Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2018. Requirement 2: Availability and Accessibility of Services

09/10/2019

The clinic provides 24-hour crisis management services, a sliding scale for payment, and does not reject or limit services by the patient's ability to pay or place of residence.

 

FIGURE C. Range of CCBHC Services
FIGURE C, Diagram: This diagram shows the services that are required to be provided directly by CCBHCs and those that can be provided through formal relationships with DCOs.

Many people in need of MH/SUD services go without help due to barriers, such as unaffordable services and medicine, lack of insurance coverage, not knowing where to go for help, and inability to get an appointment (Walker, Cummings, Hockenberry, & Druss, 2015). Requirement 2 of the CCBHC demonstration ensures better access to services where and when service recipients need them.

Increased Access

TABLE 2. Number of CCBHCs, Service Locations, and DCOs (as of March 2018)
State CCBHCs Service Locations DCOs
Minnesota 6 29[a] 5
Missouri 15 201[b] 3
Nevada[c] 3 3 1
New Jersey 7 20 8
New York 13 77[d] 4
Oklahoma 3 19 2
Oregon 12 21 5
Pennsylvania 7 7 8
  1. All six CCBHCs operate within the initial service area set prior to the demonstration, but this number reflects seven additional access points within those areas.
  2. The large number of service locations in Missouri is due to multiple locations throughout large geographic areas of coverage. Service locations often are service-specific (e.g., a medication clinic, a children's outpatient program, a psychosocial rehabilitation program, a community support office, or a rural outreach clinic open one day a week).
  3. Nevada initially certified four clinics serving five locations; however, one CCBHC withdrew from the demonstration after the state revoked its certification.
  4. In New York, some of the service locations may offer just one service.

As depicted in Figure C, CCBHCs are required to provide four core service types: (1) crisis mental health services; (2) screening, assessment, and diagnosis, including risk assessment; (3) patient-centered treatment planning or similar processes; and (4) outpatient MH/SUD services. The remaining services may either be provided directly or by a designated collaborating organization (DCO). These services are: (5) primary care screening and monitoring; (6) targeted case management; (7) psychiatric rehabilitation services; (8) peer support and counselor services and family supports; and (9) services for members of the armed forces and veterans.[5] This network of providers means CCBHC services are available at a multitude of locations, as shown in Table 2.

Among CCBHCs that offered services outside of their physical buildings, the most common locations were the homes of people served, schools, or other community-based settings, as shown in Figure D. Other locations included primary care offices and federally qualified health centers (FQHCs), homeless shelters, public spaces, and on the street. Ninety percent of CCBHCs provided transportation through bus or cab vouchers, by helping those served obtain the Medicaid transportation benefit (if they were eligible and the benefit was available in the state), via care manager or peer support, and directly in CCBHC-owned vehicles.

FIGURE D. Number and Proportion of CCBHCs that Provide Services Outside of Physical Clinic Space
FIGURE D, Bar Chart: Consumers' homes (84%, n=52), Schools (55%, n=34), Jails, courts, police offices, and other justice-related facilities (45%, n=28), Hospitals and EDs (32%, n=20), Community service agencies and nonprofit organizations (27%, n=17).

Changes to the physical structure of the clinic have also been needed to facilitate access to care for certain populations, such as those living with physical disabilities. As shown in Table 3, CCBHCs in all states reported renovations to their physical space to meet certification criteria or as a result of their participation in the demonstration. Changes included creating dedicated space for ambulatory detoxification services, adding physical health exam rooms, improving the space for child and adolescent's receiving services, and expanding office space for new staff such as peers and case managers.

TABLE 3. Number and Proportion of CCBHCs Making Changes to CCBHCs Physical Space to Meet Certification Criteria
Change to Physical Space and Accessibility N %
Renovations to existing CCBHC facilities 45 67
Expansions or additions to the CCBHC building space 33 49
Improvements to facility safety features 27 40
Other changes to CCBHC physical space 15 22

Two-thirds of the CCBHCs offer telehealth, most commonly telepsychiatry, therapy or counseling, and medication management. Those not currently offering telehealth services plan to initiate them to expand access to services.

