Monarch | Managing Change, Growth, and CCBHC Services

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Key requirements for Certified Community Behavioral Health Centers (CCBHCs) include expanded access to mental health and addiction treatment; opioid crisis service expansion; primary care health screenings; expanded behavioral health support for veterans; and collaboration among community care partners.

Monarch, a state-wide provider of services for people with intellectual and developmental disabilities (I/DD), mental illness and substance use disorders (SUD) across North Carolina, has accomplished all that and more since its initial funding as a CCBHC in 2018, while meeting detailed outcome reporting and compliance requirements.

Monarch’s CCBHC services include:

  • Crisis services telephone hotline, in-person crisis response and same-day appointment access
  • Comprehensive clinical assessments addressing both physical and behavioral health needs
  • Coordination of services with primary care physicians
  • Person and family-centered treatment plans
  • Introduction of Medication Assisted Treatment (MAT) model as an outpatient, office-based opioid treatment program
  • Tailored care for active-duty military and veterans to ensure they receive the unique health support essential to their treatment

Through the COVID-19 pandemic, Monarch has managed continued change and growth against increasing needs for outcomes data and analytics, while providing integrated care, mental health and substance use disorder services to its CCBHC patients.


“We have outreach coordinators collaborating out in the community, MAT, intensive therapy, occupational therapy, and care management programs providing wrap around support and helping to improve the social determinants of health that we’re identifying,” said Monique Lucas, BSN, CCM, CCTM, Vice President of Integrated Care for Monarch.

Monarch began its CCBHC journey with a 2018 SAMHSA expansion grant. The $1.6 million award enabled the launch of MAT for outpatient, office-based opioid use disorder care, the expansion of care management and nursing services, whole-person care, and the integration of care with primary care physicians through use of care coordination.

Monarch’s second CCBHC grant came under the Coronavirus Aid, Relief and Economic Security (CARES) Act. An additional two-year, $3.9 million CCBHC grant to continue expanding vital services for people with serious mental illness and SUDs  runs through April 2022.

Monarch’s commitment to continued CCBHC services confirmed its need for a new EHR.  “We reviewed and rebuilt our CCBHC documentation when we implemented with Credible, in a timeline aligned to that second grant, and now we can change our workflows and forms and adapt them as we need to,” Lucas said. “We have gained the data visualization, the reporting, and the analytics we need, and we are meeting those requirements more efficiently and with better productivity with Credible. We have the right EHR now,” Lucas said. “The efficiency we have gained with Credible means that clinicians can spend more time with the people we serve, our billing team can send cleaner claims, and we can get paid more accurately and more quickly for the billable services we provide.”

“I can extract the number of interventions that we have completed on specific patients, how many patients we have helped with housing, how many patients we have helped with food, and how many referrals we have made and received,” Lucas said.

For CCBHCs, outcomes reporting and demonstrating success through data is critical. “We have seen changes in the numbers, and in how we are trending. The data shows us where our successes are, and where we need to focus additional attention,” Lucas said. “The Credible outcomes tool shows us measures and trends in dashboards, so we can see where we have been and where we are,” Lucas said. “We can pull data, and we can track data, to understand productivity and caseloads, and to have visibility into contact dates and follow-ups for patients. The reporting tools in Credible enable my teams to see where we are today, and plan for where we want to be tomorrow.”


Monarch’s planned switch to the Credible Behavioral Health EHR came midway through its CCBHC journey, providing Monarch with better tools for mapping new and expanded programs and services, adding and adapting workflows, and visualizing data for compliance needs, clinical tracking, and organizational success.


“Despite the national healthcare professional staff shortage, CCBHC funding has enabled Monarch to be much more competitive in our salary offering and to create and staff 16 new positions to meet the new program requirements,” Lucas said.

Trackability of documentation in the Credible EHR platform gives existing and expanded staff and management visibility into tasks completed and tasks outstanding, for self-monitoring and for checks and balances on documentation completion.

“Visibility into documentation allows staff to see that assessments and reviews are done when they are supposed to be done,” Lucas said. “Credible’s easy to use data and tracking supports follow up and engagement to improve outcomes.”


Monarch has built partnerships across the community for CCBHC care coordination, including a primary care agreement with a mobile clinic from a Federally Qualified Health Center (FQHC) that brings on-site care just footsteps away, to a mobile office space  in Monarch’s parking lot.

