Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration. EXECUTIVE SUMMARY

09/12/2020

Section 223 of the Protecting Access to Medicare Act (PAMA), enacted in April 2014, authorized the Certified Community Behavioral Health Clinic (CCBHC) demonstration to allow states to test new strategies for delivering and reimbursing services provided in community mental health centers (CMHCs). The CCBHC demonstration aims to improve the availability, quality, and outcomes of ambulatory services provided in CMHCs and other providers by establishing a standard definition and criteria for CCBHCs and developing a new payment system that accounts for the total cost of providing comprehensive services to all individuals who seek care. The demonstration also aims to provide coordinated care that addresses both behavioral and physical health conditions.

In October 2015, the U.S. Department of Health and Human Services (HHS) awarded planning grants to 24 states to begin certifying providers to become CCBHCs, develop new prospective payment systems (PPS), and plan for the demonstration's implementation. To support the demonstration's first phase, HHS, as required by PAMA, developed criteria for use in certifying CCBHCs in six important areas: (1) staffing; (2) availability and accessibility of services; (3) care coordination; (4) scope of services; (5) quality and reporting; and (6) organizational authority.[1] The criteria established a minimum threshold for the structures and processes that CCBHCs should have in place to provide high-quality care, although states may exercise some discretion in implementing the criteria to reflect their particular needs.

States used the planning grants to develop infrastructure to support the CCBHC demonstration, and to select a PPS model and develop PPS rates. States chose between two broad PPS models developed by the HHS Centers for Medicare & Medicaid Services (CMS) (although they may exercise some flexibility in operationalizing the models). The first model (PPS-1) is similar to the PPS model used by federally qualified health centers--it reimburses costs by using a fixed daily rate for all services rendered to a Medicaid beneficiary. If a state elected the PPS-1 model, CMS reimburses participating CCBHCs at a fixed daily rate for all services provided to a Medicaid beneficiary. The PPS-1 model also includes a state option to provide quality bonus payments (QBPs) to CCBHCs that meet defined quality metrics. The second model (PPS-2) reimburses costs by using a standard monthly rate per person served, with separate monthly rates that vary with beneficiaries' clinical conditions. Under the PPS-2 model, CMS reimburses participating CCBHCs at a fixed monthly rate for all services provided to a Medicaid beneficiary. The PPS-2 also includes outlier payments for costs above and beyond a specific threshold (that is, payment adjustments for extremely costly Medicaid beneficiaries). The PPS-2 model also requires bonus payments for clinics that meet defined quality metrics. Both PPS models aim to enhance Medicaid reimbursement by ensuring that reimbursement rates more closely reflect the cost of providing an enhanced scope of services. While clinics cannot reject or limit services on the basis of a client's ability to pay, CCBHCs can, however, only bill Medicaid for services provided to Medicaid beneficiaries. In addition, states must establish and publish a sliding fee discount schedule for consumers.

TABLE ES.1. Number of CCBHCs, Demonstration Start Date, and PPS
State Number of CCBHCs Demonstration Start Date PPS
Minnesota 6 July 1, 2017 PPS-1*
Missouri 15 July 1, 2017 PPS-1*
Nevada 3a July 1, 2017 PPS-1*
New Jersey 7 July 1, 2017 PPS-2
New York 13 July 1, 2017 PPS-1*
Oklahoma 3 April 1, 2017 PPS-2
Oregon 12 April 1, 2017 PPS-1
Pennsylvania 7 July 1, 2017 PPS-1*
SOURCE: Mathematica/RAND review of CCBHC demonstration applications and telephone consultations with state officials.
NOTES:
  1. Nevada initially certified 4 clinics; however, 1 is no longer participating in the demonstration. In March 2018, that CCBHC withdrew from the demonstration after Nevada revoked its certification. The total in the table reflects the number of participating CCBHCs in May 2019.

* = PPS-1 with QBPs.

