting Access to Medicare Act.
In order to join the demonstration,
states have to have received a Planning Grant.
This is an exciting option for funding CCBHCs
because it provides flexible and cost-based reimbursement
for clinics providing CCBHCs services
through a prospective payment,
that's either a daily or a monthly rate,
depending on which option the state opted for
when they created their CCBHC program.
The CCBHC receives a global payment
for covering a comprehensive service package
through the prospective payment.
The built-in quality incentives and quality measurement
is a part of the program.
States, when they participate in the demonstration--
we want a big incentive for them to participate in the demonstration
as they receive an enhanced Federal match,
or eFMAP,
for Medicaid expenditures that support the program.
That is the rate for the Children's Health Insurance Program.
That's the equivalent rate that they get
as opposed to their normal Medicaid rate,
which is a little bit lower.
States certify CCBHCs participating in the Demonstration program.
That's a really important role of the state
is an oversight role of the CCBHCs
participating in the program for the state Demonstration programs.
CCBHCs participating in state Demonstration programs
may also be receiving payment through SAMHSA's Expansion grants,
which I'll talk about in a second.
What are SAMHSA's Expansion grants?
These are the grants that started in 2018 separate from the Medicaid Demonstration.
They provide a fixed grant amount,
right now, up to $1 million a year for four years
to support the CCBHC model.
Before 2022,
these were shorter, more intense grants for $2 million a year up to two years,
but we spread that money out over four years
because we felt it was a more sustainable and realistic funding stream.
We have two tracks in the program.
One for existing CCBHCs
and one for new CCBHCs,
so our program supports both the continuation of existing CCBHCs
and also funds to build new CCBHCs.
Our grant funds are used
in addition to existing funding that these clinics are receiving
to help those CCBHCs
meet the full CCBHC certification criteria requirements
and then also help them improve their programs
and build out their programs and areas that meet their community needs.
We do not certify
CCBHCs that are participating in our grant program.
Instead, what we do is we go through an attestation process with that
in which the CCBHCs submit a detailed 30-page attestation to SAMHSA.
Then we review that attestation.
We often go back and forth with clinics a few times to sort out details.
Then when we accept that attestation,
we consider them a CCBHC, but we don't actually certify them.
As I said,
some of those Expansion grants,
they are also be participating in a CCBHC Demonstration program,
but they also may be participating in a separate state program
to support CCBHCs.
One of the things we've seen is that some states are supporting CCBHCs
outside of the demonstration,
which is the third way that CCBHCs are supported using Federal funds.
Some states have developed other mechanisms through Medicaid,
either through state plans or through waivers
to support CCBHC programs.
These are programs that are using different Medicaid authorities
for the demonstration.
They align with the CCBHC model, though.
States, when they create these other programs,
they don't receive that enhanced FMAP.
They receive whatever rate they would have received otherwise
for supporting the CCBHC program.
A lot of these programs,
these other Medicaid programs
are actually in states that are part of the demonstration,
but they're using this other mechanism through Medicaid
to reach clinics that weren't included in the demonstration originally.
That's something that's changing
because we're allowing states now to add sites
to their existing demonstration programs.
Something they hadn't been able to do until this year
when we just put out guidance.
Again, some of these CCBHCs
that are supported through these state programs
outside the demonstration
also receive CCBHC Expansion grants.
Next slide, please.
A couple of updates really quickly on our CCBHC Expansion grant program.
We revamped the program last year.
We were excited to put out 300 awards
or a little bit more than 300 awards at the end of the year.
As I said, they're now $1-million-a-year grants
for up to four years.
We did revamp the program, as I mentioned, to two tracks last year.
This year, we have a Notice of Funding Opportunity
that is out on the streets right now.
You can see the links here. The first one is for new CCBHCs.
The second one is for existing CCBHCs.
We are planning on putting out a warning at the end of this fiscal year.
At least 124 new grants applications are due for those grants,
May 22nd, so if you...
You, at this point, would already have to be working on your applications,
but, please, I know there's some of you who are on the webinar today
who may be interested in becoming CCBHCs.
This is a really great opportunity for you to receive support for work on the model.
As I said, the anticipated start date for these grants
is at the end of the fiscal year, September 30th.
Next slide, please.
We're very excited to spread.
In a short period of time that we've seen with the CCBHC model,
the model started with 67 clinics across eight states.
We now have activity happening in 47 states.
The District of Columbia, Guam,
Puerto Rico, and the US Virgin Islands.
This map lays out what's happening in various forms across the country.
The states that are red with lines through them
are states that are in the Medicaid Demonstration.
The states that have check marks on them
are states that have some other mechanism in Medicaid
to support work around CCBHCs.
The green states have at least one of our Expansion grants in that.
That doesn't mean that they have statewide coverage,
but it just means they have at least one SAMHSA Expansion grant
in their state.
