(Melinda) Hello, everyone. Welcome to today's webinar,
Integrated Care Delivery: Lessons From CCBHCs.
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Next.
So, just a reminder, this webinar provides an intermediate level of information.
Next.
Thank you for joining us today.
And I'd now like to introduce Julia Finken,
the Executive Director
with the Behavioral Health & Human Services
Accreditation Program at The Joint Commission.
Julia?
(Julia) Thanks, Melinda, good morning or good afternoon, everyone,
depending on where you're located in the country.
As Melinda said, my name is Julia Finken,
and I'm the Executive Director of the Behavioral Health Care
and Human Services Program here at The Joint Commission.
I want to thank you for joining us here today
for our presentation on
Integrated Care Delivery: Lessons from CCBHCs.
I'm so happy to be joined here today by Rebecca Farley.
She's the Senior Advisor for Public Policy
at The National Council for Mental Wellbeing.
I'm also joined by Peggy Terhune,
the Chief Executive Officer for Monarch North Carolina
and her colleague, Monique Lucas,
the Vice President of Integrated Care for Monarch North Carolina.
Next slide.
Today, Rebecca is going to talk about the CCBHC model of care
now and into the future.
She's going to include information about regulations and reimbursement.
Peggy Terhune and Monique Lucas
will talk about the Monarch North Carolina's journey
as a CCBHC,
and they're going to provide you with some ideas
on how Joint Commission accreditation can be utilized
as a strong framework for building a successful CCBHC.
So, with that, I'm going to turn the presentation over to Rebecca.
Next slide.
(Rebecca) Thank you so much, Julia.
Thank you for inviting me to be here today.
As you said, I'm Rebecca Farley David, I'm the Senior Advisor for Public Policy
with The National Council for Mental Wellbeing.
For those of you who aren't familiar with us,
we are the national organization
representing over 3,000 community-based providers
of mental health and substance use services nationwide.
Our role is to be a voice for those organizations
in advancing public policies, to strengthen the safety net,
and provide support to clinics
who are implementing new models of care or new services.
One of those new models, of course, is the CCBHC model.
So I'm thrilled to be here with you today talking about that model.
And I think, before we get started, it's really worth taking a moment
to reflect on what brought us to this point.
Why do we need CCBHCs?
It certainly is not news to anyone on this call
that our nation is experiencing a crisis in access to care
that leaves most people
with mental illness or substance use disorders with unmet needs.
There, of course, is a workforce shortage,
exacerbated by low payment rates in the sector
that make it quite often impossible for clinics
to offer competitive salaries and retain staff.
And we see tremendous variability in care cost
and quality around the nation and from community to community.
I do think we're seeing a growing recognition
that behavioral health is a critical ingredient
to improving outcomes and reducing costs.
But the financing models that we have in place
have really not kept pace with needed investments
and capacity expansions to meet so many of those unmet needs.
So that brings us to CCBHC.
Next slide, please.
And I think we can go to the next one.
CCBHC is a new model of care delivery.
It comes with a standardized definition
of what it means to be a safety net behavioral health provider.
That definition includes requirements around CCBHC's scope of services,
around their staffing, the care coordination activities
that they engage in, and a lot more.
And together, those standards really do raise the bar
for the delivery of community-based services.
I say that not because clinics are doing a bad job currently,
but because financing models have not consistently supported them
in ways that are critical for allowing them
to sustainably deliver comprehensive care.
The model also comes with data and quality reporting requirements
that are aimed at holding clinics accountable for improving health outcomes
and to do so in ways that ensure access to evidence-based practices,
ways that reduce health system utilization
and improve chronic disease management.
And for all CCBHCs, there's funding available to support this,
but in particular, I want to highlight for you
the Medicaid Prospective Payment rate, which is a new payment model
that allows participating CCBHCs
to include their anticipated cost of doing business as a CCBHC
in their payment rate.
And to have that payment rate reflect the cost of activities
that are typically not billable under Medicaid.
Things like care coordination, community outreach,
and so on and so forth.
And so, all of this together, this whole package,
the standards, the quality reporting,
the payment,
has allowed clinics to rethink how care is being delivered.
And it has also provided them with resources,
much needed resources, to expand capacity,
and ultimately, to deliver a more sustainable way to fund services.
So when you think about CCBHC,
know that this isn't just business as usual
with a different reimbursement stream,
it's a new way of delivering care,
it's a new way of running a business,
and it's a new way of integrating services with community partners.
Next slide, please.
So there are currently-- looking at the CCBHC landscape,
there are currently three implementation options for CCBHCs.
One of those is the Medicaid demonstration.
This has been in effect for the longest, since 2017.
That demonstration is currently open only in ten states.
So, it's not really an option for most clinics in the nation
barring congressional action to expand that demonstration,
which I think we will continue to see.
But, nonetheless, for most clinics, right now,
the primary route to becoming a CCBHC
is through federal grant funding from SAMHSA
that flows directly to individual clinics
to get them functioning essentially as a CCBHC.
There are challenges to sustainability with grant funding alone,
and we'll talk about that.
But luckily, states also have the ability
to implement CCBHCs through Medicaid independently from the demonstration.