In December 2016, HHS selected eight states from among the 24 that received planning grants to implement their PPS models and provide services that align with the CCBHC certification criteria. Consistent with PAMA requirements, HHS selected Minnesota, Missouri, Nevada, New Jersey, New York, Oklahoma, Oregon, and Pennsylvania based on the completeness of the scope of services that their CCBHCs will offer; the CCBHCs' ability to improve the availability of, access to, and engagement with a range of services (including assisted outpatient treatment); and their potential to expand mental health services without increasing federal spending. CCBHCs participating in the demonstration must also provide coordinated care and make available a comprehensive range of nine types of services[2] to all who seek help, including but not limited to those with serious mental illness, serious emotional disturbance, and substance use disorder (SUD). Services must be person-centered and family- centered, trauma-informed, and recovery-oriented, and the integration of physical and behavioral health care must serve the "whole person." To ensure the availability of the full scope of CCBHC services, service delivery could involve the participation of Designated Collaborating Organizations (DCO), which are entities not under the direct supervision of a CCBHC but that are engaged in a formal, contractual relationship with a CCBHC to provide selected services. CCBHCs that engage DCOs maintain clinical and financial responsibility for services provided by a DCO to CCBHC consumers, and DCOs provide services under the same requirements as CCBHCs and are reimbursed for these services directly by the CCBHC. In addition, CCBHCs and participating states must be able to collect, track, and report on a wide range of encounter, outcome, cost, and quality data. As summarized in Table ES.1, 66 CCBHCs are participating across eight states; only two states elected the PPS-2 model. As of August 2019, the demonstration will end on September 13, 2019.

In September 2016, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) contracted with Mathematica and its subcontractor, the RAND Corporation, to conduct a comprehensive national evaluation of the demonstration. ASPE is overseeing the evaluation in collaboration with CMS.

Working with these federal partners, Mathematica and RAND designed a mixed-methods evaluation to examine the implementation and outcomes of the demonstration and to provide information for HHS to include in its reports to Congress. Specifically, Section 223 of PAMA mandates that HHS's reports to Congress must include: (1) an assessment of access to community-based mental health services under Medicaid in the area or areas of a state targeted by a demonstration program as compared to other areas of the state; (2) an assessment of the quality and scope of services provided by CCBHCs as compared to community-based mental health services provided in states not participating in a demonstration program and in areas of a demonstration state not participating in the demonstration; and (3) an assessment of the impact of the demonstration on the federal and state costs of a full range of mental health services (including inpatient, emergency, and ambulatory services). To date, the evaluation has focused on providing critical information to Congress and the larger behavioral health community about the strategies that CCBHCs employ to improve care. As more data become available, the evaluation will describe the effects of the demonstration on consumer outcomes and costs.

In June 2018, Mathematica and RAND submitted to ASPE a report titled "Interim Implementation Findings from the National Evaluation of the Certified Community Behavioral Health Clinic Demonstration," which described--through April 2018--the progress that states and CCBHCs made in implementing the demonstration and their successes and challenges. The current report provides updated information on implementation of the demonstration through April 2019 (approximately the first 22 months of the demonstration for six states and 24 months for the remaining two states). The findings in this report draw on data collected from interviews with state Medicaid and behavioral health agency officials and progress reports submitted by all participating CCBHCs (hereafter referred to as clinics). Unless otherwise noted, the 2018 and 2019 findings in this report are based on the number of clinics participating in the demonstration at the time of data collection each year (67 CCBHCs in 2018, and 66 CCBHCs in 2019 respectively).[3]

The clinic profiles in the report are based on site visits to CCBHCs in four states. In future reports, we will examine the impact of the demonstration on health care utilization, quality, and costs, using claims data and information submitted by CCBHCs and states. In August 2019, we will submit a separate report that summarizes states' and clinics' experiences with the required quality measures (based on interview and site visit data) and costs (using data from the CCBHC cost-reporting template).[4]

Implementation Findings

During the demonstration, states and CCBHCs have focused on increasing access to care, maintaining the staffing and scope of services requirements in the certification criteria, and ensuring coordinated care for CCBHC clients. Although some CCBHCs experienced early implementation challenges related to staffing or the implementation of new services, state officials reported that the CCBHCs addressed these challenges and appear to be adhering to the certification criteria in the second demonstration year.

Most CCBHCs hired additional staff as part of the certification process. As shown in Figure ES.1 and detailed in Appendix Table A.1, most CCBHCs already employed licensed clinical social workers (LCSWs), SUD specialists, nurses, a medical director, bachelor's degree-level counselors, case managers, adult psychiatrists, and peer specialists/recovery coaches before they received certification. The CCBHCs most often hired case managers, peer specialists/recovery coaches, and family support workers, perhaps reflecting the criteria's focus on enhancing care coordination and person-centered and family-centered care. In addition, CCBHCs often hired various types of nurses and child/adolescent psychiatrists to provide the full scope of required services. Although states had the latitude to determine the specific types of staff their CCBHCs must employ, as of March 2018 (Demonstration Year 1 [DY1]), nearly all CCBHCs employed the types of staff mentioned in the CCBHC certification criteria.