Then the states with dollar signs on them
are states that have received Planning Grants in the most recent round
to potentially join the CCBHC Medicaid Demonstration
in 2024.
We're very excited to be working with those states
that have been selected to join the Medicaid Demonstration.
All right, next slide, please.
I do think if you want to understand what the CCBHC model entails,
the best place to go is the certification criteria.
You can see here just a broad summary of what's in the certification criteria.
There are six areas of program requirements
in the certification criteria.
CCBHCs must meet staffing standards informed by a local needs assessment.
They have to meet standards around timely and meaningful access to services.
They have to provide 24/7 access to crisis services.
They have to get anybody who needs care in a crisis
care in three hours.
If they have an urgent need that's a noncrisis need,
they need to be able to be seen within one business day.
Everybody else needs to be able to be seen within ten business days.
They have to have developed a treatment plan
within 60 days of initial service.
Then they have to update that treatment plan
at least twice a year thereafter.
That treatment plan should be providing
everything across this set of services that that person needs.
CCBHCs are responsible for care coordination.
They have to coordinate care across providers.
They have to have the infrastructure to support that,
including health information technology.
CCBHCs have to provide nine required services.
You can see them on the right side of the slide here.
Crisis services;
outpatient mental health and substance use services;
screening, diagnosis, and risk assessment;
person- and family-centered treatment planning;
psychiatric rehabilitation services;
community-based mental health care for veterans;
outpatient primary care screening and monitoring;
peer, family support, and counselor services;
and targeted case management.
These are all defined in much more detail
in the certification criteria document.
You can see the links at the bottom of the screen.
CCBHCs also have to collect quality measures
and have quality improvement processes built into their clinic operations.
CCBHCs have to meet standards
around organizational authority and governance,
so they have to have representation
from the people who both have the experience
and the people being served by the CCBHCs and their family members
in the governance of the CCBHC.
They also have to have appropriate state accreditation
and participate in Medicaid.
To really understand the CCBHC model,
I would suggest that folks go to our website
and take a look at the certification criteria.
We just went through a major update to the certification criteria,
so you can get the latest and greatest.
Just read the updates to the criteria that we released in March.
Again, the links are here at the bottom of the slide for that.
If you just google "SAMHSA" and "CCBHC,"
they're also on our main page when you go to our CCBHC page at SAMHSA.
That's about a 65-page document, but it is really worth it,
if you want to understand this model, to read through those criteria.
Next slide, please.
We're here today to talk about accreditation.
There's a couple of things I felt like were pertinent to mention.
First is that we're about to see a pretty big expansion
in the number of states that have CCBHC programs.
First, there's already eight states that are in the demonstration.
There are several independent states also.
We're going to be adding ten more states in 2024.
Those are all states that may think about using accreditation
as a part of how they certify clinics
to become CCBHCs
and as a part of their ongoing monitoring of their CCBHCs
to make sure that they're compliant with the CCBHC model.
You can see here,
these are just two excerpts from our certification criteria
down at the bottom of the slide.
This is too from the most recent version.
We make clear in the certification criteria
that states can choose.
They may use an independent accrediting body
as a part of their certification process,
as long as it meets the standards for certification process in their state.
Then, there's also a separate criteria:
this 6.c.3 here at the bottom of the State.
This is a holdover from the original criteria.
It's in the old version of the criteria and the new version of the criteria.
But states are encouraged to require accreditation of CCBHCs
by an appropriate independent accrediting body.
States have the option of using accreditation
as a part of their CCBHC model.
Until very recently,
there really wasn't much
in the way of CCBHC-specific accreditation happening out in the world,
but as I think we'll hear more today,
The Joint Commission has been working on developing capacity
around CCBHC-specific accreditation.
I think there's other players in the field also
who are working towards developing capacity
to do some of this accreditation work.
It's very exciting for us.
We think it's a really positive development in the field,
but it is, I think, first going to affect states that can elect.
Either these new states that are joining the demonstration in 2024
or some of the existing states already part of the demonstration,
they can elect to use accreditation
as a part of their CCBHC certification and oversight processes.
Another thing that may be driving this is
the existing states in the demonstration are going to be able to add sites
to their programs
because we just released guidance
allowing CCBHC Demonstration programs, these state programs,
to add additional CCBHCs to their programs.
That means that the burden on states to do direct certification
is going to increase.
As that burden increases, that may increase
their incentives to use independent accrediting bodies
as a part of their certification process.
One other thing I wanted to note
is that in the most recent President's budget
for fiscal year 2024--
and this was the budget that was released
along with the President's State of the Union Address
this past spring, late winter--
there was an explicit statement
supporting the development of accreditation process for CCBHCs.
It says that the President's budget proposal support CCBHCs
by proposing accreditation process,
similar to the process which I wish many health facilities are accredited.