So, if you are a grantee or a prospective grantee
in a state that is not part of that demo, just know that your state has the ability
to leverage Medicaid to implement CCBHC statewide.
And we'll talk more about what those options for states are as well.
Next slide, please.
For those who may not already be aware,
here's a map showing the CCBHC state landscape.
States with any kind of CCBHC in them are noted in orange,
those that are also in the demonstration have light gray stripes,
and states that are working on that independent Medicaid implementation
that I mentioned a moment ago are marked with dark stripes.
We are expecting another round of announcements for CCBHCs very soon,
and that will definitely add to the number of clinics
and the number of states that have at least one CCBHC in them.
We're also seeing more states moving ahead independently
with Medicaid implementation of CCBHC,
Texas, of course, being the first,
but others like Kansas following close on their heels.
So, you can absolutely see the program growth here over time.
Next slide, please.
Let's go to the next one.
So, I'm taking a look at CCBHC's impact and results.
They really have achieved tremendous successes
over the last four years since the model began.
CCBHCs have been able to leverage their fundings
for new staff, new service lines.
They are also looking to redesign sort of the way that staff,
the way that teams are structured, the way that clients access services.
So, we're seeing a lot more same-day access in care,
a lot more elimination of waitlists,
and clients being able to access and improve scope of services,
maybe meeting more of their needs than what they had access to before.
CCBHCs are also using their funding
to invest in technology, anything from telehealth to EHR upgrades,
to patient tools that supports outside
or in-between appointments, data dashboards, and more.
Along the lines of data, CCBHCs are leveraging data tracking
and analytics for continuous quality improvement,
which is something, again, that has been quite difficult for clinics
to finance in the past,
and investing in partnership development
to improve coordination with other systems that serve the same clients,
and much, much more.
And so, if we can go to the next slide.
Really the ability of CCBHCs to do all of this
is rooted in that payment model, which might begin with a grant,
but ideally, we would see
that funding transition to the Prospective Payment,
also known as PPS under Medicaid,
because grant funding certainly does support these functions
for the time period of the grant,
but sustainability requires that ongoing cost-related payment rate.
And it's that cost-related payment
that supports the costs associated with expanded access
and with enhanced operations that are critical to becoming a CCBHC.
I've already mentioned a lot of ways
in which CCBHCs are using their increased payment
to enhance operations.
Most of these things--
I think what I want you to take away from this slide
is that most of these things are not truly supported
under other financing models.
And so where clinics have been able to do these things sustainably
like expand service lines, hire and retain specialty providers,
deliver a high impact flexible staffing models
targeted to patient need and so on--
where clinics have been able to do those things sustainably,
it's the exception rather than the norm,
and it does tend to require a lot of scrambling year after year
to keep funding available to continue those activities.
So, not surprisingly,
having solid financing to enhance your operations has improved,
it has produced improved outcomes
and that includes bringing more people into care,
many of which previously had needs that had gone unmet.
It includes reducing emergency department visits,
hospitalizations, incarceration, and so on
and it has included helping to improve clients' physical health
as well as increasing client satisfaction.
Next slide, please.
So, looking at what goes into being a CCBHC,
there are six domains of CCBHC criteria.
I won't go into all of them today.
The criteria are robust and extensive.
I actually don't know of any organization
that was able to meet all of the criteria right off the bat.
Every clinic that I've worked with had to make improvements
in some way to staffing and training,
or they had to expand the scope of services,
or initiate new partnerships, or engage in new quality reporting.
Some changes of some kind were required across the board.
And in return for making those investments,
the clinics that got certified, or that received the grant,
do get that enhanced payment.
So either the Medicaid Prospective Payment System
or the grant funding.
And let's see, we'll go to the next slide,
and we'll go into just a few of the criteria.
I want to start with scope of services.
There are nine required types of services as a CCBHC
which are listed here.
Looking at your own service array,
you might find that you are already providing some
or most of these services.
And again, that is common.
We know that lots of CCB-- for lots of clinics,
moving to CCBHC status meant adding to what they were already doing,
not completely reinventing the wheel.
For services that are not already being provided by a CCBHC,
there is an option to partner with another type of organization
known as a designated collaborating organization, or DCO.
A DCO relationship is really about bringing services
under the umbrella of your CCBHC activities,
carving them in, if you will.
So it's not a traditional referral relationship,
but it's about integrating other providers into your scope,
your team, your coordinated care efforts,
and really making those DCOs
part of your fundamental mission as a CCBHC.
There's a lot more details
about what goes into each of these types of services
that would be available either from your state,
if you're in a state that's doing CCBHC through Medicaid,
or from SAMHSA if you're a grantee.
But typically, it is founded on a needs assessment
that gives you flexibility to tailor the scope of services
to the needs in your community
with the federal criteria, of course, as the minimum baseline.
But you can see here
how that CCBHC is allowing for customized scopes
within communities, while also standardizing
the array of services available across every community.
Next slide, please.
One of the most important functions of a CCBHC
is to deliver care that meets people where they are,
I mean that both metaphorically and, in many cases, physically.
The CCBHC model does emphasize delivering care
outside the four walls of the clinic.
