What it Means to Become a Certified Community Behavioral Health Clinic (CCBHC)
foreign hello and thank you for joining us the Southeast Mental Health technology Transfer Center is pleased to present today’s webinar event what it means to become a certified community behavioral health clinic or ccbhc my name is Emily Moore and joining me in moderating today’s event is Dr Benjamin dress director of the Southeast Mental Health technology Transfer Center before beginning I would like to take a quick moment to describe the work of our Center followed by an introduction of today’s Speakers by Dr Benjamin Dross please note that the work of our Center is supported by a grant from the Substance Abuse and Mental Health Services Administration or Sansa and our Center and the larger mhttc Network use affirming respectful and Recovery oriented language in all activities the Southeast Mental Health technology Transfer Center is located in Atlanta Georgia at Emory University’s Rollins School of Public Health we are proud to serve the eight states of HHS region 4. our expertise in public health programs systems research and evaluation provides a unique lens through which we can address mental health priorities the goal of the southeast mhttc is to accelerate the adoption of evidence-based mental health programs by providing training and technical assistance to region 4. we use a public health approach to build leadership capacity and to provide mental health trainings and resources to Providers agencies and communities across the southeast we encourage you to visit the southeast mhttc website to learn more about our Center and upcoming event a brief reminder that today’s event is being recorded and will be made available on our website in a few days I’d now like to turn it over to Dr dress so that he can introduce today’s speakers thanks so much Emily we’re really excited about today’s presentation uh the two speakers will be Rebecca Frawley David and Jonathan Brown Rebecca Farley David is senior director of public policy and special initiatives at the National Council for Behavioral Health she’s worked to advance and support the ccbhc model for more than 10 years from introduction of the original authorizing legislation through implementation of the demonstration and expansion grants she currently oversees the national council’s ccbhc Success Center an initiative to support States clinics and other stakeholders throughout ccbhc implementation and ongoing operations Jonathan Brown is a senior fellow and director of Behavioral Health at Mathematica where his work focuses on improving the quality and outcome of Behavioral Health Services he directs an ongoing National evaluation of the ccphc demonstration for the office of the assistant secretary for planning and evaluation and recently completed a national evaluation of the primary and Behavioral Health Care integration program for samsa he provides evaluation related technical assistance for State Medicaid demonstrations and has worked with States health plans consumer organizations and Community Mental Health Centers to develop and use Behavioral Health quality measures Dr Brown is a native of Alabama and currently lives in Atlanta with that I will pass it over to you hey good morning everyone thank you so much for having us with you to talk about the certified community behavioral health clinic model um before we get started I think we’d like to just begin with a quick poll of folks who are on the line to understand a little bit about your experience with ccbhc so far so if you could just take a moment to tell us if your organization is currently a ccbhc either through the Medicaid demonstration or an expansion Grant perhaps you aren’t a ccbhc yet but thinking of becoming one or maybe in a mode where you’re still learning more before deciding whether to pursue it and if none of these answers apply to you I think we’d also love to just hear you chime in in the chat with you know what what is your status relative to the ccbhd program or you’re thinking so we’ll give folks just a moment to submit their answers and when we’ve got a high enough response rate I think we can go ahead and close the poll so let’s take a look at the results all right so it sounds like about a quarter of you um are already ccbhcs um either as a result of receiving an expansion Grant or participating in the ccbhd demonstration for those of you that uh that are already um a ccbhc some of this information may be familiar to you although you might get some new ideas about some approaches that clinics have used elsewhere looks like about 20 of you are um in that uh planning phase planning to become a ccbhc at a future point and the majority of folks on the line are still learning more so we’re glad to be able to provide you with information to help inform some of those decisions and just help you explore this model I think we’d welcome questions at any time in the chat and we will be saving all questions until the end but uh you know please do please do engage with us through the or through the Q a function um to let us know if you have any questions as we go along all right so with that I will share some slides foreign so we want to start by providing some context and an overview of ccbhds for those who may be less familiar with the model ccbhcs are a model of Service delivery and payment built on the idea that if we want to expand and improve care in our mental health and substance use system we need to actually pay for the activities that make those goals possible for Generations uh reimbursement rates for mental health and addiction treatment have been set so low that clinics find themselves quite often trying to Cobble together funding from multiple different sources simply to keep their doors open and make payroll we also know that there is an incredible Workforce shortage that is particularly devastating in the safety net where a little reimbursement often inhibits provide organization’s ability to offer competitive salaries and to recruit and retain staff and so um and and furthermore you know there’s just a lot of work that clinics do that we know is really critical to improving outcomes um that isn’t billable under traditional Insurance models and so ccbhc really