This hasn't taken shape yet,
but it does put us on record publicly
as saying that SAMHSA would like to build out an accreditation process
for CCBHCs.
This is something we would hope in the future
be able to use for our Expansion grants.
It doesn't exist at this time,
but that is something that we are thinking about.
Again, the first road for the use of accreditation for CCBHCs
will likely be through states,
but something that could be coming in the future,
depending on what happens
with how Congress acts on the budget proposal
is our ability to think about accreditation
for our Expansion grants as well.
With that, I'm going to turn it over to Becca Farley
with the National Council, I think.
(Colette) Thank you. Before Rebecca starts,
thank you so much, David.
As he said,
Rebecca is next on the agenda.
Rebecca Farley David leads
the National Council for Mental Wellbeing's
CCBHC Success Center,
an initiative to advance
the Certified Community Behavioral Health Clinic model.
Rebecca has been involved in the CCBHC movement
since its inception.
Today, she provides strategic guidance and implementation,
support to state officials,
provider organizations, and other stakeholders
working to adopt the CCBHC model.
Welcome, Rebecca.
(Rebecca) Hi, there. Thank you so much for having me with you today.
Really, I'm excited to be able to build on David's presentation.
He gave such a wonderful and thorough overview of the CCBHC model.
Over the many years that I've been working on CCBHCs,
this is a time that is...
I think we're on the verge of major expansions
of the adoption of this model around the country
and a real opportunity to bring this nationwide.
Next slide, please.
I'd like to pause for just a moment here
and reflect on what is so transformative about the CCBHC model.
When you look at the framework that David laid out
for how CCBHCs work--
the criteria, the payment,
all the requirements that go along with that--
the CCBHC model,
it begins with the clinical model.
What do we know to be effective?
What works when it comes to improving people's health and their lives
based on that compilation of comprehensive services,
of all sorts of nonbillable activities,
like outreach and care coordination
that go into supporting access to care and service delivery?
Then it asks:
What financing is needed to support what really works?
I think that's fundamentally different
than the typical environment that clinics operate in,
which is they have to look out there and see what funding is available
and then ask themselves:
How can we cobble together a comprehensive service array from that?
The prospective payment that's available
under the Medicaid Demonstration
or State Plan Amendments,
the grant funding that is available for organizations
who win those grants--
all of that brings new flexibility
and enhance funding into the safety net,
but at the same time, it does come along with weightier expectations
that clinics must demonstrate that they can meet.
These requirements reflect best practices within our field.
The CCBHC model does require a greater scope of services
than most clinics previously provided.
I've worked with CCBHCs over almost a decade now,
and I don't know a single clinic
that did not have to add services or partnerships or staffing
in order to meet the CCBHC Criteria.
The model also establishes standards and expectations
related to active collaboration.
The expectations for collaboration with partners are really much more.
They go well beyond the referral relationship
that clinics might be used to.
There's a lot of expectations
regarding bidirectional collaboration and communication
and the integration of other entities or providers
from outside the clinic onto treatment teams
in order to be able to help address an individual's entire spectrum of needs.
Those partnerships are required with health and non-health care partners,
which I think is also a new and transformative aspect of this model.
The requirements related to those partnerships
do support improved coordination and integration.
The idea being that through the CCBHC model,
we can help break down silos across systems.
We can help foster connections
that will improve the way systems work together
to serve individuals who come in contact with all of them.
It supports service delivery outside the four walls of the clinic.
One of the things that is so exciting about this model
is to see the innovative ways
that CCBHCs are using clinical and nonclinical staff
to engage with individuals in the right place at the right time.
They're doing so in ways that are responsive to
and adapted to local needs.
That local facet of implementation is such a critical one,
recognizing that communities know best
what is needed to reach people in their own community.
This model provides flexibility to support CCBHCs in doing that.
There's new sets of standardized quality reporting
across the whole universe of clinics that are operating as CCBHCs.
There are opportunities, of course,
for states to customize what that quality reporting looks like,
but taken together,
we are starting to develop
what will someday become, I hope, a national body of data
about the reach and the efficacy of the CCBHC model.
For organizations that are participating in the model
under the Medicaid Demonstration
or as part of their state's Medicaid CCBHC State Plan Amendment,
there is new payment models.
They introduced risk and flexibility into provider pay.
Through the partnership framework of the CCBHC model,
there's opportunities for partner provider organizations
to also participate in that financial model.
Next slide, please.
All of this is to say that CCBHCs are not business as usual.
As we look at the many hundreds of clinics now
that have gone through the process
to take on the services and activities of a CCBHC,
there's so much that we've learned.
I know that many of you that are on the line today
are brand-new in your CCBHC journey
or considering embarking on that path.
I just wanted to take a few moments
to share some of the lessons we've learned
from watching and supporting implementation
in clinics around the country.