CCBHCs' ability to maintain the required types of staff throughout the demonstration varied by staff type. For example, as shown in Figure ES.1, there was no substantial difference between DY1 and second Demonstration Year (DY2) in the proportion of clinics that employed the following staff types: LCSWs, nurses, associate's degree-level or non-degree counselors, case management staff, peer specialists/recovery coaches, licensed psychologists, other clinician types, mental health professionals, family support staff, and community health workers. However, the proportion of clinics that employed psychiatrists declined from DY1 to DY2. Seventy-six percent of clinics employed child psychiatrists in DY1 versus 64 percent in DY2. Likewise, 91 percent of clinics employed adult psychiatrists in DY1 versus 82 percent in DY2. There was also a 13 point decline from DY1 to DY2 in the percentage of clinics that employed interpreters or linguistic counselors. Such changes in staffing may suggest clinics' efforts to experiment and identifying ways to use staff and resources more efficiently. CCBHCs and states reported that clinics faced several ongoing challenges associated with hiring and retaining staff, including, for example, uncertainty around the future of the demonstration, retaining enough of each staff type to meet increased demand for services, and increases in caseloads and responsibilities leading to staff burnout. However, officials generally perceived that clinics effectively used strategies such as increased salaries and benefits to overcome challenges.

FIGURE ES.1. Proportion of CCBHCs that Employed Specific Types of Staff Before Certification and in March 2018 (DY1) and March 2019 (DY2)
FIGURE ES.1, Bar Graph: This graph shows the proportion of CCBHCs that employed specific types of staff before certification and in March 2018 (DY1) and March 2019 (DY2). Before the demonstration, 12%-94% of CCBHC employed each type of staff (depending on the staff type). In March 2018 (DY1), 15%-100% of CCBHC employed each type of staff (depending on the staff type). In March 2019 (DY2), 17%-100% of CCBHC employed each type of staff (depending on the staff type). Comparing the first demonstration year to the period prior to the demonstration, the most sizable increase in staffing was for adult psychiatrists (70% before the demonstration compared with 91% in DY1),  child/adolescent psychiatrists (58% before the demonstration compared with 76% in DY1), peer specialists/recovery coaches (69% before the demonstration compared with 99% in DY1), and family support staff (37% before the demonstration compared with 67% in DY1).
SOURCE: CCBHC Annual Progress Report Demonstration Year 1 and Year 2 data collected by Mathematica and the RAND Corporation, March 2018 and March 2019.
NOTES: Denominator is 67 CCBHCs for "Proportion of CCBHCs that employed staff type before certification" and March 2018 findings, and 66 CCBHCs for March 2019 findings.
See Appendix Table A.1 for detailed findings and number of clinics corresponding to the percentages.
See Appendix Table A.2 for state-level findings. These findings were generally consistent across states, with the exception of Minnesota and Pennsylvania, where the proportion of clinics employing each type of staff did not decrease from 2018 to 2019.
Consistent with the CCBHC cost-reporting template, the mental health professional category includes only providers trained and credentialed for psychological testing.
"Other clinician types" is a write-in category.

In the second year of the demonstration, officials in all but one state cited uncertainty around the future of the demonstration as the most significant staffing challenge for clinics. State officials reported that the uncertainty has adversely affected clinics' ability to retain staff and maintain workforce morale as the demonstration draws to a close, noting that clinics have been reluctant to add new positions or fill vacancies for fear of not being able to sustain those staff positions after the demonstration ends.

CCBHCs have worked throughout the demonstration to make services more convenient and tailored to the needs of specific populations. As reported by states, the most common strategy used by CCBHCs to increase access to care was to introduce open-access scheduling. In addition, as shown in Figure ES.2, CCBHCs provided services in locations outside of the clinic, such as consumers' homes and community service agencies like Social Security offices and community centers, in both demonstration years. Clinics also have continued to make broad use of telehealth to extend the reach of CCBHC services. Clinics have used a variety of other strategies to improve accessibility, such as conducting outreach to new and underserved populations, and remodeling the physical space of clinics to accommodate the delivery of new services (such as detoxification and physical health screening and monitoring) Stakeholder organizations representing consumers and their family members reported that the strategies CCBHCs have employed, such as open-access and expanded hours of service provision, have significantly improved access to care for CCBHC clients in their states.

