COA and CCBHC CROSSWALK - National Council...CROSSWALK COA and CCBHC This crosswalk compares and...

CROSSWALK

COA and CCBHC

This crosswalk compares and aligns the Council on Accreditation’s (COA) standards

and the criteria for Certified Community Behavioral Health Clinics (CCBHCs). It is

designed as a resource to inform states that COA accredited organizations possess

the capacity to operate as CCBHCs by having already met the criteria set forth

through their achievement of COA Private Organization Accreditation.

BACKGROUND

Signed into law on April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) is a statute that requires the

establishment of demonstration programs to improve community behavioral health services. The legislation creates criteria for

“Certified Community Behavioral Health Clinics” (CCBHCs) as entities designed to serve individuals with serious mental illnesses

and substance use disorders, emphasizing high quality and evidence based practices. The COA standards applied to illustrate

congruence with CCBHCs and detailed in this document include: Administration & Management; Service Delivery

Administration; Crisis Response and Information Services; Integrated Care/Health Homes; Services for Mental Health and/or

Substance Use Conditions (MHSU); and Primary Care Services (PCS).

Questions about COA’s recognition efforts throughout the United States can be directed to Jaclyn Green-Stock, Public Affairs

and Strategic Partnerships Associate, by phone at 866.262.8088, extension 226 or by email at [email protected]. Questions

about this crosswalk can be directed to Tamara Frere, Research Associate, by phone at 866.262.8088 extension 239 or by email

at [email protected].

mailto:[email protected]

mailto:[email protected]

Prepared by the Council on Accreditation of 273 October 2015

CCBHC Criteria

Corresponding Council on Accreditation Standards

Standards Match Assessment / Verification of Implementation

(Tables of Evidence)

PROGRAM REQUIREMENT 1: STAFFING

Criteria 1.A: General Staffing Requirements

1.a.1

As part of the process leading to certification, the state will prepare an assessment of the needs of the target consumer population and a staffing plan for prospective CCBHCs. The needs assessment will include cultural, linguistic and treatment needs. The needs assessment is performed prior to certification of the CCBHCs in order to inform staffing and services. After certification, the CCBHC will update the needs assessment and the staffing plan, including both consumer and family/caregiver input. The needs assessment and staffing plan will be updated regularly, but no less frequently than every three years.

GOV 4.02 The organization collaborates with community members and service recipients to advocate for issues of mutual concern consistent with the organization’s mission, such as:

a. making improvements to existing services and filling gaps in service;

b. the full and appropriate implementation of applicable laws and regulations regarding issues concerning the service population;

c. improved supports and accommodations for individuals with special needs;

d. addressing community-specific needs including cultural and linguistic diversity; and

e. service coordination. Interpretation: The standard requires the organization to actively advocate and work for the provision of a full array of community services, and to provide personnel with time to carry out advocacy activity. Advocacy activities comply with the legal and regulatory requirements governing such activities. The organization can work at several levels to advocate with, and on behalf of, persons, groups, and families served. Direct service personnel can advocate with persons and families served to solve problems related to their individual cases.

COA meets the intent of this CCBHC standard.

COA’s timeframes exceed the CCBHC standard by

requiring assessment be performed annually as

opposed to a minimum of every 3 years.

Table of Evidence for GOV 4

Provide PSAs/newspaper articles, or other significant uses of social media within the past two years (GOV 4.01)

Documentation of participation in community advocacy efforts (GOV 4.02)

Interview: a. Governing Body b. CEO c. Program and clinical managers d. Community stakeholders e. Persons served

Table of Evidence for HR 2

Assessment of workforce needs

Analysis of workforce composition

EEO plan (as necessary)

Documentation of actions taken

Annual Network-wide Analysis report

Interview: a. CEO b. HR Director c. Supervisory personnel

Table of Evidence for CR 1

Client rights policy and procedures

Policy for providing services to minors


CCBHC Criteria



(Tables of Evidence) Advisory board members, management, and other personnel, along with persons served, can engage in legislative and other system-wide advocacy activities. They also work collaboratively with other community organizations to monitor federal, state, and/or local activity that impacts the service population. HR 2.01 The organization assesses its workforce as part of annual planning and prepares for future needs by:

a. comparing the composition of its current workforce, including number of employees, skills, and demographics, with projected workforce needs; and

b. determining how to close gaps, when possible, through recruiting, training or outsourcing.

CR 1.09 The organization designs and adapts its programs and services, as appropriate, to accommodate the visual, auditory, linguistic, and motor abilities of persons served."

without the consent of the parent or legal guardian

Rights and responsibilities document provided to individuals and families at initial contact

Interview: a. Relevant personnel b. Individuals or families served c. Review case records

Facility Observation


Criteria 1.A: General Staffing Requirements (Continued)


CCBHC Criteria




1.a.2

The staff (both clinical and non-clinical) is appropriate for serving the consumer population in terms of size and composition and providing the types of services the CCBHC is required to and proposes to offer. Note: See criteria 4.K relating to required staffing of services for veterans.

HR 2: Human Resources Planning The organization assesses the type and number of personnel needed to accomplish its mission, goals, and objectives. MHSU 13: Personnel Personnel are appropriately supervised and qualified by education, training, experience, and licensure to meet the service needs of the target population.

COA meets the intent of this CCBHC standard.








Table of Evidence for MHSU 13








CCBHC Criteria




1.a.3

The Chief Executive Officer (CEO) of the CCBHC maintains a fully staffed management team as appropriate for the size and needs of the clinic as determined by the current needs assessment and staffing plan. The management team will include, at a minimum, a CEO or Executive Director/Project Director, and a psychiatrist as Medical Director. The Medical Director need not be a full-time employee of the CCBHC. Depending on the size of the CCBHC, both positions (CEO/Executive Director/Project Director and the Medical Director) may be held by the same person. The Medical Director will ensure the medical component of care and the integration of behavioral health (including addictions) and primary care are facilitated. Note: If a CCBHC is unable, after reasonable and consistent efforts, to employ or contract with a psychiatrist as Medical Director because of a documented behavioral health professional shortage in its vicinity (as determined by the Health Resources and Services Administration (HRSA) (Health Resources and Services Administration [2015]), psychiatric consultation will be obtained on the medical component of care and the integration of behavioral health and primary care, and a medically trained behavioral health care provider with appropriate education and licensure with prescriptive authority in psychopharmacology who can prescribe and manage medications independently pursuant to state law will serve as the Medical Director.

GOV 8.01 The executive director’s primary responsibilities are:

a. management of the organization; b. implementation of organization-wide, long-

term strategic planning and periodic reviews;

c. encouragement of timely, engaged, mission-oriented board deliberations;

d. working with the governing body to secure adequate resources;

e. development of policies governing the organization’s program of services, planned and coordinated with the governing body, as appropriate;

f. attendance at all meetings of the governing body or advisory group, except possibly those held to review the executive’s performance, status, or compensation;

g. to actively promote strategic, planned adaptation to changing conditions;

h. provision of regular reports to the governing body on the organization’s operations, finances, and implementation of the long-term plan; and

i. establish a workplace environment that is respectful of and supportive of the rights and welfare of the organization’s staff, volunteers and consumers.

Interpretation: The executive director involves, consults with, and gives leadership to the governing body and/or advisory group in visioning, planning, policy, and decision-making processes. The executive director and governing body work as an effective team with information, coordination, staffing, and assistance provided by the executive, to support the

COA meets the intent of this CCBHC standard. Table of Evidence for GOV 8

CEO job description

CEO resume

Interview: a. CEO b. Governing Body Chair c. Personnel at all levels


A description of service provided by the clinical care team

Job description and resumé of physician or qualified health professional and/ or formal agreement with psychiatrist or a community mental health center

Interview: a. Clinical or program director b. Physician or qualified health

professional c. Relevant personnel d. Individuals or families served

Review case records

Review physician or qualified health professional's personnel record or the formal consulting agreement, as appropriate


CCBHC Criteria



(Tables of Evidence) governing body in its leadership, policy making, and oversight functions. Interpretation: Regarding element (g), the executive director should stay current on issues that could impact service delivery and operations that may require sustained efforts to address logical changes. Adapting to changing conditions requires the leader to be flexible and capable of addressing systemic challenges that may require development of new processes, systems, or skills. MHSU 7.01 A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating persons with mental health and/or substance use disorders is responsible for the medical aspects of treatment. Interpretation: Medical aspects can include: prescribing medication and medication management;

a. providing or reviewing diagnostic, toxicological, and other health related examinations of persons not currently under medical care and supervision;

b. review of complicated cases where co-occurring substance use, health, and mental health conditions intersect;

c. seizure disorders; d. psychosomatic disorders; and e. other medical and psychiatric related issues

such as traumatic brain injury.

The organization ensures that medication management includes appropriate monitoring and


CCBHC Criteria



(Tables of Evidence) administration of pharmacotherapy for individuals with co-occurring health, mental health, and substance use conditions. Interpretation: The qualifications and training of the physician should be appropriate to the program. For example, organizations that provide mental health services should have a board-eligible psychiatrist who is responsible for the medical aspects of treatment or a qualified health professional with the appropriate training, licensure, and/or credentials. Examples of qualified health professionals include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision. Interpretation: It is permissible under the standard to use a consulting psychiatrist or a community mental health center for psychiatric consultation, provided that the organization has a formal agreement or contract. "

1.a.4

The CCBHC maintains liability/malpractice insurance adequate for the staffing and scope of services provided.

RPM 4: Insurance Protection The organization is adequately insured. RPM 4.01 The organization annually assesses insurance needs, and obtains coverage that is commensurate with the scope and complexity of its services. Interpretation: Relevant types of insurance can include:

COA meets the intent of this CCBHC standard. Table of Evidence for RPM 4

Network procedures for identifying and verifying provider insurance

Network copy of written communication to providers regarding required insurance

Current insurance policies, with descriptions, amounts and dates of


CCBHC Criteria




a. general liability; b. workers’ compensation; c. disability; d. fire and theft; e. medical; f. indemnification; g. professional liability; h. officer’s or director’s liability; i. automobile liability; j. property and casualty; k. malpractice; and l. bonding or other forms of employee theft

insurance, as appropriate, for all staff and governing body members who sign checks, handle cash or contributions, or manage funds.

coverage

Minutes of meetings related to the organization’s annual review and approval of insurance coverage

Documentation that the organization provides a written description to personnel regarding its: insurance types, coverage amounts, and assumes legal assistance costs, as relevant

Network documentation of insurance verification

Interview: a. Governing Body members b. CEO/CFO c. Personnel at all levels

Network Interview: a. Provider Governing Body

members


Criteria 1.B: Licensure and Credentialing of Providers

1.b.1

All CCBHC providers who furnish services directly, and any Designated Collaborating Organization (DCO) providers that furnish services under arrangement with the CCBHC, are legally authorized in accordance with federal, state and local laws, and act only within the scope of their respective state licenses, certifications, or registrations and in accordance with all applicable laws and regulations, including any applicable state

RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations. RPM 10.01 Contractors who provide human or social services:

a. have sufficient human and financial resources to fulfill the terms of the contract; and


Contract monitoring procedures

Contracts

Contractor progress reports

Interview: a. Governing Body b. CEO/CFO c. Contract manager(s)


CCBHC Criteria



(Tables of Evidence) Medicaid billing regulations or policies. Pursuant to the requirements of the statute (PAMA § 223 (a)(2)(A)), CCBHC providers have and maintain all necessary state-required licenses, certifications, or other credentialing, with providers working toward licensure, and appropriate supervision in accordance with applicable state law.

b. are licensed or otherwise legally authorized to provide the contracted services.

RPM 10.02 The organization routinely monitors contractor progress toward fulfilling the terms of the contract. RPM 10.03 Contracts for social and human services include:

a. service quality, client satisfaction, and outcomes that accord with the organization’s expectations;

b. criteria for evaluating vendor performance; and

c. protocols for routine communication of related data.

RPM 10.04 When areas of concern are identified, the organization:

a. develops an improvement plan in conjunction with the contractor; and

b. ensures contractor follow-up and remediation.

d. PQI personnel e. Vendors

Network Interview: a. Provider CEO/CFO b. Provider contract manager(s)

1.b.2

The CCBHC staffing plan meets the requirements of the state behavioral health authority and any accreditation standards required by the state, is informed by the state’s initial needs assessment, and includes clinical and peer staff. In accordance with the staffing plan, the CCBHC maintains a core staff comprised of employed and, as needed, contracted staff, as appropriate to the needs of CCBHC consumers as stated in consumers’ individual treatment plans and as required by program requirements 3 and 4 of these

RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations. MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary.


Provide a letter signed by the Governing Body Chair and CEO certifying the organization is presently in compliance with license requirements, regulations and decrees. Networks are to provide procedures for ensuring provider compliance with applicable licenses, regulations, and decrees for services provided by the network.


CCBHC Criteria



(Tables of Evidence) criteria. States specify which staff disciplines they will require as part of certification but must include a medically trained behavioral health care provider, either employed or available through formal arrangement, who can prescribe and manage medications independently under state law, including buprenorphine and other medications used to treat opioid and alcohol use disorders. The CCBHC must have staff, either employed or available through formal arrangements, who are credentialed substance abuse specialists. 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: (1) psychiatrists (including child, adolescent, and geriatric psychiatrists), (2) nurses trained to work with consumers across the lifespan, (3) licensed independent clinical social workers, (4) licensed mental health counselors, (5) licensed psychologists, (6) licensed marriage and family therapists, (7) licensed occupational therapists, (8) staff trained to provide case management, (9) peer specialist(s)/recovery coaches, (10) licensed addiction counselors, (11) staff trained to provide family support, (12) medical assistants, and (13) community health workers. The CCBHC supplements its core staff, as necessary given program requirements 3 and 4 and individual

Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services. MHSU 7.01 A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating persons with mental health and/or substance use disorders is responsible for the medical aspects of treatment. Interpretation: Medical aspects can include:

a. prescribing medication and medication management;

b. providing or reviewing diagnostic, toxicological, and other health related examinations of persons not currently under medical care and supervision;

c. review of complicated cases where co-occurring substance use, health, and mental health conditions intersect;

d. seizure disorders; e. psychosomatic disorders; and f. other medical and psychiatric related issues

such as traumatic brain injury. The organization ensures that medication management includes appropriate monitoring and administration of pharmacotherapy for individuals with co-occurring health, mental health, and substance use conditions. Interpretation: The qualifications and training of the

See Governing Body minutes

Relevant licenses and legal regulation documents, as applicable to the organization

Reports from licensing/ regulatory review, as applicable

Network copies of relevant licenses and legal regulation documents, as applicable to the providers, at the office of the managing entity

Interview: a. Governing Body b. CEO/CFO


A description of services, including strategies for identifying and engaging other community-based providers, as appropriate

Copies of agreements with cooperating service providers and/ or an up-to-date referral list of identified community-based providers, as applicable

Interview: a. Clinical or program director b. Relevant personnel c. Individuals or families served

Review case records Table of Evidence for MHSU 7




CCBHC Criteria



(Tables of Evidence) treatment plans, through arrangements with and referrals to other providers. Note: Recognizing professional shortages exist for many behavioral health providers: (1) some services may be provided by contract or part-time or as needed; (2) in CCBHC organizations comprised of multiple clinics, providers may be shared among clinics; and (3) CCBHCs may utilize telehealth/ telemedicine and on-line services to alleviate shortages. CCBHCs are not precluded by anything in this criterion from utilizing providers working towards licensure, provided they are working under the requisite supervision.

physician should be appropriate to the program. For example, organizations that provide mental health services should have a board-eligible psychiatrist who is responsible for the medical aspects of treatment or a qualified health professional with the appropriate training, licensure, and/or credentials. Examples of qualified health professionals include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision. Interpretation: It is permissible under the standard to use a consulting psychiatrist or a community mental health center for psychiatric consultation, provided that the organization has a formal agreement or contract. MHSU 13.01 Supervisors are qualified by:

a. an advanced degree in a human service field and a minimum of two years professional experience;

b. specialized training in supervision; and c. certification and/or licensure by the

designated authority in their state, as appropriate.

MHSU 13.03 Clinical personnel and personnel who conduct assessments are competent, qualified by education, training, supervised experience, licensure or the



Review case records



Program staffing chart that includes lines of supervision

List of program personnel that includes: a. name; b. title; c. degree held and/or other

credentials; d. FTE or volunteer; e. length of service at the

organization; f. time in current position

Table of contents of training curricula

Procedures and criteria used for assigning and evaluating workloads

Documentation of training

Job descriptions

Training curricula

Documentation of workload assessment

Interview: a. Supervisors b. Relevant personnel c. Review case records


CCBHC Criteria



(Tables of Evidence) equivalent, and able to recognize individuals and families with special needs. Interpretation: Clinical personnel qualifications will vary depending on the services provided and program design. Clinical personnel may also include individuals who are license-eligible and supervised by experienced, licensed staff. MHSU 13.04 Clinical personnel receive ongoing training and education in the following areas:

a. delivering culturally and linguistically responsive care;

b. evidence-based practices and other relevant emerging bodies of knowledge;

c. psychosocial and ecological or person-in-environment perspectives;

d. methods of engagement, including establishing rapport and building trust;

e. assessing for signs and symptoms of trauma and risk, and implementing trauma-informed care practices; and

f. health information technology and electronic interventions, including mobile and web-based technologies, as appropriate.

