We held a call on Wednesday, September 7, to discuss the required CCBHC services and hear your thoughts.
This document and the accompanying CCBHC Services Summary and CCBHC Evidence Based Practices tables summarize the Massachusetts CCBHC program requirements and services. CCBHC providers should use these materials in preparing their cost report.
The program requirements focus on staffing and administrative activities, such as the availability and accessibility of services, care coordination, the scope of services, quality and other reporting, and organizational authority.
The document follows the outline of the SAMHSA Criteria included in Appendix II of the SAMHSA RFA (see below). Federal and state CCBHC requirements are described in the following documents:
For additional information, CCBHC requirements and other federal documents can be found at http://www.samhsa.gov/section-223.
Key elements of the Program Requirements are summarized below:
The CCBHC will budget for a staffing plan that is informed by their local needs assessment and that documents how they meet CCBHC staffing requirements described in the Services Summary and in the CCBHC Criteria 1.A through 1.D. The staffing plan shall ensure that staff meet all applicable MA licensing criteria and standards and shall include the staff sufficient to support the nine required services and the Program Requirements.
The CCBHC shall offer services that are accessible and available to individuals in their community (federal and state requirements for services are described in the accompanying Services Summary) and shall adhere to the following additional requirements regarding access and availability:
Section 223 (a)(2)(C) of PAMA states that CCBHCs must coordinate care “across settings and providers to ensure seamless transitions for patients across the full spectrum of health services…”. Care coordination activities are outlined in detail in Program Requirement 3 in the CCBHC Criteria. This includes general requirements for coordination, consent, consumer choice, health information systems, provider and community agency agreements, and post-discharge follow-up requirements. In addition to these federal requirements for all MassHealth clients, care coordination activities for MA CCBHCs shall also include the following:
CCBHCs will provide a full array of the nine required CCBHC services to clients including crisis services. Each of the 9 required CCBHC services is described in the accompanying Services Summary table, summarizing SAMHSA requirements and describing additional state requirements.Because MA has a “state sanctioned” crisis intervention system and network of providers, crisis services will be available through DCO agreements between participating CCBHCs and one or more of the network of designated, state sanctioned, Emergency Services Program (ESP) for the CCBHC coverage area.
See Attachment 7 of Massachusetts proposal to participate in the CCBHC Demonstration for a list of mandatory and recommended Evidence Based Practices.
CCBHCs must maintain electronic health records, including hardware and staffing, that are capable of the required data collection and reporting outlined in the Criteria and described in further detail on the SAMHSA Quality Measures page.
CCBHC must maintain a governing board, CCBHC accreditations, auditing and other governance requirements outlined in the CCBHC Criteria.
|CCBHC Services||SAMHSA Requirements||Additional State Specifications|
|Crisis Behavioral Health||
Unless there is an existing state-sanctioned, certified, or licensed system or network for the provision of crisis behavioral health services that dictates otherwise, the CCBHC will directly provide robust and timely crisis behavioral health services. Whether provided directly by the CCBHC or by a state-sanctioned alternative acting as a DCO, available services must include the following:
PAMA requires provision of these three crisis behavioral health services. As part of the certification process, the states will clearly define each term as they are using it but services provided must include suicide crisis response and services capable of addressing crises related to substance abuse and intoxication, including ambulatory and medical detoxification. States may elect to require the employment of peers on crisis teams. CCBHCs will have an established protocol specifying the role of law enforcement during the provision of crisis services.
The CCBHC shall provide robust and timely crisis behavioral health services for individuals who require crisis behavioral health services. When a CCBHC screens and assesses a client as needing crisis services, the CCBHC shall promptly make a referral to the Emergency Services Program (ESP) covering their area. ESPs are a state sanctioned delivery system and network of providers for the provision of crisis behavioral health services. For these referred clients, the ESP will act as a Designated Collaborating Organization (DCO) to the CCBHC and the CCBHC shall be responsible for payment of the ESP. Clients or families needing more immediate response should contact the ESP directly, go to their local emergency room or call 911. ESP services, defined in the current MA ESP contracts, include Emergency Crisis Interventions, Mobile Crisis Intervention (child/youth), Adult Mobile Crisis Intervention, and Adult Community Crisis Stabilization (CCS).
CCBHCs shall develop formal agreements with the state designated ESPs in their area for the coordination of care and exchange of healthcare information for clients referred by the CCBHC as well as clients in the care of the CCBHC who accessed ESP services through a local emergency room or by self-referral. In addition, the CCBHC shall develop formal agreements with local emergency departments and law enforcement officials for referrals and service coordination.
CCBHCs shall provide access to a physician or psychiatric nurse practitioner on-call at all times for an emergency consult. CCBHCs shall also ensure that NARCAN is available to treat overdoses.
CCBHCs shall ensure that individuals and families receive timely follow up services after receiving ESP services for a mental health or substance abuse crisis.
|Screening, Assessment, and Diagnosis||
The CCBHC directly provides screening, assessment, and diagnosis, including risk assessment, for behavioral health conditions. In the event specialized services outside the expertise of the CCBHC are required for purposes of screening, assessment or diagnosis (e.g., neurological testing, developmental testing and assessment, eating disorders), the CCBHC provides or refers them through formal relationships with other providers, or where necessary and appropriate, through use of telehealth/telemedicine services.
