Behavioral Health Brief: Certified Community Behavioral Health Clinics — How and Why They Work
By Sue Coyle, MSW
Social Work Today
Vol. 20 No. 4 P. 30

Increasingly, we have recognized the need for better access to quality health care services throughout the country. However, much of the focus has been on physical health care, finding ways to offer primary care to a wider range of individuals and communities. Only recently—in the past few years—has attention turned toward behavioral health care and access to those services, as well.

In 2014 that attention manifested in the establishment of Certified Community Behavioral Health Clinics (CCBHCs). The bipartisan Protecting Access to Medicare Act provided a definition and guidelines for CCBHCs and launched a demonstration program, as outlined by the Excellence in Mental Health Act. Eight states were selected for the program, and the first CCBHCs opened in 2017.

Since then, 113 CCBHCs have been established in 21 states throughout the country. They provide services to individuals struggling with mental health and substance use needs. And they have managed to do something that very few have done in recent years: draw bipartisan support.

Why? The answer to that question lies in understanding what CCBHCs do and the effects they have already had on the communities served.

Effectiveness
CCBHCs are facilities in which any individual can receive care for a mental health or substance use need. “CCBHCs are required to serve everyone, regardless of their ability to pay, regardless of their diagnosis, regardless of their [insurance] coverage,” says Chuck Ingoglia, MSW, president and CEO of the National Council for Behavioral Health. “We are here to serve everyone. No matter what you need, we’re here for you.”

Nine core services must be offered by CCBHCs. According to the National Council (2020a), these requirements are the following:

• crisis mental health services;
• screening, assessment, and diagnosis, including risk assessment;
• patient-centered treatment planning;
• outpatient mental health and substance use services;
• primary care screening and monitoring of key health indicators/health risk;
• targeted case management;
• psychiatric rehabilitation services;
• peer support and family supports; and
• intensive, community-based mental health care for members of the armed forces and veterans.

The combination of mental health and substance use treatment is key, Ingoglia says. Many individuals have co-occurring mental health and substance use disorders. In fact, according to the National Institute on Drug Abuse (2020), “about half of those who experience a mental illness during their lives will also experience a substance use disorder and vice versa.”

However, many facilities do not offer quality care for both. CCBHCs do.

CCBHCs also attempt to address the issue of timely services. The goal, if not mandate, of CCBHCs is for individuals seeking help to receive care as quickly as possible once they’ve reached out or been referred. In many instances, behavioral health facilities have long waits for intake and longer waits for ongoing appointments after that. “Because our mental health and addiction treatment is so underfunded, it could be weeks or months before you’re called to come in. By the time someone works up the courage for care, the last thing they need to hear is ‘It’s going to be weeks,’” Ingoglia says. CCBHCs are often able to provide same-day care.

They are able to do this in part because of the payment structure for CCBHCs. Rather than fee for service, CCBHCs operate under a prospective payment system. This means that they bill for the anticipated cost of care, and that cost takes into account everything from staff salaries to the technology used. Using this Medicaid payment methodology allows CCBHCs to be better staffed and better prepared to provide the required services in an appropriate timeframe.

Preparing and Training
But it is not just funding that allows CCBHCs to provide the services they do. Preparation and ongoing training play a big part, as well. CCBHCs must comply with the requirements outlined in the Excellence in Mental Health Act, and they also must be able to provide services that earn the trust of not only individual clients but also the community as a whole. Training and preparation when facilities are becoming CCBHCs make both of those things possible.

One of the first priorities, says Melissa Lewis-Stoner, MSW, LCSW-C, group product manager at Relias, is to train staff on the nine core services. “For many people, expanding and getting ready [to become] a CCBHC might mean introducing substance use services for the first time. You need to understand what those services are, [and] make sure that your staff is feeling comfortable and competent.” Relias provides training for 90% of the current CCBHCs.

Beyond the core services, training may also entail ongoing assessments of clinicians to determine their strengths and weaknesses, as well as extensive onboarding. “Onboarding is often viewed as orientation,” Lewis-Stoner says. However, research has shown that true onboarding takes between 12 and 18 months. At that point, a staff person should be truly competent in their position. Having an onboarding experience that enables ongoing learning leads to better retention and better services.

“Staff will stay because they are engaged. They’re getting what they need,” Lewis-Stoner says. “If you don’t have a culture of learning or you don’t have personal development plans, you don’t have the ability to get continuing education credits, you’re going to have high turnover and you’re also going to have a poor patient experience of care. That is big with CCBHCs.”

Outcomes
Given the training and focus on access to quality care, it is not surprising that CCBHCs have already proven to have positive outcomes. One of the most telling outcomes is how many individuals have been served. The National Council (2020b) found that “in the first six months of implementation, 87% of CCBHC reported an increased number of patients served, with the majority reporting an increase of up to 25% in total patient caseload.”

“I have been blown away by how many people who had never been seen before are now being treated at a CCBHC,” Ingoglia says. He adds that in addition to the increase in access to care, data indicate that there has also been a reduction in the number of people having unnecessary emergency department visits, increases to medication adherence, and decreases in the number of people having contact with the criminal justice system.

Such an increase in patients is handled by an increase in staffing. As of November 2018, an additional 3,009 new staff had been hired at CCBHCs throughout the country.

CCBHCs are also creating an opportunity for the behavioral health care field to standardize and report back on operating procedures. “Right now every state organizes and delivers care differently,” Ingoglia says. “The next real opportunity with CCBHCs and the rest of the field is how do we identify core interventions and replicate those. CCBHCs give us an opportunity to have that conversation.”

Additional positive outcomes will likely be seen once society is able to reflect on the coronavirus pandemic. When COVID-19’s first impacts were being felt in the United States, many facilities had to scramble to determine how best to provide care to their communities. “At this point, all behavioral health organizations are just trying to figure out business continuity,” Ingoglia says. “CCBHCs are better prepared to do that.

“It’s very likely when we come out of this that we’re going to see an increased need for services. Without more CCBHCs, I don’t know how we’re going to respond to that need,” he adds.

Expansion
Fortunately, the number of CCBHCs in the country has continued to expand. The original demonstration program is ongoing, having been extended numerous times by Congress. It is currently in effect through November 2020. Since 2018, a separate grant fund has provided grants to clinics so that they may take on all of the functions of a CCBHC. The total funds appropriated to that grant fund in the 2018–2020 appropriations bills are $450 million.

This is happening with bipartisan support because CCBHCs work, Ingoglia emphasizes. “People see that it’s working. This is actually a solution. People are excited about the changes they are seeing in their communities. That gets attention,” he says.

But what helps even more is the simple fact that “mental illness and addiction don’t discriminate by party, class, or location,” Ingoglia adds. “Everybody knows somebody who is struggling.”

As the bipartisan support continues, more CCBHCs will form throughout the country. The hope is that, eventually, while everybody may still know somebody who is struggling, they will also know that those individuals have access to care.

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.

References
National Council for Behavioral Health. (2020a). CCBHC. https://www.thenationalcouncil.org/topics/certified-community-behavioral-health-clinics/.

National Council for Behavioral Health. (2020b). Hope for the future: CCBHCs expanding mental health and addiction treatment. https://www.nationalcouncildocs.net/wp-content/uploads/2020/03/2020-CCBHC-Impact-Report.pdf.

National Institute on Drug Abuse. (2020). Common comorbidities with substance use disorders. https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness.