Managing Your CCBHC Transformation | Stage 4 Reporting and Stabilization

Stage 4 Reporting and Stabilization | Supporting the Five Stages of the CCBHC Experience 

Phase 4

Stage 4 can be a stressful stage, as this is when your CCBHC first reports its progress on outcomes measures and other performance indicators to the reporting entity. If you have followed the recommended steps in our process, you will be ready for it.  

  • Your workflows are well established: review one more time and establish that you are where you want to be or make changes in the remaining time. 
  • You have a firm grasp on your outcome measures. You know where your successes are, and you know where you need to make changes.  
  • You have made tweaks to workflows, forms, and training to move toward greater success on the measures.  
  • Stage four stabilization includes being ready to move forward, with well-defined and iterated workflows, forms, and processes. Now is the time for maintenance and continued progress.  

Stage 4 is the right time to firm up your quality improvement plan because Stage five (and beyond) is really focused on Continuous Quality Improvement (CQI). As a CCBHC whose success is tied to quality, you will never attain perfection, but you must always be striving for improvement.  

Let’s look at some of the tangible tasks and deliverables of Stage 4.  

Submit Progress Report: Regardless of where you received your grant funding from (SAMHSA or the state), the funding source will want regular progress reports. Each funding entity will define what should be included in the progress report, as well as the frequency in which the progress report should be submitted. I have listed below some of the elements you can expect to include in a progress report.  

  • Number of clients you are serving in the CCBHC (Children, Adults) 
    • With the right EHR, this should be a simple report 
  • Progress, successes, barriers, and challenges in implementing the required CCBHC activities 
    • This is your opportunity to brag on your successes.  
    • For barriers and challenges, identify them and include your mitigation for each along with timelines if possible 
  • Challenges with NOMS reporting (if relevant) 
    • Talk about challenges such as getting clients to participate in the reassessment and include what creative things you are doing to overcome those challenges 
  • “Disparities in Healthcare” impact statement 
    • According to the AMA, “Recent studies have shown that despite the improvements in the overall health of the country, racial and ethnic minorities experience a lower quality of health care—they are less likely to receive routine medical care and face higher rates of morbidity and mortality than non-minorities.”
    • Provide specific details on how you are mitigating any disparities in healthcare in your agency including any outreach activities, processes, and procedures you have put in place. 
    • Perhaps speak to the specific cultural make up of your catchment area and how you are addressing each need such as a foreign language. 
  • Results and changes to the needs assessment 
    • Review the states community needs assessment, identify what has changed and how you are specifically addressing that change.  
  • Results and changes to the staffing plan 
    • We all know there is a national healthcare shortage-speak to the creative ways you are addressing that issue in your CCBHC.  
    • If your staffing plan has changed, identify the changes and reason for the change 
  • Results and changes to the quality improvement plan 
    • Again-the right time to relook at your CQI plan. Have you changed your change management process? Has the frequency in which you meet changed? Has the Quality team members changed? List any changes and improvements you have made to your quality improvement plan.  
  • Results and changes in training plan 
    • This is the right time to assess your training plan. Have you identified additional types of training that you have had to implement? What about frequency of trainings? Training staff? 
  • Your efforts to meet the Health Information Technology requirements 
    • The CCBHC criteria include a call for specific HIT. Include details on how you are leveraging each required feature such as clinical decision support rules for ensuring continuity in using EBPs across populations. 

Analyze progress report: Take some time to reflect on your findings of the progress report. Does the report call for changes to any of your source documents, such as the training plan or the needs assessment? Perhaps, in the course of delivering services, you have identified a previously unmet need that now should be addressed. An example might be that by looking at the high number of “no shows” for CCBHC intake appointments, you identified “lack of childcare” as one of the reasons people don’t show up for the intake. This might indicate the need to add “adequate childcare” to the SDOH screening and case management initiatives.

Developing a comprehensive progress report is a lot of work but what can come out of it are insights for further improvement in your CCBHC program. Having to write the progress report requires you to stop and look at the barriers, successes, and challenges your CCBHC has faced to date, which allows you to make changes to move forward.  

Another data point to consider analyzing is the demographics of the people you serve. Is your demographic data reflective of the community you serve?  Consider all market segments, including adults, children, military, veterans, seniors, race, ethnicity, and LBGQT. If you live in an area such as Colorado Springs where there are three military bases and 9.6% of the population are veterans, does your client base of the CCBHC reflect that you have adequately reached out to and are serving military veterans?  