MHSU 13.05 Clinical personnel demonstrate competency in:

a. methods of crisis prevention and intervention;

b. identifying the needs of exploited, abused, and neglected children and adults;

c. understanding child development and individual and family functioning;

d. working with difficult to reach, traumatized,


CCBHC Criteria



(Tables of Evidence) or disengaged individuals and families;

e. criteria to determine the need for more intensive services;

f. recognizing and working with individuals with co-occurring physical health, mental health, and substance use conditions; and

g. collaborating with other disciplines and services.

Interpretation: When the organization serves military or veteran populations, it is essential that staff have the competencies needed to effectively support and assist service members, veterans, and their families, including sufficient knowledge regarding: military culture, values, policies, structure, terminology, unique barriers to service, traumas and signature injuries, co-occurring conditions, effective and evidence-based interventions, applicable regulations, benefits, and other relevant issues. When providers possess the requisite military competency, they are capable of supporting improved communication and more effective care. Signature injuries and co-occurring conditions include post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance abuse, and intimate partner violence. Personnel serving military and veteran populations should have the competencies to identify, assess, and develop a treatment plan for these injuries and conditions. Interpretation: In addition to having the knowledge and skills to identify co-occurring mental health and substance use disorders, clinical personnel should also be able to recognize physical health issues commonly associated with mental health or


CCBHC Criteria



(Tables of Evidence) substance use disorders. MHSU 13.06 Clinical personnel receive training and demonstrate knowledge of the latest information, theories, and proven practices related to the treatment of alcohol and other drug use disorders, including:

a. the signs and symptoms of withdrawal; b. addiction as a disease; c. relapse prevention; and d. interventions that demonstrate respect for

sociocultural values, personal goals, life style choices, and complex family interactions.

MHSU 13.07 Individuals who provide peer support must:

a. obtain formal training and certification, as appropriate;

b. be willing to share their personal recovery stories; and

c. have adequate support and appropriate supervision.

Interpretation: Peer support workers must complete training and certification as defined by their state. MHSU 13.08 Individuals who provide peer support received pre- and in-service training on:

a. how to recognize the need for more intensive services and how to make an appropriate referral;

b. established ethical guidelines including setting appropriate boundaries; and

c. skills, concepts, and philosophies related to recovery and peer support.


CCBHC Criteria




Interpretation: Peer support workers should receive ongoing education to remain current on wellness support methods, trauma-informed care practices, and recovery resources as the field of recovery and peer support is rapidly evolving. Interpretation: Peer support workers establish relationships with service recipients that are based on mutual respect and trust and support bidirectional learning and reciprocity. One of the greatest perceived challenges of delivering peer support services is peers’ ability to handle confidentiality and boundaries. Clearly defining and communicating the roles of the peer worker is critical when establishing the peer-to-peer relationship.


Criteria 1.C: Cultural Competence and Other Training

1.c.1

The CCBHC has a training plan, for all employed and contract staff, and for providers at DCOs who have contact with CCBHC consumers or their families, which satisfies and includes requirements of the state behavioral health authority and any accreditation standards on training which may be required by the state. Training must address cultural competence; person-centered and family-centered, recovery- oriented, evidence-based and trauma-informed care; and primary care/behavioral health integration. This training, as well as training on the clinic’s continuity plan, occurs at orientation and thereafter at reasonable intervals as may be required by the state or

HR 5: Human Resource Practices Human resource practices are equitable, consistently applied, and in compliance with applicable laws and regulations. TS 1: Personnel Development and Training The organization’s training and development program provides personnel with the information necessary to competently provide services. TS 1.01 The organization implements a training and development program that enhances the knowledge, skills, and abilities of personnel and prepares personnel to assume their responsibilities.

COA meets the intent of this CCBHC standard. Table of Evidence for HR 5

Table of Contents for Personnel Manual

Procedures for conducting an annual audit of human resource practices

Reports from the most recent HR audit including documentation of corrective action, as needed

Personnel Manual

Personnel records

Review and analysis reports of compensation/benefits

Interview: a. CEO


CCBHC Criteria



(Tables of Evidence) accrediting agencies. At orientation and annually thereafter, the CCBHC provides training about: (1) risk assessment, suicide prevention and suicide response; (2) the roles of families and peers; and (3) such other trainings as may be required by the state or accrediting agency on an annual basis. If necessary, trainings may be provided on-line. Cultural competency training addresses diversity within the organization’s service population and, to the extent active duty military or veterans are being served, must include information related to military culture. Examples of cultural competency training and materials include, but are not limited to, those available through the website of the US Department of Health & Human Services (DHHS), the SAMHSA website through the website of the DHHS, Office of Minority Health, or through the website of the DHHS, Health Resources and Services Administration. Note: See criteria 4.K relating to cultural competency requirements in services for veterans.

TS 2: Training Content Personnel throughout the agency are trained to fulfill their job responsibilities. TS 2.01 New personnel are oriented within the first three months of hire to:

a. the organization’s mission, philosophy, goals, and services;

b. the cultural and socioeconomic characteristics of the service population;

c. the organization’s place within its community;

d. the organization’s personnel manual; e. the organization’s performance and quality

improvement system; and f. lines of accountability and authority within

the organization. TS 2.02 All personnel who have regular contact with clients receive training on legal issues, including:

a. mandatory reporting and the identification of clinical indicators of suspected abuse and neglect, as applicable;

b. federal and state laws requiring disclosure of confidential information for law enforcement purposes, including compliance with a court order, warrant, or subpoena;

c. duty to warn, pursuant to relevant professional standards and as required by law;

d. the agency’s policies and procedures on confidentiality and disclosure of service recipient information, and penalties for violation of these policies and procedures;

b. Governing Body regarding CEO c. HR Director d. Supervisory personnel e. Personnel at all levels

Table of Evidence for TS 1

Outline of required training for different positions or job categories and timeframes for completion

Annual budget with line for training and personnel development

Interview: a. Clinical or program director b. Relevant personnel c. Volunteers


Table of contents of the organization’s orientation and training curricula

Annual training calendar and/or training schedules

Training files, database, or personnel files that demonstrate attendance at required trainings

Training curricula

Interview: a. Clinical or program director b. Relevant personnel





CCBHC Criteria



(Tables of Evidence) e. the legal rights of service recipients; and f. any requirements associated with consent

decrees. TS 2.03 All personnel receive training on proper documentation techniques and the maintenance and security of case records. TS 2.04 Direct service personnel demonstrate competence in, or receive training on, as applicable:

a. positive engagement with individuals and families receiving services;

b. the needs of individuals and families in crisis including recognizing and responding to mental health crisis and the special service needs of victims of violence, abuse, or neglect and their family members;

c. basic health and medical needs of the service population;

d. procedures for working with foreign language speakers and persons with communication impairments; and

e. public assistance and government subsidies. TS 2.05 Training for direct service personnel addresses differences within the organization’s service population, including:

a. interventions that address cultural and socioeconomic factors in service delivery;

b. the role cultural identity plays in motivating human behavior; and

c. understanding bias or discrimination.






Job descriptions

Training curricula




CCBHC Criteria



(Tables of Evidence) TS 2.06 Personnel demonstrate competence in, or receive training on, the needs of special populations within the defined service population, such as the need for normalizing experiences and social inclusion. Interpretation: “Special populations” include, but are not limited to, those who are abused and neglected, those with a developmental disability, and those with mental health and substance use disorders. Depending on the services provided and the population served, the organization’s training may vary from different treatment approaches, to procedures for referring individuals to other providers when those needs cannot be addressed by the organization. For example, staff at a credit counseling agency may encounter individuals with substance abuse or mental health disorders. In such situations, staff should be aware of the agency’s protocols and how to refer those individuals to appropriate services. TS 2.07 Direct service personnel demonstrate competence in, or receive training on, advocacy, including how to:

a. access financial and other community resources;

b. identify the impact of the socioeconomic environment on the service population; and

c. empower service recipients and their families to advocate on their own behalf.

TS 2.08 Direct service personnel who administer clinical diagnostic tests used to establish treatment goals are


CCBHC Criteria



(Tables of Evidence) appropriately trained according to testing protocols. TS 2.09 Residential services, shelter services, day services, opioid treatment services, and youth development services ensure that there is at least one person certified in basic first aid and CPR on duty at each program site, at any time the program is in operation. MHSU 13: Personnel Personnel are appropriately supervised and qualified by education, training, experience, and licensure to meet the service needs of the target population. MHSU 13.04 Clinical personnel receive ongoing training and education in the following areas:

a. delivering culturally and linguistically responsive care;






Interpretation: Ecological or person-in-environment perspectives view social, economic, and environmental factors as critical in the development


CCBHC Criteria



(Tables of Evidence) and resolution of personal and family problems. Factors may include:

a. poverty and lack of employment opportunities;

b. local mores; c. language and cultural differences; and d. alternative medicine and traditional healing

processes. MHSU 13.05 Clinical personnel demonstrate competency in:




d. working with difficult to reach, traumatized, or disengaged individuals and families;


f. recognizing and working with individuals with co-occurring physical health, mental health, and substance use conditions; and


Interpretation: When the organization serves military or veteran populations, it is essential that staff have the competencies needed to effectively support and assist service members, veterans, and their families, including sufficient knowledge regarding: military culture, values, policies, structure, terminology, unique barriers to service, traumas and signature injuries, co-occurring conditions, effective and evidence-based interventions, applicable regulations,


CCBHC Criteria



(Tables of Evidence) benefits, and other relevant issues. When providers possess the requisite military competency, they are capable of supporting improved communication and more effective care. Signature injuries and co-occurring conditions include post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance abuse, and intimate partner violence. Personnel serving military and veteran populations should have the competencies to identify, assess, and develop a treatment plan for these injuries and conditions. Interpretation: In addition to having the knowledge and skills to identify co-occurring mental health and substance use disorders, clinical personnel should also be able to recognize physical health issues commonly associated with mental health or substance use disorders.


Criteria 1.C: Cultural Competence and Other Training (Continued)

1.c.2

The CCBHC assess the skills and competence of each individual furnishing services and, as necessary, provides in-service training and education programs. The CCBHC has written policies and procedures describing its method(s) of assessing competency and maintains a written accounting of the in-service training provided during the previous 12 months.

HR 6.01 The organization has a standardized process for providing every full-time and part-time employee and volunteer with a written performance review at regular intervals that involves the employee or volunteer and the supervisor. HR 6.02 The performance review process assesses job performance, recognizes accomplishments, provides constructive feedback, and emphasizes self-development and professional growth, in relation to:

a. specific expectations defined in the job


Performance evaluation forms/templates or description of ongoing review process

Personnel records

Performance review procedures

Contract policy and procedures

Contracts

Interview: a. HR Director b. Supervisory personnel


CCBHC Criteria



(Tables of Evidence) description;

b. organization-wide expectations for personnel;

c. objectives established in the most recent review, accomplishments and challenges since the last review period, and objectives for future performance;

d. developmental and professional objectives; e. recommendations for further training, skill

building, and other resources that may contribute to improved job performance; and

f. knowledge and competence related to the characteristics and needs of service recipients, if applicable.

HR 7.01 Personnel records are updated regularly, and contain:

a. identifying information and emergency contacts;

b. application for employment, hiring documents including job postings and interview notes, and reference verification;

c. job description; d. compensation documentation, as

appropriate; e. pre-service and in-service training records;

and f. performance reviews and all documentation

relating to performance, including disciplinary actions and termination summaries, if applicable.

c. Direct service personnel d. Personnel at various levels e. Independent contractors


Personnel records

Procedures regarding access to personnel records

Review the Network managing entity’s records for independent practitioners

Interview: a. HR Director b. Supervisory personnel c. Personnel at all levels


CCBHC Criteria




1.c.3

The CCBHC documents in the staff personnel records that the training and demonstration of competency are successfully completed.

HR 7.01 Personnel records are updated regularly, and contain:

a. identifying information and emergency contacts;

b. application for employment, hiring documents including job postings and interview notes, and reference verification;

c. job description; d. compensation documentation, as

appropriate; e. pre-service and in-service training records;

and f. performance reviews and all documentation

relating to performance, including disciplinary actions and termination summaries, if applicable.


Personnel records

Procedures regarding access to personnel records

Review the Network managing entity’s records for independent practitioners

Interview: a. HR Director b. Supervisory personnel c. Personnel at all levels

1.c.4

Individuals providing staff training are qualified as evidenced by their education, training and experience.

TS 2: Training Content Personnel throughout the agency are trained to fulfill their job responsibilities.

COA meets the intent of this CCBHC standard. Table of Evidence for TS 2




Training curricula

Interview: a. Clinical or program director b. relevant personnel


CCBHC Criteria





Criteria 1.D: Linguistic Competence

1.d.1

If the CCBHC serves individuals with Limited English Proficiency (LEP) or with language-based disabilities, the CCBHC takes reasonable steps to provide meaningful access to their services.

CR 1.06 The organization accommodates the written and oral communication needs of clients by:

a. communicating, in writing and orally, in the languages of the major population groups served;

b. providing, or arranging for, bilingual personnel or translators or arranging for the use of communication technology, as needed; providing telephone amplification, sign language services, or other communication methods for deaf or hearing impaired persons;

c. providing, or arranging for, communication assistance for persons with special needs who have difficulty making their service needs known; and

d. considering the person’s literacy level.

COA meets the intent of this CCBHC standard. Table of Evidence for CR 1


Policy for providing services to minors without the consent of the parent or legal guardian




1.d.2

Interpretation/translation service(s) are provided that are appropriate and timely for the size/needs of the LEP CCBHC consumer population (e.g., bilingual providers, onsite interpreters, language telephone line). To the extent interpreters are used, such translation service providers are trained to function in a medical and, preferably, a behavioral health setting.



b. providing, or arranging for, bilingual personnel or translators or arranging for the use of communication technology, as needed;

c. providing telephone amplification, sign language services, or other communication methods for deaf or hearing impaired persons;





Interview: a. Relevant personnel b. Individuals or families served


CCBHC Criteria



(Tables of Evidence) d. providing, or arranging for, communication

assistance for persons with special needs who have difficulty making their service needs known; and

e. considering the person’s literacy level. Interpretation: Basic program information is available in languages representative of consumer groups. Organizations that fully implement CR 1.06 proactively reach out to ensure that all individuals can use its services and fully participate in planning. The organization has sufficient numbers of bilingual personnel for all programs in which confidential interpersonal communication is necessary for adequate service delivery. There is a bilingual worker on staff for each language group large enough to comprise an average-sized caseload. Trained translators or interpreters are available in other instances or in non-counseling services when bilingual personnel are not available. Assistive technology, such as amplification for hearing-impaired persons or a language telephone line, is used when appropriate. MHSU 2: Screening and IntakeThe organization’s screening and intake practices ensure that service recipients receive prompt and responsive access to appropriate services.

c. Review case records

Facility Observation Table of Evidence for MHSU 2

Screening and intake procedures

List of community-based providers/ referral sources


Review case records


CCBHC Criteria




1.d.3

Auxiliary aids and services are readily available, Americans With Disabilities Act (ADA) compliant, and responsive to the needs of consumers with disabilities (e.g., sign language interpreters, teletypewriter (TTY) lines).

CR 1.09 The organization designs and adapts its programs and services, as appropriate, to accommodate the visual, auditory, linguistic, and motor abilities of persons served. CR 4.06 The organization provides assistive technology, or helps the person gain access to assistive resources, as needed, and the person is:

a. involved in the selection of specific technologies;

b. afforded the opportunity to try the device prior to purchase or assignment; and

c. trained on the use of specific assistive devices being provided.

Interpretation: Assistive technology is any tool, device, service, or software that helps persons with disabilities perform tasks that otherwise might be difficult or impossible.






Facility Observation Table of Evidence for CR 4

Include service philosophy in the Narrative of each applicable service section (CR 4.01, CR 4.02, and CR 4.07)

Procedures for use of interventions that limit movement, diminish sensory experience, limit personal freedom, or cause personal discomfort

Include service planning procedures with the service planning and monitoring evidence of each applicable service section (CR 4.03, CR 4.04, and CR 4.05)

Procedures for helping persons access assistive technology

Procedures for providing or making referrals for family support services

Training curricula, educational material and/or other material provided to persons served regarding sexuality and relationships


CCBHC Criteria




Interview: a. Clinical or program director b. Relevant personnel c. Persons served d. Review case records


Criteria 1.D: Linguistic Competence (Continued)

1.d.4

Documents or messages vital to a consumer’s ability to access CCBHC services (for example, registration forms, sliding scale fee discount schedule, after-hours coverage, signage) are available for consumers in languages common in the community served, taking account of literacy levels and the need for alternative formats (for consumers with disabilities). Such materials are provided in a timely manner at intake. The requisite languages will be informed by the needs assessment prepared prior to certification, and as updated.