And that's often done in partnership
with other entities that are serving the same populations.
So, we've seen CCBHC is getting really creative
about where and how to deliver care,
anywhere from schools
to corresponding with police to emergencies,
to providing mobile units in frontier areas
and much, much more.
There's very few limits in how CCBHCs have been creative thinkers
about how and where to make care
more accessible to the folks that they serve.
And, again, a lot of the services or activities
that take place outside the four walls of a clinic
would not be traditionally billable,
but can be supported financially if you're CCBHC financing.
Next slide, please.
Another domain of CCBHC criteria pertains to care coordination.
The criteria do require an extensive array of care coordination partners,
both within the healthcare space and beyond.
Basically, CCBHCs have to be able to coordinate care
with any other system that touches the lives of the people that they serve.
And this goes back to the philosophy behind CCBHC,
which is that your local CCBHC
should be your one-stop shop for all your needs.
And if you can't get a service there on site,
they're working hand in hand with the other people who support you
to make sure that you're fully taken care of
in the way that's most accessible and convenient for you.
So, this actually goes beyond health homes
and some of the other earlier basic levels of integrated care
that you might be used to.
Medicaid health homes, for example,
are focused on specific populations living with certain conditions,
with care coordination aimed
at addressing those conditions specifically.
But CCBHC takes the concepts of care coordination much broader.
Care coordination is available to everyone to meet any need,
and CCBHCs work differently with their care coordination partners.
Those partners are quite often included on treatment teams.
There are very often data sharing agreements in place
or notification systems that allow the CCBHC to know
when a client has utilized services
or come in contact with another system.
CCBHCs are frequently delivering services on site
in their care coordination partner's facilities.
And again, as a CCBHC funding is available
to support the clinics' costs associated with care coordination
and outreach and so on.
So, I keep mentioning how the CCBHC funding works.
Let's talk about that a little bit more,
I want to move into how CCBHCs are paid and regulated.
So to do that, we'll start on the next slide, actually.
Next slide again, please.
Differences in how the two types of CCBHCs are paid and regulated.
There are some key differences
between the grant program and Medicaid CCBHCs.
Prospective Payment, of course, is probably the most critical
from the clinic's sustainability perspective,
and we'll dive into that deeper in a moment.
But bear in mind, there's also differences related to oversight and certification.
So grantees aren't technically certified as CCBHCs by SAMHSA,
they go through a process of self-attestation.
And in states with Medicaid CCBHCs,
the State is actually the one doing that oversight,
determining who is eligible,
what the certification process will look like,
and refining or enhancing the certification criteria,
and so on and so forth.
So some significant differences between those two types of CCBHCs.
Next slide, please.
Then moving into the sources of CCBHC reimbursement,
there are differences.
Again, both types of reimbursement are aimed at supporting CCBHCs
and doing all of the activities a CCBHC needs to do.
The PPS, however, is an encounter-based Medicaid payment
in which the clinic receives one payment per day--
well, usually one payment per day, it could be per month--
in which the client receives services.
That level of payment is the same,
regardless of the number or intensity of services
and is calculated based on a cost report
that allows the clinic to include their anticipated costs
and their indirect costs in addition to any direct service costs.
And the Medicaid rate, then,
is ultimately an average per encounter amount,
inclusive of all the activities-- billable and non-billable--
that go into being a CCBHC.
So you don't draw down a payment for those non-billable activities.
But every time there's an encounter,
the payment that you get for that encounter is set at a level
that includes financial support for those non-billable activities,
with the goal being that at the end of the year,
your total Medicaid reimbursement is more or less equal
to your actual cost of delivering care.
In contrast, the grant funding is a fixed pot of money,
a total of $4 million over two years.
Grantees do continue to bill other payers as usual,
and grant funding can supplement,
but it cannot supplant those funding sources.
And unlike Medicaid Prospective Payment
where funding can flex,
based on the number of clients or volume of encounters,
clinics have to very carefully plan their grant activities
to ensure that that funding will be available
to cover all the planned work and the clients that they intend to see.
The key takeaway here is that the grants themselves
aren't enough to fully replicate the effects of Medicaid implementation,
but they do serve as a really important springboard
to bring federal investment into your state,
hopefully, in preparation for state Medicaid implementation.
Next slide, please.
So, CCBHCs have expanded dramatically over the last four years
due to large and growing bipartisan support.
And we do expect to see continued investment in CCBHC expansion grants.
I think the number of grants
and the amount of funding will drop in future years
because so much funding has flowed to CCBHCs
through COVID relief this last year and a half.
That, of course, we do not expect to continue indefinitely into the future.
But, at the same time,
legislation to further expand the demonstration
continues to gain support.
So, we hope to see that legislation pass this year,
we're working hard at it, I don't know if it will,
but the great news is that states don't have to wait for Congress to act
to expand that demonstration,
they can implement CCBHCs on their own through Medicaid.
And we do see that happening right now
in places like Kansas and Texas, that I've mentioned,
and movement in that direction happening in many other states.
I'm more than happy to talk about what that looks like or answer questions.
But let's go to the next slide, please.
But as you think about
what your possible next steps might be towards CCBHC status,
just know that the National Council team is here to help.