reimagines all of that it establishes a national definition regarding the scope of services the timeliness of access to care Staffing models and so on that all clinics who get this designation have to meet um I think that national definition can really be considered as raising the bar on the scope of services available within communities uh most clinics around the country offer some combination of the required ccbhd Services very few offer all of them and so as a result of this national definition we’ve seen clinics making really big improvements to the the services available within their community and also partnering with other organizations in new ways that extend the availability of other services to more clients um the program also comes with standardized data and Quality Reporting which is really helpful for States and payers thinking through uh you know how how do we know what sort of value we’re getting for our investment in this model and for clinics that are able to meet that criteria and get certified it comes with a payment model that covers the anticipated cost of opening access to new patients and new services and I think most critically that payment model does include those non-billable activities like Outreach care coordination technology and many other things that we know to be critical but far too often are you know just simply have no source of funding within our system so there’s currently three implementation options for clinics um or States looking to adopt the ccbhc model um there is a Medicaid demonstration program that is ongoing that demonstration program began in eight states um currently it has expanded to 10. um if you’re not in one of those 10 states the option for becoming a ccbhc would be through a pot of Federal grant funding that flows directly to clinics enabling them to implement the ccbhc model over the two-year Grant period that grant funding it’s really helpful you know because it does cover many of the costs of being a ccbhc but it’s not sustainable because it is a grant and so you know we see the grants really as a springboard into Statewide implementation of ccbhcs in Medicaid through a waiver or a state plan Amendment if the Medicaid demonstration were to expand to additional states that could be another option but but in those non-demo States right now the primary option available for Statewide implementation would be through a Medicaid waiver or plan Amendment and we’ll come back to these options at the end before I turn things over to Jonathan I just want to spend another minute kind of clarifying the difference between the expansion grants and the Medicaid demonstration because there’s a lot of confusion around this and rightfully so it is a confusing differentiation um the Medicaid demonstration was the original um was where ccbhcs were originally established as I mentioned that demonstration is only open to 10 participating States um in contrast the ccbhd expansion grants are open to individual clinics in all states so if you look at kind of the structure of each approach um sorry I don’t know why there is Colorado specific information in this slide my apologies um if you look at the the states that were originally uh or the the original kind of implementation of the ccbhc model um it was founded around the sort of the state being the Arbiter of the ccbhc certification and the payment the state decided who got certified the state established the payment rate with those clinics and so their significant State involvement administered by those State Medicaid and Behavioral Health authorities the expansion grants are um administered by samsa and there’s not really any involvement of the state in those grants again we see the the grants as a springboard into State implementation um so we certainly encourage grantees to work closely with your state let them know that um uh you intend to go after a grant or have one that you’re interested in exploring sustainability options with them um so certainly all those states are not um don’t have a formal role in those grants for grantees there’s a great opportunity to engage with your state to try and build this program into a longer term initiative um and then in the demonstration ccbhcs do receive a special Medicaid payment methodology that’s known as prospective payment we’ll talk more about it in a moment um uh but it does because it’s a Medicaid payment it flexes with the number of enrollees or the frequency of their encounters um in contrast the grantee ccbhcs um receive a fixed pot of funding over those two years they continue to Bill Medicaid and other payers per usual um and and Grant funds as you all know don’t flex in quite the same way that um that Medicaid does when there’s changes uh perhaps to the level of need among clients or the number of of clients enrolled so both are really important ways of implementing ccbhcs but there’s critical differences between them and I think together both can build towards a more Nationwide implementation of the model um so uh let’s take a look at what the status of participation in the model is Nationwide you can see the the demonstration states are marked in dark blue um I want to point out Kentucky here is one of the newly added ccbhc States they’ll begin their demonstration in the late summer or fall of this year and then the states and light blue are states where individual grantees are operating to dive more deeply into the Southeast region um you can see here again there’s one demonstration State there are five states with individual grantees um and then there are two states with no ccbhcs yet but I certainly know that there is interest among clinics in both States um and I expect that we will very shortly see some grantees there as well all right so let’s talk a little bit about ccbhc criteria and payment I mentioned that ccbhcs have to meet a um a standardized array of criteria those cover six domains um you can see them listed here I’m not going to dive deep into all of these domains we’ll talk in detail about some of them I’m happy to answer questions about any of it however as we look at the ccbhd criteria and what ccbhds are doing um you know under this model I do want to make the point here that um by and large ccbhcs aren’t necessarily