When it comes to access to care,
the CCBHC model is driving major expansions
in the number of clients served.
In many cases,
the individuals who are newly coming into care within CCBHCs
are people who did not previously have a regular source of care
despite having, in many cases, severe needs for treatment.
What we're finding is that CCBHCs client demographics
are changing.
The diagnostic [makes] the intensity of needs for services.
As a result,
the types of organizations
that CCBHCs are partnering with are changing too
as they're starting to work with other sectors
who are also touching the lives of this client population.
We have seen CCBHCs having to increase staff
in order to meet the demand for services as their client base also increases.
We've seen CCBHCs implementing new intake and scheduling protocols
in order to increase timeliness of access.
The SAMHSA criteria do have requirements
around how quickly the CCBHCs have to be able to meet emergency
and urgent and routine needs.
There's a ten-day timeline
for being able to offer appointments for individuals with routine needs.
In general, as we have seen,
the access expansions play out across the country.
We've seen CCBHCs doing a really good job
of meeting that ten-day timeline for access to intake.
I think where we see the greatest levels of client satisfaction and engagement
are when CCBHCs work really hard
beyond ensuring timely access to intake
to ensure timely access to initiation of treatment.
As I reflect on what lessons the clinics have learned
throughout implementation,
I would strongly encourage those who are just starting down this road
to really look critically at your access protocols
and think about are there ways we can expedite
same-day access to treatment
as a mechanism to support and engage the influx of clients
who will be coming our way.
CCBHCs have also, as I mentioned, had to take on
a variety of new kinds of services,
and in many cases, these services might be unfamiliar to them.
One of the biggest areas where CCBHCs expressed need for support
in the early days of the demonstration
was with integrating substance use services
into their existing array of mental health services.
Some CCBHCs partner
with external substance use treatment organizations
to deliver some of the required services.
Others have opted to bring substance use treatment entirely in-house.
Whatever structure CCBHCs use to provide access to substance use care,
it's critically important that that be fully integrated with mental health
and not just exist as a separate silo within the CCBHC scope of services.
I think organizations that focus intently
on that integration of substance use and mental health care at the beginning
really saw that pay off
as they were able to identify unmet substance use needs
within their existing population
and expand access to important treatments,
like medication-assisted treatment
and peer-recovery support specialists.
Speaking of peers,
peer services were one of the most commonly added services
for organizations going through the CCBHC transformation.
Many CCBHCs hired peers directly
to deliver those services.
Others partnered with peer-run organizations
within their communities.
I would say that peer services are consistently cited
as one of the most transformative aspects
of this model.
One clinic said that adding peer services to their service array
was like learning how to use a microwave.
Once you start doing it,
you don't see how you could ever possibly go back.
I think that speaks to how critical peers are
in making sure that people have access to
and are engaged in services
and really getting services in a way that it's person-centered
and respectful of where they are in their recovery journey.
Some CCBHCs had to really think differently
about providing specific services to certain populations.
We had CCBHCs that had previously served only adults
that had to take on services for children, is just one example.
Vice versa, there were organizations
that had previously only served kids
that now had to be able to offer services to adults.
As CCBHCs are looking at how their client population might change,
they should also be thinking through
not only how our services need to change in response to that,
but what kind of training, what kind of staffing,
what kind of organizational culture shift
might be needed to support those changes as well.
As clinics were taking on a new scope of services,
they also had to navigate, in many cases,
new state credentialing and licensure requirements,
sometimes including accreditation,
in order to be able to offer those services
within the scope of state law.
Those are all some areas I'd encourage you to be thinking about
when it comes to those expansions of your scope of services.
Staffing, of course, was another area where clinics made a lot of changes.
Of course, workforce shortages plague everyone.
There's no place in the country that's not affected
by the behavioral health workforce shortage.
CCBHCs were able to think really creatively
about the composition of their teams,
about their salaries and bonus structures
in order to recruit folks to come and work at the CCBHC.
I would say, in general,
staff report that CCBHCs are able to offer better pay and benefits
and a more preferred working environment.
Because of the flexibility that the payment model offers,
clinicians are freed up to practice in different ways
that we hear are quite rewarding
compared to a traditional practice environment.
I think the CCBHC model offers lots of opportunities
for clinics thinking through how can we continue to grow our staff
in the face of the workforce shortage
and how can we improve retention as well.
CCBHCs have to meet a number of criteria related to partnerships.
There's two kinds of partners envisioned under the model.
There are your care coordination partners
who you work with to coordinate services and support
within your own respective fields.
There are also your designated collaborating organization partners,
or DCOs.
These are service providers that fill gaps in your own service array.
The DCO relationship is really meant to tightly weave together
services provided across organizations
in a way that makes the experience seamless
from a client point of view.