We have our CCBHC Success Center with a fabulous team
that can provide support around your readiness as a CCBHC,
or in thinking through how to work with your state
on implementation and Medicaid and much, much more.
So please don't hesitate to reach out at any time.
And with that, I'd like to stop and turn things over to Peggy and Monique.
(Monique) Thank you, Rebecca.
That was a great introduction to explaining exactly
what it requires for us to become a CCBHC.
My name is Monique Lucas,
and I'm the Vice President of Integrated Care at Monarch,
and I hope to support standing up our CCBHC for Monarch in North Carolina.
And I just wanted to take some time to share with you
by some of the accomplishments that we have made, thanks to this grant,
as well as some of the challenges and barriers that we have experienced
trying to formulate to this new model.
Next screen.
Just to give you guys a little bit of background about Monarch,
we're a rather large agency,
we serve over 28,000 people
with intellectual and developmental disabilities.
We also support mental illness and substance abuse
across all of North Carolina state.
At our CCBHC location,
which is located in Stanly County, North Carolina,
we currently have about 1,400 people who we're seeing annually to support.
Next slide.
So we were lucky enough to receive our first grant
as part of the expansion in 2018.
So we did not get to do all of the fun stuff
with the reimbursement and the Prospective Payment System,
But ultimately, we were able to put together our program
and see how these programs impacted our outcomes.
We received our second grant in 2020,
which is the grant that we're currently in.
We are actually just rounding up on our first year,
and we've got one more year of grant funding to support our work.
Next slide, please.
So, Rebecca referenced to a lot of the different programs
that folks need to add on in order to be qualified
as a CCBHC for certification.
At Monarch, we did have an ACTT team,
and we had med management and outpatient services,
but really there were tons of programs
that we had not launched in this location that needed to be built, staffed,
and implemented to support our goals.
Next slide.
So the first program that we worked on building
was our Case Management Program.
This is a requirement of the CCBHC,
and basically, our Care Managements are a community-based team
that supports patients with social determinants of health
and helps with coordination of care.
So, these folks are working on getting people food,
housing, supporting when they have crisis episodes,
helping to navigate to different levels of care,
and then helping to promote self-advocation for our patients
and self-management.
Next slide.
The next program that we added to our CCBHC
was the Family Partner Program.
This is not a program that we can build for right now,
but we thought that it was an integral part of our program,
given the amount of youth that we work with.
The family partners role is to work with parents who have children
who suffer from behavioral health or substance abuse diagnoses.
And this Family Partner actually has lived experience,
so they can help the parents to understand what's going on,
help them to maneuver through the system, support with IEPs,
and things like that.
Next slide.
Occupational therapy is another offering
that we decided to add to our CCBHC program.
While occupational therapy was not a required program,
we believe that occupational therapy has significant impact on our patients
and how they are progressing.
So we launched this program at the beginning of this year
and have seen lots of success.
It's really amazing to see how the occupational therapist
is able to work with our patients in a different way
to help them to be successful with their goals.
So it's been a very interesting opportunity for us to experience.
Next slide, please.
Another program that we launched
is our Medication Assisted Treatment Program.
This program is a requirement for the CCBHC,
and it offers medication treatment for folks who have opioid addiction.
With this team, we actually have a psychiatrist,
a targeted case manager, and a peer support
who are here in the pictures.
These folks work together to make sure
that our MAT patients are completely supported out in the community
and being touched even when they're not in the doctors' offices
just to make sure that we wrap around care with them.
Next slide, please.
So, because we had so much success with our MAT program,
with this second grant initiative,
we decided to add an advanced layer of therapy
with a SAIOP program,
to offer Intensive outpatient therapy in our office,
in conjunction with the MAT program, to promote better outcomes.
Unfortunately, our SAIOP program is a little bit slow picking up.
We did find that there are some challenges
just getting people to commit to nine hours of therapy per week
because they want to.
And, unfortunately, in Stanly County,
we've got some folks that have the justice system
kind of locked down where they are sending
all of their referrals through them.
So we are having some struggles with this program,
but still hopeful that it's the right thing to do
for our patient population.
Next slide, please.
Peer Recovery Community.
This is really a fun project that we put together.
We realized that our patients don't necessarily always get referred
to case management,
They don't always disclose that they need help.
So we've actually opened the Peer Recovery Community,
where folks can come,
they can apply for jobs, they can work on the computers,
we've got food there to share with patients.
We do a number of workshops,
anywhere from housing education to computer literacy,
cooking demonstrations, we do community walks,
so lots of different opportunities for us to engage folks in our community,
and giving them a place to come when they need help.
Next slide, please.
Our new approach to care.
This really changed the way we thought about things,
the way we are approaching things, and the way we deliver care day to day.
And what we found is a lot of the things that we're working on in the CCBHC
are super beneficial
and actually things that we can scale throughout our agency.
Some of the things that we've really focused on with this grant
is team-based value-focused care,
increased care coordination,
looking at the patient as a whole person,
not just looking at their behavioral health needs,
but identifying any physical health needs or social issues that they may have.
We've gone to more of a patient-centered treatment planning model,
where we're really trying to integrate patients
and their families in the actual planning.