coming up with innovations that no one ever thought of before um what they’re doing is securing a funding source to make those Innovations possible and sustainable and Implement more of them so you hear me talk a lot about ccbhc successes and um you know and I certainly don’t mean that to imply that non-ccbhcs are not doing many of these things it’s just that they struggle harder to do it without that financing there um you know to fully support those programs or activities and so in that way the ccbhc model brings together all the best of what clinics are doing throughout the nation in the safety net to provide access to mental health and addiction care um and you know sort of combining them into a defined model that has a payment that comes along with it to support those activities foreign so let’s take a look at the ccbhc scope of services there’s nine required types of services that ccbhcs have to provide you can see them listed here those in blue must be delivered directly by the ccbhc and those in green can be delivered by a ccbhc or a partner organization known as a dco because ccbhc wasn’t a clunky enough acronym we added dco into the mix and so together the ccbhc and their dco or their partner deliver all of these services in their Community quite often what we’ll see is the ccbhc delivers some amount for example of peer support or primary health screening and monitoring but they might also contract out to another provider to supplement what they do so you start to see how even when ccbhcs are expanding their own Services they’re also strengthening those Partnerships with other providers in the community substance use disorder treatment and Specialty Mental Health Care are to really big areas where we see this happening so a lot of ccbhcs for example are working with dcos to deliver a specialty child an adolescent-focused Services a lot of them are offering a minimum amount of substance use service on site but then also Contracting with substance use providers to um you know to supplement that so we’re seeing some really uh really exciting Partnerships happening across the healthcare system and when it comes to crisis Services um the you know ccbhcs are not meant to duplicate existing crisis infrastructure and so in areas where there is a Statewide network of crisis response the ccbhcs can contract with those crisis providers rather than trying to rebuild what already exists in their community hair coordination is another critical feature of the model I think most uh Most states and clinics that I talk to um you know that are participating in this call the care coordination features of this model one of the most game changing aspects of it um the the model does require Partnerships or care coordination agreements with a number of entities that you see listed here that includes both some of the usual suspects in the healthcare world that you know that you would expect so fqhc’s Primary Care Providers hospitals and so on it also includes providers of Social Services across the Spectrum you know folks who are maybe not necessarily Healthcare Providers but who touch the lives of individuals served by ccbhcs and you know who should be coordinated with in order to make sure that that individual is receiving the Right Care at the right time in the right setting and so ccbhcs are required to partner with schools and child welfare agencies and criminal justice agencies and so on um I’m sure Jonathan could could tell you more about what this had looked like in practice but um really ccbhds are thinking even more extensively about their care coordination Partnerships and partnering with entities well beyond the um you know the the required minimum list um that was set out in the statute um so we just see some really tremendous strides towards improved care coordination and integration of services across that spectrum of entities that engage with individuals served by ccbhcs yeah the payment model for all of this is known as a prospective payment system and if any of you are federally qualified health centers or familiar with the federally qualified Health Center payment this will be familiar to you to establish the ccbhc payment the ccbhc completes a cost report that basically articulates the entire cost of doing business as a ccbhd not only historical costs that you know you’re going to incur based on what you’ve done previously but also your anticipated costs based on the services or the Staffing that you’re adding the influx of new clients that you anticipate you will serve and so um all of that I’d like to think of this as a um like a Soup pot so all of the all of the costs that go into operating your clinic and that includes both direct and indirect costs both billable and non-billable expenditures it all goes into the Soup pot they’re like the ingredients in the soup and then every time an encounter happens and this could be on either a daily or a monthly basis you take a ladle of soup out of the pot and that is your payment for that encounter now the payment is going to be the same regardless of the volume or intensity of services delivered on that day or in that month so if you have someone who came in on one day for um let’s say a med check um and that was all um the clinic is going the payment is going to be much greater than the actual expense of caring for that client on that day if the client comes in and needs the med check plus um a meeting with their case manager plus a group therapy session um plus uh you know other services you still get the same payment and so the clinic might not make enough from that single payment to cover that higher intensity client on that day but over the course of a year if you’ve done a really good job estimating your costs and your number of encounters um the payment over a year will roughly cover um or roughly equal what it costs to deliver those services to that population um so and again the you know the states or the state states that are in this model have the option to choose an encounter that is calculated on either a daily or a monthly basis so with the daily one you get one encounter or one payment per day that an encounter occurs for a monthly system you would get one payment per month in which an encounter occurred um uh both have