CR 1.01 At initial contact clients receive and are helped to understand a written summary of their rights and responsibilities, including:

a. a description of the client’s rights, including the obligations the organization has to the client;

b. basic expectations for use of the organization’s services;

c. hours that services are available; d. rules, expectations, and other factors that

can result in discharge or termination of services; and

e. a clear explanation of how to lodge complaints, grievances, or appeals.

Interpretation: If a client is disoriented or suffering from impaired cognition at initial contact, the summary of client rights and responsibilities should be provided at an appropriate time. When working with individuals who have been deemed








CCBHC Criteria



(Tables of Evidence) incapacitated by the court, the depth or content of information provided may vary based on the individual’s assessed capacity to understand the information, the court order, and state law. Interpretation: The organization’s explanation of how to lodge complaints, grievances, or appeals should include informing clients about their right to file a complaint with the appropriate public authority or regulatory body. Interpretation: For networks, when the scope of a network’s services includes service authorization and placement decisions, the client’s right to appeal placement and authorization decisions are outlined in written network client rights and responsibilities material available to clients, and in the provider manual or other document outlining network operational procedures. Interpretation: Organizations that use web-based technologies or electronic communications to deliver services shall implement a system for assuring and documenting that clients receive and understand their rights and responsibilities. CR 1.06 The organization accommodates the written and oral communication needs of clients by:




CCBHC Criteria



(Tables of Evidence) c. providing telephone amplification, sign

language services, or other communication methods for deaf or hearing impaired persons;

d. providing, or arranging for, communication assistance for persons with special needs who have difficulty making their service needs known; and

e. considering the person’s literacy level. Interpretation: Basic program information is available in languages representative of consumer groups. Organizations that fully implement CR 1.06 proactively reach out to ensure that all individuals can use its services and fully participate in planning. The organization has sufficient numbers of bilingual personnel for all programs in which confidential interpersonal communication is necessary for adequate service delivery. There is a bilingual worker on staff for each language group large enough to comprise an average-sized caseload. Trained translators or interpreters are available in other instances or in non-counseling services when bilingual personnel are not available. Assistive technology, such as amplification for hearing-impaired persons or a language telephone line, is used when appropriate.

1.d.5

The CCBHC’s policies have explicit provisions for ensuring all employees, affiliated providers, and interpreters understand and adhere to confidentiality and privacy requirements applicable to the service provider, including but not limited to the requirements of Health Insurance Portability and Accountability Act (HIPAA) (Pub. L. No.

CR 2: Confidentiality and Privacy Protections The organization protects the confidentiality of information about clients and assumes a protective role regarding the disclosure of confidential information. Interpretation: The organization must carefully reconcile its policies, procedures, and practices with


Confidentiality policy and procedures

Sample release form for disclosure of confidential information

Interview: a. Clinical or program director


CCBHC Criteria



(Tables of Evidence) 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule allows routine – and often critical – communications between health care providers and a consumer's family and friends, so long as the consumer consents or does not object. If a consumer is amenable and has the capacity to make health care decisions, health care providers may communicate with a consumer's family and friends

all applicable confidentiality laws and regulations including, but not limited to, laws and regulations governing information about youth involved with the juvenile justice system, mental health consumers, victims of domestic violence, drug and alcohol treatment, and HIV/AIDS. The organization’s procedures must reconcile legal restrictions on the release of identifying information about clients with mandatory reporting and duty to warn requirements. Written procedures should include guidance to personnel in determining the degree of danger a person may pose to him or herself or to the community. Adult Guardianship (AG) programs must have procedures in place to ensure the decision to release confidential information is made in an ethical manner. See AG 8.02 for more information on ethical decision-making. The level of client involvement in the decision to release confidential information will vary based on the court order and state law. CR 2.01 The organization informs the client, prior to his or her disclosure of confidential or private information, about circumstances when the organization may be legally or ethically permitted or required to release such information without the client’s consent. CR 2.02 When the organization receives a request for confidential information about a client, or when the release of confidential information is necessary for the provision of services, prior to releasing such information, the organization:

b. Relevant personnel c. Individuals or families served

Review case records Table of Evidence for TS 2




Training curricula


Table of Evidence for RPM 6

Policies and procedures for managing web-based technologies and electronic communications

Plan or procedures for managing data interruptions

MIS case record procedures

HIPAA compliance policies and procedures, as applicable

Interview: a. Finance personnel b. PQI personnel c. MIS manager d. Program directors e. Direct service personnel

Case record room/files and MIS accessibility observation

RPM 7 Case Records*


CCBHC Criteria



(Tables of Evidence) a. determines if the reason to release

information is valid; b. obtains the client’s informed, written

authorization to release the information; and

c. obtains informed, written authorization from a parent or legal guardian, as appropriate.

Interpretation: In the context of this standard, “valid” means justifiable, legitimate, convincing, legally permissible, and in the best interest of the client. The organization obtains legal counsel regarding the confidentiality of records and the conditions under which they may be subpoenaed. Unless otherwise required by law, authorization to release confidential information is not necessary where the request for information is pursuant to a subpoena. The organization seeks additional legal counsel, as necessary, when others seek identifying information about an individual or family, or when the release of confidential information is necessary for the provision of services. When the client is a minor or an adult under the care of a guardian, the organization should follow any laws or regulations allowing or requiring the organization to obtain the authorization of clients’ parents or legal guardians. When permitted or required by law, regulation, or court order, confidential information may be released without the authorization of the client and legal guardian. However, the client and legal guardian


CCBHC Criteria



(Tables of Evidence) should still be informed that the information will be released. CR 2.03 Informed, written consent is obtained from the client, or a legal guardian, prior to recording, photographing, or filming. Interpretation: When required by law, consent may not be necessary. However, it is still expected that the organization inform clients prior to recording, photographing, or filming CR 2.04 The release form for disclosure of confidential information includes the following elements:

a. the name of the person whose information will be released;

b. the signature of the person whose information will be released, or the parent or legal guardian of a person who is unable to provide authorization;

c. the specific information to be released; d. the purpose for which the information is to

be used; e. the date the release takes effect; f. the date, event, or condition upon which the

consent expires, not to exceed one year from when the release takes effect;

g. the name of the person(s) or organization(s) that will receive the disclosed information;

h. the name of the person or organization that is disclosing the confidential information; and

i. a statement that the person or family may withdraw their authorization at any time


CCBHC Criteria



(Tables of Evidence) except to the extent that action has already been taken.

Interpretation: In relation to element (f), the expiration event or condition should relate to the individual or to the purpose of the use or disclosure. The date, event, or condition upon which the consent expires must ensure that the authorization will last no longer than reasonably necessary. When the release of information is required for ongoing service provision, all elements of the form must be reviewed and updated annually at minimum to ensure that consent continues to be informed and appropriate. Interpretation: When a release form is used to authorize the exchange of information between multiple parties, the form must comply with all elements of the standard. All relevant parties must be authorized to disclose and receive the information specified, for the purpose indicated, in the consent. Interpretation: Blanket release forms signed by clients when service is initiated do not meet the requirements of this standard, except as put forth by federal regulation, for example, when making application to FEMA/DHS in a declared disaster. Interpretation: When permitted or required by law, regulation, or court order, confidential information may be released without the authorization of the person or legal guardian. In this case elements (b) and (i) will not apply. However, the organization should still inform the person and/or legal guardian that the information will be shared, as referenced in CR 2.01 and CR 2.02, and maintain documentation of the disclosure in the client’s file.


CCBHC Criteria



(Tables of Evidence) Interpretation: In credit counseling organizations this standard applies in situations where a client specifically requests release of information to a third party, such as a letter of reference regarding payment history, or in instances when a program specific release does not exist. Debt management agreements or releases signed at the initiation of a debt management program allow for information sharing with all creditors included in the program or added to the program for the duration of service, unless state laws indicate otherwise. CR 2.05 The organization offers a copy of the signed form to the person or family authorizing the disclosure of confidential information, and places a copy in the case record. Interpretation: When there are concerns about the individual’s capacity to understand the confidential nature of the document, such as when the individual has been deemed incapacitated by the court, it may be inappropriate to provide the individual with a copy of the release form. Instead, the worker should include a copy of the release form in the case record and document reasons why the form was not provided. Interpretation: A copy of the completed release form should be offered to the person, and placed in the case record, even when it is permissible by law to release confidential information without the person’s authorization and signature. TS 2.02 All personnel who have regular contact with clients


CCBHC Criteria



(Tables of Evidence) receive training on legal issues, including:

a. mandatory reporting and the identification of clinical indicators of suspected abuse and neglect, as applicable;

b. federal and state laws requiring disclosure of confidential information for law enforcement purposes, including compliance with a court order, warrant, or subpoena;

c. duty to warn, pursuant to relevant professional standards and as required by law;

d. the agency’s policies and procedures on confidentiality and disclosure of service recipient information, and penalties for violation of these policies and procedures;

e. the legal rights of service recipients; and f. any requirements associated with consent

decrees. Interpretation: Personnel should be familiar with federal, state, and local laws and know how to identify, document, and report cases of suspected abuse and neglect. TS 2.03 All personnel receive training on proper documentation techniques and the maintenance and security of case records. RPM 6: Security of Information Electronic and printed information is protected against intentional and unintentional destruction or modification and unauthorized disclosure or use.


CCBHC Criteria



(Tables of Evidence) Interpretation: Regulations that govern the protection of individually identifiable health information and set national standards for the security of electronic protected health information include the Health Insurance Portability and Accountability Act (“HIPAA” Privacy and Security Rule) and the Health Information Technology for Economic and Clinical Health Act (“HITECH”). Interpretation: The standards in this section address security of all types of records, including case records, administrative, financial, health, and personnel records, unless otherwise noted. See also RPM 7 Case Records and RPM 8 Access to Case Records.

PROGRAM REQUIREMENT 2: AVAILABILITY AND ACCESSIBILITY OF SERVICES

Criteria 2.A: General Requirements of Access and Availability

2.a.1

The CCBHC provides a safe, functional, clean, and welcoming environment, for consumers and staff, conducive to the provision of services identified in program requirements.

ASE 1: Promotion of Health and Safety In its daily operations, the organization ensures the health and safety of its personnel and the individuals and families it serves. ASE 1.01 The organization ensures that its administrative and service environments promote the health and safety of personnel and service recipients. ASE 1.02 The organization develops and implements a policy

COA meets the intent of this CCBHC standard. Table of Evidence for ASE 1

Copies of resources and educational materials on healthy living available to service recipients

Smoking policy

Interview: a. Program director b. Facility management staff c. Personnel


CCBHC Criteria



(Tables of Evidence) to prohibit smoking in all areas of its buildings except in specified circumstances and in locations environmentally separate from administrative and service areas. ASE 1.03 The organization offers information on healthy living choices to service recipients, if desired. ASE 1.04 The organization takes steps to reduce the environmental impact of its daily operations in one or more of the following ways:

a. instituting a recycling program; b. using environmentally friendly products; or c. reducing water and energy consumption.

ASE 1.05 The organization maintains a work environment for its personnel that is conducive to effectively providing services to individuals and families in a private and confidential manner, as needed. ASE 1.06 When services are offered in a location operated by another organization or entity on a regular and ongoing basis, the organization ensures:

a. the space and required equipment is appropriate to the services being offered, and the ages and abilities of clients;

b. facilities are clean; c. there are adequate bathroom and hand

washing facilities; d. drinking water will be readily available; e. the temperature, ventilation, noise level,

and light in the space are comfortable and

d. Individuals or families served

Observe facility


CCBHC Criteria



(Tables of Evidence) appropriate to the services being offered;

f. there are no observable safety hazards in the space and required equipment is safe; and

g. smoking is prohibited in all areas of the building except in specified circumstances and in locations environmentally separate from administrative and service areas.

2.a.2

The CCBHC provides outpatient clinical services during times that ensure accessibility and meet the needs of the consumer population to be served, including some nights and weekend hours.

MHSU 5: Clinical Counseling The organization provides clinical counseling services that:

a. provide an appropriate level and intensity of support and treatment;

b. recognize individual and family values and goals;

c. accommodate variations in lifestyle; d. emphasize personal growth, development,

and situational change; and e. promote recovery, resilience, and wellness.

Interpretation: Recovery is a holistic process of change where individuals learn to overcome or manage their diagnosed symptoms and conditions in order to improve overall well-being and achieve optimal health. MHSU 6.01 Services are delivered in a holistic, trauma-informed, and culturally and linguistically responsive manner, and focus on the treatment of mental health and/or substance use disorders.

COA’s standards have an implied alignment with the CCBHC standard listed here. In, element (c) of MHSU 5, accommodating variations in lifestyle includes nontraditional schedules. In MHSU 6.01, taking a holistic approach in the delivery of services accounts for the whole person with regard to how much needed services fit into the other obligations and commitments the service recipient has to meet in their day-to-day lives. Table of Evidence for MHSU 5

A description of clinical counseling services

Procedures for evaluating level and intensity of care (MHSU 5.05)




Copies of agreements with cooperating service providers and/ or an up-to-date


CCBHC Criteria



(Tables of Evidence) referral list of identified community-based providers, as applicable


Review case records


Criteria 2.A: General Requirements of Access and Availability (Continued)

2.a.3

The CCBHC provides services at locations that ensure accessibility and meet the needs of the consumer population to be served.

ASE 2.02 In planning the location and use of offices and branches, the organization considers:

a. accessibility, availability, and affordability of public transportation;

b. location of other relevant community resources; and

c. the special needs of service recipients. Interpretation: In addition to the needs of the defined service population, this standard requires the organization to address the needs of persons with disabilities.

COA meets the intent of the CCBHC standard. Table of Evidence for ASE 2

Documentation of legal compliance

Interview: a. Program director b. Relevant personnel

Observe facility

2.a.4

To the extent possible within the state Medicaid program or other funding or programs, the CCBHC provides transportation or transportation vouchers for consumers.

MHSU 10.01 The organization provides, either directly or by referral, necessary support services which may include, as appropriate:

a. work-related services and job placement; b. supported housing; c. transportation; d. social skills training; e. public benefits; f. educational services; and g. respite care.

COA meets the intent of the CCHBC standard. Table of Evidence for MHSU 10

Procedures for the provision of support services, including strategies for identifying and engaging other community-based providers, as appropriate

A description of services, including child care services when applicable


CCBHC Criteria




Copies of agreements with cooperating service providers and/ or an up-to-date referral list of identified providers, as appropriate


Review case records

2.a.5

To the extent possible within the state Medicaid program and as allowed by state law, CCBHCs utilize mobile in-home, telehealth/telemedicine, and on-line treatment services to ensure consumers have access to all required services.

ICHH 1.06 The organization uses health information technologies to: a. link services; b. organize, track, and analyze critical program information; and c. satisfy applicable reporting requirements MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services. Research Note: Evidence shows that prevention interventions such as cognitive behavior therapy, crisis lines, and mobile applications are useful for helping individuals at risk for suicide and individuals with severe and persistent mental health disorders. Research Note: Research suggests that individuals who participate in more structured and directed treatment are more

COA’s standard closely align with CCBCH standard language here in that technology is listed as a medium to ensure the service delivery objective of providing access to the widest array of needed services possible. Technology is also recognized in the COA standard listed here to facilitate service coordination. Table of Evidence for ICHH 1

Service Philosophy

Include program outcomes and outputs in the Narrative

A description of mechanisms for linking behavioral health and primary care services

Copies of informational materials provided to clients and other stakeholders

Interview: a. Program director b. Relevant personnel c. Persons served

Review case records

Observe health information technologies Table of Evidence for MHSU 6

A description of services, including


CCBHC Criteria



(Tables of Evidence) involved in care and become more engaged in social activities, develop more supportive relationships, and are more likely to complete treatment.

strategies for identifying and engaging other community-based providers, as appropriate



Review case records


Criteria 2.A: General Requirements of Access and Availability (Continued)

2.a.6

The CCBHC engages in outreach and engagement activities to assist consumers and families to access benefits, and formal or informal services to address behavioral health conditions and needs.

ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. Interpretation: This includes coordination of any services provided directly by the organization as well as those provided through linkages to community providers. ICHH 4.05 The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:

a. establishing partnerships and coordination procedures with direct service providers in

COA meets the intent of the CCBCH standard. Table of Evidence for ICHH 4

Description of care coordination services

Care coordination procedures

Care transition procedures

Procedures / mechanisms for tracking medication reconciliation and adherence

Copy of agreement with and/or job description and resume for each member of the care planning team, including a physician and psychiatrist for consultation

Copies of agreements with community providers, as applicable

Up-to-date referral list

Interview: a. Program director


CCBHC Criteria



(Tables of Evidence) the community;

b. maintaining a comprehensive, up-to-date referral list;

c. removing barriers to the initiation of needed services including procedures for providing a warm hand off when needed services are provided directly by the program or on-site through a partnering provider; and

d. assisting the person with system navigation. Interpretation: Examples of community and social support services and behavioral and physical health care services that should be made available to persons served include:

a. preventative and health promotion services; b. mental health and substance use services; c. comprehensive care management, care

coordination, and transitional care; d. chronic disease management, including self-

management; e. community, social support, and recovery

services; and f. long-term care supports and services.

MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services.

b. Care planning team members c. Persons served






Procedures for care coordination, including strategies for identifying and engaging other community-based providers

Copies of agreements with cooperating service providers and/ or an up-to-date referral list of identified community-based providers, as appropriate


Review case records


CCBHC Criteria



(Tables of Evidence) MHSU 9: Care Coordination The organization coordinates services in order to promote continuity of care and whole-person wellness. MHSU 9.04 In collaboration with the service recipient, the organization coordinates with, as needed:

a. the child welfare system; b. the juvenile justice system; c. courts; and d. the school system.








Review case records

2.a.7

Services are subject to all state standards for the provision of both voluntary and court-ordered services.

RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations.

COA meets the intent of the CCBHC standard. Table of Evidence for RPM 1



CCBHC Criteria









2.a.8

CCBHCs have in place a continuity of operations/disaster plan.

ASE 7: Emergency Response Preparedness The organization plans for and coordinates emergency response preparedness. ASE 7.01 The organization develops an emergency response plan that addresses:

a. coordination with appropriate local, state, and federal governmental authorities;

b. coordination with emergency responders; coordination and communication with service recipients;

c. evacuation of persons with mobility challenges and other special needs;

d. accounting for the whereabouts of staff and service recipients;

e. options for relocating service recipients; and f. situations involving harm or violence, or the

threat of harm or violence. Interpretation: Emergency situations include accidents, serious illness, fire, medical emergencies, water emergencies, natural disasters, emergencies

COA exceeds the intent of the CCBHC standard. Table of Evidence of Evidence for ASE 7

Emergency Response Plan/Emergency Preparedness Procedures

Emergency preparedness training materials

Documentation of staff training

Interview: a. Relevant personnel b. Observe facility

Network Interview: a. Network CEO b. Network Emergency Response

Coordinator


CCBHC Criteria



(Tables of Evidence) associated with outdoor activities, hostage situations, bomb threats, unlawful intrusion, physical assault, and other life threatening situations. Interpretation: For networks, in emergency situations where service recipients are likely to be evacuated, it is critical that the emergency response plan address arrangements for the provision of medications for persons who require them in order to remain healthy. Such persons can include individuals with psychiatric conditions, individuals taking opioid treatment medications, and older adults. Arrangements can include maintaining a list of service recipients likely to be effected, and pre-arranging for services outside the area likely to be evacuated. ASE 7.02 The organization is prepared to treat injuries and respond to medical emergencies by:

a. maintaining a readily available communication device, poison control information, and first aid supplies and manuals at all program sites;

b. consulting with a health professional, as necessary, to develop procedures for such situations; and

c. maintaining emergency contact information for personnel and service recipients.

ASE 7.03 The emergency response plan includes arrangements for:

a. a temporary work site in the event of facility


CCBHC Criteria



(Tables of Evidence) closure;

b. communicating with the governing body, personnel, service recipients, the public, and the media; and

c. notifying parents or legal guardians, as appropriate.

ASE 7.04 All personnel are trained on how to respond to medical threats and emergencies, including:

a. assessing risk and safety; b. handling emergencies; c. coordinating with medical, mental health,

law enforcement, and other professionals; and

d. implementing the organization’s health and safety procedures.


Criteria 2.B: Requirements for Timely Access to Services and Initial and Comprehensive Evaluation for New Consumers

2.b.1

All new consumers requesting or being referred for behavioral health services will, at the time of first contact, receive a preliminary screening and risk assessment to determine acuity of needs. That screening may occur telephonically. The preliminary screening will be followed by: (1) an initial evaluation, and (2) a comprehensive person-centered and family-centered diagnostic and treatment planning evaluation, with the components of each specified in program requirements. Each evaluation builds upon what came before it. Subject to more stringent state, federal, or applicable accreditation standards:

MHSU 2: Screening and Intake The organization’s screening and intake practices ensure that service recipients receive prompt and responsive access to appropriate services. MHSU 2.01 Service recipients are screened at intake and informed about:

a. how well their request matches the organization’s services;

b. what services will be available and when; and

c. rules and expectations of the program.

COA meets the intent of the CCBHC standard. Table of Evidence for MHSU 2





Assessment and reassessment


CCBHC Criteria



(Tables of Evidence) • If the screening identifies an emergency/crisis need, appropriate action is taken immediately, including any necessary subsequent outpatient follow-up.

Interpretation: Screenings will vary based on the program’s target population and services offered, and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, and/or risk of harm to self or others. Interpretation: For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program. MHSU 2.02 Prompt, responsive intake practices:

a. ensure equitable treatment; b. give priority to urgent needs and emergency

situations; c. facilitate the identification of individuals and

families with co-occurring conditions and multiple needs;

d. enable access to a comprehensive assessment process;

e. support timely initiation of services; and f. provide for placement on a waiting list, if

desired. Interpretation: Screening and intake procedures should direct staff on how to identify and respond to individuals or families experiencing emergency situations to ensure that they receive expedited treatment planning and are connected to more intensive services. Organizations should have the capacity to refer individuals in crisis to the appropriate services, which may include 24-hour mobile crisis teams, emergency crisis intervention

procedures

List of standardized assessment tools used

Copies of any standardized assessment tools used

List of identified medical referral sources, if applicable (MHSU 3.07)


Individuals or families served

Review case records


CCBHC Criteria



(Tables of Evidence) services, or crisis stabilization. Urgent situations can also include those in which an individual has a child in the child welfare system. Interpretation: Wait times are a major barrier to individuals and families receiving services. Organizations can monitor waitlists and standardize their referral process to improve accessibility. MHSU 2.03 Service recipients who cannot be served, or cannot be served promptly, are referred or connected to appropriate resources. MHSU 3: Assessment Service recipients participate in a comprehensive, individualized, trauma-informed, strengths-based, family-focused, culturally and linguistically responsive assessment to determine an appropriate level of service. Interpretation: For an assessment to be trauma-informed, the organization understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the service recipient rather than personal deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the organization actively prevents instances that could potentially re-traumatize service recipients. MHSU 3.02 Assessments are conducted in a culturally and linguistically responsive manner, and:


CCBHC Criteria



(Tables of Evidence) a. identify resources that can increase service

participation and achievement of agreed-upon goals; and

b. address issues of special relevance to various groups, such as women, older adults, young children, or adolescents, as applicable.

Interpretation: Culturally responsive assessments can include attention to geographic location, language of choice, the person’s religious, racial, ethnic, and cultural background, and military status. Other important factors that contribute to a responsive assessment include attention to age, sexual orientation, gender identity, developmental level and level of literacy attainment. Interpretation: For organizations serving children, assessments should take into account systems involvement including education, child welfare and juvenile justice. MHSU 3.03 Engagement and assessment are characterized by:

a. sensitivity to the willingness of the service recipient to be engaged;

b. a non-threatening manner; c. respect for the service recipient’s autonomy

and confidentiality; d. flexibility; and e. persistence.

MHSU 3.04 Each service recipient receives an individualized,


CCBHC Criteria



(Tables of Evidence) comprehensive assessment, which includes a summary of symptoms and diagnoses based on a standardized diagnostic tool. Interpretation: The standardized diagnostic tool should be used to match the needs of the service recipient with the appropriate level care. Assessment tools will vary depending on the age and developmental level of the service population. Examples of standardized instruments or protocols include: the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), the Addiction Severity Index, Treatment Services Review, the American Society of Addiction Medicine (ASAM) patient placement criteria, the Institute of Medicine (IOM), the Child and Adolescents Needs and Strengths (CANS), criteria required by federal or state oversight authorities, and criteria required for participation in managed care delivery systems. Interpretation: Assessments are completed within timeframes established by the organization. Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes. MHSU 3.05 The comprehensive assessment includes: the service recipient’s behavioral health, physical health, and community and social support service needs and goals; trauma history and recent incidents of trauma; individual and family strengths, risks, and protective


CCBHC Criteria



(Tables of Evidence) factors; and natural supports and helping networks. Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks. Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history. Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options.


CCBHC Criteria



(Tables of Evidence) Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 3.06 The organization engages service recipients in a risk assessment to assess their risk of suicide, self-injury, neglect, exploitation, and violence towards others. Interpretation: Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents. MHSU 3.07 Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:

a. medication monitoring and management; b. physical examinations or other physical

health services; c. medical detoxification; d. laboratory testing and toxicology screens; or e. other diagnostic procedures.

Interpretation: The nature of problems resulting


CCBHC Criteria



(Tables of Evidence) from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring. Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff, or available through a contract or formal arrangement. All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional. Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the organization for counseling or prevention. In such cases, the organization is not responsible for addressing the medical aspects of treatment, but must coordinate services with the physician. MHSU 3.08 Reassessments are conducted as necessary, according to the needs of the service recipient. Interpretation: Reassessments are completed within timeframes established by the organization depending on the service population and length of treatment. Timeframes may also be delineated by regulatory requirements. The organization may conduct a reassessment during specific milestones in


CCBHC Criteria



(Tables of Evidence) the treatment process, including:

a. after significant treatment progress; b. after a lack of significant treatment

progress; c. after new symptoms are identified; d. when significant behavioral changes are

observed; e. when there are changes to a family

situation; or f. when significant environmental changes

occur.

2.b.1

If the screening identifies an urgent need, clinical services are provided and the initial evaluation completed within one business day of the time the request is made. • If the screening identifies routine needs, services will be provided and the initial evaluation completed within 10 business days. • For those presenting with emergency or urgent needs, the initial evaluation may be conducted telephonically or by telehealth/telemedicine but an in-person evaluation is preferred. If the initial evaluation is conducted telephonically, once the emergency is resolved the consumer must be seen in person at the next subsequent encounter and the initial evaluation reviewed. Subject to more stringent state, federal or applicable accreditation standards, all new consumers will receive a more comprehensive person-centered and family-centered diagnostic and treatment planning evaluation to be completed within 60 calendar days of the first request for services.

CRI 6: Crisis Intervention Services The organization responds immediately and appropriately to individuals in crisis situations. CRI 6.01 Crisis intervention personnel respond immediately and:

a. evaluate and assess each person’s specific crisis;

b. provide intervention and stabilization; c. work with the person to develop an action

plan; d. work with the person to develop a safety

plan as needed; e. make referrals to appropriate resources; and f. follow up with each person within 24 hours,

when appropriate. CRI 6.02 Crisis personnel are available on-call by telephone 24 hours a day, on a walk-in basis during regular business hours, by mobile unit, and/or by telephone referral. Interpretation: Twenty-four hour on-call coverage can be provided through ongoing organization-

COA meets the intent of the standard reserving authority over specific timeframes for entities providing legal and regulatory oversight of the organization. Table of Evidence for CRI 6

A description of crisis intervention services

Crisis response procedures

Treatment and referral procedures Table of Evidence for MHSU 3

Assessment and reassessment procedures





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CCBHC Criteria



(Tables of Evidence) This requirement that the comprehensive evaluation be completed within 60 calendar days does not preclude either the initiation or completion of the comprehensive evaluation or the provision of treatment during the 60 day period. Note: Requirements for these screenings and evaluations are specified in criteria 4.D.

operated coverage of its telephone, or through a cooperating community emergency telephone hotline. MHSU 3.06 The organization engages service recipients in a risk assessment to assess their risk of suicide, self-injury, neglect, exploitation, and violence towards others. Interpretation: Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents. MHSU 3.07 Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:



Interpretation: The nature of problems resulting from mental health and/or substance use disorders


Service planning and monitoring procedures, including strategies for active family participation when appropriate

Crisis planning procedures

Documentation of case review


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CCBHC Criteria



(Tables of Evidence) may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring. Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff, or available through a contract or formal arrangement. All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional. Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the organization for counseling or prevention. In such cases, the organization is not responsible for addressing the medical aspects of treatment, but must coordinate services with the physician. MHSU 4.01 An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient, and expedited service planning is available when crisis or urgent need is identified. Interpretation: Service planning is conducted so that the individual retains as much personal responsibility and self-determination as possible and desired.


CCBHC Criteria



(Tables of Evidence) Individuals with limited ability in making independent choices receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for completing service plans.

2.b.2

The comprehensive person-centered and family-centered diagnostic and treatment planning evaluation is updated by the treatment team, in agreement with and endorsed by the consumer and in consultation with the primary care provider (if any), when changes in the consumer’s status, responses to treatment, or goal achievement have occurred. The assessment must be updated no less frequently than every 90 calendar days unless the state has established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent.

MHSU 3.04 Each service recipient receives an individualized, comprehensive assessment, which includes a summary of symptoms and diagnoses based on a standardized diagnostic tool. Interpretation: The standardized diagnostic tool should be used to match the needs of the service recipient with the appropriate level care. Assessment tools will vary depending on the age and developmental level of the service population. Examples of standardized instruments or protocols include: the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), the Addiction Severity Index, Treatment Services Review, the American Society of Addiction Medicine (ASAM) patient placement criteria, the Institute of Medicine (IOM), the Child and Adolescents Needs and Strengths (CANS), criteria required by federal or state










CCBHC Criteria



(Tables of Evidence) oversight authorities, and criteria required for participation in managed care delivery systems. Interpretation: Assessments are completed within timeframes established by the organization. Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes. MHSU 3.05 The comprehensive assessment includes:

a. the service recipient’s behavioral health, physical health, and community and social support service needs and goals;

b. trauma history and recent incidents of trauma;

c. individual and family strengths, risks, and protective factors; and

d. natural supports and helping networks.

Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks. Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history.








Review case records


CCBHC Criteria



(Tables of Evidence) Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 3.08 Reassessments are conducted as necessary, according to the needs of the service recipient. Interpretation: Reassessments are completed within timeframes established by the organization depending on the service population and length of treatment. Timeframes may also be delineated by regulatory requirements. The organization may conduct a reassessment during specific milestones in the treatment process, including:



CCBHC Criteria



(Tables of Evidence) progress;

c. after new symptoms are identified; d. when significant behavioral changes are



occur. Research Note: Service recipients may not be able or willing to reveal traumatic life events during the initial, comprehensive assessment process. Reassessments allow for personnel to gather new trauma-related information that can inform service delivery as well as treatment objectives and goals. Research Note: Research shows that children involved in the child welfare system, particularly children in foster care, experience high rates of mental illness, which can often be difficult to detect. Due to the many life changes they experience, multiple, ongoing assessments may be necessary as they adjust to a new situation. MHSU 4.06 The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, at minimum, to assess:

a. service plan implementation; b. progress toward achieving service goals and

desired outcomes; and c. the continuing appropriateness of the

agreed upon service goals. Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the


CCBHC Criteria



(Tables of Evidence) worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard. Interpretation: Timeframes for review should be adjusted depending upon the issues and needs of persons receiving services and the frequency and intensity of the services being provided. Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for service recipients with substance use disorders at high risk for relapse. Individuals with acute or complex needs (e.g., service recipients receiving medications for diagnosed symptoms and conditions) may require that their service plan be reviewed and updated every 30 days. MHSU 4.07 The worker and service recipient or legal guardian regularly review progress toward achievement of agreed upon goals and document revisions to service goals and plans. Interpretation: In regards to documentation, any revisions to the service plan or service goals should be signed by a member of the treatment team and the service recipient, or a legal guardian when the service recipient is a minor, or otherwise documented in a manner that is consistent with the organizations service planning and monitoring procedures. MHSU 4.08 Family members and significant others, as appropriate, and with the consent of the service recipient, are advised of ongoing progress and invited to participate in case conferences.


CCBHC Criteria



(Tables of Evidence) Interpretation: The organization facilitates the participation of family and significant others by, for example, helping arrange transportation, and including them in scheduling decisions. MHSU 9.03 The organization supports the coordination of behavioral and physical health care to increase service recipients’ access to needed services. Interpretation: To meet the standard, organizations must demonstrate that they are working towards linking behavioral health and primary care services. Examples include: providing referrals to identified primary care providers, communicating with service recipients’ primary care doctor about treatment planning, and linking individuals to navigators to help service recipients navigate the health care system.

