Certified Community Behavioral Health Centers Opportunity for Occupational Therapy December 9 th, 2015 Prepared for The American Occupational Therapy Association HealthManagement.com
CCBHC OVERVIEW 2
What is a CCBHC? A well-funded, coordinated, fully integrated comprehensive community-based provider of culturally and linguistically competent services that serves anyone, of any age, with a BH challenge while focusing on the needs of people with SED, SPMI and chronic SUD An always available single point of access and accountability for any member of the community who needs substance use or mental health treatment and support
Goals To improve behavioral health by enhancing and expanding community-based mental health and substance use disorder treatment To improve integration with medical/surgical health care To expand the use of evidence-based practices To improve access to high quality care To expand and improve data collections Although required to serve everyone, they are targeted primarily at people with Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), and chronic Substance Use Disorders (SUD) 4
Authorizing Legislation 2014 Excellence in Mental Health Act $1.1 billion investment CCBHC Demonstration Program Two year demonstration for eight states expected to go live in early 2017 $25m planning grants Enhanced FMAP/CHIP rate CCBHCs are analogous to FQHCs, but state Medicaid systems serve as intermediaries 5
Critical Planning & Implementation Activities Planning Grant Application Jun Aug 2015 Review existing certification and other CCBHC requirements Identify subject matter experts Consider PPS Payment implications Develop the Planning Grant Application Planning Grant Funding Period Oct, 2015 Oct, 2016 Broad stakeholder involvement PPS development Provide necessary TA and system enhancements to certify at least two CCBHCs that represent diverse geographic areas, including rural and underserved areas Develop and submit a proposal by October 31, 2016 to participate in the Demonstration program CCBHC Demonstration Period Jan 2017 Dec 2018 Up to 8 States will be selected to implement CCBHC demo Track, measure and report on performance and participate in the National Evaluation of the Demonstration 6
The Planning Phase States have already begun to: Identify the target Medicaid population Solicit broad-based stakeholder input, including from providers and consumers Design the scope of the Medicaid-reimbursable CCBHC service package Certify the clinics that will participate in the pilot Establish and enact the Prospective Payment System Participate with the federal government 7
Minimum Standards The Act establishes standards in six areas that an organization must meet to achieve CCBHC designation Staffing Accessibility Care coordination Service scope Quality/reporting Organizational authority 8
Staffing Standards Diverse backgrounds Psychiatrist Medical Director Psychiatric Nurse Credentialed Substance Abuse Counselor MH professional who can perform psychological testing Case management and family support staff Peer specialist/recovery coach Optional: LCSW, LMHC, Psychologist, LMFT, OT Licensed and accredited Culturally and linguistically competent and appropriate Including for Veterans and members of the Armed Services 9
Availability/Accessibility Standards Initial evaluation within one business day Comprehensive evaluation within 15 days Crisis management services available 24x7x365 Within three hours maximum Average response is within one hour Although regulated through state Medicaid systems, must serve everyone regardless of ability to pay, insurance status or state of residence Protocols in place for ED access 10
Care Coordination Standards Partnerships (MOA, MOU) or formal contracts with FQHCs/rural health clinics, unless the CCBHC provides comprehensive healthcare services Inpatient psychiatry and detoxification Post-detoxification step-down services Residential programs Inpatient acute hospitals Department of Veterans Affairs facilities Other social services providers, including Schools Child welfare agencies Juvenile and criminal justice agencies and facilities Indian Health Service youth regional treatment centers Child placing agencies for therapeutic foster care service 11
The CCBHC Palace Services for Armed Forces and Veterans 24x7 Crisis Services Screening, Assessment, Dx MH and SA Tx Patient-Centered Planning Psych Rehab Med. Screening and Monitoring Targeted Case Management Peer and Family Support
Service Scope Standards Crisis services Crisis management services Crisis stabilization Emergency crisis intervention Screening, assessment and diagnosis, including risk assessment Direct provision for behavioral health conditions (updated monthly) Assessment includes comprehensive social services needs Formal arrangements are permitted for specialized screening Patient-centered treatment planning Includes consumer Family of child/adolescent consumer Adult consumer s family per consumer s preference 13
Service Scope Standards (cont.) Evidence based/informed outpatient mental health and substance use services Individual, group and family therapies CBT DBT First episode psychosis Multisystemic therapy Motivational interviewing Youth services (including youth in foster care) Medication evaluation and management Psychiatric medication Medication assisted treatment (i.e. Buprenorphine, methadone, naltrexone) Intensive services Prevention services 14
Other Required Outpatient MH and SA Services Hospitalization follow-up Suicide prevention and safety Smoking cessation therapy Co-occurring addictions disorders treatment Trauma-informed care Services for people with co-occurring developmental disabilities Older adults services Neurological consultation 15
Service Scope Standards (cont) Primary care screening and monitoring of key health indicators and health risk At a minimum, BMI and blood pressure at intake and annually (directly by the CCBHC) Either directly or through formal arrangement the CCBHC must assure that key screenings are done and follow up Targeted case management Up to and including ACT Psychiatric rehabilitation services Psychoeducation Personal care and ADL Supported housing Supported education Supported employment 16
Service Scope Standards (cont) Peer support and family support Family psychoeducation Parent training Family-to-family Services specifically targeted at veterans and members of the armed services Military cultural competence Coordination with TRICARE Coordination with VA 17
Uniform Reporting Standards Standardized data elements modeled on the FQHC Uniform Data System Encounter data Consumer demographics Staffing Service usage Service access Care coordination Clinical outcomes data Quality data Other data as requested 18
Organizational Authority Standards Nonprofit Local government behavioral health authority Indian Health Service, Indian tribe or Tribal organization Urban Indian organization Governing board members reasonably represent those served in terms of geographic areas, race, ethnicity, sex, gender identity, disability, age, and sexual orientation At least 51% consumer or family members 19
Federal Match for States Federal Match (FMAP) follows beneficiary eligibility: Regular Medicaid: Enhanced FMAP Expansion population: 100% now, down to 90% by 2020 Medicaid CHIP Expansion: Enhanced FMAP +23% Served by Indian Health Services Clinics: 100% State plan authority not necessary for payment for CCBHC services delivered by certified clinics States may claim administrative expenditures that support the development and implementation of the demonstration 20
Impact of CCBHC This is a game changer CMHCs have struggled for decades to offer comprehensive care. CCBHCs represent an opportunity to: Establish a behavioral health safety net Integrate and coordinate care for mental health, substance abuse, and primary care Promote access to improve care via standards for quality and accessibility Expand care coordination for all 21
State Awardees: 22
CCBHC PROSPECTIVE PAYMENT SYSTEM 23
CCBHC PROSPECTIVE PAYMENT SYSTEM 24
PPS Guidance Required by Statute for payment of participating clinics for CCBHC services delivered either directly by a CCBHC or through a formal relationship between a CCBHC and Designated Collaborating Organizations (DCOs) FMAP for CCBHC services Enhanced FMAP equivalent to the standard Children s Health Insurance Program (CHIP) rate For the newly eligible population, it is equal to the current FMAP for that population 25
CC PPS - 1 Daily fixed rate (like FQHCs) for all CCBHC services provided any given day Cost-based, per clinic rate that applies uniformly to all CCBHC services rendered by a certified clinic, including those delivered by qualified satellite facilities Pays CCBHCs a daily rate that is a fixed amount for all CCBHC services provided on any given day to a Medicaid beneficiary DY1: Cost and visit data from the demonstration planning phase updated by MEI DY2: update DYI 1 rates with MEI or rebaseline. Based on total annual allowable CCBHC costs divided by the total annual number of CCBHC daily visits and results in a uniform payment amount per day, regardless of the intensity of services or individual needs of clinic users on that day 26
CC PPS-2 (Alternative) Monthly rate to reimburse for CCBHC services Separate monthly PPS rates to reimburse CCBHCs for higher costs associated with providing all services needed to meet the needs of clinic users with certain conditions (SMI, SUD) Cost-based, per clinic rate applies uniformly to all CCBHC services rendered by a certified clinic, including all qualifying sites of the certified clinic Outlier payments made in addition to PPS for participant costs in excess of a threshold defined by the state (made monthly or annual basis) DY1: Cost and visit data from the demonstration planning phase updated by MEI DY2: update DYI 1 rates with MEI or rebaseline. 27
Quality Bonus Payment Optional for daily (PPS Option 1) Required for monthly (PPS Option 2) Required measures are shown in Table 3 of PPS Guidance option for state to include other measures, with CMS approval
ROLE OF OCCUPATIONAL THERAPY IN CCBHC 29
CCBHC Treatment Team The Treatment Team includes: The consumer & families/caregivers An interdisciplinary team composed of individuals who work together to coordinate medical, psychosocial, emotional, therapeutic, and recovery support needs of consumers Person and family centered treatment planning and care coordination activities are required 30
OT Option for CCBHC Team From the CCBHC Criteria: Providers must include individuals with expertise in addressing trauma and promoting the recovery of children and adolescents with serious emotional disturbance (SED) and adults with serious mental illness (SMI) and those with substance use disorders. Examples of staff the state might require include a combination of the following: psychiatrists (including child, adolescent, and geriatric psychiatrists) nurses trained to work with consumers across the lifespan licensed independent clinical social workers licensed mental health counselors licensed psychologists licensed marriage and family therapists, licensed occupational therapists staff trained to provide case management, peer specialist(s)/recovery coaches, licensed addiction counselors staff trained to provide family support medical assistants, and community health workers 31