FIGURE ES.2. Proportion of CCBHCs that Provided Services Outside of Physical Clinic Space in the Past 12 Months
FIGURE ES.2, Bar Chart: Consumers' homes 78%; Schools 47%; Courts, police offices, and other justice-related facilities 33%; Hospitals and EDs 30%; Community service agencies and non-profit organizations 20%; Homeless shelters 11%.
SOURCE: CCBHC Annual Progress Report Demonstration Year 2 data collected by Mathematica and the RAND Corporation, March 2019.
NOTES: The denominator is the number of CCBHCs that reported offering services outside of the CCBHC physical buildings in the past 12 months as of March 2019 (n = 64).
See Appendix Table A.6 for 2018 findings.
See Appendix Table A.7 for state-level findings. The majority of clinics in all 8 demonstration states offered services outside of the CCBHC as of 2018, increasing to 100% of all CCBHCs as of 2019 in all states except New Jersey.

Most CCBHCs expanded their scope of services to meet the certification requirements. Clinics most often added services within the categories of outpatient mental health and/or SUD services, psychiatric rehabilitation services, crisis services, peer support, services for members of the armed forces and veterans, and primary care screening and monitoring (Figure ES.3). The extent to which the CCBHCs added services to meet the certification requirements varied widely across the states depending on the service infrastructure that existed before the demonstration.

FIGURE ES.3. Proportion of CCBHCs that Added Each Type of Service as a Result of Certification (as of March 2018)
FIGURE ES.3, Bar Chart: Outpatient mental health and/or 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 and veterans 45%; Primary care screening and monitoring 42%; Targeted case management 40%; Screening, assessment, and diagnosis 22%; Person and family-centered treatment planning services 18%; Other required CCBHC services 16%.
SOURCE: CCBHC Annual Progress Report Demonstration Year 1 data collected by Mathematica and the RAND Corporation, March 2018.
NOTES: Denominator is 67 CCBHCs.
See Appendix Table A.11 for detailed findings on individual services.
CCBHCs may have provided services within each of the service categories illustrated in the figure before CCBHC certification. For example, all clinics provided some type of outpatient mental health and/or SUD treatment before certification. However, 63% of clinics 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.

Officials in all states perceived that clinics were able to sustain delivery of the nine core CCBHC services throughout the demonstration, a finding confirmed by clinics in the progress report. As shown in Figure ES.4, nearly all CCBHCs in both DY1 and DY2 reported that they provided the required services, with the exception of intensive community-based mental health services for members of the armed forces and veterans, which were provided by about 70 percent of clinics in both years. State officials speculated that the armed forces/veterans populations did not comprise a large percentage of CCBHC clients and that CCBHCs may have struggled to engage these populations and to develop strong referral relationships and care coordination agreements with the U.S. Department of Veterans Affairs providers. Though not required by the demonstration, about half of clinics provided on-site primary care in each demonstration year.

FIGURE ES.4. Proportion of CCBHCs that Provided Each Type of Service Either Directly or Through a DCO
FIGURE ES.4, Bar Chart: Crisis behavioral health services 100% in 2018, 100% in 2019; Oupatient mental health and/or SUD services 100% in 2018, 100% in 2019; Psychiatric rehabilitation services 100% in 2018, 100% in 2019; Peer support services 100% in 2018, 100% in 2019; Screening, assessment, and diagnosis 100% in 2018, 98% in 2019; Person and family-centered treatment planning services 99% in 2018, 100% in 2019; Targeted case management 94% in 2018, 100% in 2019; Primary care screening and monitoring 97% in 2018, 91% in 2019; Intensive community-based mental health services for armed forces and veterans 72% in 2018, 67% in 2019; Other required CCBHC services 33% in 2018, 23% in 2019.
SOURCE: CCBHC Annual Progress Report Demonstration Year 1 and Year 2 collected by Mathematica and the RAND Corporation, March 2018 and March 2019.
NOTES: Denominator is 67 CCBHCs in 2018 (DY1) and 66 CCBHCs in 2019 (DY2).
The "other required CCBHC services" category denotes additional services that do not fall within the 9 service types defined in federal criteria but that may be required by individual states.
See Appendix Table A.12 for detailed findings and the number of clinics corresponding to the percentages.
See Appendix Table A.13 for state-level findings.