2.b.3

Outpatient clinical services for established CCBHC consumers seeking an appointment for routine needs must be provided within 10 business days of the requested date for service, unless the state has established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent. If an established consumer presents with an emergency/crisis need, appropriate action is taken immediately, including any necessary subsequent outpatient follow-up. If an established consumer presents with an urgent need, clinical services are provided within one business day of the time the

MHSU 2: Screening and Intake The organization’s screening and intake practices ensure that service recipients receive prompt and responsive access to appropriate services. MHSU 2.02 Prompt, responsive intake practices:





e. support timely initiation of services; and





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CCBHC Criteria



(Tables of Evidence) request is made. f. provide for placement on a waiting list, if

desired. Interpretation: Screening and intake procedures should direct staff on how to identify and respond to individuals or families experiencing emergency situations to ensure that they receive expedited treatment planning and are connected to more intensive services. Organizations should have the capacity to refer individuals in crisis to the appropriate services, which may include 24-hour mobile crisis teams, emergency crisis intervention services, or crisis stabilization. Urgent situations can also include those in which an individual has a child in the child welfare system. Interpretation: Wait times are a major barrier to individuals and families receiving services. Organizations can monitor waitlists and standardize their referral process to improve accessibility.


Criteria 2.C: 24/7 Access to Crisis Management Services

2.c.1

The comprehensive person-centered and family-centered diagnostic and treatment planning evaluation is updated by the treatment team, in agreement with and endorsed by the consumer and in consultation with the primary care provider (if any), when changes in the consumer’s status, responses to treatment, or goal achievement have occurred. The assessment must be updated no less frequently than every 90 calendar days unless the state has

MHSU 3.08 Reassessments are conducted as necessary, according to the needs of the service recipient. Interpretation: Reassessments are completed within timeframes established by the organization depending on the service population and length of treatment. Timeframes may also be delineated by regulatory requirements. The organization may conduct a reassessment during specific milestones in the treatment process, including:





List of identified medical referral sources,


CCBHC Criteria



(Tables of Evidence) established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent.


progress; c. after new symptoms are identified; d. when significant behavioral changes are



occur. MHSU 4: Service Planning and Monitoring Service recipients and their families participate in the development and ongoing review of an individualized, person- or family-centered service plan that is the basis for delivery of appropriate services and support. MHSU 4.01 An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient, and expedited service planning is available when crisis or urgent need is identified. MHSU 4.06 The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, at minimum, to assess:



agreed upon service goals.

if applicable (MHSU 3.07)











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CCBHC Criteria



(Tables of Evidence) Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard. Interpretation: Timeframes for review should be adjusted depending upon the issues and needs of persons receiving services and the frequency and intensity of the services being provided. Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for service recipients with substance use disorders at high risk for relapse. Individuals with acute or complex needs (e.g., service recipients receiving medications for diagnosed symptoms and conditions) may require that their service plan be reviewed and updated every 30 days. MHSU 9.03 The organization supports the coordination of behavioral and physical health care to increase service recipients’ access to needed services. Interpretation: To meet the standard, organizations must demonstrate that they are working towards linking behavioral health and primary care services. Examples include: providing referrals to identified primary care providers, communicating with service recipients’ primary care doctor about treatment planning, and linking individuals to navigators to help service recipients navigate the health care system.


CCBHC Criteria




2.c.2

The methods for providing a continuum of crisis prevention, response, and postvention services are clearly described in the policies and procedures of the CCBHC and are available to the public.

CRI 1.01 An ongoing public information campaign provides the community with information about available services, hours of operation, contact information, and how to use the organization’s services. Interpretation: The public information campaign can include such activities as posters, published brochures, public service announcements, listings in local telephone directories, and outreach to other providers. Strategies should include attention to geographic location, language of choice, age, sexual orientation, developmental level, and the person’s religious, racial, ethnic, and cultural background. CRI 6.03 Written procedures address the provision of treatment and referral in crisis situations, including those involving victims of violence, individuals threatening suicide, medical crises, and other emergencies. MHSU 1: Service Philosophy, Modalities, and Interventions The service philosophy:

a. sets forth a logical approach for how program activities and interventions will meet the needs of service recipients;

b. ensures that services are strengths-based, person- or family-centered, culturally and linguistically responsive, and trauma-informed;

c. guides the development and implementation of program activities and services based on the best available

COA meets the intent of the CCBHC standard. Table of Evidence for CRI 1

Outreach strategies and informational material

Interview: a. Program director b. Relevant personnel c. Review case records

Table of Evidence for CRI 6



Treatment and referral procedures

Coverage schedules for a recent three-month period

Interview: a. Program director b. Relevant personnel c. Review case records


Service philosophy

Procedures for the use of therapeutic interventions

Policies for prohibited interventions

Documentation of training and/or certification related to therapeutic interventions


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CCBHC Criteria



(Tables of Evidence) evidence of service effectiveness; and

d. outlines the service modalities and interventions that personnel may employ.

Interpretation: A functional service philosophy, logic model, or similar framework guides program development and implementation by linking the organization’s mission or purpose with strategies, practices, or tools needed to integrate these into daily work. A well-defined and visible practice framework will help staff and stakeholders think systematically about how the program can make a measureable difference by drawing clear connections between program values, service population needs, available resources, program activities and interventions, program outputs, and desired outcomes. Interpretation: Organizational self-assessments can evaluate the extent to which organizations’ policies and practices are trauma-informed, as well as identify strengths and barriers in regards to trauma-informed service delivery and provision. For example, organizations can evaluate staff training and professional development opportunities and review supervision ratios to assess whether personnel are trained and supported on trauma-informed care practices. Organizations can also conduct an internal review of their assessments and service planning processes to ensure that services are being delivered in a trauma-informed manner. MHSU 1.01 The program is guided by a philosophy that provides a logical basis for services and support to be delivered in a trauma-informed and culturally and linguistically responsive manner, based on program







Aftercare and follow-up procedures

Interview: a. Supervisors b. Relevant personnel

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CCBHC Criteria



(Tables of Evidence) goals and the best available evidence of service effectiveness. Interpretation: Services and support should be tailored to meet the individualized needs and goals of service recipients. MHSU 1.02 Prior to providing any therapeutic interventions, the organization:

a. explains any benefits, risks, side effects, and alternatives to the service recipient or a legal guardian;

b. obtains the written, informed consent of the individual or his/her legal guardian;

c. ensures that personnel receive sufficient training, and/or certification when it is available; and

d. monitors the use and effectiveness of such interventions.

Interpretation: Organizations that choose to engage in modalities or interventions that do not have an established evidence base should ensure that practices do not cause physical or psychological harm by demonstrating in their procedures that they have acknowledged the potential risks of implementing such methods and subsequently taken appropriate measures to minimize risks. MHSU 4.02 The service plan is based on the assessment, and includes:

a. agreed upon goals, desired outcomes, and timeframes for achieving them;

b. services and supports to be provided, and by


CCBHC Criteria



(Tables of Evidence) whom; and

c. the service recipient or legal guardian’s signature.

Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being. MHSU 4.03 During service planning, the organization explains:

a. available options; b. how the organization can support the

achievement of desired outcomes; and c. the benefits, alternatives, and risks or

consequences of planned services. MHSU 4.05 The organization engages service recipients and involved family members in crisis planning, as needed. Interpretation: While each individual service recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary. The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. Depending on the needs of the individual, crisis plans


CCBHC Criteria



(Tables of Evidence) may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care. MHSU 12: Aftercare and Follow-Up The organization and the service recipient work together to develop an aftercare plan, and follow-up occurs when possible and appropriate. Interpretation: Aftercare planning is also known as a discharge planning, and an aftercare plan may also be referred to as a discharge plan. Interpretation: While the decision to develop an aftercare plan is based on the wishes of the service recipient, unless aftercare is mandated, the organization is expected to be strongly proactive with respect to aftercare planning. The organization may provide aftercare directly or refer or link service recipients to aftercare services.


CCBHC Criteria





Criteria 2.C: 24/7 Access to Crisis Management Services (Continued)

2.c.3

Individuals who are served by the CCBHC are educated about crisis management services and Psychiatric Advanced Directives and how to access crisis services, including suicide or crisis hotlines and warmlines, at the time of the initial evaluation. This includes individuals with LEP or disabilities (i.e., CCBHC provides instructions on how to access services in the appropriate methods, language(s), and literacy levels in accordance with program requirement 1).

MHSU 2.01 Service recipients are screened at intake and informed about:



c. rules and expectations of the program. Interpretation: Screenings will vary based on the program’s target population and services offered, and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, and/or risk of harm to self or others. Interpretation: For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program MHSU 4.05 The organization engages service recipients and











CCBHC Criteria



(Tables of Evidence) involved family members in crisis planning, as needed. Interpretation: While each individual service recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary. The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. Depending on the needs of the individual, crisis plans may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care.

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2.c.4

In accordance with the requirements of program requirement 3, CCBHCs maintain a working relationship with local EDs. Protocols are established for CCBHC staff to address the needs of CCBHC consumers in psychiatric crisis who come to those EDs.

CRI 5: Community Connections and Coordination The organization establishes formal agreements with members of the community’s crisis response system, and procedures for service coordination in crisis situations. CRI 5.01 To ensure rapid and efficient access, the organization establishes procedures for working with emergency responders including:


Service coordination procedures

Written service agreements, as necessary

Community database


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CCBHC Criteria



(Tables of Evidence) a. police and fire departments; b. hospital emergency rooms; c. mental and physical health crisis teams; and d. child and adult protective services.

CRI 5.02 To ensure rapid or priority access to services, the organization has formal arrangements with local social service, mental health, and medical resources that facilitate immediate access to services, referrals, and service coordination. Interpretation: Unless otherwise required by law, COA does not require formal arrangements with emergency responders or service providers that are not ordinarily utilized by the organization. ICHH 2.05 Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:

a. giving priority to urgent needs and emergency situations;

b. expedited care planning; c. connecting the individual to more intensive

services as needed; d. facilitating the development of a safety

and/or crisis plan; and e. contacting emergency responders as

appropriate. ICHH 4.05 The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:

a. establishing partnerships and coordination procedures with direct service providers in

Table of Evidence for ICHH 2

Assessment procedures

Assessment tool

Procedures for making referrals for specialized screenings, assessments, or tests when needed

Job descriptions of personnel responsible for conducting assessments

Assessment training curricula



Review case records Table of Evidence for ICHH 4








Interview: a. Program director b. Care planning team members c. Persons served

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CCBHC Criteria



(Tables of Evidence) the community;








MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services. MHSU 9: Care Coordination









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CCBHC Criteria



(Tables of Evidence) The organization coordinates services in order to promote continuity of care and whole-person wellness. Interpretation: The standards in MHSU 9 address the efforts an organization makes to promote information sharing and collaboration with the various systems touching a particular individual. Organizations are not required to provide integrated care to implement the standards in this section. Organizations that offer integrated behavioral health and primary care services (e.g., health homes) will complete the Integrated Care; Health Home (ICHH) standards. Organizations directly providing primary care services will also complete the Primary Care Services (PCS) standards in addition to the Integrated Care; Health Home (ICHH) standards. MHSU 9.02 Service recipients with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider. MHSU 9.03 The organization supports the coordination of behavioral and physical health care to increase service recipients’ access to needed services. Interpretation: To meet the standard, organizations must demonstrate that they are working towards linking behavioral health and primary care services. Examples include: providing referrals to identified primary care providers, communicating with service


CCBHC Criteria



(Tables of Evidence) recipients’ primary care doctor about treatment planning, and linking individuals to navigators to help service recipients navigate the health care system.

2.c.5

Protocols, including protocols for the involvement of law enforcement, are in place to reduce delays for initiating services during and following a psychiatric crisis. Note: See criterion 3.c.5 regarding specific care coordination requirements related to discharge from hospital or ED following a psychiatric crisis.

CRI 5.01 To ensure rapid and efficient access, the organization establishes procedures for working with emergency responders including:

a. police and fire departments; b. hospital emergency rooms; c. mental and physical health crisis teams; and d. child and adult protective services.

CRI 5.02 To ensure rapid or priority access to services, the organization has formal arrangements with local social service, mental health, and medical resources that facilitate immediate access to services, referrals, and service coordination. Interpretation: Unless otherwise required by law, COA does not require formal arrangements with emergency responders or service providers that are not ordinarily utilized by the organization. CRI 6.01 Crisis intervention personnel respond immediately and:

a. evaluate and assess each person’s specific crisis;

b. provide intervention and stabilization; c. work with the person to develop an action


Service coordination procedures

Written service agreements, as necessary

Community database


Review case records Table of Evidence for CRI 6








Assessment tool


CCBHC Criteria



(Tables of Evidence) plan;

d. work with the person to develop a safety plan as needed;

e. make referrals to appropriate resources; and f. follow up with each person within 24 hours,

when appropriate. ICHH 2.05 Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:





appropriate. MHSU 4.05 The organization engages service recipients and involved family members in crisis planning, as needed. Interpretation: While each individual service recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary. The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan.











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CCBHC Criteria



(Tables of Evidence) Depending on the needs of the individual, crisis plans may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care.

2.c.6

Following a psychiatric emergency or crisis involving a CCBHC consumer, in conjunction with the consumer, the CCBHC creates, maintains, and follows a crisis plan to prevent and de-escalate future crisis situations, with the goal of preventing future crises for the consumer and their family. Note: See criterion 3.a.4 where precautionary crisis planning is addressed.

CRI 6.01 Crisis intervention personnel respond immediately and: evaluate and assess each person’s specific crisis;

a. provide intervention and stabilization; b. work with the person to develop an action

plan; c. work with the person to develop a safety

plan as needed; d. make referrals to appropriate resources; and e. follow up with each person within 24 hours,

when appropriate.

ICHH 2.05 Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:




and/or crisis plan; and









Assessment tool






CCBHC Criteria



(Tables of Evidence) e. contacting emergency responders as

appropriate. MHSU 4.05 The organization engages service recipients and involved family members in crisis planning, as needed. Interpretation: While each individual service recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary. The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. Depending on the needs of the individual, crisis plans may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care.







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Criteria 2.D: No Refusal of Services due to Inability to Pay


CCBHC Criteria




2.d.1

The CCBHC ensures: (1) no individuals are denied behavioral health care services, including but not limited to crisis management services, because of an individual’s inability to pay for such services (PAMA § 223 (a)(2)(B)), and (2) any fees or payments required by the clinic for such services will be reduced or waived to enable the clinic to fulfill the assurance described in clause (1).

CR 1.05 Clients have the right to fair and equitable treatment including:

a. the right to receive services in a non-discriminatory manner;

b. the consistent enforcement of program rules and expectations; and

c. the right to receive services that are respectful of, and responsive to, cultural and linguistic differences.

CR 1.08 Clients receive a schedule of any applicable fees and estimated or actual expenses, and are informed prior to service delivery about:

a. the amount that will be charged; b. when fees or co-payments are charged,

changed, refunded, waived, or reduced; c. the manner and timing of payment; and d. the consequences of nonpayment.

Interpretation: When working with individuals who have been deemed incapacitated by the court, the depth or content of information provided may vary based on the individual’s assessed capacity to understand such information, the court order, and state law. NA The organization does not charge the client any fees, co-payments, or other forms of payment in exchange for services.

COA meets the intent of the CCBHC standard. Table of Evidence for CR 1







CCBHC Criteria




2.d.2

The CCBHC has a published sliding fee discount schedule(s) that includes all services the CCBHC proposes to offer pursuant to these criteria. Such fee schedule will be included on the CCBHC website, posted in the CCBHC waiting room and readily accessible to consumers and families. The sliding fee discount schedule is communicated in languages/formats appropriate for individuals seeking services who have LEP or disabilities.




c. providing telephone amplification, sign language services, or other communication methods for deaf or hearing impaired persons;

d. providing, or arranging for, communication assistance for persons with special needs who have difficulty making their service needs known; and

e. considering the person’s literacy level. CR 1.08 Clients receive a schedule of any applicable fees and estimated or actual expenses, and are informed prior to service delivery about:



Interpretation: When working with individuals who have been deemed incapacitated by the court, the depth or content of information provided may vary based on the individual’s assessed capacity to understand such information, the court order, and state law.






Facility Observation Table of Evidence for ETH 1

Organization website URL

Publicly available documents

Network written materials (ETH 1.05)

Annual Report, mission statement, and Form 990

Interview: a. CEO b. Board Chair c. Treasurer d. Advisory/Governing Body e. CFO/fiscal director f. Persons served/community

members g. Personnel


CCBHC Criteria



(Tables of Evidence) NA The organization does not charge the client any fees, co-payments, or other forms of payment in exchange for services. ETH 1: Open, Transparent Operations The organization operates in an open and transparent manner in accordance with applicable legal requirements and uses assets exclusively and effectively to serve the purpose for which it has been created. ETH 1.01 The public has access to clear, timely, accurate information, as appropriate to the type of organization, about the organization’s programs, activities, service recipients, and finances.