their um they both have their pros and cons states are using both quite happily um and in clinics report being very satisfied with the ability of this prospective payment system to um fully fully support their activities as a ccdhc so again I just want to point out that this payment system does um although you would never you wouldn’t bill um on a you know for something like a an Outreach worker that had an encounter or like it had an engagement with an individual out in the community for example you don’t receive a payment for that the cost of your Outreach worker is built into right it’s one of the ingredients in the soup it’s built into that rate and so every time you do draw down an encounter payment it is covering in some way the cost of all those non-billable things the care coordination the Outreach work the you know the technologies that support care access right any any number of other things that um that historically are quite hard to fund um go into the soup they go into the cost report they are part of that payment so as we look at what this model has supported what this financial model has supported um and I’ll be talking primarily about the demonstration because again the grants are very different the grants are a two-year pot of a fixed sum of money um that is designed to help you do all of this work um but doesn’t it doesn’t um it doesn’t have the same flexibility as the Medicaid prospective payment that I just described so looking at the clinics that are part of that Medicaid prospective payment system um three years in almost four years at this point um that that payment model has supported increased hiring and recruitment clinics are able to offer more competitive salaries which has enabled them to fill vacancies expand staff positions and reduce turnover the clinics have spent a lot of time redesigning care teams and this more flexible environment where you are billing only on a daily or a monthly basis rather than in units of service you are free to to use your staff in different ways um uh so for example maybe your psychiatrist has more time to do things like consults on shared patients with other providers work that’s not billable um but again which is built into that payment rate clinics are rethinking who is on the care team um and really um re-envisioning what a care team should look like and how it should function ccbhcs have been able to improve access to care and when I say that I’m talking about access along several Dimensions um they’ve been able to serve more clients overall so across the eight states that were the original demonstration participants um over the first two years of the program we saw an average 25 increase in the number of people served by and large these were people who did not previously have a source of care um so you can you know they’re they’re bringing folks with an unmet need into treatment often for the first time the clinics have essentially eliminated wait lists uh the longest way the the clinics report to us for services would be around 10 days but much uh much more common is same-day access half of half of ccbhds do offer same-day access um and clients are able to access a greater scope of services so clinics that previously perhaps only offered mental health treatment are now expanding more into addiction care clinics that may have only served adults are now working with children um you know so so we’re just seeing uh access to that greater scope of care among ccbhc clients uh ccbhcs are launching new service lines to meet Community needs quite often those services are being deployed outside the four walls of the clinics um I I was reading just this morning rereading the Mathematica report that Jonathan’s going to talk to you about and um uh recall that 96 of ccbhcs are offering Services somewhere out in the community um I already mentioned the improved Partnerships that we’re seeing with schools Primary Care law enforcement hospitals and many many others which has been a huge benefit of this program and the result of that better care coordination and the improved accessibility of care is a reduction in hospitalizations and emergency department visits that states and Clinics are reporting to us as well as improvements in physical health indicators um so uh certainly you can see the you know the impact that this payment model and delivery model has had on these communities yeah so um looking ahead at what’s next for ccbhcs we do see broad bipartisan support in Congress and the administration um the Medicaid demonstration has been extended through I’m sorry there’s an error on this slide I’ll correct that before the slides go out to all of you the Medicaid demonstration has been extended through November through September 30th of 2023 um so there was a three-year extension uh passed just in December um there’s uh continues to be strong support in Congress for expanding funding for ccbhc expansion grants um so we do anticipate future rounds of funding for those expansion grants if you’re thinking about going after this there will be more opportunities um and as I mentioned before states can implement the model without congressional action Texas is the state that’s farthest down that road they’ve adopted an 1115 waiver that has enabled them to uh to implement ccbhcs across the state CMS has been quite favorable towards these efforts they have approved waivers in Texas and Minnesota they’ve approved state plan amendments in Missouri Nevada and Oklahoma um you know really I don’t think there’s necessarily a preferred approach both both the waiver or the plan amendment can equally help a state Implement ccbhcs um it’s I think it’s more a matter of preference um in terms of of how States choose to proceed um to give you a few quick details about how Texas has done this again they use 1115 waiver authorities to implement ccbhc among other delivery system reforms they’ve phased in ccbhds across the state over several years um with the ultimate goal of bringing them Statewide I think they began with um maybe around eight ccbhc certified initially and then have expanded it to a few dozen um today their prospective payment system is under development so the clinics there are already operating as ccbhcs but the payment system is the