Behavioral Health Brief: Certified Community Behavioral Health Clinics — How and Why They Work
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.
Nine core services must be offered by CCBHCs. According to the National Council (2020a), these requirements are the following:
• crisis mental health services;
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
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.”
“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.
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.
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.