And we've gotten more of an integrated model of care,
where we've got numerous layers of different programs
that are now engaged sometimes in one patient's care.
So with that, the demand
for improved communication across teams has been imperative.
We have done some new collaborative work with a partner in our community
to offer some primary care screenings,
and we've also partnered with a primary care physician
who's offering primary care services on site,
in a mobile location by our office.
We've definitely had an increase on using our evidence-based screeners,
and keeping track of how many of the screeners we're doing.
And we've made a conscious decision
to really approach co-occurring disorders with an open mind,
making sure that, again, we're looking at the whole patient
and not separating their mental and substance abuse issues.
Next slide.
Wrap around coordinated care,
what does this do?
We realize that we're trying to get people healthy,
we're trying to get them to wellness and recovery,
and we're putting all of this stress on these points.
But before CCBHC, we didn't look at what was really tipping the scales.
Our patients were not getting well, they were not recovering
because they had other issues that were going on.
So we have food insecurity, unemployment, unstable housing,
interpersonal violence--
all which will have a negative impact on the health
if we don't have something there to support patients with it.
So, that's kind of what we saw,
folks are not just not getting better because they don't want to.
There's typically something deeper that we need to dig into.
And with our community-based groups,
as well as the other enhanced services that we were able to add with this grant,
it really took us to the next level to be able to support our patients
in the way they need.
Next slide, please.
So, outcomes.
We have done a lot, we've served 3,200 patients to date
under our new CCBHC model.
Over the total time in our program,
we have enrolled over 1,027 patients
in care management and care coordination.
We have served over 50 people with substance abuse disorder
in our MAT program.
And we've been able to report out on 893 people,
average, per quarter,
for additional evidence-based screeners.
Next screen, please.
So now I want to talk a little bit about some of the partnerships
and collaborations that we were kind of moved to get involved
when with CCBHC.
The one thing that I can say is when we started this initiative,
we thought people knew us, we thought we had relationships.
We didn't have strong relationships as we actually did.
We've done a lot of work around building those relationships
with our community partners over the last few years,
and it's been really world-changing
as we've looked at the collaborations.
So the first collaborations that we have partnered with
is our EMS team.
Our EMS team, last year, was lucky enough to get a grant
to administer Suboxone out in the field.
And as part of their grant, they were seeking a peer support
to help connect those patients to treatment after the reversal.
So, over a two-year period,
our Peer Support worked alongside with our paramedics
going out on overdose calls, reversing patients,
and then helping patients to get where they needed.
Sometimes, these patients landed back at Monarch, in our MAT program.
Sometimes, those patients were taken to a detox center.
Sometimes, those patients just got phone calls from Marcus to check in.
And what we found was that over a period of time,
while folks weren't necessarily ready to change at that point of reversal,
after some time of communicating with Marcus
and building that relationship,
we did find that more patients were asked to join into our MAT program.
So, this has been a pretty significant success.
And, as part of our grant, even though EMS lost their grant,
we have decided to continue on this partnership,
to support having our Peer Support out there
working with our community EMS teams.
Next slide, please.
The next partner that we've really worked closely with
was our school collaborations.
So, before COVID-19, we were doing in-person
or in-school therapy sessions,
in collaboration with a therapist on our team and our Family Partner.
We had some barriers
where folks were not able to get into the office, to the registration.
So, we used our Family Partner
as a mobile resource to go out to the parents
and get the child registered
so that the child could continue on with therapy in school.
As COVID hit, this process turned a little bit more virtual,
so we have been doing virtual therapy
for these patients to support them,
or for the students, actually, to support them.
In addition, we had a partnership with a small charter school in our area,
and we were able to collaborate with them to do some in-person workshops
with the students to educate them on coping skills
and dealing with social disconnectedness.
We were able to educate 365 middle schoolers
on these coping strategies,
and we had a really good response and engagement from the children.
So it's pretty helpful.
Next slide, please.
Next partnership that we have is with our Department of Health.
So our Department of Health
actually has a grant on their end
where they are trying to educate primary care physicians
on mental health and substance abuse.
We have partnered with them to try and get the word out.
We're tasked with that as well for our CCBHC initiative.
We're partnering together to figure out,
what our community needs as far as education,
and get our primary care physicians more on board with coordinated care
and engagement with behavioral health services.
Next slide, please.
A lot of folks have asked me, "With COVID-19,
how has that negatively impacted your CCBHC?"
And the one thing that I can say is,
as we went into COVID-19,
I feel like our teams were more prepared than ever.
We had community boots on the ground,
we had relationships and engagements with community partners,
so we were aware of the resources and the programs
to connect our patients with.
It really made a difference
that we were already doing some virtual care
and using an open access model.
While it was an impact and gave us a little bit of a challenge,
a lot of the things that we had already had in place, thanks to CCBHC,
really helped us to keep our head up and just continue to go
and connect our patients with the resources that they needed.
Next slide, please.
Rebecca also talked a little bit about data,
and I wanted to show you guys just a little bit of some of the data
that we have started to pull out.