CCBHCs were able to add and sustain a range of evidence-based practices (EBPs) across demonstration years. In the first year of the demonstration, CCBHCs offered a wide range of EBPs and psychiatric rehabilitation and other services either directly or through DCOs. As shown in Figure ES.5, most clinics were able to sustain or provide more of these services in the second year of the demonstration. For example, 46 percent (n = 31) of clinics added medication-assisted treatment (MAT) for alcohol or opioid use as a result of certification, and 92 percent of clinics (n = 61) offered MAT in DY2 compared to 84 percent (n = 56) in DY1. Even though, early in the demonstration, CCBHCs generally addressed challenges to maintaining EBPs and providing the full scope of CCBHC services, officials continued to explore ways to support clinics in offering the full range of services, such as by providing CCBHCs with increased flexibility to better tailor EBPs and other services to reflect the needs and preferences of their client populations.

CCBHCs have used a variety of strategies to improve care coordination, including adding various provider types to treatment teams and expanding targeted care coordination strategies to different populations and service lines. In the early stages of the demonstration, improvements to electronic health records (EHR) and health information technology aided clinics in their care coordination efforts, in some cases permitting CCBHCs to integrate care plans more fully, connect with external providers, and receive alerts about clients' care transitions. As the demonstration progressed, clinics implemented additional strategies, and initiated collaboration with various external organizations to facilitate coordinated care. For example, some clinics partnered with first responders and law enforcement officials on strategies to intervene in crisis situations and divert those in crisis from the criminal justice system.

CCBHCs, for the most part, elected to offer the full scope of CCBHCs services directly, instead of engaging separate organizations to deliver required services. While the certification criteria allowed for some services to be provided by DCOs, officials suggested that CCBHCs preferred to provide services directly because they wished to embrace the model fully and were reluctant to assume oversight responsibility for another provider's services. CCBHCs did, however, continue to provide and expand services in collateral agencies such as schools and shelters and to build and sustain close formal and informal relationships with a range of external providers.

FIGURE ES.5. Proportion of CCBHCs that Provided Selected EBPs, Psychiatric Rehabilitation Services, and Other Services, Either Directly or Through a DCO
FIGURE ES.5, Bar Chart: Outpatient Mental Health and/or SUD Services--Motivational interviewing 100% in 2018, 100% in 2019; Individual CBT 100% in 2018, 100% in 2019; Evidence-based medication evaluation and management 87% in 2018, 94% in 2019; Group CBT 84% in 2018, 88% in 2019; Medication-assisted treatment for alcohol and opioid use 84% in 2018, 92% in 2019; Community wraparound services for youth/children 76% in 2018, 77% in 2019; Dialectical behavioral therapy 73% in 2018, 76% in 2019; Multisystemic therapy 40% in 2018, 56% in 2019. Psychiatric Rehabilitation Services -- Supported employer 75% in 2018, 82% in 2019; Supported housing 70% in 2018, 79% in 2019; Supported education 54% in 2018, 68% in 2019. Peer Support Services -- Peer support services for families 73% in 2018, 83% in 2019.
SOURCE: CCBHC Annual Progress Report Demonstration Year 1 and Year 2 collected by Mathematica and the RAND Corporation, March 2018 and March 2019.
NOTES: Denominator is 67 CCBHCs in 2018 and 66 CCBHCs in 2019.
See Appendix Table A.12 for detailed findings and the number of clinics corresponding to the percentages.
See Appendix Table A.11 for the number and percentage of clinics that added each type of service as a result of CCBHC certification.
See Appendix Table A.13 for state-level findings.
* = EBP listed in CCBHC criteria.

Future Evaluation Activities

In August 2019, we will submit a report summarizing information from the first year of CCBHC cost reports. The report will also draw on information from interviews and site visits to describe clinics' experience with the PPS and the progress that CCBHCs and states are making toward submission of the required quality measures. We will update the report in August 2020 to include information from the second year of CCBHC cost reports and will summarize the quality of care provided to CCBHC consumers by using data from the CCBHC-reported and state-reported quality measures.

We are in the process of obtaining Medicaid claims and encounter data from states to examine changes in service utilization and costs. We plan to examine the impacts of CCBHC services on: (1) hospitalization rates; (2) emergency department service utilization; and (3) ambulatory care relative to within-state comparison groups (Medicaid beneficiaries with similar diagnostic and demographic characteristics who did not receive care from CCBHCs). Depending on the availability of data within each state, we expect that the impact analyses will use approximately four years of Medicaid claims/encounter data (up to a two-year pre-demonstration period and a two-year post-implementation period). We will report these findings in our final report in May 2021, along with updated findings that draw on both years of CCBHC cost reports and quality measures.