Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2018. Requirement 1: Staffing

09/10/2019

Staff have diverse disciplinary backgrounds, have necessary state-required license and accreditation, and are culturally and linguistically trained to serve the needs of the clinic's patient population.

Statutory Requirement 1 ensures that CCBHCs are adequately staffed with Medicaid-enrolled providers who are prepared to meet the needs of the population served, which for all demonstration states, includes adults with SMI, children with SED, and anyone with a SUD. States have also prioritized certain subpopulations, such as people with opioid use disorders, individuals experiencing homelessness, veterans, youth in state custody, transition-age youth, people involved in the criminal and juvenile justice systems, and individuals of all ages with comorbid health conditions. Such a wide diversity of people served with intensive needs and varied life experiences requires credentialed, certified, and licensed staff who can provide person/family-centered, trauma-informed, culturally competent, and recovery-oriented care.

Hired Staff

The criteria for CCBHC Certification Requirement 1 include specific staffing requirements, such as a psychiatrist serving in the role of medical director[4] and the following staff:

  • A medically trained behavioral health care provider who can prescribe and manage medications independently under state law.

  • Credentialed SUD specialists.

  • Individuals with expertise in addressing trauma and promoting the recovery of children and adolescents with SED and adults with SMI and those with SUDs.

Photo of the Opeations staff at Red Rock Behavioral Health Services.
Operations staff at Red Rock Behavioral Health Services, one of three CCBHCs in Oklahoma.

As of March 2018, the majority of CCBHCs reported employing staff to fill the following positions:

  • Ninety-nine percent of CCBHCs reported employing a CCBHC medical director, compared to 82 percent before certification. Ninety-one percent of CCBHCs reported employing a psychiatrist as a medical director. The few clinics that did not have psychiatrists as medical directors hired psychiatric nurse practitioners to fill this role, which CCBHC criteria allows when psychiatrists are unavailable due to workforce shortages.

  • All CCBHCs employed SUD specialists, compared to 91 percent before certification.

  • Ninety-one percent of CCBHCs employed psychiatrists, compared to 70 percent before certification.

  • Seventy-six percent of CCBHCs employed child/adolescent psychiatrists, compared to 58 percent before certification.

CCBHCs also reported hiring specific types of nurses (registered nurses with or without psychiatric experience, nurses with experience in SUDs or providing medication-assisted treatment (MAT) for SUDs, nurse practitioners, psychiatric mental health nurse practitioners, and licensed practical nurses) and other clinical staff (licensed professional counselors, qualified mental health professionals or licensed mental health counselors, and licensed clinical social workers).

The certification criteria allowed states flexibility in developing detailed plans for appropriately staffing CCBHCs according to their existing systems of licensure and accreditation and based on the needs of the populations the CCBHCs serve. Interviews with state officials suggest that variation across CCBHCs and states in the types of staff CCBHCs employed was in part related to the types of services the CCBHCs provided historically. For example, clinics that primarily focused on delivering treatment for SUD before the demonstration found it necessary to hire relatively more mental health providers.

As illustrated in Figure B, a larger proportion of CCBHCs employed peer specialists/recovery coaches, case managers, and family support workers compared with the same clinics before certification. For instance, the percentage of CCBHCs that employed peer specialists/recovery coaches increased from 69 percent before certification to 99 percent by March 2018.

FIGURE B. Proportion of CCBHCs that Employed Specific Types of Staff Before and After Certification
FIGURE B, Range Line Graph. This graph describes the percent of CCBHCs employing select staff before and after certification. The X-axis shows the 2 time periods. The Y-axis shows the percentage of CCBHC’s employing the staff before and after certification. Licensed clinical social workers were employed by 94% of CCBHCs before the demonstration 99% after. SUD specialists were employed by 91% of CCBHCs before the demonstration 100% after. Nurses were employed by 85% of CCBHCs before the demonstration 100% after. CCBHC medical director were employed by 82% of CCBHCs before the demonstration 99% after. Bachelor’s degree-level counselors were employed by 73% of CCBHCs before the demonstration 75% after. Case management staff were employed by 72% of CCBHCs before the demonstration 97% after. Adult psychiatrists were employed by 70% of CCBHCs before the demonstration 91% after. Peer specialists/recovery coaches were employed by 69% of clinics before the demonstration and 99% after. Child/adolescent psychiatrists were employed by 58% of CCBHCs before the demonstration 76% after. Other clinician types were employed by 43% of CCBHCs before the demonstration 55% after. Mental health professionals were employed by 40% of CCBHCs before the demonstration 45% after. Family support staff were employed by 37% of CCBHCs before the demonstration and 67% after. Community health workers were employed by 27% of CCBHCs before the demonstration and 40% after.
NOTE: The mental health professional category includes only providers trained and credentialed for psychological testing to align with staff types included in the CCBHC cost report.

