Written by Mary Givens, CCBHC Program Manager

On March 16, 2023, the Substance Abuse and Mental Health Services Administration (SAMHSA) released new criteria for the Certified Community Behavioral Health Clinic (CCBHC) treatment model. Many of these changes are significant and will impact how the CCBHC operates on a day-to-day basis.

• The revised CCBHC criteria apply to all CCBHCs, regardless of state, territory, tribe, or funding stream.
• The revised criteria seek to strengthen and update the criteria without significantly adding to state or clinic burden.
• For a full understanding of all the SAMHSA CCBHC criteria changes, please carefully review the new criteria as they are the single “source of truth.”
• Clinics and states are on different schedules to come into compliance with the updated criteria, with most being required to come into compliance by July 1, 2024.
• SAMHSA provided this summary of changes from the existing criteria to the updated criteria and an implementation timeline for the different CCBHC programs and deadlines from coming into compliance with the updated criteria.

SAMHSA’s changes to the CCBHC criteria are grouped into six categories. Here is an overview:

• Significant Updates to Advance the Field: These are significant changes that correspond to updates to federal policies, national standards, evolving technologies, and/or infrastructure changes.
• Needed Structural Changes to the Criteria: These changes help align the delivery of service requirements with the statute or updated regulations.
• Increased Flexibility: These changes provide CCBHCs with additional flexibilities that were not available in the 2015 criteria.
• Additions that Strengthen the Model: These changes strengthen the CCBHC model.
• Updated Language and Examples: These changes reflect changing terminology in behavioral health. Examples are added to reflect emerging evidence-based services and to identify innovations in the field.
• Clarifications: These changes reflect clarification of the original criteria in areas where CCBHCs and states identified ambiguities.

Here are details of what SAMHSA calls Significant Updates to Advance the Field, with my analysis:

• Crisis Care | Changes include adoption of guidance around the components of a comprehensive crisis system in the National Guidelines for Behavioral Health Crisis Care – A Best Practice Toolkit, close coordination with 988, and “trauma Informed” approaches to be applied to crisis services.
  • 988 Collaboration: This change seeks to put in place tight alignment between the CCBHC and the 988 Suicide & Crisis Lifeline call center. These changes include the need for the CCBHC to incorporate education about 988 to its clients; ensure that each person receiving services in the CCBHC has a crisis plan; and requires that the CCBHC have a care coordination partnership with the 988-center serving the area in which the CCBHC is located. For the CCBHCs that I talked to, in many cases it is the CCBHC who gets deployed out into the field if the 988 Suicide & Crisis Lifeline call requires further support beyond just the call.
  • Adoption of best practices included in the National Guidelines for Behavioral Health Crisis Care – The Best Practice Toolkit includes minimum standards for the coordination of crisis services, mobile crisis response, and crisis stabilization. One of these minimum requirements includes tracking referrals in real time to ensure the timely delivery of mobile crisis team response and follow up care.
• Responding to the Opioid Epidemic | Amidst the ongoing overdose crisis in the United States, the new CCBHC Criteria have been enhanced in various aspects to place more emphasis on substance use disorders and opioid overdose.
  • Addiction Medicine Specialist: A new criteria for the CCBHC to consult with or have addiction medicine specialist or physician on staff unless the Medical Director has experience with substance use disorder.
  • Availability of Methadone: either the CCBHC has the ability to prescribe Methadone directly or it refers to an OTP through care coordination to ensure access to Methadone within the scope of their facility’s legal ability to do so.
  • Overdose and Prevention: Besides training on overdoses and prevention, includes adding withdrawal and overdose risk concerns to the comprehensive assessment; focus on harm reduction and motivational techniques; “including risk of overdose and intervention following overdose reversal.” Overdose prevention activities must include the provision of naloxone for overdose reversal to individuals who are at risk of opioid overdose, and as appropriate, to their family members.
• Improving Health Equity | Updates criteria focus more heavily on health disparities in the CCBHC community and the social determinants of health.
  • National Standards for Culturally and Linguistically Appropriate Services (CLAS): Found here, SAMHSA changes criteria to align more closely with the CLAS to move health equity, improvement of quality of services, and the ability to eliminate disparities forward. One important clarification in the new criteria is the meaning of “outreach and engagement activities” to include reaching out to those individuals in underserved communities.