You can see here, using our virtual open access model,
we had 90% of all our patients
who needed comprehensive clinical assessment,
that received those assessments within ten days of that referral.
For us, we definitely want to have it less than ten days.
But, for this standard, it seems that we're doing pretty well
keeping up with the time,
so that was pretty impressive,
especially considering even throughout the COVID months,
we still continued to keep that 90% average.
Next slide, please.
So, emergency room visits.
We were lucky enough to partner with a vendor called Patient Ping,
who gives us the ability to be able to see
when our patients are walking through the doors of hospitals,
emergency rooms, urgent cares, or skilled nursing facilities.
We've been able to really analyze what our patients have been doing,
what locations have they been utilizing.
We can look and see that over a period of time,
from January until September,
we really had a decrease in emergency room visits.
And we like to think that
that is because of some of the comprehensive wrap-around care
that we've been able to do.
Next slide, please.
So, employment. This is the big thing.
We were able to create 16 new positions
to support our CCBHC clinic.
Those positions gave us opportunities
to hire folks from the community who could work in the community
and give back to the folks that we support.
So, that has been definitely a great position for us
as we've gone into the CCBHC model.
Next slide.
And now I will turn it over to Peggy Terhune
to talk a little bit about the Joint Commission standards and CCBHC.
Thank you.
(Peggy) Thanks, Monique. This is Dr. Peggy Terhune.
Next slide, please.
I wanted to talk about The Joint Commission
and the incredible impact that that has been able to have.
We add this new CCBHC, and we're trying to figure out
how that works with Joint Commission and how we're going to work together.
We began diving into this and discovered to our amazement
that Joint Commission made a huge difference in our ability
to provide high-quality, better care.
The first thing I wanted to talk about was the safety culture framework.
And this comes from Joint Commission.
And it defines safety culture as a sum of what an organization is
and does in the pursuit of safety.
And I always thought, well, we're safe, we're doing everything right,
we're doing everything well.
People don't have terrible outcomes,
and so I think we're doing things well,
and I discovered to my amazement
that there was a lot more that we could do.
Because I was thinking about, you know, we have policies,
but I wasn't really breaking safety down.
Next slide, please.
So, what Joint Commission does
is it breaks safety into three different kinds of errors that people can make.
A staff could make a skill-based error where they don't have a skill.
And maybe they are not doing DBT with fidelity to model,
or maybe we have a CMA taking blood pressures,
and they've forgotten how to do that.
People can make a skill-based error.
They can make a rule-based error,
where we're telling them the rule says you have to do
these four things in order to bill
or these four things in order to give quality care,
and maybe they're only doing three of them
because they're cutting corners.
And then the third type of error that we see are knowledge-based errors
where our staff are lacking in information and knowledge
to do something in a higher quality or a better way to keep people safe.
So what we did was we began with doing a survey.
Next slide, please.
So we actually did this Safety Culture Improvement survey.
When my staff came to me and said, "We're going to do this survey,"
I'm like, "Yeah, yeah, yeah. I know what it's going to be."
And I was amazed to see what the results were.
They were not necessarily what I thought or expected they would be,
which I found interesting.
If you can look at this, the question was,
are staff treated fairly when they make mistakes?
This is just one of the questions on the survey,
because it's really important for staff to know
that we're human and it's okay to make mistakes,
but are we treating you fairly or not?
And I was delighted to see that in the survey
that 71% of the folks felt they were treated fairly,
they agreed or strongly agreed they were treated fairly,
and that was really good and important
because, of course, we tend to, at the CEO level,
you tend to hear all of the bad things.
And so it's nice to know the culture.
And so when we did the Safety Culture Improvement Survey,
we learned all kinds of things about ourselves,
about what we were doing well,
what we weren't doing well, and what we needed to do better.
So in this particular thing, we wanted to improve this score.
Even though I was tickled it was as high as it was,
it wasn't anywhere near as high as I wanted it to be.
So, we began creating some accountability decision trees,
which you see on the right,
and I know you probably can't read it, but it gives you a general idea.
We implemented it and shared it with our staff
by creating a newsletter that we call Hot Topics.
And this is something that goes out every month,
and it really talks to people about different safety issues.
And, again, when I use that term safety, I mean a whole host of issues.
And so, for example, one of these things that happened
was we had a Direct Support Professionals Celebration Week.
And we specifically did so many different things
to celebrate our Direct Support staff.
We'd had these in the past,
but they'd been generic, bringing people cookies,
doing this, doing that.
This time, we were celebrating data
and the good things that people were doing,
and people were so appreciative, and they felt respected,
they felt honored, they felt recognized,
and those are oftentimes the things that cause employees to leave.
So we discovered that by doing these data-oriented celebrations
rather than just "You're wonderful, we love you,"
but "We're wonderful. We love you because,
hey, your group has been monitoring handwashing,
and you've all been washing your hands.
And kudos to you for that."
They went, "Oh, that darn survey we have to fill out every month?
I guess it's worth it."
So that was really helpful.
Next slide, please.
The second thing we looked at were near misses,
and this was something I don't think we had ever looked at
until we got into talking with Joint Commission.
And when you think about it,
the near misses are incredibly important for risk management and people's lives.