In terms of health information technology requirements, are you leveraging all of the certified functionality available within the EHR? Examples of typically underutilized features are clinical decision support rules (CDSR) and the sending and receiving of the Summary of Care C-CDA. Each of these are important features for different reasons. The CDSR can ensure that your CCBHC is consistently using evidence based practices for a specific population. The sending of the Summary of Care C-CDA is an interoperability feature that enables your CCBHC to share comprehensive healthcare information with external providers and entities of care upon discharge or consultation. The receiving of a C-CDA enables your CCBHC to have a comprehensive picture of the health and treatment of the client you are receiving for intake. It also allows your CCBHC to conduct a clinical information reconciliation upon intake which is so critical. Analyze the elements of your progress report and make changes as indicated.  

Stabilization of Outcome Data Collection: By now you have worked and reworked the workflows for collecting the data for the CCBHC outcomes. You have tweaked and adapted the forms for the most efficient data collection. It’s time to stabilize these processes and forms, meaning that now is the time to complete any further work to be done. Stabilizing data collection for the current workflows supports your providers in moving towards mastery of those outcomes. Once these outcomes are mastered, you can introduce new outcomes and begin new cycles of hypotheses, testing, learning, adapting, and mastery. . Everyone should be thoroughly trained and the only training you should need to deliver at this point would be for new hires.  

Develop and Review your “Quality Improvement Plan”: A Quality Improvement Plan includes essential information about how your organization will design, implement, manage, and assess quality. The process would be that you do an assessment of your CCBHC, you identify gaps, deficiencies, and problems and you complete a root cause analysis for each.

Here is one sample of a root cause analysis template from the state of Indiana. From your root cause analysis, your CCBHC will build a comprehensive Quality Improvement Plan that ties back to the root cause analysis. The Quality Improvement Plan will be broken down by targeted areas where problems were identified. Some examples might be:   

  • Intake process 
  • NOMS completion 
  • Primary care screening and follow through 
  • Risk screening and crisis workflows 
  • Access to care 
  • Care coordination 
  • Training plan 
  • Staff turnover or Staff retention 

According to the State of Indiana, “Comprehensive Quality Improvement Plan: Guide and Example- Data Driven Review”  an effective Quality Improvement Plan includes the following elements: 

  • A description of quality improvement goals and objectives  
  • A description of the activities designed to meet the quality improvement goals and objectives  
  • A description of how quality initiatives will be managed and assessed/measured  
  • A description of any training and/or support that will be developed and implemented, based on the quality improvement process  
  • A description of the communication plan for quality improvement activities and processes, including how updates will be communicated to all staff on a regular basis  
  • A description of evaluation/quality assurance activities that will be used to determine the effectiveness of the plan’s implementation 

From the same resource cited above, each targeted area plan should include 

  • The root cause addressed by this plan 
  • Action Steps /Activities-Enter the Action Steps/Activities for completing the Quality Improvement Plan. (A separate Quality Improvement Plan should be used for each initiative.) 
  • Lead Person-List the name of the lead person responsible. 
  • Timeline-Indicate start and end dates for the full activity and for each step 
  • Evidence-List possible ways for verifying the activity took place. 
  • Resources/ Materials Needed-List any specific resources needed in order to complete the activity. 

I can’t stress enough the importance of this Quality Improvement Plan as it will drive your continuous quality improvement from this point forward through stage five and beyond. Remember that the Plan Do Study Act (PDSA) process (introduced in article 2 of this series) can also be used for managing the smaller changes your CCBHC needs to make for continuous improvement.  

As your CCBHC continues to move forward you will continue to study and analyze any performance metrics or outcomes that are not performing well. You will identify what is working and what is not. You will continue the processes that work and make changes (act) for those processes that need change. This will be an ongoing cycle resulting in Continuous Quality Improvement.  

 Written by Mary Givens, CCBHC Program Manager


Mary Givens, MRA
CCBHC Program Manager

Mary Givens has been with Qualifacts for 13 years. She has a Masters in Rehabilitation Administration from the University of San Francisco. Before coming to Qualifacts, Mary was the CEO of a non-profit organization that served IDD, she was the Director of Client Services and a Director of Supported Employment for people with SPMI. Since coming to Qualifacts, she has been a Project Manager for Implementation and a Program Manager of Meaningful Use, and is currently the CCBHC Program Manager.

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