Needed Structural Changes to the Criteria

• Community Needs Assessments and Staffing Plans (criteria 1.a.1)
  • Must be updated regularly but no less than every 3 years
  • The components of the community needs assessment and staffing plans are described in the terms and definitions of the criteria
  • The staffing plan is responsive to the community needs assessment
• CCBHCs required to directly provide 51% or more encounters across CCBHC services* (criteria 4.a.1)
  • CCBHC is responsible for ensuring access to all care specified in PAMA
  • The criteria bolster expectations that CCBHCs are fully licensed and credentialed behavioral health providers and that they will provide a substantial proportion (51% or more of encounters across the required services excluding Crisis Services*)
• Quality Measures for Section 223 Demonstration Program have been updated (criteria 5.a.2)
  • List of new measures found in Appendix B of the new CCBHC criteria document
  • Reporting requirements for CCBHCs funded through expansion grants are distinguished from those funded under the Demonstration
• CCBHC must be enrolled as a Medicaid provider and licensed provider of both mental health and substance use disorder services (criteria 6.c.1)
  • Including developmentally appropriate services to children, youth, and their families unless there is a state administrative, statutory, or regulatory framework that prevents or substantially prevents the CCBHC organization provider type from obtaining the necessary licensure, certification, or accreditation to provide these services.
  • CCBHCs are also required to participate in the SAMHSA Behavioral Health Treatment Locator.
• Limit on CCBHC certification (criteria 6.c.2)
  • CCBHCs are certified and notes that state certified CCBHCs may retain certification no longer than three years before certification lapses or they are recertified
  • Clinics that have submitted an attestation to SAMHSA as a part of participation in the SAMHSA CCBHC Expansion grant program are designated as CCBHCs only during the period for which they are authorized to receive federal funding to provide CCBHC services

Increased Flexibility

• Role of the Medical Director (Criteria 1.a.3) | In this time of a great shortage of healthcare professionals, this change is important. Despite all of your best efforts, you may not be able to secure a psychiatrist to fill the role of Medical Director. The updated criteria allow some flexibility if you find yourself in that scenario.
  • New criteria remove the requirement that only CCBHCs operating within behavioral health professional shortage areas were permitted to hire a non-psychiatrist as the Medical Director.
    • “If a CCBHC is unable, after reasonable efforts, to employ or contract with a psychiatrist as Medical Director, a medically trained behavioral health care professional with prescriptive authority and appropriate education, licensure, and experience in psychopharmacology, and who can prescribe and manage medications independently, pursuant to state law, may serve as the Medical Director.”
  • CCBHCs unable to hire a psychiatrist and hire another prescriber instead, psychiatric consultation will be obtained regarding behavioral health clinical service delivery, quality of the medical component of care, and integration and coordination of behavioral health and primary care

• DCO formal agreement requirements have been relaxed
  • The criteria have been revised to allow CCBHCs to achieve meaningful partnerships with community partners and expanded howmy they can be documented. No longer is it required that the CCBHC obtain legal documents to work with a DCO. New guidelines for how DCO: CCBHC partnerships may be documented.
• Care Coordination documentation requirements relaxed (criteria 3.c)
  • The criteria 3.C is retitled “Care Coordination Partnerships” from “Care Coordination Agreements.”
  • Each of the sub-criteria under 3.c. Care Coordination Partnerships is now accompanied by a note (below) that describes how partnerships may be documented.
    • Note: These partnerships should be supported by a formal, signed agreement detailing the roles of each party. If the partnering entity is unable to enter into a formal agreement, the CCBHC may work with the partner to develop unsigned joint protocols that describe procedures for working together and roles in care coordination. At a minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be developed. All partnership activities should be documented to support partnerships independent of any staff turnover.