2.d.3

The fee schedules, to the extent relevant, conform to state statutory or administrative requirements or to federal statutory or administrative requirements that may be applicable to existing clinics; absent applicable state or federal requirements, the schedule is based on locally prevailing rates or charges and includes reasonable costs of operation.










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CCBHC Criteria




2.d.4

The CCBHC has written policies and procedures describing eligibility for and implementation of the sliding fee discount schedule. Those policies are applied equally to all individuals seeking services.





CR 1.08 Clients receive a schedule of any applicable fees and estimated or actual expenses, and are informed prior to service delivery about:








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Criteria 2.E: Provision of Services Regardless of Residence

2.e.1

The CCBHC ensures no individual is denied behavioral health care services, including but not limited to crisis management services, because of place of residence or homelessness or lack of a permanent address.









Interview:


CCBHC Criteria



(Tables of Evidence) a. Relevant personnel b. Individuals or families served

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2.e.2

CCBHCs have protocols addressing the needs of consumers who do not live close to a CCBHC or within the CCBHC catchment area as established by the state. CCBHCs are responsible for providing, at a minimum, crisis response, evaluation, and stabilization services regardless of place of residence. The required protocols should address management of the individual’s on-going treatment needs beyond that. Protocols may provide for agreements with clinics in other localities, allowing CCBHCs to refer and track consumers seeking non-crisis services to the CCBHC or other clinic serving the consumer’s county of residence. For distant consumers within the CCBHC’s catchment area, CCBHCs should consider use of telehealth/telemedicine to the extent practicable. In no circumstances (and in accordance with PAMA § 223 (a)(2)(B)), may any consumer be refused services because of place of residence.

ASE 2.02 In planning the location and use of offices and branches, the organization considers:

a. accessibility, availability, and affordability of public transportation;

b. location of other relevant community resources; and

c. the special needs of service recipients. ICHH 4.02 The care planning team includes at a minimum:

a. a designated care coordinator; b. a primary care professional such as a

physician’s assistant or nurse practitioner with access to a physician for needed consultation;

c. a behavioral health professional such as a social worker, psychologist, or other licensed clinician with access to a psychiatrist for needed consultation; and

d. other providers and supports based on the individual needs of the person.

Interpretation: The qualifications of the designated care coordinator will vary given the needs of the identified service population. For adults with serious and persistent mental health conditions, for example, a medical professional such as a nurse practitioner

COA meets the intent of the CCBHC standard Table of Evidence for ASE 2

Documentation of legal compliance


Observe facility Table of Evidence for ICHH 4










CCBHC Criteria




may be preferred given the high prevalence of comorbid, chronic, physical health conditions present in this population. For children, however, where chronic medical conditions are far less common, the coordination of behavioral health care and linkages to community and social support services might best be carried out by a behavioral health practitioner with experience working with children and families. Interpretation: Organizations should leverage alternative service delivery methods such as telehealth and telemental health when regional shortages of certain professional groups, such as psychiatrists, make in-person consultation impractical. Interpretation: Supports that might also be included on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual MHSU 2.02 Prompt, responsive intake practices: ensure equitable treatment;

a. give priority to urgent needs and emergency situations;

b. facilitate the identification of individuals and families with co-occurring conditions and multiple needs;

c. enable access to a comprehensive assessment process;

d. support timely initiation of services; and e. provide for placement on a waiting list, if

desired. Interpretation: Screening and intake procedures









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CCBHC Criteria



(Tables of Evidence) should direct staff on how to identify and respond to individuals or families experiencing emergency situations to ensure that they receive expedited treatment planning and are connected to more intensive services. Organizations should have the capacity to refer individuals in crisis to the appropriate services, which may include 24-hour mobile crisis teams, emergency crisis intervention services, or crisis stabilization. Urgent situations can also include those in which an individual has a child in the child welfare system. Interpretation: Wait times are a major barrier to individuals and families receiving services. Organizations can monitor waitlists and standardize their referral process to improve accessibility. MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services.

PROGRAM REQUIREMENT 3: CARE COORDINATION

Criteria 3.A: General Requirements of Care Coordination


CCBHC Criteria




3.a.1

Based on a person and family-centered plan of care aligned with the requirements of Section 2402(a) of the ACA and aligned with state regulations and consistent with best practices, the CCBHC coordinates care across the spectrum of health services, including access to high-quality physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person. Note: See criteria 4.K relating to care coordination requirements for veterans.

ICHH 3.01 A care plan is developed:

a. within established timeframes; and b. with the full participation of the individual

and his or her family. Interpretation: Care planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and gradually assume more responsibility for making decisions independently. When the person receiving services is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring the involvement or consent of the person’s legal guardian. Interpretation: Generally, care plans should be developed following completion of all necessary assessments and reviewed with the person at their next visit. ICHH 3.02 The care plan is based on the assessment and includes:

a. the person’s behavioral health, physical health, and community and social support service needs and goals;

b. steps for working toward achievement of desired goals including timeframes where appropriate;

c. services and supports to be provided, and by whom;

COA meets the intent of the CCBCH standard. Table of Evidence for ICHH 3

Care planning and monitoring procedures







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CCBHC Criteria



(Tables of Evidence) d. supports and/or services to improve family

functioning; e. strategies for building on individual and

family strengths and natural supports; f. agreed upon timelines for conducting

regular case reviews; and g. documentation of the individual’s or family’s

involvement in care planning. Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. MHSU 4.02 The service plan is based on the assessment, and includes:


b. services and supports to be provided, and by whom; and


Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being. MHSU 9: Care Coordination The organization coordinates services in order to promote continuity of care and whole-person wellness. MHSU 9.02

c. Individuals or families served

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CCBHC Criteria



(Tables of Evidence) Service recipients with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider. Note: This standard is applicable to all programs regardless of the services offered. Organizations that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and organizations that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders. MHSU 9.03 The organization supports the coordination of behavioral and physical health care to increase service recipients’ access to needed services. Interpretation: To meet the standard, organizations must demonstrate that they are working towards linking behavioral health and primary care services. Examples include:

a. providing referrals to identified primary care providers,

b. communicating with service recipients’ primary care doctor about treatment planning,

c. and linking individuals to navigators to help service recipients navigate the health care system.

MHSU 9.04 In collaboration with the service recipient, the organization coordinates with, as needed:

a. the child welfare system;


CCBHC Criteria



(Tables of Evidence) b. the juvenile justice system; c. courts; and d. the school system.

3.a.2

The CCBHC maintains the necessary documentation to satisfy the requirements of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state privacy laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule allows routine – and often critical – communications between health care providers and a consumer's family and friends. Health care providers may always listen to a consumer’s family and friends. If a consumer consents and has the capacity to make health care decisions, health care providers may communicate protected health care information to a consumer's family and friends. Given this, the CCBHC ensures consumers’ preferences, and those of families of children and youth and families of adults, for shared information are adequately documented in clinical records, consistent with the philosophy of person and family-centered care. Necessary consent for release of information is obtained from CCBHC consumers for all care coordination relationships. If CCBHCs are unable, after reasonable attempts, to obtain consent for any care coordination activity specified in program requirement 3, such attempts must

CR 2: Confidentiality and Privacy Protections The organization protects the confidentiality of information about clients and assumes a protective role regarding the disclosure of confidential information. CR 2.01 The organization informs the client, prior to his or her disclosure of confidential or private information, about circumstances when the organization may be legally or ethically permitted or required to release such information without the client’s consent. CR 2.02 When the organization receives a request for confidential information about a client, or when the release of confidential information is necessary for the provision of services, prior to releasing such information, the organization:

a. determines if the reason to release information is valid;

b. obtains the client’s informed, written authorization to release the information; and

c. obtains informed, written authorization from a parent or legal guardian, as appropriate.





Review case records Table of Evidence for RPM 6

Policies and procedures for managing web-based technologies and electronic communications

Plan or procedures for managing data interruptions

MIS case record procedures

HIPAA compliance policies and procedures, as applicable

Interview: a. Finance personnel b. PQI personnel c. MIS manager d. Program directors e. Direct service personnel

Case record room/files and MIS


CCBHC Criteria



(Tables of Evidence) be documented and revisited periodically. Interpretation: In the context of this standard,

“valid” means justifiable, legitimate, convincing, legally permissible, and in the best interest of the client. The organization obtains legal counsel regarding the confidentiality of records and the conditions under which they may be subpoenaed. Unless otherwise required by law, authorization to release confidential information is not necessary where the request for information is pursuant to a subpoena. The organization seeks additional legal counsel, as necessary, when others seek identifying information about an individual or family, or when the release of confidential information is necessary for the provision of services. When the client is a minor or an adult under the care of a guardian, the organization should follow any laws or regulations allowing or requiring the organization to obtain the authorization of clients’ parents or legal guardians. When permitted or required by law, regulation, or court order, confidential information may be released without the authorization of the client and legal guardian. However, the client and legal guardian should still be informed that the information will be released. CR 2.03 Informed, written consent is obtained from the client, or a legal guardian, prior to recording, photographing, or filming. Interpretation: When required by law, consent may not be necessary. However, it is still expected that the organization inform clients prior to recording, photographing, or filming.

accessibility observation

RPM 7 Case Records* Table of Evidence for RPM 7

Record content and maintenance procedures

Mock case record, table of contents, or outline for each service section

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Interview: a. Personnel b. Supervisors c. Program directors d. Persons served

Network interview: a. Managing entity screening,

assessment, and authorization staff, if these services are provided

b. Providers who request authorizations from the managing entities

c. Provider personnel d. Provider supervisors e. Provider program directors


Case record access policies and procedures

Interview: a. MIS Manager b. Case record clerk c. Program directors d. Direct service personnel e. Persons served

Observe case record room/ files and MIS


CCBHC Criteria



(Tables of Evidence) CR 2.04 The release form for disclosure of confidential information includes the following elements:

a. the name of the person whose information will be released;

b. the signature of the person whose information will be released, or the parent or legal guardian of a person who is unable to provide authorization;

c. the specific information to be released; d. the purpose for which the information is to

be used; e. the date the release takes effect; f. the date, event, or condition upon which the

consent expires, not to exceed one year from when the release takes effect;

g. the name of the person(s) or organization(s) that will receive the disclosed information;

h. the name of the person or organization that is disclosing the confidential information; and

i. a statement that the person or family may withdraw their authorization at any time except to the extent that action has already been taken.

Interpretation: In relation to element (f), the expiration event or condition should relate to the individual or to the purpose of the use or disclosure. The date, event, or condition upon which the consent expires must ensure that the authorization will last no longer than reasonably necessary. When the release of information is required for ongoing service provision, all elements of the form must be reviewed and updated annually at minimum to ensure that

accessibility observation


CCBHC Criteria



(Tables of Evidence) consent continues to be informed and appropriate. Interpretation: When a release form is used to authorize the exchange of information between multiple parties, the form must comply with all elements of the standard. All relevant parties must be authorized to disclose and receive the information specified, for the purpose indicated, in the consent. Interpretation: Blanket release forms signed by clients when service is initiated do not meet the requirements of this standard, except as put forth by federal regulation, for example, when making application to FEMA/DHS in a declared disaster. Interpretation: When permitted or required by law, regulation, or court order, confidential information may be released without the authorization of the person or legal guardian. In this case elements (b) and (i) will not apply. However, the organization should still inform the person and/or legal guardian that the information will be shared, as referenced in CR 2.01 and CR 2.02, and maintain documentation of the disclosure in the client’s file. Interpretation: In credit counseling organizations this standard applies in situations where a client specifically requests release of information to a third party, such as a letter of reference regarding payment history, or in instances when a program specific release does not exist. Debt management agreements or releases signed at the initiation of a debt management program allow for information sharing with all creditors included in the program or added to the program for the duration of service, unless state laws indicate otherwise.


CCBHC Criteria



(Tables of Evidence) Interpretation: Release forms may also include a statement regarding the impact, if any, of refusing to sign the authorization, as well as rules regarding re-disclosure of information in accordance with applicable federal and state laws. CR 2.05 The organization offers a copy of the signed form to the person or family authorizing the disclosure of confidential information, and places a copy in the case record. Interpretation: When there are concerns about the individual’s capacity to understand the confidential nature of the document, such as when the individual has been deemed incapacitated by the court, it may be inappropriate to provide the individual with a copy of the release form. Instead, the worker should include a copy of the release form in the case record and document reasons why the form was not provided. Interpretation: A copy of the completed release form should be offered to the person, and placed in the case record, even when it is permissible by law to release confidential information without the person’s authorization and signature. RPM 6: Security of Information Electronic and printed information is protected against intentional and unintentional destruction or modification and unauthorized disclosure or use. Interpretation: Regulations that govern the protection of individually identifiable health information and set national standards for the


CCBHC Criteria



(Tables of Evidence) security of electronic protected health information include the Health Insurance Portability and Accountability Act (“HIPAA” Privacy and Security Rule) and the Health Information Technology for Economic and Clinical Health Act (“HITECH”). Interpretation: The standards in this section address security of all types of records, including case records, administrative, financial, health, and personnel records, unless otherwise noted. See also RPM 7 Case Records and RPM 8 Access to Case Records. RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including:

a. demographic and contact information; b. the reason for requesting or being referred

for services; c. up-to-date assessments; d. the service plan, including mutually

developed goals and objectives; e. copies of all signed consent forms; f. a description of services provided directly or

by referral; g. routine documentation of ongoing services; h. documentation of routine supervisory

review; i. discharge or aftercare plan; j. recommendations for ongoing and/or future

service needs and assignment of aftercare or follow-up responsibility, if needed; and

k. a closing summary entered within 30 days of termination of service.


CCBHC Criteria



(Tables of Evidence) Interpretation: RPM 7.02 describes the basic elements to be included in individual case records. COA recognizes that in some cases not all listed information is obtainable for a person or family. In these cases, an explanation should be placed in the case record. The listed information may not be routinely available due to the nature of the service, e.g., a low demand shelter or drop-in center. Interpretation: Case records and signatures can be paper, electronic, or a combination of paper and electronic. When using electronic signatures, organizations should take appropriate measures to verify the individual’s identity and ensure that each electronic signature is unique to the individual. Electronic signatures (by both personnel and service recipients) can include, for example, a digitalized signature via tablet or two identifying components such as a user identification code (ID) and password/personal identification number (PIN). Procedures or protocols for electronic signatures should be included in the organization’s record content and maintenance procedures. Interpretation: To most effectively collect information on trends and outcomes, consistent terminology and structured data should be used within the electronic records system. Interpretation: In EAPs case records contain appropriate information to demonstrate the status of the case and whether it is open or closed. RPM 7.03 The case record contains essential legal and medical


CCBHC Criteria



(Tables of Evidence) information, including, as applicable:

a. orders for and results of psychological, medical, toxicological, diagnostic, or other evaluations;

b. documentation of all prescribed and over-the-counter medications including copies of all written orders for medications, when applicable;

c. special treatment procedures, allergies, or adverse treatment responses; and

d. court reports, documents of guardianship or legal custody, birth or marriage certificates, and any legal directives related to the service being provided.

RPM 8: Access to Case Records Service recipients or designated legal representatives can access their case records, consistent with legal requirements. Interpretation: Organizations are expected to have policies and procedures that address access to case records by service recipients. Interpretation: For networks, RPM 8 applies to case records and case information that is maintained by the network management entity, as well as records maintained by members of organizations or subcontracted providers. RPM 8.01 Access to confidential case records meets legal requirements, and is limited to:

a. the service recipient or, as appropriate, a parent or legal guardian;

b. personnel authorized to access specific information on a “need-to-know” basis;

c. others who are permitted access;


CCBHC Criteria



(Tables of Evidence) d. former service recipients; e. requests for records of deceased service

recipients; and f. auditors, contractors, and licensing or

accrediting personnel consistent with the organization’s confidentiality policy.

Interpretation: Case records should not be left in public areas such as on carts in hallways, on desks, or in non-secured areas. When not being used by authorized staff, files should be returned to a secure area. RPM 8.02 Reviews of case records by service recipients are:

a. conducted in the presence of professional personnel on the organization’s premises; and

b. carried out in a manner that protects the confidentiality of family members and others whose information may be contained in the record.

Interpretation: For organizations using electronic record systems, allowing the service recipient to directly access the case record through a staff account represents a security risk. Access for service recipients may be provided, for example, through a separate user portal or by printing the case record. RPM 8.03 If the organization determines that it would be harmful for a service recipient to review his/her case record, and applicable law provides no guidance on case record access, then:

a. senior management reviews, approves in


CCBHC Criteria



(Tables of Evidence) writing, and enters into the case record the reasons for refusal; and

b. procedures permit a qualified professional to review records on behalf of service recipients, provided the professional signs a statement that information determined to be harmful will be withheld.

