Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2018. Requirement 4: Scope of Services

09/10/2019

CCBHCs provide, in a manner reflecting person-centered care, the following services:

  • Crisis mental health services, including 24-hour mobile crisis teams, emergency crisis intervention services, and crisis stabilization.

  • Screening, assessment, and diagnosis, including risk assessment.

  • Patient-centered treatment planning or similar processes, including risk assessment and crisis planning.

  • Outpatient MH/SUD services.

CCBHCs also provide directly, or through referral with DCOs, the following services:

  • Outpatient clinic primary care screening and monitoring of key health indicators and health risk.

  • Targeted case management.

  • Psychiatric rehabilitation services such as supported employment and supported housing.

  • Peer support and counselor services, as well as family supports.

  • Intensive, community-based mental health care for members of the armed forces and veterans, particularly those members and veterans located in rural areas.

A hallmark of this demonstration program is its capacity to offer recipients a comprehensive range of high-quality services, delivered directly by the CCBHC or through DCOs. Recognizing the inherent complexity of providing such a range, states were permitted flexibility in aligning the scope of services with their Medicaid State Plans and other state regulations. Requirement 4 also calls for the continuous integration of evidence-based practices (EBPs).

Photo of Grand Lake Mental Health Center clients participating in whole-person health care.
Demonstrating the spectrum of whole-person health care, clients participate in services at Grand Lake Mental Health Center, Inc., a CCBHC serving rural populations of Oklahoma.

Added Services

Eighty-four percent of CCBHCs made changes to the range of services they provide. They most often added services within the categories of outpatient MH/SUD services, psychiatric rehabilitation services, and crisis behavioral health services. (See Figure G.) Responding to a write-in question on the progress report, CCBHCs reported providing "other" CCBHC services, including emergency room enhancement services, CMHLs, and withdrawal management services.

FIGURE G. Proportion of CCBHCs that added Services within Each Service Category as a Result of Certification
FIGURE G, Bar Chart: Outpatient MH/SUD services (63%); Psychiatric rehabilitation services (55%); Crisis behavioral health services (51%); Peer support services (49%); Intensive community-based mental health services for members of the armed forces (45%); Primary care screening and monitoring (42%); Targeted case management (40%); Screening, assessment, and diagnosis (22%); Person/family-centered treatment planning services (18%); Other required CCBHC services (16%).
NOTE: CCBHCs may have provided services within each of the service categories illustrated in Figure G prior to CCBHC certification. For example, all CCBHCs provided some type of outpatient mental health and/or SUD treatment prior to certification. However, 63 percent of CCBHCs added some type of outpatient mental health and/or SUD treatment as a result of certification. The service categories illustrated in this figure correspond to the service categories described in the CCBHC certification criteria.

Table 7 presents the availability of services in CCBHCs and DCOs. 24-hour mobile crisis teams and MAT for alcohol and opioid use are the services most often added as a result of CCBHC certification. Eighty-four percent of CCBHCs provide MAT for alcohol and opioid use; among the 11 CCBHCs that did not provide MAT either directly or through a DCO, nine had either a formal (four) or informal (five) relationship with a MAT provider.

In addition to MAT, other services frequently added because of certification include targeted case management (40 percent) and illness management and recovery (31 percent). State officials attributed variability in the proportion of CCBHCs providing certain EBPs (e.g., MAT, multi-systemic therapy, assertive community treatment, supported education) to a combination of perceived population needs, state priorities and ongoing state initiatives, and workforce shortages.