“We’ve had quite a few instances of seeing patients at the CCBHC who we’ve walked over there for urgent care, and we’ve had those who have been rushed to the hospital with serious conditions that would not have been caught otherwise,” Lucas said. “We can do clinical triage, where our nurse practitioner can evaluate a patient, and we can refer with our partner to the emergency room when we need to, and we can have care given here or by our partner. It’s a game changer.”

Credible’s workflow flexibility and interoperability support plus a third-party integration with Bamboo Health has given Monarch visibility into notifications across transitions of care. “We have scale that throughout the entire agency now, so we know exactly what’s going on. We can see if a patient has been hospitalized outside of our referrals, and when they’re discharged,” Lucas said.

“Being notified in real time if a client’s discharge from an IP stay allows the CCBHC to follow up in a timely manner thereby preventing possible readmissions or ED visits,” said Mary Givens, CCBHC Program Manager for Qualifacts + Credible, Inc. “Monarch reports an overall decrease in ER utilization for patients supported by the CCBHC, which is visible through its data integrations across the community.”


“Veterans can sometimes resist seeking care when they need it, but community partnerships that make referrals and encourage self-referrals are planting seeds for growth,” Lucas said.

“Serving the active military and veterans is new to most agencies that have become CCBHCs. There are very specific guidelines and protocols associated with serving this population which are outlined in the Uniform Mental Health Services Handbook,” Givens said. “Self-referrals are important for this demographic, and community relationships truly increase visibility.”


“We’ve partnered with EMS, to provide peer support for when patients have overdosed and are reversed in the community, to offer CCBHC MAT enrollment right then. They don’t always accept our program at that moment, but the outreach can work to bring them in later,” Lucas said.

Over a two-year period, Monarch has provided support to 120 people in the community who suffered from an overdose. Peer Support was utilized as the key engagement piece to build relationships and connect people in the community with the correct level of care for each individual.

Monarch also uses the Credible EHR to enable professional peers to stay in touch with people they meet in crisis, to support them through their CCBHC journey, from when they become ready to enroll to when they graduate.

Looking to the Future
Monarch’s CCBHC funding expires in Q2 2022, and planning for how to continue delivering the services it has built when that happens has been ongoing. Demonstrating CCBHC success to the MCOs in the state to update future contracts to include wraparound services and care coordination is one possibility, supported by the outcomes metrics, reports and data generated by the Credible EHR.

“Our grants are ending, but we have proven that the value of what we have built and presenting data of how many people we have served with continuing care from mental health and opioid treatment to high blood pressure and diabetes, is evidence to support vital ongoing care,” Lucas said.

“Monarch has built the map for where they need to go with their CCBHC services, and they have the metrics and analytics to track their progress,” said Mary Givens, CCBHC Program Manager for Qualifacts + Credible, Inc. “They have expanded their programs and services, they are acting on what the data is showing them, and they are widening the door for access with peers walking people through that open door.”

“When Monarch chose Credible as their EHR platform, they were already underway on their CCBHC journey, and they wanted to better support their mission. We are proud to partner with Monarch as they continue to deliver expanded and needed services to the people they serve,” said Robert Patton, VP of Implementation Services for Qualifacts +Credible, Inc.


Monarch provides high-quality and trauma-informed care in a nurturing environment for people with I/DD, mental illness and SUDs  across North Carolina. The care we provide is based on each individual’s needs and is delivered through a customized treatment plan, designed to help each person we support achieve what is most important in his or her life. We are here to help.

Monarch is accredited by The Joint Commission.

Monarch’s CCBHC focuses on mental health and SUD  needs in Stanly County. A caring and qualified team of professionals works with primary care physicians, other providers and community partners to provide a comprehensive range of outpatient, person-centered and trauma-informed care services for adults and children ages 3 and up with complex needs.

We offer evidence-based practices and care coordination services that focus on the whole person. People who seek services will have a team to manage their healthcare needs and to connect individuals and families to supports and resources that address medical, housing, employment and other important needs. This innovative concept brings the community together to provide increased service options for Stanly County. Monarch’s CCBHC provides a safe, secure and healthy environment where healing and recovery can begin.