Trained Staff

CCBHCs are required to provide training to new staff that addresses cultural competence; person/family-centered, recovery-oriented, evidence-based and trauma-informed care; and primary care/behavioral health integration at orientation and at reasonable interval thereafter. Other training required at orientation and annuallythereafter includes risk assessment, suicide prevention, and suicide response; the roles of families and peers; and other trainings required by the state or accrediting agency.

As presented in Table 1, CCBHCs have been diligent in providing the required training. Nearly all CCBHCs provided training on risk assessment, suicide prevention and suicide response, evidence-based and trauma-informed care, and cultural competency. More than three-quarters of CCBHCs provided training on each of the other required topics.

TABLE 1. Number and Proportion of CCBHCs Providing Staff Training in Required Topics since Start of the Demonstration Certification
Required Training N %
Risk assessment, suicide prevention, and suicide response 62 93
Evidence-based and trauma-informed care 61 91
Cultural competency training to address diversity within the organization's service population 59 88
The role of family and peers in the delivery of care 52 78
Person/family-centered care 51 76
Recovery-oriented care 51 76
Primary and behavioral health care integration 51 76

In addition to the required training, CCBHCs provided a range of other training for their staff. The most commonly reported "other" training focused on serving active duty military and veterans, which is consistent with the criteria's call for cultural competency training that includes information related to military culture among those CCBHCs serving this subpopulation. Multiple CCBHCs provided training on specific evidence-based and best practices, including motivational interviewing, cognitive behavioral therapy, and MAT for SUDs.

With respect to the quality measures that are required components of CCBHC certification, staff received training on collecting and using new clinical screening tools, as well as on providing new services implicitly or explicitly required as part of the measurement implementation, such as smoking cessation programs.

States provided support for demonstration clinic staff training during and beyond the initial certification period. Officials from all states held regular meetings with CCBHCs during the early stages of implementation to identify and address CCBHC training and technical assistance needs. Once the types of trainings and knowledge-sharing that would be helpful for clinics were determined, officials in most states used webinars, site visits, regular phone meetings, email and other written communication, or some combination thereof, to assist clinics.

States also leveraged external support to facilitate training. Four states partnered with educational institutions (state or private universities) or other organizations (MH/SUD coalitions) to help provide training opportunities to CCBHCs. Two states used supplementary state or grant funding to help pay for training for the CCBHCs. In addition, multiple states made these trainings accessible throughout the duration of the demonstration. Training sessions are held on an ongoing basis, available ad hoc (e.g., for new staff), or in some instances, saved digitally so that staff can access them as needed.

Identified Challenges

Although nearly all CCBHCs employ the required staff, challenges related to hiring and retaining staff are ongoing. Seventy-two percent of CCBHCs had at least one required staff position vacant for at least 2 months since the start of the demonstration. In six of the eight demonstration states, at least three-quarters of CCBHCs reported having trouble filling staff positions.

CCBHCs most frequently reported vacancies among adult and child/adolescent psychiatrists, peer support staff/recovery coaches, SUD treatment providers, and licensed clinical social workers. Rural or remote CCBHC locations, unworkable salary expectations, and regional and state workforce shortages, were the most commonly cited reasons for hiring and retention difficulties. Demonstration state officials corroborated these findings, noting general mental health and addictions workforce shortages, particularly in rural/frontier areas. Of note, all demonstration states have some CCBHCs in areas designated by the Health Resources and Services Administration as a medically underserved area, medically underserved population, or mental health professional shortage area.

Demonstration state officials cited long-standing workforce issues, such as staff turnover and low compensation for public sector mental health positions, as challenges to maintaining CCBHC staffing requirements. These officials viewed turnover not only as a challenge to CCBHC implementation, but also as a more general and pervasive issue in the behavioral health field.