CCBHCs shall provide an initial screening and assessment visit for all clients needing services within 10 business days of their initial request.
CCBHCs are required to use standardized evidence based screening tools for child and adult mental health and addiction disorders. This includes standardized risk assessment tools for suicide and overdose risk screening. Required and recommended screening tools are summarized in the CCBHC Evidence Based Practices table (Attachment 7 of the Massachusetts CCBHC Demonstration Proposal).
The CCBHC shall ensure that the results of all screenings and assessments are included in the health record, incorporated in the person centered plan, and any and all applicable follow-up services indicated.
|Person Centered and Family Centered Treatment Planning||
The CCBHC directly provides person-centered and family-centered treatment planning or similar processes, including but not limited to risk assessment and crisis planning. This shall include the following, with specifications outlined in the Criteria:
Treatment Planning is an integral part of outpatient mental health and substance abuse services. It should be delivered in accordance with existing regulations of the Commonwealth. CCBHC treatment planning should include planning for and coordination of care for the full array of CCBHC services as well as other rehabilitation and support services. Treatment plans and risk assessments shall be reviewed and approved by a licensed mental health or substance abuse clinician.
The CCBHC shall ensure that the treatment planning process and the treatment plan is fully documented in the health record.
|Outpatient Mental Health and/or Substance Abuse Services||
The CCBHC directly provides outpatient mental and substance use disorder services that are evidence-based or best practices, consistent with the needs of individual consumers as identified in their individual treatment plan. In the event specialized services outside the expertise of the CCBHC are required for purposes of outpatient mental and substance use disorder treatment (e.g., treatment of sexual trauma, eating disorders, specialized medications for substance use disorders), the CCBHC makes them available through referral or other formal arrangement with other providers or, where necessary and appropriate, through use of telehealth/telemedicine services.
Treatments are provided that are appropriate for the consumer’s phase of life and development, specifically considering what is appropriate for children, adolescents, transition age youth, and older adults, as distinct groups for whom life stage and functioning may affect treatment. These treatments are delivered by staff with specific training in treating the segment of the population being served.
Children and adolescents are treated using a family/caregiver-driven, youth guided and developmentally appropriate approach that comprehensively addresses family/caregiver, school, medical, mental health, substance abuse, psychosocial, and environmental issues.
The Commonwealth has outlined required and recommended Evidence Based services as a part of outpatient services in the summary of required and recommended CCBHC Evidence Based Practices (Attachment 7 of the Massachusetts Demonstration Proposal).
Outpatient services are generally clinic-based services though they may be scheduled off-site, at client homes, schools or other community locations and provided through telemedicine using HIPAA-compliant technology.
To ensure clients with a substance use disorder have access to appropriate care, CCBHCs shall provide a DATA-waived1 physician for urgent medication assisted treatment during all business hours. People requiring medication assisted treatment shall have access to the following services in the CCBHC:
Clients requiring methadone shall receive timely referrals with follow up for the separately licensed, state sanctioned ambulatory Opioid Treatment Providers. CCBHCs must have formal agreements in place with these providers to ensure care coordination.
When a client requires more intensive services that are provided under other licensing standards, they shall be referred to the needed services or the CCBHC shall develop strategies to deliver these services directly including more frequent visits, new licensing and a more comprehensive set of services.
|Outpatient Clinic Primary Care Screening and Monitoring||
CCBHCs are responsible for outpatient clinic primary care screening and monitoring of key health indicators and health risk. The CCBHC is responsible for ensuring these services are received in a timely fashion. These screening and monitoring services may be delivered directly or through a DCO.
Required primary care screening and monitoring of key health indicators and health risk provided by the CCBHC include those for which the CCBHC will be accountable pursuant to Appendix II, Program Requirement 5 and applicable evidence based practices from Attachment 7 of the Massachusetts CCBHC Demonstration Proposal. The key physical health quality measures follow: 1) Screening for tobacco use (2) adult body mass index (BMI) screening and follow‐up; (3) weight assessment and counseling for nutrition and physical activity for children and adolescents; (4) diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications.
The CCBHC ensures children receive age appropriate screening and preventive interventions including, where appropriate, assessment of learning disabilities, and older adults receive age appropriate screening and preventive interventions.
|No additional state requirements|
|Targeted Case Management (TCM) Services||
The CCBHC is responsible for high quality targeted case management services that will assist individuals in sustaining recovery, and gaining access to needed medical, social, legal, educational, and other services and supports. Targeted case management should include supports for persons deemed at high risk of suicide, particularly during times of transitions such as from an ED or psychiatric hospitalization.
CCBHCs provide targeted case management services (TCM) to the following high risk groups: individuals at high risk of suicide, those with co-occurring disorders of mental health and substance abuse, and those recently discharged from an ED, crisis, detox services and/or inpatient services. TCM services are particularly important for improving follow-up measures and to coordinate care with people with substance use disorders.