next phase that’s that’s coming down the road and Texas estimates that as a result of this change they’ll save 10 billion dollars by 2030. again those savings are predominantly from things like reduced hospitalizations and emergency department visits um so so start you know you can see the sort of the projections there for uh for how this model can can make a dent in in that area in two years in the first two years of Texas doing this there were no more wait lists at any ccbhc Clinic um and you can see as I mentioned earlier the sort of the better accessibility of a comprehensive scope of treatment at a ccbhc um reflected in the fact that 40 of clients at ccbhces are being treated for co-occurring substance use and mental health needs compared to 25 of other clinics so again you can see how this payment model is enabling um uh expansions that many clinics have wanted to do for quite some time but haven’t had the resources to support the National Council is here to help if you are interested in moving towards ccbhc status we provide support to individual clinics that are thinking about going after one of the grants or implementing the grant that they just received we also provide supports to States who are are thinking through what would our roadmap towards implementation look like what has this model generated in other states um and and how could we move towards this as a state uh looking ahead so um you can see our our website and our contact information here at the bottom of the screen and with that I’d like to stop and turn things over to Jonathan okay thanks Rebecca let the attempt to share my screen here all right well thanks for the invitation uh to share some of the findings today uh so I thought that we would uh just take a moment to share some of our observations about the types of Investments that states and Clinics have made over the past few years to meet the certification criteria and become CCBC’s talk a little bit about some of the common implementation challenges and how they’ve been able to overcome them and uh hopefully if we have some time uh share a few lessons about what we’ve learned about the prospective payment models as well so um as Rebecca mentioned and Ben as well are ongoing evaluation is for uh office as assistant secretary for planning and evaluation and uh that has included just the eight original uh demonstration States so we’re not evaluating um the two new states that we just recently came on board or the samhsa funded grant program but some of the findings might still apply to kind of future ccbhc efforts or similar uh kind of value-based payment efforts going forward so there’s a lot of slides here a lot of material and in the interest of time I’m going to skip through some things and uh go over this some some of this very quickly uh because some of it Rebecca did a fantastic job of covering so I’m not going to talk too much uh more about the ccdhc criteria uh you’ve got the link there if you want to kind of take a deeper deeper dive uh and we’re happy to answer your questions about it as well just wanted to give you kind of a brief orientation to the evaluation that we’re conducting um it’s really designed with to our overarching goals the first being to assess different dimensions of implementation in terms of how States supported the model the successes and challenges that that they’ve had in implementing that full scope of services looking at the Quality and cost of care and also experiences uh of different stakeholders with the model and then the second goal being to measure the impacts of the demonstration on Medicaid service utilization and costs um so I’m going to focus today on just giving you a few highlights from our implementation findings that might be relevant as you’re kind of thinking about uh the ccbhc model in your States and communities the uh were concluding the analysis of the Medicaid service utilization cost now so I won’t be sharing that today but I hope to have those findings to come back and share with you all the near future not going to go deep into our data sources or methods other than to tell you that we have collected both qualitative and quantitative data over time at different points in the implementation of the demonstration to uh track progress over time and and kind of understand the rollout of the demonstration uh primarily uh what I’ll what I’ll draw from today in some of the the findings uh uh come from the progress reports that ccbhc submitted in both years of the demonstration as well as those cost reports that Rebecca mentioned earlier uh and some of our our qualitative data collection as well so again just want to give you some real high level highlights of um some of the Investments that uh States and Clinics have made to meet the certification criteria and become CCBC’s so um really I think those uh can be summarized a bit here there certainly are a lot of other Investments that are not captured here but these are some of the major things that we’ve observed from the evaluation and I think um they just Echo a good bit of what Rebecca talked about earlier um one being the hiring and training of staff to provide team-based care as Rebecca mentioned there are some uh requirements in the certification criteria about the types of staff that ccbhcs should employ but there’s also flexibility in that criteria to kind of design treatment teams in a way that meets the needs of the clients at that particular clinic or in that particular community um adding Behavioral Health and expanding behavioral health physical and rehabilitative services in particular uh as Rebecca mentioned it’s not that these clinics were not necessarily providing some of these Services prior to the demonstration but we have definitely observed uh the expansion of of those services in uh kind of kind of different different ways that I’ll talk about in a second the Partnerships that Rebecca talked about was have also been extremely important um nearly all of the clinics have developed these Partnerships with a range of external providers both to facilitate referrals to the clinic and referrals from the clinic and to coordinate care with those external providers and the final thing I’ll say is um you can’t really underscore enough some of