Opportunities and Strategic Decisions for CCBHCs: Maximizing Mental Health and Addiction Treatment

1. CCBHCs 101: Opportunities and Strategic Decisions Ahead Rebecca C. Farley, MPH National Council for Behavioral Health Speaker Name Title Organization

2. It Passed! The largest federal investment in mental health and addiction treatment in a generation. Senators Roy Blunt and Debbie Stabenow Representatives Leonard Lance and Doris Matsui

3. “This is a B.F.D.”–Joe Biden

4. The Vision • Improve overall health by bolstering community-based mental health and addiction treatment • Advance behavioral health care to the next stage of integration with physical health care • Assimilate and utilize evidence-based practices on a more consistent basis Certified Community Behavioral Health Clinics

5. What makes CCBHCs so different? • New provider type in Medicaid • Distinct service delivery model: trauma-informed recovery outside the traditional four walls • New prospective payment system (PPS) methodology • Requirement to contract with other organizations

6. Why pursue CCBHC status? • Improved care and enhanced access to care • Potential for secure payment based on actual anticipated costs via a Prospective Payment System (PPS) • Expansion of person-centered, family-centered, trauma-informed, and recovery oriented care that integrates physical and behavioral health care to serve the whole person

7. 24 States Selected for Planning Grants

8. Decisions Ahead • Under my state’s CCBHC certification process, do we have a shot? • What changes to our service array are needed? • What workforce education/training do we need to do? • What capital investments do we need to make? • Is it worth it to pursue these changes, even if our state isn’t picked for the demo?

9. Timeline SAMHSA has granted a 6-month extensionfor states that are selected to participate in the demonstration • The demonstration start date may be between Jan. 1 and June 30, 2017

10. Do I have to be a CCBHC? • DCOs augment or fill gaps in CCBHCs’ service array… No! You could become a… Designated Collaborating Organization • …And can benefit from CCBHCs’ enhanced reimbursement

11. CCBHC Criteria Scope of Services

12. 9 Types of CCBHC Services • Crisismental health and addiction services • Screening, assessment and diagnosis, including risk assessment • Person and Family-centered treatment planning • Direct provision of outpatient mental health and substance use services • Outpatient primary care screening and monitoringof key health indicators and health risk • Targeted case management • Psychiatric rehabilitation services • Peer support and counselor services and family supports • Intensive, community-based mental health care for members of the armed forces and veterans, particularly those in rural areas

13. CCBHC Scope of Services Must be delivered directly by CCBHC Delivered by CCBHC or a Designated Collaborating Organization (DCO)

14. Evidence-based practices • Based on community needs assessment, states must establish a minimum set of required evidence based practices, such as: • Motivational Interviewing • Cognitive Behavioral individual, group, and on-line therapies (CBT) • Dialectical Behavioral Therapy (DBT) • First episode early intervention for psychosis • Multi-systemic therapy • Assertive Community Treatment (ACT) • Forensic Assertive Community Treatment (F-ACT) • Community wrap-around services for youth and children • And more…

15. Breaking through old limitations… Services are not confined to delivery within the 4 walls of a clinic Think creatively! • In-home services for newly placed foster youth • Post-booking assessment in jails • Outreach to homeless populations

16. CCBHC Criteria Staffing

17. Staffing Standards • Medicaid-enrolled providers • Credentialed, certified, and licensed professionals • Individuals with expertise in addressing the needs of children and adolescents Culturally and linguistically competent and appropriate *Including for Veterans and members of the Armed Services

18. Staffing: Positions • Management team: • Chief Executive Officer or Executive Director/Project Director • Psychiatrist as Medical Director • States will specify disciplines required for certification, but must include: • Medically trained BH provider able to prescribe and manage meds (i.e., opioid and alcohol treatment) • Credentialed substance abuse specialists • Individuals with trauma expertise able to promote recovery of children with SED, adults with SMI, and those with SUD

19. CCBHC Criteria Availability and Accessibility of Services

20. Availability & Accessibility Standards • Access required at times and places convenient for those served • Prompt intake and engagement in services • Access regardless of ability to pay (sliding scale fees) and place of residence • Crisis management services available 24 hours per day

21. CCBHC Criteria Care Coordination

22. Care Coordination: The “Linchpin” of CCBHC • CCBHC coordinates care across the spectrum of health services, including physical and behavioral health and other social services • CCBHC establishes or maintains electronic health records (EHR) • Health IT system is used to conduct population health management, quality improvement, reducing disparities, and for research and outreach