CCBHCs shall ensure that referrals and care coordination are provided for individuals eligible for DMH targeted case management and children and youth receiving Targeted Case Management through the Intensive Care Coordination Service of the CBHI initiative.
CCBHC staff providing TCM services must have a bachelor’s degree or equivalent experience in social work, psychology or a related field or certification as a peer support or recovery coach provider. The state will establish a review process and standards for experience.
|Psychiatric Rehabilitation Services (PRS)||
The CCBHC is responsible for evidence-based and other psychiatric rehabilitation services. Psychiatric rehabilitation services that might be considered include: medication education; self-management; training in personal care skills; individual and family/caregiver psycho-education; community integration services; recovery support services including Illness Management & Recovery; financial management; and dietary and wellness education. States also may wish to require the provision of supported services such as housing, employment, and education, the latter in collaboration with local school systems.
At a minimum, CCBHC PRS services should include the availability of weekly psychosocial groups on topics including health and literacy, substance abuse, medication education, chronic disease -management, and individual and family/caregiver psycho-education services. The exact topics and scope of the groups should be based upon the needs of the populations being served.
For individuals recently discharged from an acute psychiatric inpatient episode or from a substance abuse detox, CCBHCs should consider referral to more intensive, evidence-based psychiatric rehabilitation services as outlined in the CCBHC Evidence Based Practices table (Attachment 7 of the Massachusetts CCBHC Demonstration Proposal).
Psychiatric rehabilitation services may be provided by Occupational Therapists, Certified Peer Specialists or Recovery Coaches and other professionals with appropriate training. PRS services may be provided in a group, in home or other community setting based on best practices and the needs of the individual.
|Peer Supports, Peer Counseling and Family Caregiver Supports||
The CCBHC is responsible for peer specialist and recovery coaches, peer counseling, and family/caregiver supports. Peer services that might be considered include: peer‐run drop‐in centers, peer crisis support services, peer bridge services to assist individuals transitioning between residential or inpatient settings to the community, peer trauma support, peer support for older adults or youth, and other peer recovery services. Potential family/caregiver support services that might be considered include: family/caregiver psycho-education, parent training, and family-to-family/caregiver support services.
CCBHCs shall provide peer and/or family support services when needed and when included in the treatment plan. Peer Support Services include social and emotional support, mentoring or support counseling, problem solving, assistance in daily skills and linkage to community services. At a minimum, CCBHCs must have at least one Certified Peer Specialist and at least one Recovery Coach on staff or on site during clinic hours. Additional peer support services may be provided directly or through a DCO relationship. CCBHCs should pay additional attention to the needs of youth aged 18-25 and older adults in their communities.
The current peer certification criteria and processes can be found in the Massachusetts Certified Peer Specialist Program Policy Manual Approved by the CPS Oversight Committee June 11, 2015: http://transformation-center.org/wp-content/uploads/2012/06/CPS-Policy-Manual-approved-June-2015.pdf. Recovery coaches should be certified as Certified Addiction Recovery Coach (CARC) in Massachusetts as administered by the Massachusetts Board of Substance Abuse Counselor Certification. This is further described on http://www.ma-atr.org/Recovery-Coaching.aspx. Peer specialists and Recovery coaches who do not have current certification will have a year from the date of hire to obtain certification.
|Intensive Community- Based Mental Health Care for Members of the Armed Forces and Veterans||
The CCBHC is responsible for intensive, community-based behavioral health care for clients who are members of the U.S. Armed Forces and veterans, particularly those for Armed Forces members located 50 miles or more (or one hour’s drive time) from a Military Treatment Facility (MTF) and veterans living 40 miles or more (driving distance) from a VA medical facility, or as otherwise required by federal law. Care provided to veterans is required to be consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration (VHA), including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration. Specifications for services to Veterans are described in more detail in Appendix II Sections 4.k.2 – 4.k.7. All individuals inquiring about services are asked whether they have ever served in the U.S. military and if so, they are offered assistance to enroll in the VH for behavioral health services. Every veteran seen for BH services is assigned a Principal Behavioral Health Provider who is responsible for treatment planning and care coordination.
CCBHCs shall provide the full array of CCBHC services to veterans (all veterans regardless of VA eligibility). CCBHCs shall use care coordination, assessment and referral practices that are informed by an understanding of military culture and that demonstrate competence in working with members of U.S. Armed Forces, veterans’ and military families. CCBHC clinical staff will have a working knowledge of www.MassVetsAdvisor.org and when to appropriately utilize and refer to this resource.
CCBHCs shall provide services directly and wherever possible provide referrals for veterans to the following: the services offered by the United States Department of Veteran Affairs (VA), including the Veterans Benefits Administration (VBA), Veterans Health Administration (VHA), and National Cemetery Administration (NCA);the VA Choice Program where applicable; MA Veteran Service Officers (VSOs); the Massachusetts Department of Veterans' Services, and; the Statewide Advocacy and Veterans Empowerment (SAVE) Team.
1Physicians approved by the Drug Enforcement Administration to administer, dispense and prescribe narcotic treatment with Schedule II-V controlled substances.
Attachment 5. CCBHC Program Requirements and Services Summary