DCO partnerships do require a different lens
of looking at coordination, collaboration, and integration,
and that organizations that have navigated that successfully
have reported that they find tremendous value in the DCO partnership.
It's also a partnership that can be challenging to take on.
I think it's an area where clinics should be thinking carefully.
What kinds of partners do we want and need
to deliver services on our behalf
and what opportunities are there for us
in partnering with other organizations within our community
compared to taking on services in-house?
When it comes to electronic health records and data and IT systems,
I think this is an area where it became clear right off the bat
that the clinics' existing systems could not meet their needs
under the CCBHC model.
97% of CCBHC Demonstration sites
had to change their EHRs
or purchase new ones
in the first few years of the demonstration.
Nearly everyone had to either upgrade or replace their EHR
in order to be capable of the kind of electronic communication
and data reporting that is required under the model.
I think there's really exciting opportunities
to leverage IT systems and data collection for population health management,
for data-informed care,
to bring on technologies
that can support reaching clients outside of the clinic.
There's a lot going on in the data and technology space.
I think, historically,
a lot of those innovations have felt like they weren't for us
because there's no payment for them.
The wonderful thing about the CCBHC model
is that it allows you to--
if you're a demonstration site or operating under a State Plan Amendment,
it allows you to bring in those kinds of technologies
and have them paid for through your new Medicaid payment rate.
Also, those that have the grant, of course,
can devote a certain amount of grant funding
to activities such as this.
Finally, when it comes to quality reporting,
I would say this is one to focus on very early on
in the implementation process.
I think clinics, in general, report
that it takes a significant amount of time
to get up and running with the quality reporting.
New data systems, of course, can help with that,
but that is an important aspect of the criteria to focus on
quite early in the process.
Next slide, please.
I'm taking a look at the time,
and I want to make sure I get through with my slides
in plenty of time for The Joint Commission
to share their content.
I'll just quickly say, as we look ahead,
this is a really exciting time for CCBHCs.
There's currently more than 500 CCBHCs
in almost every state in the nation.
12 states have implemented the CCBHC model in some way
through Medicaid.
More than 15 other states are planning to compete
for ten open slots in the demonstration in 2024.
Of course, there will be opportunities for ten new states to join the demo
every two years thereafter.
States also don't have to wait for the demo.
They can use the State Plan Amendment at any time
to implement the CCBHC model.
There is a lot of interest in that.
I would say we're at a tipping point.
Interest is growing tremendously across the nation,
but lots of work remains ahead of us
if we're going to bring this model to every state and every community.
To my mind, a critical piece of that
is going to be demonstrating success at the clinical level.
That means demonstrating adherence to the Federal criteria;
it means showing success in meeting quality goals;
and it means demonstrating
that CCBHCs are really changing practice in meaningful ways;
that they're reaching the people who need care;
they're ensuring swift access;
they're providing services and support that help people get demonstrably better;
and they're alleviating the burden on other systems
that serve people with serious mental illness
and substance use disorder.
At the end of the day,
I would say that a clinic's success under this model
is going to be what helps us spread,
and accreditation can be a really important part of that.
Like SAMHSA, at the National Council,
we are supportive of development of accreditation.
We're not endorsing any particular product or approach,
but we're very eager to see how this field evolves
to support clinic success under the CCBHC model.
Next slide, please.
The National Council is here
to support anyone with an interest in CCBHCs.
We operate the SAMHSA Training and Technical Assistance Center
for CCBHC Expansion grantees.
You can see links on the screen here.
They'll be clickable in your handouts
to request individualized support through the TTA Center.
Next slide, please.
Anyone who is not a CCBHC
can also access support through our general CCBHC Success Center,
which provides information and support to everyone.
Now, I'd like to turn it back over to The Joint Commission.
(Colette) Thank you so much, Rebecca.
Next slide.
I would now like to introduce Stacey Paul,
who is the Project Director for Healthcare Standards Development
at The Joint Commission.
Stacey has been in her role for five years.
Prior to joining The Joint Commission,
Stacey worked as a psychiatric nurse practitioner
across various settings.
She is going to speak
on Joint Commission's accreditation for CCBHCs.
Stacey?
(Stacey) Thanks, Colette.
Yes, as Colette mentioned,
I've been in Joint Commission for five years
in the role of Health Care Standards Development.
I was the Project Lead on creating our CCBHC program.
I'd like to talk a little bit about that.
Next slide.
Some of you might be wondering--
although maybe not as much after the last two presenters--
but why did we decide to include CCBHC as an option in our accreditation program.
I think that David and Rebecca did a really great job
of explaining why this is becoming more of a need,
but as you can see from their presentation,
CCBHCs are becoming more common.
There's more grant opportunities.
More states are going to be added every two years.
It's very evident from both of their presentations
on why there's a need for this.