CCBHCs have made services more convenient by introducing same-day or next-day appointments and accepting walk-in appointments. They have tailored services to the needs of specific populations, such as veterans, school-aged youth, and people experiencing homelessness. For example, more frequent and shorter appointments for high-need individuals is being tested as a strategy for reducing crises and use of emergency services among these populations. CCBHCs have also implemented processes to improve client engagement and retention in services, including monitoring the frequency of phone follow-ups and increasing the number of reminder calls for clients before appointments. Ninety-six percent of the CCBHCs provided translation services, usually through an external interpreter contract.

Photo of Lake Shore Behavioral Health.
Lake Shore Behavioral Health, Inc., a CCBHC in upstate New York.

Engagement of New Individuals in Service

CCBHCs have been proactive in reaching out to individuals who may need services, such as school-age youth, veterans, individuals transitioning from incarceration, and people experiencing homelessness, as illustrated in Figure E. A CCBHC in Oregon stations a therapist at a nearby U.S. Department of Veterans Affairs (VA) facility to provide screening and monitoring when VA staff are not available or when demand exceeds the VA clinic capacity. Other populations to which CCBHCs have targeted efforts include individuals with SUD, diagnoses of mental illness or comorbid chronic physical health conditions; frequent users of emergency department and inpatient services, and those who identify as sexual or gender minorities, especially youth.

CCBHCs also expanded access to care within their communities by:

  • Initiating new relationships with community-based organizations, including hospital systems, external primary care and mental health or addiction service providers, schools, social service organizations (e.g., shelters), and the criminal justice system (including juvenile justice).

  • Conducting direct outreach to people with mental or substance use disorders and their families through community informational sessions featuring CCBHCs and their service offerings, and through advertising campaigns (including newspaper and television) in their local service areas.

FIGURE E. Proportion of CCBHCs that Targeted Outreach to Specific Populations since the Start of the Demonstration
FIGURE E, Bar Chart: School-age youth (81%), Members of teh armed forces or veterans (67%), Consumers who were previously incarcerated (67%), Consumers experiencing homelessness (64%), Older adults (49%), Other populations (42%).

State agencies have supported targeted outreach efforts by facilitating connections between providers (e.g., assisting CCBHCs in coordinating agreements with provider networks, such as the VA) and providing information on high utilizers of health care services so CCBHCs can target these individuals.

Ensured Affordability

CCBHCs serve people regardless of insurance status or ability to pay. As illustrated in Table 4, almost all CCBHCs reported offering a sliding fee schedule, providing services to people with Medicare and private insurance, and serving people not residing in their catchment area. Among those offering a sliding fee schedule, 73 percent published the fee schedule on their website or provided it to people being served through other means, such as in welcome packets at intake.

TABLE 4. CCBHC Payment Policies and Service Provision
Payment Policy and Service Provision Yes Response
N %
Provide services to consumers unable to pay 67 100
Offer a sliding fee schedule 66 99
Provide services to consumers with Medicare 66 99
Provide services to consumers with private insurance 66 99
Provide services to consumers not residing in clinic catchment area 65 97

Some demonstration states have taken additional steps to mitigate the impact of providing services regardless of individual ability to pay. For example, Nevada's Division of Mental Health contracts with clinics to help offset costs of providing services to those who are unable to pay, and Nevada Substance Abuse Prevention and Treatment Block Grants make funds available to serve people with co-occurring mental illnesses and SUDs. The Nevada Division of Welfare embeds staff in CCBHCs to help uninsured clients enroll in Medicaid on-site. Eligibility workers assist with enrollment in Temporary Assistance for Needy Families (TANF) and Women, Infants and Child (WIC) programs, as well.