  • Intervention and crisis stabilization
  • Medication Assistance Treatment (MAT) for opioid and substance use
  • Outpatient health screening and monitoring
  • Psychiatric rehabilitation services
  • Screening, assessment and diagnosis
  • Person-centered treatment planning
  • Individual and group therapy
  • Targeted case management and care coordination
  • Occupational therapy services to support mental health and substance use disorder treatment
  • Training and skill-building to help people find jobs, housing and other resources
  • Support from peer specialists with similar, lived experiences
  • 24-hour mobile crisis teams
  • Referrals to appropriate services for additional help
  • Coming soon! Substance Abuse Intensive Outpatient (SAIOP) Services
  • Peer Recovery Community


Qualifacts is one of the largest behavioral health, rehabilitative and human services EHR vendors in the country. Its mission is to be an innovative and trusted technology and solutions partner, enabling exceptional outcomes for its customers and those they serve. With more than 20 years of experience, Qualifacts’ products and services help customers achieve interoperability goals, optimize efficiency, improve productivity, and maximize reimbursement. The company offers three EHR platforms –  CareLogic, Credible and InSync, serving all segment sizes in the market.


The CCBHC model expands access to integrated, evidence-based addiction and mental health services, including 24/7 crisis response and MAT for addiction.

CCBHC programs have grown nationally from the original eight state demonstration grants funded by SAMHSA to 430 CCBHCs in 40 states, plus Washington D.C. and Guam, supported by multiple funding streams, including state plan amendments or Medicaid waivers, SAMHSA expansion grants, CARES Act funding, and American Rescue Plan funding.


We support a range of EHR platform capabilities for CCBHCs, including evidence-based practices, billing requirements and reporting and required outcome measures.


Our partnerships include a CCBHC cohort of peers whose guidance includes how to market new CCBHC services/ programs, set up and configure the EHR and re-engineer workflows.  A national CCBHC user group led by experienced agency leaders and supported by staff who are nationally recognized for CCBHC thought leadership is a forum for sharing information and best practices, both nationally and state by state. Our cross functional teams gather and post federal and state updates on funding and support to the forum. Engagement with subject matter experts includes a complete kit of implementation success tools for the CCBHC.


CCBHC providers offer specialized mental health and substance use disorder services across teams who need visibility into the continuum of care. Support for CCBHCs includes:

  • Best practice workflows, configured across specialized teams
  • Clinical decision support triggers that teams can self-configure, with links available to the latest research-based, evidence-based, best practices, and to clinical references and patient education materials
  • Outcomes management platform, with industry-standard assessments and screening tools, and data integration into clinical documentation
  • Mobile capabilities that offer clinicians in the field disconnected documentation
  • Outcomes Measures, data analytics and reporting built specifically to comply with CCBHC outcome tracking measures include:
    • Out-of-the-box, drillable dashboards support data-driven decision making to manage clinical, financial, and revenue cycle management reporting
    • Standard reports for actionable insights


Integrations include capabilities to:

  • Exchange CCDAs with clients and external providers, using patient-portal messaging
  • HIPAA compliant message exchanges
  • Enable clients to access clinical summaries through an ONC API and third-party apps
  • Electronically prescribe medications, including controlled substances, with formulary and drug interaction checks at the point of care, with PDMP capabilities within the clinical workflow

Specialized Billing, Claims, and RCM

  • Client-specific fee structure can be copied forward for easy edits and management
  • Copy authorizations feature copies forward authorization information
  • Individualized rates and for PPS billing with daily or monthly frequency
  • Visibility into client mix, by programs and services


  • Intuitive navigation allows users to quickly customize workflows for different roles through a user-controlled back end.
  • Agencies can self-service add and update programs, services and locations without expert IT intervention.
  • Self-service Forms: Design individualized forms to support required CCBHC services
    • Crisis mental health services including 24-hour mobile crisis teams, emergency crisis intervention and crisis stabilization*
    • Screening, assessment and diagnosis including risk management*
    • Patient-centered treatment planning*
    • Outpatient mental health and substance use services*
    • Primary care screening and monitoring**
    • Targeted case-management**
    • Psychiatric rehabilitation services**
    • Peer support, counseling services, and family support services**
    • Services for members of the armed forces  and veterans**

* CCBHC must directly provide
** May be provided by CCBHC and/or designated collaborating organization (DCO)

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