the Investments and enhancements that were made to the ehrs or other hit systems to support the demonstration uh both to support the sharing of information across providers and those care coordination functions as well as to capture and Report the quality measures that are required as part of the the demonstration and really what we’ve heard from States and Clinics is that it’s been both the the combination of the the two-year planning grants that the states received prior to the launch of the demonstration as well as this new payment model that has facilitated these types of Investments so um the next few slides just really really give you um kind of some brief uh snapshots of um what I just talked about there um to kind of dig in a little further um so so in terms of Staffing and hiring uh this is not an exhaustive list of all the types of Staff of these clinics uh employ or have hired but uh does illustrate some of the staff types for which we observed uh some pretty substantial increases from before the demonstration to the first and second years of the demonstration so in particular uh case managers adult psychiatrists and peer staff were some of the uh Staffing types that clinics really invested in hiring uh leading up to the demonstration and in the first year you don’t have to tell you all why it may be more difficult to find psychiatrists for uh child adolescent population but that was another area uh where clinics made Investments in terms of the type of training that that I just mentioned earlier again this slide just gives you a bit of a snapshot for the types of trainings that clinics provided in the first year of the demonstration so nearly all providing training in the areas of risk assessment and suicide response or prevention from informed care cultural competency if you look down the list there most clinics are also making investments in providing training around primary and Behavioral Healthcare integration um and these trainings you know do you know continue throughout the demonstration as well again as Rebecca talked about there really is an expansion of services under this model it’s not just providing um kind of the same Services under a new payment model but there is uh uh kind of the the addition of various types of services that the clinics may have offered to a certain degree prior to the demonstration but have enhanced in some way and again this gives you a bit of a snapshot of their of those services in particular as Rebecca mentioned there has been this expansion of substance use services for clinics that may have been more predominantly focused on mental health treatment in the past and also expansion to different populations as well most clinics are providing um some type of emergency Crisis Intervention directly about 80 percent of clinics have their own uh 24-hour mobile crisis teams uh and as Rebecca mentioned about a third of clinics in addition to providing their own services do partner with another entity to provide either some type of Crisis stabilization or uh suicidal crisis hotline and uh again those are typically in states or communities where those Services existed and it made sense to tap into that rather than recreate it at a ccbhc level communist people are the Partnerships because we talked a good bit about that might just say that some of the Partnerships with the organizations listed in that second bullet here urgent care centers school-based or rural Health Centers were a bit less common in the demonstration States or for those clinics but that was mostly because they were just located in communities that weren’t adjacent to those types of of uh of clinics or providers where they were um located and where they had those Partnerships they were really critical and they finally have mentioned the investment in the the data systems and the ehrs and other systems nearly all clinics did need to make some kind of enhancements to their systems and in addition to making enhancements to whatever current systems they had about a third adopted some entirely new system to capture some type of information that their existing system um didn’t have the capabilities to do and I I don’t want to minimize this because this really was a heavy lift for a good number of clinics um and for state but States really did provide a lot of technical assistance and support and during the the planning Grant phase of the demonstration kind of leading up to the launch um they made uh kind of good strides to be able to build out some of these functions that you see listed here below and ultimately to capture the information for the quality measures and for uh care coordination so I’m just going to talk for just a second slow down just for a minute here to talk about some of the implementation challenges uh that we’ve observed across States uh none of which I think were really unanticipated uh but still are probably good to have on everyone’s radar um so in terms of Staffing um not surprisingly most clinics did report that at least one position that was required in the certification criteria was bacon for a period of time um and that uh particularly um looking for substance use treatment providers and peer support staff were challenging in some communities um and and these weren’t really kind of uh challenges that were unique to CCBC’s but but but really kind of um common in Community Mental Health Services in terms of Workforce shortages and and being located in areas where maybe rural areas where uh it was difficult to find those staff uh but but uh you know the clinics were really able to largely overcome these Staffing challenges both because they were able to use the new payment model to offer more attractive and salary salaries and and they also we heard from clinics and and staffs that they were also just attractive places to work because people wanted to be part of these models um I talked a little bit about some of the challenges delivering these new Services again that was mostly just related to Staffing defining staff to to implement them uh as well as uh some of the challenges reporting their quality measures that really required to build out of the their ehrs or hit systems uh I think what we also learned though was that they in some cases need to