Also, Rebecca talked about this a lot,
but integrative models have shown to improve quality.
If you just think about yourself
on being able to go one place
and have seamless care for all that you need
is really helpful.
It helps decrease no-show rates
and helps people feel supported,
not just under the roof of the healthcare organization
but in the community.
The direct partnerships are also extremely helpful.
As Rebecca said, it's more than just a referral.
In addition, there's care coordination
for other aspects of community care,
things related to a crisis.
So basically, the whole spectrum,
especially of mental health and substance abuse care,
is taken care of under one roof,
which can really improve quality.
As many of you know, Joint Commission has expertise
in integrated physical health care.
We have many programs that focus on physical health care,
of course, our hospital programs, our ambulatory care programs,
and many others.
There's a provision for really great high-quality programs
combining SAMHSA's CCBHC Criteria
with The Joint Commission accreditation requirements.
I will talk more about that as we go on.
Next slide.
The CCBHC standards that we created,
they are going to be effective July 1st, 2023.
What we did was we looked at all of our Joint Commission requirements
in the Behavioral Health Care Manual,
and we looked at the SAMHSA's CCBHC requirements.
We basically saw
where do we already meet some of these requirements--
where we don't really need to create something new,
we already speak to the requirement--
and then where do we need to create new requirements.
We found that there were 81 new requirements that we developed
to meet the CCBHC Criteria.
The 81 new requirements are developed directly from the CCBHC Criteria.
I'll show you some examples of these later,
but both Dave and Rebecca spoke to specificity
that is in the CCBHC Criteria:
timelines for crisis care,
provision of crisis care,
timeline for a routine intake-- things like that--
that specificity wasn't necessarily in our requirements.
We created requirements to meet those.
Also, I wanted to show you this chart.
I know it's kind of small,
but there were 81 requirements show up
across different chapters in our Behavioral Health Care Manual.
In our Care, Treatment, and Services, or CTS, chapter,
there are 45 new requirements;
in our Human Resources Management,
there are four;
in our Information Management, there are four;
in our Leadership chapter, there are 21;
and in our Performance Improvement chapter,
which has a lot to do with data,
there are seven new requirements for a grand total of 81.
I also wanted to mention,
David talked about the updates
that the CCBHC Criteria were updated in March.
These standards that we're releasing July 1st
were based on the previous before-the-update criteria.
We are now currently working
on integrating the update into our criteria.
On July 1st, you will get the SAMHSA criteria prior to March.
SAMHSA is giving organizations until July 1st, 2024,
to come into compliance with fair and new criteria,
so we'll be doing the same.
We'll be releasing our updated requirements
on January 1st, or before, of 2024
and giving organizations until July 1st, 2024
to abide by those new updated requirements.
Next slide.
All right.
In addition, as I mentioned,
we're not just asking people who have CCBHCs
to abide by the CCBHC requirements,
but also additional Joint Commission accreditation requirements.
Other applicable requirements for Joint Commission accreditation
to the CCBHC service specifically,
there's 1,127 total requirements.
That's including the 81 we've created for CCBHCs.
You can see here they're across every chapter in our manual.
In addition...
These are just what's applicable
if you're choosing CCBHC on your application,
but many organizations will also have things that aren't required
to be part of the CCBHC.
For example,
they may have a residential.
If you also have a residential,
then those Elements of Performance that are applicable to the residentials
will also be applicable to you.
For example, I've seen some CCBHCs
that also have a foster care or a treatment foster care component.
If that were also part of your organization,
that would be additional
on top of what you get from clicking on CCBHC.
Those are just a couple of examples.
Next slide.
All right.
The process for applying
to become accredited as a CCBHC through Joint Commission,
organizations will apply as a CCBHC via their application,
or some of you may know that as the E-App for accreditation,
by checking CCBHC Services box on Tab 5.
The standards will be available July 1st, as I mentioned,
in their E-dition customized standards
once you go ahead and update that E-Application.
CCBHC standards are going to be surveyed
as part of your regular accreditation and survey process.
This is not a standalone certification.
This is just part of your every three-year survey.
You will be surveyed to the new CCBHC requirements,
as well as the existing Joint Commission requirements.
Lastly, your organization will be recognized and searchable
as accredited as a CCBHC on our website
at www.qualitycheck.org
Next slide.
I wanted to give you some examples
of Elements of Performance that we added
to meet SAMHSA's criteria
where Joint Commission standards
didn't already have the aspects of the CCBHC Criteria in them.
This is just two of them.
There are 81, as I mentioned.
David actually covered a lot of the specificity
that we have created to meet the CCBHC Criteria.
But one example here,
this is in our Human Resources Management chapter, or HRM.
Our current standards do require training on cultural competency.
However, we don't have a specificity in our current Elements of Performance
that relates to military and veterans' culture.