And so Joint Commission helped us step in and look at our processes
and improve what happens.
So these are three examples of things that were near misses that we identified.
So, a therapist was working with a patient.
And the patient was suicidal, basically.
And so the therapist wanted to make sure the provider knew about it
and sent them an e-mail.
Well, that's not okay.
Now, we were fortunate.
The person did not try to hurt themselves.
But we were able to say, "Who would ever think of that?
I would have never thought I needed to train therapists
on how to notify someone about suicide."
But by bringing that up and bringing it to people's attention,
it began to change a lot of the things we did around how we manage suicide,
suicide thoughts and concerns
and the way people report suicide to us.
In the second situation, we did a CCA in our electronic health record,
and in the CCA the person had started by doing a PHQ-9
and had received a very high score.
But then later in the conversation
with the comprehensive clinical assessment,
the person kind of backed off of that sum
and seemed to not be that suicidal.
So, at the end of the comprehensive clinical assessment,
the therapist wrote that the person was minimal risk.
While the psychiatrist reviewed that, and said, "Wait a minute,
This is not what's going on.
This person is suicidal,
and I need to step in and do something different."
So again, we realized
"Hmm, if we hadn't had someone that caught that comment
and realized that, we could have, again, had a really bad near miss."
And then, we do nursing check-ins.
And a nurse had talked with an individual,
and then the provider talked to the individual.
The person was not comfortable with the nurse
and didn't share their suicide risk.
But when they talked to the provider, it was very, very high.
So we discovered that near misses were something to report,
and then to look and figure out, were these one-offs,
where it was one person that made a bad decision,
or were these system issues?
And how could we set things up
so that we had a double check on everything
so that every system had a double check
so that we wouldn't have these bad things happen?
Next slide, please.
We actually then put our near misses on the SAFER Matrix,
and it tells us how serious our near misses are
and what we need to do or think about doing with our near misses,
and you can see only one of them ended up high,
and it was a very limited situation.
But this is part of how we determine
how we're going to deal with something,
whether it's an individual person, limited and low risk,
or if it were widespread or if it was a pattern,
then that tells us that's something we need to do.
Next slide, please.
We also do something called tracers,
and I think the tracers have been
one of the biggest benefits that Joint Commission has brought to us.
We have quality management staff that follow a specific format,
and they go and do--
during COVID, a lot of this has been virtual or by record only,
but they do rather significant observations.
You might think of these as a peer review of a chart,
but it is significantly higher, because what we're looking at now
is all of the quality issues, all of the safety issues,
all of the policies and procedures that we've put in.
And what's really happening? And are people getting better?
I think between CCBHC and Joint Commission,
as Monique said, we used to do treatment and we helped people get better,
but oftentimes with other things in their lives,
you know, I have nowhere to live, I'm homeless, my family's left me,
and I have no food,
and you're telling me I should take this medication I have no money for.
And, yeah, I'm going to get better, right?
And now we can do with all of that.
With the tracers, the tracers also really helped us figure out
what we needed to do to help people get better.
And so now, instead of just tracking
how many visits it takes for a PHQ-9 to go down,
we're looking at what are we doing to make the PHQ-9 score go down,
that sort of thing.
Next slide, please.
This is another piece of the tracer, and you can see the kinds of questions.
So during the intake admission process, was the individual screened
to determine if there's a need for immediate intervention
to protect the individual from self-harm?
So we need to be able to go in the record and find that
and see that we're actually looking
to make sure that we're doing the screening
using a validated screening tool,
and that we're doing this for everyone over the age of 12.
And so, we're not only checking ourselves against the Joint Commission Standards,
we're checking ourselves against a quality standard,
and we're making sure that people are safe.
So this becomes huge for us.
Next slide, please.
Another thing that we did because of Joint Commission
was we created a committee structure that has also made a big difference.
We have, now, a lot of committees that meet, that get together,
that really talk about safety, and performance, and quality.
And while I could go through all of these, what I want to stress to you is,
as we have been getting ready for alternative payment models
and value-based contracting,
which we are now doing with eight different entities,
these committees made the difference,
because these committees told us, this is what we're tracking,
this is how we're tracking,
these are the outcomes we can tell you we're getting,
this is how we're getting the outcomes.
So every time we have gone to meet with a prospective payer,
an insurance company, or a Medicaid payer,
they always say to us,
"Monarch, you're so far ahead of everybody else in the state
with your data, how did you do this?"
And I link a lot of that to Joint Commission
and their expectations for how we were tracking things.
Next slide, please.
Handwashing is a great example.
I'm like, "You're kidding. They want us to look at handwashing?"
"Yes, Peggy. We have to do it at 100% compliance."
"Oh, come on, nobody's 100%, put it in 95 or 90."
"No, Peggy, they want us to do it at 100%."
Well, we were doing this before COVID.
Then, COVID hit.
And it was absolutely amazing how prepared we were.
We had no difficulty in immediately switching to virtual,
no difficulty in our 60-some group homes
where people were being exposed by staff coming in,
but following appropriate infection control standards,
because we were ready,
we had been following the infection control standards,
that Joint Commission had taught us.
So, boy, did I have to eat my words!
That was kind of fun.