TABLE 7. Required Services Provided by CCBHCs and/or DCOs
Service CCBHC Directly
Provided Service
DCO Provided Service Either CCBHC and/or
DCO Provided Service[a]
Added as a Result
of CCBHC Certification
N % N % N % N %
Crisis behavioral health services
   24-hour mobile crisis teams 49 73 23 34 65 97 31 46
   Emergency crisis intervention 59 88 20 30 67 100 21 31
   Crisis stabilization 60 90 14 21 66 99 21 31
Screening, assessment, and diagnosis
   Mental health 67 100 4 6 67 100 9 13
   SUD 67 100 3 4 67 100 15 22
Person/family-centered treatment planning services 66 99 5 7 66 99 12 18
Outpatient mental health and/or SUD services
   First episode/early intervention for psychosis 40 60 0 0 40 60 9 13
   MAT for alcohol and opioid use[b] 55 82 2 3 56 84 31 46
   Outpatient SUD treatment 67 100 0 0 67 100 13 19
   Specialty MH/SUD services for children and youth 58 87 0 0 58 87 15 22
   Community wraparound services for youth/children[b] 50 75 2 3 51 76 10 15
Psychiatric rehabilitation services
   Illness management and recovery 62 93 4 6 65 97 21 31
   Medication education 65 97 3 4 66 99 14 21
   Self-management 63 94 5 7 65 97 16 24
   Skills training 64 96 5 7 66 99 14 21
   Supported employment 45 67 5 7 50 75 18 27
   Supported education 33 49 5 7 36 54 11 16
   Wellness education services (diet, nutrition, exercise, tobacco cessation, etc.) 65 97 6 9 67 100 24 36
Peer support services
   For consumers/clients 66 99 4 6 67 100 29 43
   For families 48 72 4 6 49 73 23 34
Targeted case management 62 93 1 1 63 94 27 40
Primary care screening and monitoring 63 94 3 4 65 97 28 42
Community-based mental health care for armed forces and veterans 47 70 1 1 48 72 30 45
NOTE:
  1. This column was calculated by first combining the CCBHC and DCO responses for each CCBHC to determine whether the service was provided by the CCBHC at all (either directly or by one of its DCOs). These responses were then combined across CCBHCs to determine the percentage of CCBHCs that provided the service either directly or through a DCO.
  2. EBP included in the CCBHC certification criteria.

To facilitate crisis planning, CCBHCs used best practices such as psychiatric advance directives, and safety/crisis plans, as presented in Table 8. "Other" strategies listed include suicide assessments such as the Columbia Suicide Severity Rating Scale (C-SSRS), relapse prevention and planning, critical intervention planning, and working with external partners and stakeholders to provide patient-centered services in crisis planning.

TABLE 8. Number and Proportion of CCBHCs using Specific Crisis Planning Strategies
Strategy N %
Wellness recovery action plan 49 73
Psychiatric advance directives 46 69
Develop a safety or crisis plan 29 43
Other 37 55

Resolved Challenges

State officials described overcoming the following initial barriers to implementing a full scope of services:

  • State credentialing and licensure requirements. State officials worked with state licensure offices and CCBHCs to obtain licensure for certain required services (e.g., ambulatory withdrawal management [AWM]) or hiring staff with the credentials necessary to provide required services (e.g., peer support).

  • Workforce shortages. As noted previously, several states experienced challenges in recruiting and hiring certain types of staff, such as peer support staff in rural areas. Strategies to attract and retain employees included offering competitive salaries and leveraging professional networks within the state to advertise CCBHC positions.

  • Inexperience in providing specific services to certain populations. CCBHCs in some states were required to add new service lines, to fulfill demonstration criteria. CCBHCs in other states needed to expand certain services to new populations, such as youth in order to become a CCBHC.

  • Billing and claims/encounter data. States supported CCBHCs in administering PPS claims and recording encounters during the planning phase and the initial months of the demonstration. In the March 2018 interviews, officials from all states reported that the CCBHCs were using the systems they had put in place, the payment and encounter information was being appropriately recorded and submitted, and the PPS claims were being paid. However, most state officials also noted that they have not yet conducted detailed audits, so early impressions are subject to change. For instance, detailed audits of the data would be required to identify gaps in the encounter data or systematic errors in PPS claims.