That's something that we added,
so organizations know that it's important
as a CCBHC to train staff on military and veterans' culture.
There are a lot of different provisions for military and veteran individuals
that are being served by the CCBHC
that we've also added into our Elements of Performance.
Next slide.
Here's another one.
I think David did mention this,
but there is specificity required
for the board of a CCBHC
to be representative of the individuals served
in terms of demographics,
so geographic area, race, ethnicity,
sex, gender identity,
disability, age, and sexual orientation,
as well as 51% representation of those with lived experience,
so with mental illness, substance use disorder,
or a family member of those served by the CCBHC.
Those are just some examples of ways we incorporated CCBHC Criteria
into our Elements of Performance.
Next slide.
The CCBHC accreditation standards,
all 81 of them, are available by request
on our prepublication standards page through June 30th.
Once July 1st hits,
these will be in our manuals and in our E-dition manual as well.
I will turn it over to Melinda
who will maybe take questions if we have time.
(Melinda) Thanks, Stacey. Yes.
Our first question is for David.
"How does accreditation interface with state certification
and with CCBHC attestation?"
(David) Thanks for that question.
Accreditation is a voluntary process that states may enter into.
They may decide to use accreditation as a part of their certification process.
Right now, there isn't a relationship between attestation and certification,
but I will say this:
if a CCBHC had been through an accreditation process,
they would be really well-prepared
to participate in SAMHSA's attestation process.
The long and short of it is that it'll be up to state discussion
about how they want to use any accreditation options
that are available for them
as a part of their state certification process
to participate in the CCBHC Medicaid Demonstration.
Then as far as our grants go,
right now, for the Expansion grants,
there is not a relationship
between accreditation and our attestation process
for the Expansion grants,
but I would think that if a grant site
had been through the accreditation process,
they would really be well-positioned to submit that attestation.
The thing I'll add is that, depending on what happens
over the next couple of years,
SAMHSA would like to explore how we can use accreditation
in our Expansion grants,
although that is something that isn't in place at this point.
(Melinda) Thank you very much for that answer, David.
Our next question.
I think this is for Colette.
"For organizations who underwent accreditation during 2022,
how can we seek CCBHC certification?"
I think they mean accreditation.
(Colette) Thanks, Melinda.
Yes, as I believe Stacey mentioned,
around July-ish-- beginning of July--
you will be able to go into your application,
and on Tab 5,
select that you are a CCBHC,
and during your next survey,
you will be surveyed under the CCBHC standards.
(Melinda) Thank you.
Our next quest--
(David) Can I jump in really quick on that question?
This is really from SAMHSA.
I just want to make it clear,
right now, unless a state decides to use accreditation
as a part of its process,
accreditation in itself doesn't automatically qualify a CCBHC
to be a part of a state program.
It doesn't qualify an organization to get one of our grants
or to receive any other funding sources.
I think the CCBHC model is a strong model.
I think any clinic that meets the accreditation standards for CCBHC,
it certainly would be a way of strengthening their scope of services
and being in line with some of the best national centers that we have.
But accreditation in and of itself
doesn't qualify anybody for joining a state program
or any other funding source,
unless a state makes a decision that that is a part of their process.
Just want to make sure that's clear.
(Melinda) Thank you, David, for that clarification.
Our next question is,
"Under CCBHC guidelines,
can you provide integrated care
to only a subset of the population you are serving
or must it be open to all individuals served?"
(David) I think this may be a question for me.
The requirement in the CCBHC certification criteria
is that there be primary care screening and monitoring,
I think, if the question is about integrated primary care.
CCBHCs are expected to adhere to the certification criteria in the area.
What that means basically is to do an initial screening and identification
of common physical health conditions and chronic conditions
that are being experienced by the people being served by the CCBHC
and ensuring that people are connected back
with primary and physical health care conditions
to address those conditions.
Then also ongoing monitoring of those conditions over time
to make sure that people are getting the care they need.
That's the expectation of what happens under a CCBHC.
All people receiving services from a CCBHC
should be able to get access to that care.
Some CCBHCs also provide primary care on-site
as a part of what they do at that clinic.
That's not necessarily a part of the nine required CCBHC services.
They wouldn't necessarily be required that that primary care
be made available to everybody at the CCBHC,
but that primary care screening and monitoring,
again, that initial screening
for common physical health and chronic conditions
and then referral on and connection and care coordination
around making sure those needs are met,
that would have to be provided to all people being served by CCBHC.
(Melinda) Thank you. We have a similar question.
"Can you confirm if the crisis/mobile crisis
can be managed through an agreement or partnership?"
(David) We didn't get into this, but there's something called
"a designated collaborating organization relationship"
built into the CCBHC model.
