Coordinated care across settings and providers promotes seamless transitions for patients across the full spectrum of health services, including physical and MH/SUD needs. The clinics maintain partnerships or formal contracts with the following:
Patients, mental health and addiction service providers, physical health providers, and providers of social, housing, educational, and employment services must work together to achieve the objectives of person/family-centered plans of care. Requirement 3 addresses the formal agreements, health information systems, and treatment planning activities necessary for maintaining consistency, clarity, and confidentiality among all partners.
CCBHCs have leveraged or expanded care management programs through the demonstration program. For example, CCBHCs in Pennsylvania provide targeted case management for all CCBHC patients and use two other models of care coordination: a nurse navigator model in rural areas that utilizes nurses to navigate the health care system and improve access to services, focusing on improving medication adherence for physical conditions and MH/SUDs and a case management model in urban and rural areas focusing on SUD treatment for individuals receiving MAT.
"The main difference [between what CCBHCs and other behavioral health providers are providing] is the standards that go along with CCBHC care coordination. We had care coordination before, but now we have the care coordination agreements with the various entities that are required, so it's really an increase in intensity of care coordination."
-- Oregon CCBHC Official
CCBHCs have also engaged in more sophisticated approaches to care coordination. Oklahoma officials cite a client progress dashboard as an example of a CCBHC's transition from a "one-size-fits-all" approach. This one-page tool shows laboratory results, medication compliance, the number of services received, and screenings for a given client. It provides feedback to the agency on not only the extent to which practitioners are providing the services that clients need, but also on how well the services are coordinated. Results are available to all staff involved in the individual's care.
Strengthened Treatment Planning and Teams
More than three-quarters of CCBHCs reported that treatment teams have changed because of the certification process. The addition of care coordinators, case managers, peer support staff, SUD providers, psychiatrists, and primary care staff has prompted more frequent treatment team meetings and "huddles." These regular meetings allow team members to share information about clients, which reduces "silo-ing" and facilitates treatment planning. Table 5 presents the types of providers who participate in CCBHC treatment planning and treatment teams. Per responses to an open-ended question in CCBHCs' progress reports, other providers who participate in treatment planning include nurses, peer support staff, vocational or employment specialists, care coordinators, nurse care managers, and family support providers.
|TABLE 5. Number of Proportion of CCBHCs that include Types of Providers...|
|Type of Provider||in Developing and Updating
a Comprehensive Treatment Plan
|on Treatment Teams|
|Mental health clinicians||67||100||67||100|
|Consumer/client family members||64||96||52||78|
|Primary care physicians||27||40||36||54|
|Community support and social service providers||NA||NA||56||84|
|NOTE: Columns are not mutually exclusive; CCBHCs could select that a provider participated in treatment planning and/or the treatment team.
NA = Not applicable (question was not asked).
With respect to information-sharing, 72 percent of CCBHCs reported receiving notification about their clients' use of emergency department services when the emergency department visit was for a mental or substance use disorder. In contrast, only 51 percent of CCBHCs reported receiving such notifications from an emergency department for the treatment of physical health conditions (Figure F).
|FIGURE F. Proportion of CCBHCs that Receive Notification about Treatment for Physical Conditions and MH/SUDs|
Expanded Care Provider Networks
Establishing partnerships with external providers and support services in the community has been another important strategy for improving care coordination. CCBHCs most often developed relationships with FQHCs (to provide primary care), family support service organizations, and hospitals but also established relationships with a wide variety of external providers. Nearly all reported an informal or formal relationship with the providers listed in Table 6, with the following exceptions: 72 percent have a relationship with an urgent care center, 58 percent with a school-based health center, 48 percent with a rural health center, and 40 percent with IHS or tribal programs.
As presented in Table 6, DCOs, organizations providing required CCBHC services through a formal relationship, are most frequently used to provide suicide/crisis services. Officials from the four demonstration states in which CCBHCs established DCO relationships with suicide/crisis hotlines and warmlines commented that using a DCO to provide this service made sense, because it is a specialized service. In explaining why CCBHCs prefer to provide services directly rather than establish a formal relationship with a DCO, state officials cited CCBHCs' concerns about: (1) legal requirements for DCO agreements (preferring informal relationships and/or more flexible partnership arrangements that existed before the demonstration); (2) information sharing; and (3) lack of experience with the PPS. New York State resolved the issue of "lack of experience with the PPS" by hiring staff from a DCO through a contract and building this cost into the cost report, thus eliminating DCO billing and a DCO payment agreement.
|TABLE 6. Number and Proportion of CCBHCs that have Relationships with Other Facilities and Providers|
|Facility/Provider Type||DCO||Other Formal Relationship||Other Informal Relationship||Any Relationship[a]|
|Rural Health Clinics||0||0||21||31||12||18||32||48|
|Primary care providers||2||3||48||72||25||37||66||99|
|Inpatient psychiatric facilities||1||1||52||78||19||28||67||100|
|Psychiatric residential treatment facilities||1||1||40||60||28||42||64||96|
|SUD residential treatment facilities||3||4||43||64||28||42||67||100|
|Medical detoxification facilities||2||3||42||63||23||34||64||96|
|Ambulatory detoxification facilities||1||1||32||48||26||39||55||82|
|Post-detoxification step-down facilities||0||0||31||46||24||36||52||78|
|Residential (non-hospital) crisis settings||3||4||35||52||24||36||57||85|
|MAT providers for substance use||2||3||43||64||20||30||61||91|
|School-based health centers||0||0||21||31||20||30||39||58|
|Child welfare agencies||0||0||43||64||26||39||66||99|
|Therapeutic foster care service agencies||0||0||31||46||31||46||56||84|
|Juvenile justice agencies||0||0||38||57||26||39||60||90|
|Adult criminal justice agencies/courts||0||0||51||76||19||28||65||97|
|Mental health/drug courts||0||0||52||78||15||22||62||93|
|IHS or other tribal programs||0||0||10||15||18||27||27||40|
|IHS youth regional treatment centers||0||0||4||6||13||19||17||25|
|Suicide/crisis hotlines and warmlines||19||28||38||57||15||22||65||97|
|Employment services/supported employment||2||3||35||52||29||43||63||94|
|Older adult services||0||0||27||40||30||45||56||84|
|Other social and human service providers||2||3||38||57||35||52||65||97|
|Consumer-operated/peer service provider organizations||3||4||26||39||31||46||55||82|
|VA treatment facilities||0||0||37||55||32||48||66||99|
|Urgent care centers||0||0||21||31||29||43||48||72|
|Hospital outpatient clinics||0||0||29||43||37||55||62||93|
|NOTE: Columns are not mutually exclusive.
Color shading approximately represents the five main care coordination groupings from the CCBHC certification criteria: light gray (rows 1-3) = FQHCs, Rural Health Clinics, other primary care providers; green rows 4-10) = inpatient and residential behavioral health treatment; dark gray (rows 11-28) = community or regional services, supports, and providers; orange (row 29) = VA facilities; purple (rows 30-32) = inpatient acute care hospitals. For more information about the grouping of providers/facilities, see the criteria available at https://www.samhsa.gov/sites/default/files/programs_campaigns/ccbhc-criteria.pdf, pp. 27-31.