23. Care Coordination: The “Linchpin” of CCBHC • Partnerships or care coordination agreements required with: • FQHCs/rural health clinics • Inpatient psychiatry and detoxification • Post-detoxification step-down services • Residential programs • Other social services providers, including • Schools • Child welfare agencies • Juvenile and criminal justice agencies and facilities • Indian Health Service youth regional treatment centers • Child placing agencies for therapeutic foster care service • Department of Veterans Affairs facilities • Inpatient acute care hospitals and hospital outpatient clinics

24. CCBHC Criteria Quality and Other Reporting

25. Quality and Other Reporting Standards • Standardized data elements modeled on the FQHC Uniform Data System: • Encounter data • Consumer demographics • Staffing • Service usage • Service access • Care coordination • Clinical outcomes data • Quality data • Other data as requested

26. Quality Measures Required Measures for Quality Bonus Payments • Follow-Up after Hospitalization for Mental Illness (adult age groups) • Follow-Up after Hospitalization for Mental Illness (child/adolescents) • Adherence to Antipsychotics for Individuals with Schizophrenia • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment • Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

27. Quality Measures Eligibility Measures for Quality Bonus Payments • Follow-Up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication • Screening for Clinical Depression and Follow-Up Plan • Antidepressant Medication Management • Plan All-Cause Readmission Rate • Depression Remission at Twelve Months-Adults

28. CCBHC Criteria Organizational Authority, Governance, and Accreditation

29. Organizational Authority Governance and Accreditation • CCBHCs must be: • Nonprofits • Part of local government behavioral health authority • Under the authority of Indian Health Service, Indian Tribe or Tribal organization • Governing board members “reasonably represent” those served • States are encouraged to require national accreditation (e.g. CARF, COA, JCAHO)

30. CCBHC Payment Establishment of a Prospective Payment System

31. Prospective Payment System • CMS Guidelines • PPS rates are CCBHC-specific • CCBHCs will be required to develop annual cost reports • The cost of DCO services is included in the CCBHC prospective payment rate, and DCO encounters are treated as CCBHC encounters for purposes of the prospective payment. • States have two options to choose from: PPS-1 vs. PPS-2

32. PPS-1 Guidelines • CCBHC’s receive a fixed dailyreimbursement per visit • Based on the FQHC PPS approach used nationally • Payment is the same regardless of intensity of services Total allowable costs of providing services Daily per-visit rate Total number of daily visits per year

33. PPS-1 • Pros • Methodology and requirements familiar from the FQHC experience • Completion & review of cost report less complex • Implementation of one payment rate per CCBHC less complex • Data/system requirements may be more likely to be currently available at CMHCs • Option to include quality bonus payments to CCBHCs • Cons • One payment rate per visit • Does not account for matching payment to disparate consumer conditions • Errors in predicting patient mix more problematic

34. PPS-2 Guidelines • CCBHCs receive afixed monthly reimbursement for every individual who has at least one visit in the month • Payment is the same regardless of number of visits per month or intensity of services • CCBHCs do NOT get paid in months when the patient does not receive any services • Allows CCBHCs to establish separate reimbursement rates for distinct populationsin addition to a base rate • adults with serious mental illness • children and youth with serious emotional disorders, • individuals with serious substance use disorders, • individuals with a recent history of frequent hospitalizations due to behavioral health conditions

35. PPS-2 • Pros • Includes a process to address outlier costs • Allows for more ability to match payment to patient condition • Requires quality bonus payments to CCBHCs • Cons • Completion of cost report more complex • Data/system requirements are complex to produce required cost report elements by condition level • Difficult for State to review and validate payment rates • Administratively more complex for State to make payments to CCBHCs when factoring in condition level, outliers and quality bonus payments

36. Special Considerations for DCOs • What required services do you provide that CCBHCs in your community lack? • Can you collect the required data and communicate electronically with your local CCBHC? • What payment arrangement will you negotiate with the CCBHC?

37. NatCon16: CCBHC Track • Monday: • 12:00: Becoming Best Friends: CCBHCs and DCOs • 3:00: Getting Paid as a CCBHC: Cost Reporting Principles • Tuesday: • 10:00: Quality Reporting and CCBHCs • 10:00: The Role of CCBHCs in Monitoring & Managing Chronic Illness

38. Visit our resource hub! http://www.thenationalcouncil.org/topics/certified-community-behavioral-health-clinics/

39. What happens after 2 years?

40. Questions? Rebecca FarleyDirector, Policy and AdvocacyRebeccaF@thenationalcouncil.org