All CCBHCs have to provide the nine required services,
either directly by the CCBHC organization
or through a designated collaborating organization relationship,
which is a relationship that's governed by a formal agreement,
but it should look to the person being served
as if it is one organization providing the services--
I've heard people describe it.
This isn't contracting out services.
It's almost like contracting in services into the CCBHC service package.
CCBHCs do have the option of providing crisis services
through the designated collaborating organization relationship,
but it has to be with the crisis service provider
that's participating in the state-sanctioned programs.
It can't just be any crisis service provider.
It has to be one that's endorsed or supported by the state.
(Melinda) Great, thank you.
This also is for you, David.
"Is there a contact list maintained for state contacts?
The CCBHC model is not fully recognized in Arizona,
so it would be helpful if some direction was available
for working with the state bodies for CCBHC."
(David) Right, the state doesn't have a CCBHC program.
I think the way that CCBHCs will be supported
is through our Expansion grants.
As I mentioned, there is a Notice of Funding Opportunity
out in the streets right now about that.
If people want to email CCBHC at samhsa.hhs.gov
we can provide them with contact information for their state,
but if there is not a program in your state right now,
there really isn't a pathway in that state
for the joy of demonstration or an independent state program.
It doesn't exist in every state at this point,
but we're getting there.
(Melinda) Great, and I think we'll squeeze in time
for just one or two more questions.
Although this one, I think we might need more time than we have.
"I am new to the CCBHC program.
Can you clarify the reimbursement model?"
(David) Sure, I'll try and do this really quickly.
There's different pathways.
One is through a state demonstration program.
That's a defined model with the prospective payment.
There are only currently eight states that are participating in that right now.
We're adding ten more in 2024
and ten more every two years after that
until we run out of states that are interested.
Some states have independent programs
to support CCBHCs outside of that model.
They're all designed a little bit differently
depending on what part of Medicaid
or what part of state funding they use to support the CCBHC model.
Then there's our SAMHSA Expansion grants,
which basically provide grant funds,
$1 million a year for four years, to meet the CCBHC standards.
Those funds are layered
on top of whatever funding that clinic is already receiving,
so they can build out their CCBHC services.
Those are right now the three primary sources of support
for CCBHCs.
There's work in state general revenues.
There's work happening in pockets in other areas,
but those are the three main sources of funding
right now for CCBHCs.
(Melinda) Thank you, David. That was very concise.
I appreciate it.
The next question is for Rebecca or David.
"As we look to find and choose care partners,
are there any specific criteria we need to assess?"
(David) Feel like I've been hogging the questions,
so, Becca, if you want to go, but I can say something too.
(Rebecca) All right, no, sorry, I was having a mute issue.
If you don't mind, Melinda,
going back to the questioner from Arizona
who was asking about how to move the model forward in their state.
I would also welcome connecting with you
to chat about that.
National Council is happy to chat with you
about what we know about implementation efforts in states
and make connections for you
with officials or state associations within your state
that are working on CCBHC implementation.
Regarding what you should be looking for in your partnerships,
the SAMHSA criteria outlined a number of expectations
for CCBHC partners.
I would definitely recommend starting with a good, strong look at the criteria
to see what expectations
your partners will need to be able to meet.
That includes expectations for you around care coordination partners,
but then also,
even more comprehensive requirements
for those designated collaborating organizations.
I think starting with a solid understanding
of what those partnerships must entail
is a really good place,
and then understanding what organizations are out there in your community
offering really high-quality services
that could add to and complement your service array.
You can also consider
from the results of your needs assessment
what partners you might want to establish,
what partnerships you might want to establish
that you don't have in place already to meet your community's needs.
Again, I'm happy to follow up with more information
if folks want to connect with our Success Center
or our SAMHSA Training and Technical Assistance Center.
(Melinda) Thank you very much, Rebecca.
I will now turn it back over to Colette
for our closing slides.
Thank you, everyone, for your questions.
(Colette) Thank you, Melinda. Next slide.
Again, thank you.
Please remember, when you become part of The Joint Commission
and earn our Gold Seal of Approval,
you have reached for and achieved
the highest level of performance recognition
available in the behavioral health and human services field.
Next slide.
As you know, we are ongoing--
we're doing free webinars and our replays are available.
Please sign up for our next webinar,
which is Peer Perspectives
on Joint Commission Behavioral Health and Human Services Accreditation.
That will be on June 15th of this year.
Next slide.
On the last slide here,
I think you all who have stayed with us a little longer...
There's our contact information for our Business Development team.
Please feel free to reach out to any of us at any time
with any questions or if you need assistance.
With that, I will turn it over to Melinda again.
(Melinda) Thank you very much.
Thanks, everybody, for attending today's webinar.
There's going to be a short poll available for you after you leave
if you want to provide your feedback on today's presentation.
We really appreciate you joining us today.
We hope to see you again.
Thank you very much. This concludes our presentation.