implement new processes of care uh that are in the criteria uh such as such as new screening which also kind of feeds into the quality measures and ultimately the clinics were largely able to report the measures and use them for quality improvement and found them valuable uh and and also not unanticipated um some initial billing challenges just as folks are getting getting oriented to this new way of building for daily or monthly services and kind of the new new processes around that but clinics were able to overcome that and and get paid um with with help from the state uh kind of in the first uh a few months or a year of the demonstration and again just to reiterate that the agencies really did provide a critical support in in many different ways through technical assistance around uh building out Data Systems uh providing kind of quality monitoring and feedback to clinics as well as in some cases making some changes at the state level um to support implementation of the model so in the last um kind of uh six minutes or so because I want to make sure we have time for questions uh we did just want to share a few lessons about the the payment models so just to recap um say say it again because I always have to remind myself as well um these are the eight states that we’re focused on here and six of those States chose that daily payment model uh that Rebecca talked about and two states Oklahoma New Jersey chose that monthly payment model where um the the clinic gets a monthly payment for any month in which the consumer receives Services regardless of how much Services the person receives during the month or how many visits they have and again there’s kind of trade-offs of each of each model um but I want to talk just for a second about the sort of the rate setting process and what we’ve learned about the rates that might be applicable for kind of the the future of this model and kind of similar models not surprisingly you know rate setting was kind of a challenge at the outset um just to reiterate State set a rate for each Clinic there’s not a single rate that applies to all clinics in the state and so for each Clinic they really got to kind of look at what are the pre-oper pre-demonstration operating costs before you become a ccbhc and then forecast what what are the costs of these new services that you’re going to add and how many people are you going to bring into the clinic as well um the existing population as well as these new populations that you’re expanding to um and so States again provide a lot of technical assistance uh to help um clinics complete those cost reports that Rebecca talked about which fed into the rate setting process and they recognize the limitations of the available data at the time and kind of aired on the side of prioritizing that the clinics would have the financial support they needed to operate even if that may have meant setting the rates a little bit High initially so um we’ve gotten some questions in the past about what the rates really are and um are they you know have they been enough to cover the costs of services so uh there’s a lot of numbers on this screen but um just want to kind of show you quickly the the range of the rates across States and across clinics within a state so uh that daily rate range from a low of um 210 in Nevada to a high of 403 dollars in uh Minnesota um with some variation in between um and again this is sort of reflect this sort of reflecting like the local market conditions as well as kind of the cost of operating before the demonstrations in each of these states but then if you look at the next two columns you also see that range of uh rates within a state um and so again Minnesota having the largest range from about 269 to 709 in the first year across clinics and in Nevada the the clinics were paid um generally the same rate um and then New Jersey and Oklahoma have those uh higher rates because those are those are the monthly um those are the monthly as opposed to the Daily payment rates um so on average it’s um and those are all the first year rates on average um those rates um did cover the cost of uh operating in seven of the eight demonstration States uh but uh still in each state there were some clinics for for which the the rate didn’t fully cover the cost in the first year um and that’s what Illustrated here on this slide each Clinic being a uh green or blue dot depending on the PPS model in the state and the the orange there being the state average and so what you see is that you know on average the the rates are actually exceeding the cost in the first year uh but for but there are clinics that are below that line meaning that their the rates weren’t fully covering the cost of of the services uh for those individual clinics and so in the second year of the demonstration the states did have the option to revise those raids so a process they called uh rebasing um based on the cost of delivering care in the first year of the demonstration so they could either revise those rates up or down um the states listed here did choose to uh kind of recalibrate their rates for the second year most moved in the direction of bringing the rates down to kind of bring them in closer alignment with the with the cost that they observed from the first year um to the states Oklahoma New Jersey did actually in um uh uh increase the the rates for for the clinics and their states and two states decided that they wanted just to hold off Missouri and Oregon um to to get more data to inform um changing those rates so um you know I think really kind of the taking a step back the lesson from all this is that uh you know it’s difficult to predict these first year costs when you’re adding new services and expanding to new populations states often don’t have the best data and Clinics don’t often have the best data uh kind of going into this to uh make those predictions but as we’re seeing over time you know it kind of take some time to align those rates with the cost and states have been able to kind of learn from the first year of the model um to to kind of uh better align those rates and costs over time uh so you know don’t don’t you might not want to make decisions about whether this is all working just based on the first year year cost um