Additions that Strengthen the Model

• Stronger definition of the community needs assessment
  • Staffing plans, accessibility, and scope of service tied directly to the CCBHC Community needs assessment
  • Includes the requirement that CCBHCs coordinate crisis care response with law enforcement agencies
  • CCBHC itself is responsible for conducting the community needs assessment
  • Criteria that are impacted by the information gained from the CCBHC community needs assessment are identified throughout the criteria.
• Expands requirements for staff training (criteria 1.c.1)

For staff who have contact with clients-

• Training now includes evidenced based practices (EBP)
• Training now includes cultural competency
• Training now includes policies and procedures for integration of primary care
• Training now includes the need for training on care of co-occurring mental health, substance use, and health
• Training must also adhere to CLAS standards

• Sliding Fees (criteria 2.d.2)
  • Recognizes literacy barriers as an issue for communicating sliding fees.
• PDMP (criteria 3.a.5)
  • Appropriate care coordination requires the CCBHC to make and document reasonable attempts to determine any medications prescribed by other providers.
  • The state Prescription Drug Monitoring Program (PDMP) must be consulted before prescribing medications and during the comprehensive evaluation to the extent that state law allows.
• Assist to Access Benefits (NEW Criteria 3.a.7)
  • The CCBHC assists people receiving services and families to access benefits, including Medicaid, and enroll in programs or support that may benefit them.
• Continuous Quality Initiatives (CQI) Plan (NEW Criteria 5.b.3)
  • requires CQI plans to use quantitative and qualitative data because it is required that it is data driven
  • includes an explicit focus on populations experiencing health disparities and addresses how the CCBHC will use data to track and improve outcomes for populations facing health disparities

Updated Language and Examples | The new criteria replaced much of the restrictive or outdated language. Some examples include:

• Replaced the label “Consumer” with “person (people) receiving services”
• Replaced “detoxification” with “medical withdrawal management”
• Replaced “mental health and substance use” with “behavioral health”
• Replaced “Medicaid Demonstration” with “Section 223 CCBHC Demonstration”
• And maybe most importantly, the definition of “behavioral health” is updated to reflect promotion and prevention as well as treatment.

Clarifications

• Designated Collaborating Organizations (DCOs) | DCOs more tightly integrated with CCBHC- an important change for DCO’s is that they are now required to work towards being more closely integrated with eh CCBHC including participation on the CCBHC treatment teams and collocating services. I view this as a positive change considering the CCBHC is responsible for the quality of the services the DCO delivers.
  • Use of the term “Disabilities” is clarified: In criteria 1.d.3, the new criteria expand the need for auxiliary aids and services (compliant with the Americans with Disabilities Act) goes beyond those with hearing impairments to include those with physical, cognitive, and/or developmental disabilities.
  • Accessibility clarified: Criteria 2.1.2 – clarifies that the times and locations of CCBHC operation are informed by the CCBHC’s community needs assessment.
  • Treatment Plan Reviews frequency decreased: The frequency of treatment plan reviews and updates have been reduced from four times per year (every 90 days) to two times per year (every 6 months) and that changes are endorsed by the person receiving services.

In my analysis, SAMHSA’s changes to the CCBHC Criteria are positive, in that many seek to reduce the burden on the CCBHC. Some of the changes provide greater clarification of terms or concepts that were previously somewhat ambiguous, which is also positive. All the changes strengthen the “value-based care tenets” that are the foundation of the CCBHC treatment model. I’m such a strong advocate for the CCBHC treatment model because it is person (served) centric, holistic in its approach, outcomes based, and it works in that it moves people toward a better quality of life.

I’d love to hear your thoughts on the new CCBHC criteria.

Please reach out anytime with questions or comments at mary.givens@qualifacts.com