The staff enjoyed that.
The next thing I want to talk to you about-- next slide, please--
is emergency management.
So this is another huge thing
that we had never done before Joint Commission.
And we have used this multiple times.
We started by using it with hurricanes.
North Carolina gets a lot of hurricanes.
So we got a hurricane, and we would have Incident Command,
which is called by a person who is specifically--
it's our Director of Quality Management and Performance Improvement.
And she knows she's the person in charge of calling Incident Command.
All management staff are on this call, so you can have 40 or 50 people
in our organization that are on this call.
We go over details of what we know, what we need to do.
And oftentimes, these meetings occur daily
or twice a day in the beginning,
and then, gradually, they move out.
So we immediately started emergency management with COVID.
And this was another thing that meant
that everybody knew what was happening.
Everybody in the whole agency was informed.
Everybody knew who was sick, who was not sick,
what we were doing about it, whether you were still working or not,
whether you had a job, whether you were going to see people,
whether you're going to call them, what the protocols were--
all because of our emergency management.
And if you look at the next slide, please.
This is the tracking tool that we use for the emergency management.
And these are minutes, and we can go back to these minutes.
I can go back to them from several years ago
and look and see how we did things.
So at the end of one of these major incident events,
we then sit down and figure out,
"OK, now, in hindsight, what could we have done differently?
What could we have done better that might have made a difference?"
And if you look at the next slide, please.
This is an example of documentation and critique.
How did we do this? Did we do it well? Could we have done it better?
What pieces did we miss?
And so we've gone through this now, I think, with four hurricanes.
And we've got this down, we're so good at it, it isn't funny.
And again, it's because Joint Commission required that we do all of this.
Next slide, please.
This is my last slide, and so this is the continual readiness.
And again, this is another thing that we work on so hard.
We're continually-- you see it says, "Monarch Company News."
So this is something that we provide in our monthly newsletter.
But we do tracer updates and micro learnings,
little things that people needed to know,
little things they wanted to hear about,
psychiatric advance directives, kitchen and food storage.
I know this will sound funny, but I was so excited last month,
we had 100% compliance in the refrigerators
where we have thermometers.
And I was like, "Yay!"
Whoever thought I would get excited about thermometers and refrigerators?
But I did because I now understand
how important all of these safety features are.
Next slide.
And I'll turn this back to Julia.
(Julia) Thank you so much, Rebecca, Monique, and Peggy.
A fabulous job.
I'm going to turn this over to Melinda to see if we have any questions,
and then we will close out the webinar today.
Melinda?
(Melinda) Yes, thank you, everyone.
Our first question today, and you can submit questions
by typing them into the Questions panel,
is "Under CCBHC rules,
can you provide care to a subset of your population served,
or must it be all individuals?
(Rebecca) This is Rebecca. I'd be happy to take that one.
It's a little bit of a tough question.
I think some of it depends on whether you're a state-certified CCBHC
or whether you are a grantee.
The grantees certainly do have the ability to become a CCBHC
at one of their sites, but not all.
But remember that one of the fundamental requirements of being a CCBHC
is serving all individuals regardless of their residence
or ability to pay or insurance status.
So you are expected to serve your entire client population
with the CCBHC array of services,
but can certainly limit it to one site if you are pursuing grant status.
Melinda, are you still with us? Do you have any more questions?
(Melinda) I'm sorry about that. I was on mute.
The next question, "Is funding a CCBHC by grants only?"
(Julia) For most clinics right now, that is how they are being funded.
However, the grant is typically only a two-year grant,
although Monarch, due to how fabulous they are,
as you heard from Peggy and Monique,
did manage to get a second grant after their first one was over.
Once grants are over, we really see Medicaid
as a crucial pathway for sustainability for those grants.
(Melinda) Great, thank you.
And then our next question,
and it will have to be our last one today,
but it looks like it is.
Are substance use disorder treatment services
required to be provided directly,
or could those be coordinated with a collaborating organization?
(Peggy) This is Peggy. Let me take that one.
We provide them directly,
but we do contract, for example, Mobile Crisis out.
Because Stanly County is a small county,
it doesn't need two Mobile Crisis providers.
We needed that 24-hour Mobile Crisis, so we contracted out.
So what the CCBHC allows you to do
is to coordinate and work with other providers;
not duplicate, but enhance the community
in places that it wasn't previously working effectively.
(Melinda) Thank you.
And then we'll go to the next slide, please.
We just wanted to
remind you of some resources that we have from JCR on this page
that are new for our Joint Commission accredited organizations.
Next slide.
This is our contact information for the Behavioral Health team
here at The Joint Commission.
And next slide.
Just also a reminder that we have another webinar on Thursday
that's going to be our COVID Q&A webinar.
So thank you, everyone.
I know we went a little over,
but thank you for bearing with us and attending today's webinar.
Once you exit, you're going to receive a short survey,
and we'd appreciate it if you provide feedback on today's presentation.
And you'll also receive an e-mail this afternoon
with a copy of the slides and a link to view the replay of today's webinar.
So, on behalf of The Joint Commission, thank you for joining us today,
and have a great rest of your day,
This concludes our presentation.