as the as the states and Clinics are really learning uh from the model so you know stop there um say uh stay tuned for uh future findings from our evaluation uh around both the the quality measures uh and the impacts of the demonstration on the service utilization and cost happy to answer more questions now there’s also uh several um pretty dense reports pretty thorough reports uh online if you want to kind of take a deeper deeper dive into any of the uh evaluation findings and then I’m happy to answer questions all right thank you so much to both of you we have now reached the Q a portion of today’s webinar so everyone please feel free to submit your questions for our presenters by typing them into the Q a feature I’m going to go ahead and start with the first question um which was will this presentation be available to download yes it will be available to download on our website in a couple of days um I’m going to go to the chat because I know we had some questions in the chat um the first question is is Massachusetts one of the Medicaid demo States and I did see another question in the Q a feature about which of those 10 which states are included in those 10 states sure I can um repeat the list um it’s also in the slides we saw earlier so the question may have been answered but um just as a refresher of the original eight demonstration states where Oregon Nevada Oklahoma Missouri Minnesota New York Pennsylvania and New Jersey and then Michigan and Kentucky were recently added so no Massachusetts is not one of those original or not one of those demonstration States I will say as states are you know National Council our team is in a lot of conversations with different states that are really interested in exploring whether ccbhc could be right for them and um when we talked to when we had similar conversations with States five years ago as they were considering whether to go after participation in the demo um so much was unknown um when States would ask me questions quite often the answer was well we don’t know you could you know you’ll you propose something and see what you can do see what works um and adjust as needed as you go along the way and I think you heard from Jonathan about some of the ways that states were adjusting as they went um you know around the the payment rates and the um you know the billing structures and the the data and Quality Reporting and you know the EHR system upgrades and so on and so forth and the great news is that we’ve learned so much from those eight states that went first um so states that now would consider moving after you know going after ccbhc implementation are in a much much different position where they can see what has worked really well in other states they can learn those lessons um and they can have hopefully a much more streamlined experience of implementing them all so if you’re in a state like Massachusetts that um you know isn’t it isn’t already there um I I think there’s certainly a lot to be learned from these prior states that could help pave the way for new states to adopt it foreign thank you so much Rebecca uh it looks like we don’t have any further questions in the Q a feature or in the chat I just wanted to open it back up to you and to Jonathan to see if you had any final comments or remarks before we go on to evaluation um I guess I would just um repeat that National Council would love to continue the conversation with anyone who might be interested in exploring the ccbhc model further whether that’s answering more questions about what it looks like or helping you think through what your next opportunity to apply for a grant might be and how to get ready um you know we’re we’re available to support so please don’t hesitate to reach out to us our goal is to make sure that as many clinics as possible can become ccbhcs and that they can all be as successful as possible as they do it yeah uh likewise probably on that same note I’ll just say if uh there’s anything you’d like to learn more from about the evaluation or uh perhaps you know how the findings from the evaluation could be applicable to um any decisions that that you’re trying to make please don’t hesitate to reach out I think my email contact information uh is um at the end of the slides there and we’d be glad to chat all right thank you both so much okay we’ve come to the end of our webinar today everyone the southeast mhttc would like to thank you for your participation in today’s event we value your feedback and invite you to evaluate this event by completing the brief samsa required survey visiting the link presented on your screen in the chat box or by scanning that QR code completion of this survey will provide information to samsa and assist us in planning future events like this one afterwards you will be automatically redirected to additional questions from the southeast mhttc regarding the impact of this event on your Knowledge and Skills there you will have the opportunity to download a certificate of attendance for your records please allow about five to ten seconds for your browser to redirect you again our Center appreciates your participation in feedback Rebecca and Jonathan thank you so much for joining us today and for providing this amazing information we hope that you all will join us for future events please visit our website to learn more and this will conclude today’s presentation okay thank you thank you thank you
This webinar provided a snapshot of CCBHCs across the country, described the changes and investments that clinics made to become CCBHCs for the national demonstration program, and discussed the various funding avenues available to states and clinics to support the CCBHC model.
CCBHCs are designed to increase access to mental health and substance use disorder treatment, expand states’ capacity to address the overdose crisis, promote partnerships with law enforcement, schools, and hospitals to improve care, reduce recidivism and prevent hospital readmissions. Today, 340 CCBHCs are operating in 40 states, plus Washington, DC and Guam. Congress has expanded the demonstration and authorized grants to support the model. A growing number of states are moving to implement the model independently via a state plan amendment or Medicaid waiver.