Service Scope: Evidence-based practices States must establish a minimum set of required evidence based practices, such as: Motivational Interviewing Cognitive Behavioral individual, group, and on-line therapies (CBT) Dialectical Behavioral Therapy (DBT) Addiction technologies Recovery supports First episode early intervention for psychosis Multi-systemic therapy Assertive Community Treatment (ACT) Forensic Assertive Community Treatment (F-ACT) Evidence-based medication evaluation and management (including but not limited to medications for psychiatric conditions, medication assisted treatment for alcohol and opioid substance use disorders, prescription long-acting injectable medications for both mental and substance use disorders, and smoking cessation medications) Community wrap-around services for youth and children Specialty clinical interventions to treat mental and substance use disorders experienced by youth (including youth in therapeutic foster care) 32
OT Within CCBHC Model Services for Armed Forces and Veterans 24x7 Crisis Services Screening, Assessment, Dx MH and SA Tx Patient-Centered Planning Psych Rehab Med. Screening and Monitoring Targeted Case Management Peer and Family Support Potential area for occupational therapist contribution 33
OT can contribute to many CCBHC goals: Span the gap between CCBHC Services and Daily Living: Facilitate the development of day-to-day independent living skills for those with SMI Teach compensatory strategies that mitigate the impact of mental illness Help people with serious BH challenges translate coping skills into daily lives Reduce the symptoms of mental illness by engaging in healthy roles and routines Promote emotional wellness by enhancing people s skills and competencies Address the physical, cognitive, and sensory functioning of people with chronic behavioral health challenges Promote health and wellness through the use of everyday activities Help people improve critical reasoning skills Address the social determinants of health Span the boundary between behavioral and medical fields Help people identify and achieve outcomes that are important to them 34
OT Enhancement Promote Person- Centered Care Cognitive Functional Testing Individualized Interventions Performance based Testing Cognitive Functioning Testing: Determines degree of functional impairments Enables teams to better understand client thinking and processing skills related to diagnosis, care planning, medication adherence, appointment attendance, and interventions Facilitates appropriate engagement of individuals in the treatment and recovery support planning If functional cognition reduce capacity to understand diagnosis Improved Behavioral Health Performance Based Testing Assesses client s ability to perform real-world tasks Enables rapid client engagement Evaluates client awareness of and attention to environmental stimuli Helps to calibrate interventions (group or individual), develop health promotion plans, and support chronic disease management 35
OT in the Integrated Care Team Occupational Therapy supports critical behavioral health goals: Improve cognitive behavioral interventions understanding cognitive capacity is critical for these evidence-based approaches Promote self-management understanding functional capacity is critical to skill building Facilitate coordination between PC and BH improved person-centered care planning plus wellness programming and individualized wellness interventions OT promotes vocational goals vital and underaddressed aspect of whole person planning 36
Special Populations Promoting Wellness and Supporting Healthy Lifestyles NEW-R intervention Individualized plans for Peer Specialists to implement Vocational Assessment and Planning Strategy Training Promoting community independence for those with Serious Mental Illness Promoting independence for older adults and others with physical and behavioral health limitations Sensory Profiling Veterans with PTSD Youth with Serious Emotional Disturbance Those experiencing First Episode Psychosis 37
Making the OT Case with State Planners: STRATEGY RECOMMENDATIONS FOR CCBHC PLANNING 38
Act Now: Connect with/join your state s Planning Grant Steering Committee Participate in your state s stakeholder engagement process Connect with community mental health centers in your state/region which are likely to be certified as CCBHCs Watch/participate in the CCBHC webinar provided by AOTA to learn more about the Demonstration Sign up to receive OT advocacy material developed for CCBHC planners 39
Get Involved with Central Players Executive Officer, Department of Human Services, Division of Mental Health and Disability Services Director of Policy Implementation & the Administrator of Research, Data Evaluation, and Compliance Both at the Dept. of Behavioral Healthcare, Developmental Disabilities, and Hospitals Deputy Director of Behavioral Health and Development Disabilities, Department of Health and Human Services Assistant Division Director of Planning, Research, Evaluation, & Prevention at the Division of Mental Health and Addiction Services within the Dept. of Human Services. 40
Tips for Behavioral Health Engagement Educate planners about OT Find out what they need populations, services, outcomes? Keep it simple use examples rather than terms to describe OT Be prepared to make state-specific financing policy recommendations Provide technical support to CCBHC Steering Committee and training for sites 41
Q and A Heidi Arthur Lee Repasch Josh Rubin 42