Interpretation: An individual’s right to review his or her care or treatment may be denied, or otherwise limited, only in the most extreme circumstances where serious harm is likely to ensue. In such cases, objective criteria must guide decisions to deny access. In all cases, the organization must operate in accord with applicable law.


Criteria 3.A: General Requirements of Care Coordination (Continued)

3.a.3

Consistent with requirements of privacy, confidentiality, and consumer preference and need, the CCBHC assists consumers and families of children and youth, referred to external providers or resources, in obtaining an appointment and confirms the appointment was kept.

ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. Interpretation: This includes coordination of any

COA meets the intent of the CCBHC standard. Table of Evidence for ICHH 4




Procedures / mechanisms for tracking


CCBHC Criteria



(Tables of Evidence) services provided directly by the organization as well as those provided through linkages to community providers. ICHH 4.01 All individuals and their families receive:

a. direct provision of, or linkages to needed services and supports, as outlined in the care plan; and

b. individual care coordination and monitoring of services.

ICHH 4.06 Persons served are assisted in making appointments for needed or requested services, and the care coordinator follows up to:

a. ensure the service was received; b. identify any needed follow-up; and c. make needed changes to the care plan in

partnership with the person and his or her family.

MHSU 9: Care Coordination The organization coordinates services in order to promote continuity of care and whole-person wellness. MHSU 9.05 Care coordination activities are documented in the case record, including:

a. linkages to community providers, as well as completed follow-up when possible;

b. communication with partnering providers both internally and externally; and

c. communication with the service recipient.

medication reconciliation and adherence


Copies of agreements with community providers, as applicable Up-to-date referral list






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CCBHC Criteria




3.a.4

Care coordination activities are carried out in keeping with the consumer’s preferences and needs for care and, to the extent possible and in accordance with the consumer’s expressed preferences, with the consumer’s family/caregiver and other supports identified by the consumer. So as to ascertain in advance the consumer’s preferences in the event of psychiatric or substance use crisis, CCBHCs develop a crisis plan with each consumer. Examples of crisis plans may include a Psychiatric Advanced Directive or Wellness Recovery Action Plan..






appropriate. ICHH 3: Care Planning and Monitoring The person and his or her family participate in the development and ongoing monitoring of a care plan that is the basis for delivery of needed services. ICHH 3.01 A care plan is developed:


and his or her family. Interpretation: Care planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and gradually assume more responsibility for making decisions independently. When the person receiving services is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring the involvement or consent of the person’s



Assessment tool















CCBHC Criteria



(Tables of Evidence) legal guardian. Interpretation: Generally, care plans should be developed following completion of all necessary assessments and reviewed with the person at their next visit. MHSU 4: Service Planning and Monitoring Service recipients and their families participate in the development and ongoing review of an individualized, person- or family-centered service plan that is the basis for delivery of appropriate services and support. Interpretation: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law. Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child and can include the child’s birth, foster, adoptive, or kinship caregivers as appropriate. MHSU 4.05 The organization engages service recipients and involved family members in crisis planning, as needed. Interpretation: While each individual service


Review case records


CCBHC Criteria



(Tables of Evidence) recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary. The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. Depending on the needs of the individual, crisis plans may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care.

3.a.5

Appropriate care coordination requires the CCBHC to make and document reasonable attempts to determine any medications prescribed by other providers for CCBHC consumers and, upon appropriate consent to release of information, to provide such information to other providers not affiliated with the CCBHC to the extent necessary for safe and quality care.

ICHH 4.07 The care coordinator supports smooth transitions between care settings by:

a. coordinating information sharing and service provision with providers and the person;

b. developing, or supporting the development of, a comprehensive discharge or transition plan with steps for follow-up; and

c. facilitating face-to-face interactions between providers, whenever possible.

Interpretation: Supported transitions can include, but are not limited to, transitioning from inpatient hospitalization, residential treatment, therapeutic







Copies of agreements with community


CCBHC Criteria



(Tables of Evidence) group care, the juvenile justice system, foster care, and from pediatric to adult settings. ICHH 4.08 The organization has mechanisms in place to track medication reconciliation and adherence. Note: While it may not be the organization’s responsibility to conduct medication reconciliation, they should have processes in place to ensure it is being done as part of their care coordination activities. MHSU 7.01 A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating persons with mental health and/or substance use disorders is responsible for the medical aspects of treatment. Interpretation: Medical aspects can include:




d. seizure disorders; e. psychosomatic disorders; and f. other medical and psychiatric related issues


providers, as applicable








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CCBHC Criteria



(Tables of Evidence) The organization ensures that medication management includes appropriate monitoring and administration of pharmacotherapy for individuals with co-occurring health, mental health, and substance use conditions. Interpretation: The qualifications and training of the physician should be appropriate to the program. For example, organizations that provide mental health services should have a board-eligible psychiatrist who is responsible for the medical aspects of treatment or a qualified health professional with the appropriate training, licensure, and/or credentials. Examples of qualified health professionals include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision. Interpretation: It is permissible under the standard to use a consulting psychiatrist or a community mental health center for psychiatric consultation, provided that the organization has a formal agreement or contract. MHSU 9: Care Coordination The organization coordinates services in order to promote continuity of care and whole-person wellness. Interpretation: The standards in MHSU 9 address the


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CCBHC Criteria



(Tables of Evidence) efforts an organization makes to promote information sharing and collaboration with the various systems touching a particular individual. Organizations are not required to provide integrated care to implement the standards in this section. Organizations that offer integrated behavioral health and primary care services (e.g., health homes) will complete the Integrated Care; Health Home (ICHH) standards. Organizations directly providing primary care services will also complete the Primary Care Services (PCS) standards in addition to the Integrated Care; Health Home (ICHH) standards.

3.a.6

Nothing about a CCBHC’s agreements for care coordination should limit a consumer’s freedom to choose their provider with the CCBHC or its DCOs.

CR 1: Protection of Rights and Ethical Obligations The organization protects the legal and ethical rights of all clients by:

a. informing clients of their rights and responsibilities;

b. providing fair and equitable treatment; and c. providing clients with sufficient information

to make an informed choice about using the organization and its services.

Interpretation: Although mandated clients may be required to attend a program, they should still have the right to refuse particular aspects of service or treatment unless mandated by law or court order, as addressed in CR 1.07. Interpretation: Individuals receiving Adult Guardianship (AG) services should retain as much personal responsibility and self-determination as possible given their assessed capacity, the court order, and state law. Refer to AG for more information on appropriately involving the client in








CCBHC Criteria



(Tables of Evidence) decision-making. CR 1.07 Clients participate in all service decisions and have the right to:

a. receive service in a manner that is non-coercive and that protects the person’s right to self-determination;

b. participate in decisions regarding the services provided;

c. request a review of their care, treatment, and service plan;

d. refuse any service, treatment, or medication, unless mandated by law or court order; and

e. be informed about the consequences of such refusal, which can include discharge.

Interpretation: When the client is a minor, or an adult under the care of a guardian, the organization follows applicable laws or regulations governing the right of the parent or legal guardian, to refuse service, treatment, or medication unless mandated by law or court order. Adult guardianship workers should refer to the court order and state law when determining an appropriate level of involvement for each service recipient. See AG 8 for more information on including the client in service decisions.



CCBHC Criteria




Criteria 3.B: Care Coordination and Other Health Information Systems

3.b.1

The CCBHC establishes or maintains a health information technology (IT) system that includes, but is not limited to, electronic health records. The health IT system has the capability to capture structured information in consumer records (including demographic information, diagnoses, and medication lists), provide clinical decision support, and electronically transmit prescriptions to the pharmacy. To the extent possible, the CCBHC will use the health IT system to report on data and quality measures as required by program requirement 5.

ICHH 1.06 The organization uses health information technologies to:

a. link services; b. organize, track, and analyze critical program

information; and c. satisfy applicable reporting requirements

RPM 5: Information and Technology Management The information management and technology systems have sufficient capability to support the organization’s operations, planning, and evaluation. Interpretation: The standards in this section address the management of all types of paper and electronic information maintained by the organization, including:

a. case records and other information of persons served;

b. administrative, financial, and risk management records and reports;

c. personnel files and other human resources records; and

d. performance and quality improvement data and reports.

Interpretation: Implementing a controlled document system is one way an organization can organize, track, store and ensure the use of the most current version of documents. These systems address, for example, processes for:

a. updating, creating, and deleting documents; b. notification of changes; c. identifying documents, i.e., control


Service Philosophy





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Observe health information technologies Table of Evidence for RPM 5

Technology and information management plan or relevant sections of the strategic plan that address technology planning

Information management procedures/guidelines

Interview: a. Finance personnel b. PQI personnel c. MIS manager

MIS observation


CCBHC Criteria



(Tables of Evidence) numbers; and

d. maintaining a master list of documents.

3.b.2

The CCBHC uses its existing or newly established health IT system to conduct activities such as population health management, quality improvement, reducing disparities, and for research and outreach.

RPM 5.03 The organization has an electronic management information system appropriate to its size and complexity, that permits:

a. timely access to information about persons served by any part of the organization, or by other practitioners within the organization, to support continuity and integration of care across settings and services;

b. capturing, tracking, and reporting of financial, compliance, and other business information;

c. longitudinal reporting and comparison of performance over time; and

d. the use of clear and consistent formats and methods for reporting and disseminating data.





MIS observation


Criteria 3.B: Care Coordination and Other Health Information Systems (Continued)


CCBHC Criteria




3.b.3

If the CCBHC is establishing a health IT system, the system will have the capability to capture structured information in the health IT system (including demographic information, problem lists, and medication lists). CCBHCs establishing a health IT system will adopt a product certified to meet requirements in 3.b.1, to send and receive the full common data set for all summary of care records and be certified to support capabilities including transitions of care and privacy and security. CCBHCs establishing health IT systems will adopt a health IT system that is certified to meet the “Patient List Creation” criterion (45 CFR §170.314(a)(14)) established by the Office of the National Coordinator (ONC)7 for ONC’s Health IT Certification Program.



information; and c. satisfy applicable reporting requirements

ICHH 5.04 Health data for persons served is collected, aggregated, and analyzed to inform individual and organization-wide health promotion activities. Interpretation: Patient registries are one effective method for collecting, organizing, and analyzing health data. RPM 5: Information and Technology Management The information management and technology systems have sufficient capability to support the organization’s operations, planning, and evaluation. Interpretation: The standards in this section address the management of all types of paper and electronic information maintained by the organization, including:

a. case records and other information of persons served;

b. administrative, financial, and risk management records and reports;

c. personnel files and other human resources records; and

d. performance and quality improvement data and reports.

Interpretation: Implementing a controlled document system is one way an organization can organize,


Service Philosophy





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Observe health information technologies Table of Evidence for ICHH 5

A description of health promotion activities

A description of how individual characteristics and abilities, health data, and evidence-based practices inform health promotion activities

Health promotion educational materials, training curricula, and other information made available to clients

Aggregate reports and analysis from health data tracking

Evidence of improvements made to health promotion activities based on data collection activities



CCBHC Criteria



(Tables of Evidence) track, store and ensure the use of the most current version of documents. These systems address, for example, processes for:

a. updating, creating, and deleting documents; b. notification of changes; c. identifying documents, i.e., control

numbers; and d. maintaining a master list of documents.

RPM 5.03 The organization has an electronic management information system appropriate to its size and complexity, that permits:

a. timely access to information about persons served by any part of the organization, or by other practitioners within the organization, to support continuity and integration of care across settings and services;

b. capturing, tracking, and reporting of financial, compliance, and other business information;

c. longitudinal reporting and comparison of performance over time; and

d. the use of clear and consistent formats and methods for reporting and disseminating data.

b. Relevant personnel c. Persons served

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Observe system for tracking health data Table of Evidence for RPM 5




MIS observation

3.b.4

The CCBHC will work with DCOs to ensure all steps are taken, including obtaining consumer consent, to comply with privacy and confidentiality requirements, including but not limited to those of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors.

ICHH 1.03 The organization has developed clear mechanisms for linking behavioral health and primary care services through:

a. shared access to the person’s health information consistent with applicable privacy regulations;

b. documentation techniques that utilize common terms and concepts to facilitate clear and effective communication; and


Service Philosophy



Copies of informational materials


CCBHC Criteria



(Tables of Evidence) c. systems for tracking referrals and needed

follow-up provided to clients and other stakeholders


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Observe health information technologies

3.b.5

Whether a CCBHC has an existing health IT system or is establishing a new health IT system, the CCBHC will develop a plan to be produced within the two-year demonstration program time frame to focus on ways to improve care coordination between the CCBHC and all DCOs using a health IT system. This plan shall include information on how the CCBHC can support electronic health information exchange to improve care transition to and from the CCBHC using the health IT system they have in place or are implementing for transitions of care.

RPM 5.01 The organization develops a written technology and information management plan to ensure sufficient capability to support current and future operations which includes:

a. an explanation of how technology will aid in accomplishing the overall mission of the organization;

b. an overview of current information and technology systems in use by the organization;

c. short- and long-term goals for utilizing technology;

d. an assessment of current technical skills of staff and a plan for additional staff training, as necessary; and

e. criteria for meeting technology goals, such as a strategy, timeline, and budget.

Interpretation: The technology plan may be integrated into the organization’s strategic or long term plan. Interpretation: An assessment of current technical skills of staff and a plan for additional staff training can be conducted as part of human resources planning outlined in HR 2 and the annual assessment





MIS observation Table of Evidence for ICHH 1

Service Philosophy






CCBHC Criteria



(Tables of Evidence) of training outlined in TS 1.03. ICHH 1.03 The organization has developed clear mechanisms for linking behavioral health and primary care services through:



c. systems for tracking referrals and needed follow-up



information; and c. satisfy applicable reporting requirements.


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Criteria 3.C: Care Coordination Agreements


CCBHC Criteria




3.c.1

The CCBHC has an agreement establishing care coordination expectations with Federally-Qualified Health Centers (FQHCs) (and, as applicable, Rural Health Clinics [RHCs]) to provide health care services, to the extent the services are not provided directly through the CCBHC. For consumers who are served by other primary care providers, including but not limited to FQHC Look-Alikes and Community Health Centers, the CCBHC has established protocols to ensure adequate care coordination. Note: If an agreement cannot be established with a FQHC or, as applicable, an RHC (e.g., a provider does not exist in their service area), or cannot be established within the time frame of the demonstration project, justification is provided to the certifying body and contingency plans are established with other providers offering similar services (e.g., primary care, preventive services, other medical care services). Note: CCBHCs are expected to work toward formal contracts with entities with which they coordinate care if they are not established at the beginning of the demonstration project.

ICHH 4.05 The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:

a. establishing partnerships and coordination procedures with direct service providers in the community;




a. preventative and health promotion services; b. mental health and substance use services;. c. comprehensive care management, care













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Criteria 3.C: Care Coordination Agreements (Continued)


CCBHC Criteria




3.c.2

The CCBHC has an agreement establishing care coordination expectations with programs that can provide inpatient psychiatric treatment, with ambulatory and medical detoxification, post-detoxification step-down services, and residential programs to provide those services for CCBHC consumers. The CCHBC is able to track when consumers are admitted to facilities providing the services listed above, as well as when they are discharged, unless there is a formal transfer of care to a non-CCBHC entity. The CCBHC has established protocols and procedures for transitioning individuals from EDs, inpatient psychiatric, detoxification, and residential settings to a safe community setting. This includes transfer of medical records of services received (e.g., prescriptions), active follow-up after discharge and, as appropriate, a plan for suicide prevention and safety, and provision for peer services. Note: For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.



















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CCBHC Criteria




3.c.3

The CCBHC has an agreement establishing care coordination expectations with a variety of community or regional services, supports, and providers. Services and supports to collaborate with which are identified by statute include: • Schools; • Child welfare agencies; • Juvenile and criminal justice agencies and facilities (including drug, mental health, veterans and other specialty courts); • Indian Health Service youth regional treatment centers; • State licensed and nationally accredited child placing agencies for therapeutic foster care service; and • Other social and human services. The CCBHC has, to the extent necessary given the population served and the needs of individual consumers, an agreement with such other community or regional services, supports, and providers as may be necessary, such as the following: • Specialty providers of medications for treatment of opioid and alcohol dependence; • Suicide/crisis hotlines and warmlines; • Indian Health Service or other tribal programs; • Homeless shelters; • Housing agencies; • Employment services systems; • Services for older adults, such as Aging and Disability Resource Centers; and • Other social and human services (e.g., domestic violence centers, pastoral services, grief counseling, Affordable Care Act navigators, food and transportation programs). Note: For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are

ICHH 3.02 The care plan is based on the assessment and includes:




d. supports and/or services to improve family functioning;

e. strategies for building on individual and family strengths and natural supports;

f. agreed upon timelines for conducting regular case reviews; and

g. documentation of the individual’s or family’s involvement in care planning.

Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. ICHH 4.05 The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:

COA meets the intent of the CCBHC standard although an exhaustive list of providers and supports is not included. The language of COAs standards is broad enough to encompass the full range or array of supports and services that an organization might need to coordinate for a service recipient. Table of Evidence for ICHH 3











Interview: a. Program director b. Care planning team members


CCBHC Criteria



(Tables of Evidence) developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.









MHSU 9: Care Coordination The organization coordinates services in order to promote continuity of care and whole-person wellness. Interpretation: The standards in MHSU 9 address the efforts an organization makes to promote information sharing and collaboration with the various systems touching a particular individual. Organizations are not required to provide integrated

c. Persons served





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CCBHC Criteria



(Tables of Evidence) care to implement the standards in this section. Organizations that offer integrated behavioral health and primary care services (e.g., health homes) will complete the Integrated Care; Health Home (ICHH) standards. Organizations directly providing primary care services will also complete the Primary Care Services (PCS) standards in addition to the Integrated Care; Health Home (ICHH) standards MHSU 9.02 Service recipients with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider. Note: This standard is applicable to all programs regardless of the services offered. Organizations that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and organizations that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders. MHSU 9.04 In collaboration with the service recipient, the organization coordinates with, as needed:



CCBHC Criteria




3.c.4

The CCBHC has an agreement establishing care coordination expectations with the nearest Department of Veterans Affairs' medical center, independent clinic, drop-in center, or other facility of the Department. To the extent multiple Department facilities of different types are located nearby, the CCBHC should explore care coordination agreements with facilities of each type. Note: For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.










MHSU 9: Care Coordination The organization coordinates services in order to promote continuity of care and whole-person wellness. Interpretation: The standards in MHSU 9 address the

COA meets the intent of the CCBHC standard although an exhaustive list of service providers or service types is not provided. COA’s language is deliberately broad to accommodate a wide-array of circumstances and options. Table of Evidence for ICHH 4












Interview:


CCBHC Criteria



(Tables of Evidence) efforts an organization makes to promote information sharing and collaboration with the various systems touching a particular individual. Organizations are not required to provide integrated care to implement the standards in this section. Organizations that offer integrated behavioral health and primary care services (e.g., health homes) will complete the Integrated Care; Health Home (ICHH) standards. Organizations directly providing primary care services will also complete the Primary Care Services (PCS) standards in addition to the Integrated Care; Health Home (ICHH) standards. MHSU 9.02 Service recipients with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider. Note: This standard is applicable to all programs regardless of the services offered. Organizations that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and organizations that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders.

a. Clinical or program director b. Relevant personnel c. Individuals or families served

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CCBHC Criteria







CCBHC Criteria




3.c.5

The CCBHC has an agreement establishing care coordination expectations with inpatient acute-care hospitals, including emergency departments, hospital outpatient clinics, urgent care centers, residential crisis settings, medical detoxification inpatient facilities and ambulatory detoxification providers, in the area served by the CCBHC, to address the needs of CCBHC consumers. This includes procedures and services, such as peer bridgers, to help transition individuals from the ED or hospital to CCBHC care and shortened time lag between assessment and treatment. The agreement is such that the CCBHC can track when their consumers are admitted to facilities providing the services listed above, as well as when they are discharged, unless there is a formal transfer of care to another entity. The agreement also provides for transfer of medical records of services received (e.g., prescriptions) and active follow-up after discharge. The CCBHC will make and document reasonable attempts to contact all CCBHC consumers who are discharged from these settings within 24 hours of discharge. For all CCBHC consumers being discharged from such facilities who presented to the facilities as a potential suicide risk, the care coordination agreement between these facilities and the CCBHC includes a requirement to coordinate consent and follow-up services with the consumer within 24 hours of discharge, and continues until the individual is linked to services or assessed to be no longer at risk. Note: For

ICHH 1.03 The organization has developed clear mechanisms for linking behavioral health and primary care services through:



c. systems for tracking referrals and needed follow-up.






appropriate. ICHH 3.03 The care coordinator and the care planning team actively review the case according to established timelines to assess:

a. continued accuracy of the assessment; b. care plan implementation; c. the person’s continued engagement in his or

her treatment;

COA meets the intent of the CCBHC standard Table of Evidence for ICHH 1

Service Philosophy





Review case records




Assessment tool








CCBHC Criteria



(Tables of Evidence) these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.

d. the person’s progress toward achieving goals and desired outcomes; and

e. the continuing appropriateness of agreed upon service goals.

Interpretation: Timeframes for the review should be defined by the person and the care coordinator and take into consideration the issues and needs of the person and the frequency and intensity of services provided. Traumatic events or other significant life changes such as changes in housing, disclosure of abuse, hospitalization, or contact with the criminal justice system should trigger an immediate review of the case. ICHH 4.05 The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:





a. preventative and health promotion services;











Interview: d. Program director e. Care planning team members f. Persons served

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CCBHC Criteria



(Tables of Evidence) b. mental health and substance use services; c. comprehensive care management, care




ICHH 4.06 Persons served are assisted in making appointments for needed or requested services, and the care coordinator follows up to:

a. ensure the service was received; b. identify any needed follow-up; and c. make needed changes to the care plan in

partnership with the person and his or her family.


a. coordinating information sharing and service provision with providers and the person;



Interpretation: Supported transitions can include, but are not limited to, transitioning from inpatient hospitalization, residential treatment, therapeutic group care, the juvenile justice system, foster care, and from pediatric to adult settings.


CCBHC Criteria



(Tables of Evidence) ICHH 4.08 The organization has mechanisms in place to track medication reconciliation and adherence. Note: While it may not be the organization’s responsibility to conduct medication reconciliation, they should have processes in place to ensure it is being done as part of their care coordination activities.


Criteria 3.D: Treatment Team, Treatment Planning and Care Coordination Activities


CCBHC Criteria




3.d.1

The CCBHC treatment team includes the consumer, the family/caregiver of child consumers, the adult consumer’s family to the extent the consumer does not object, and any other person the consumer chooses. All treatment planning and care coordination activities are person-centered and family-centered and aligned with the requirements of Section 2402(a) of the Affordable Care Act. All treatment planning and care coordination activities are subject to HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule does not cut off all communication between health care professionals and the families and friends of consumers. As long as the consumer consents, health care professionals covered by HIPAA may provide information to a consumer’s family, friends, or anyone else identified by a consumer as involved in their care.

CR 2: Confidentiality and Privacy Protections The organization protects the confidentiality of information about clients and assumes a protective role regarding the disclosure of confidential information. Interpretation: The organization must carefully reconcile its policies, procedures, and practices with all applicable confidentiality laws and regulations including, but not limited to, laws and regulations governing information about youth involved with the juvenile justice system, mental health consumers, victims of domestic violence, drug and alcohol treatment, and HIV/AIDS. The organization’s procedures must reconcile legal restrictions on the release of identifying information about clients with mandatory reporting and duty to warn requirements. Written procedures should include guidance to personnel in determining the degree of danger a person may pose to him or herself or to the community. Adult Guardianship (AG) programs must have procedures in place to ensure the decision to release confidential information is made in an ethical manner. See AG 8.02 for more information on ethical decision-making. The level of client involvement in the decision to release confidential information will vary based on the court order and state law. ICHH 3: Care Planning and Monitoring The person and his or her family participate in the development and ongoing monitoring of a care plan that is the basis for delivery of needed services





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Interview:


CCBHC Criteria



(Tables of Evidence) ICHH 4.02 The care planning team includes at a minimum: a designated care coordinator;

a. a primary care professional such as a physician’s assistant or nurse practitioner with access to a physician for needed consultation;

b. a behavioral health professional such as a social worker, psychologist, or other licensed clinician with access to a psychiatrist for needed consultation; and

c. other providers and supports based on the individual needs of the person.

Interpretation: The qualifications of the designated care coordinator will vary given the needs of the identified service population. For adults with serious and persistent mental health conditions, for example, a medical professional such as a nurse practitioner may be preferred given the high prevalence of comorbid, chronic, physical health conditions present in this population. For children, however, where chronic medical conditions are far less common, the coordination of behavioral health care and linkages to community and social support services might best be carried out by a behavioral health practitioner with experience working with children and families. Interpretation: Organizations should leverage alternative service delivery methods such as telehealth and telemental health when regional shortages of certain professional groups, such as psychiatrists, make in-person consultation impractical. Interpretation: Supports that might also be included

a. Program director b. Care planning team members c. Persons served





Interview: a. Clinical or program director b. relevant personnel c. Individuals or families served

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Network copies of relevant licenses and legal regulation documents, as applicable


CCBHC Criteria



(Tables of Evidence) on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual. MHSU 4: Service Planning and Monitoring Service recipients and their families participate in the development and ongoing review of an individualized, person- or family-centered service plan that is the basis for delivery of appropriate services and support Interpretation: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law. Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child and can include the child’s birth, foster, adoptive, or kinship caregivers as appropriate. MHSU 4.08 Family members and significant others, as appropriate, and with the consent of the service recipient, are advised of ongoing progress and invited to participate in case conferences. Interpretation: The organization facilitates the participation of family and significant others by, for example, helping arrange transportation, and

to the providers, at the office of the managing entity



CCBHC Criteria



(Tables of Evidence) including them in scheduling decisions. RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations. Interpretation: The organization is expected to be familiar with all applicable, federal, state, and local legal and regulatory requirements. When necessary, the organization consults legal counsel to provide comprehensive necessary information regarding codes, regulations, licensure requirements, employment laws, and general guidance regarding legal compliance. Interpretation: The network management entity annually verifies that member organizations, subcontracting organizations, and independent practitioners meet the legal and regulatory requirements to provide the services that they provide on behalf of the network. Interpretation: Non profit credit counseling organizations are required to meet IRS 501 q regulations.


Criteria 3.D: Treatment Team, Treatment Planning and Care Coordination Activities (Continued)


CCBHC Criteria




3.d.2

As appropriate for the individual’s needs, the CCBHC designates an interdisciplinary treatment team that is responsible, with the consumer or family/caregiver, for directing, coordinating, and managing care and services for the consumer. The interdisciplinary team is composed of individuals who work together to coordinate the medical, psychosocial, emotional, therapeutic, and recovery support needs of CCBHC consumers, including, as appropriate, traditional approaches to care for consumers who may be American Indian or Alaska Native. Note: See criteria 4.K relating to required treatment planning services for veterans.









Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. Note: Regarding element g, the organization should review state regulations governing the documentation of the individual’s or family’s involvement to ensure documentation meets all applicable requirements. ICHH 4.02 The care planning team includes at a minimum:














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CCBHC Criteria



(Tables of Evidence) physician’s assistant or nurse practitioner with access to a physician for needed consultation;



Interpretation: The qualifications of the designated care coordinator will vary given the needs of the identified service population. For adults with serious and persistent mental health conditions, for example, a medical professional such as a nurse practitioner may be preferred given the high prevalence of comorbid, chronic, physical health conditions present in this population. For children, however, where chronic medical conditions are far less common, the coordination of behavioral health care and linkages to community and social support services might best be carried out by a behavioral health practitioner with experience working with children and families. Interpretation: Organizations should leverage alternative service delivery methods such as telehealth and telemental health when regional shortages of certain professional groups, such as psychiatrists, make in-person consultation impractical. Interpretation: Supports that might also be included on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual.


CCBHC Criteria




3.d.3

The CCBHC coordinates care and services provided by DCOs in accordance with the current treatment plan. Note: See program requirement 4 related to scope of service and person-centered and family-centered treatment planning.

ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services.









Interview: c. Program director d. Care planning team members e. Persons served

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PROGRAM REQUIREMENT 4: SCOPE OF SERVICES

Criteria 4.A: General Service Provisions


CCBHC Criteria




4.a.1

CCBHCs are responsible for the provision of all care specified in PAMA, including, as more explicitly provided and more clearly defined below in criteria 4.B through 4.K, crisis services; screening, assessment and diagnosis; person-centered treatment planning; outpatient behavioral health services; outpatient primary care screening and monitoring; targeted case management; psychiatric rehabilitation; peer and family supports; and intensive community-based outpatient behavioral health care for members of the US Armed Forces and veterans. As provided in criteria 4.B through 4.K, many of these services may be provided either directly by the CCBHC or through formal relationships with other providers that are DCOs. Whether directly supplied by the CCBHC or by a DCO, the CCBHC is ultimately clinically responsible for all care provided. The decision as to the scope of services to be provided directly by the CCBHC, as determined by the state and clinics as part of certification, reflects the CCBHC’s responsibility and accountability for the clinical care of the consumers. Despite this flexibility, it is expected CCBHCs will be designed so most services are provided by the CCBHC rather than by DCOs, as this will enhance the ability of the CCBHC to coordinate services. Note: See CMS PPS guidance regarding payment.

ICHH 2: Assessment The person and his or her family participate in a comprehensive, strengths-based, individualized assessment to identify service needs and goals. ICHH 2.02 Assessments are conducted within established timeframes using a standardized assessment tool to identify:


b. history of trauma; c. individual and family strengths, risks, and

protective factors; d. natural supports and helping networks; and e. the impact of the individual’s health care

needs on the family unit. Interpretation: Basic needs such as food, clothing, and shelter should be considered when identifying the person’s service needs. For organizations serving children, the assessments should take into account systems involvement including education, child welfare and juvenile justice. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for conducting assessments. Organizations serving children in the child welfare system should also be aware of any assessment timeframe requirements applicable to that population.



Assessment tool









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Copy of agreement with and/or job description and resume for each member of the care planning team, including a


CCBHC Criteria



(Tables of Evidence) Note: See ICHH 3.03 for more information on keeping the assessment up-to-date as part of the case review process. ICHH 2.05 Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:





appropriate. ICHH 3: Care Planning and Monitoring The person and his or her family participate in the development and ongoing monitoring of a care plan that is the basis for delivery of needed services. ICHH 3.02 The care plan is based on the assessment and includes:





physician and psychiatrist for consultation




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CCBHC Criteria



(Tables of Evidence) e. strategies for building on individual and

family strengths and natural supports; f. agreed upon timelines for conducting

regular case reviews; and g. documentation of the individual’s or family’s

involvement in care planning. Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. Note: Regarding element g, the organization should review state regulations governing the documentation of the individual’s or family’s involvement to ensure documentation meets all applicable requirements. ICHH 4.05 The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:




d. assisting the person with system navigation. Interpretation: Examples of community and social support services and behavioral and physical health


Review case records


CCBHC Criteria



(Tables of Evidence) care services that should be made available to persons served include:





ICHH 4.10 Persons served and their families are connected with peer support services appropriate to their request or need for service. MHSU 3.07 Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:



Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring.


CCBHC Criteria



(Tables of Evidence) Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff, or available through a contract or formal arrangement. All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional. Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the organization for counseling or prevention. In such cases, the organization is not responsible for addressing the medical aspects of treatment, but must coordinate services with the physician. MHSU 4.02 The service plan is based on the assessment, and includes:




Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being.


CCBHC Criteria



(Tables of Evidence) Note: For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and wishes of the client. Research has shown that this population is often unsure of the services to which they are entitled and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible.


Criteria 4.A: General Service Provisions (Continued)

4.a.2

The CCBHC ensures all CCBHC services, if not available directly through the CCBHC, are provided through a DCO, consistent with the consumer’s freedom to choose providers within the CCBHC and its DCOs. This requirement does not preclude the use of referrals outside the CCBHC or DCO if a needed specialty service is unavailable through the CCBHC or DCO entities.

CR 1.07 Clients participate in all service decisions and have the right to:






Interpretation: When the client is a minor, or an adult under the care of a guardian, the organization follows applicable laws or regulations governing the right of the parent or legal guardian, to refuse service, treatment, or medication unless mandated by law or court order. Adult guardianship workers should refer to the court order and state law when






Review case records








CCBHC Criteria



(Tables of Evidence) determining an appropriate level of involvement for each service recipient. See AG 8 for more information on including the client in service decisions. ICHH 4.01 All individuals and their families receive:









coordination, and transitional care;












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CCBHC Criteria



(Tables of Evidence) d. chronic disease management, including self-



MHSU 3.05 The comprehensive assessment includes:




d. natural supports and helping networks. Interpretation: In regards to element (a), the comprehensive assessment may include:

a. an evaluation of mental health and/or substance use disorders;

b. a psychiatric history; c. a complete alcohol and drug use history,

medical history; and d. an evaluation of social support and

community support networks.

Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history.


CCBHC Criteria



(Tables of Evidence) Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 3.07 Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:



Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The


CCBHC Criteria



(Tables of Evidence) organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring. Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff, or available through a contract or formal arrangement. All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional. Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the organization for counseling or prevention. In such cases, the organization is not responsible for addressing the medical aspects of treatment, but must coordinate services with the physician.

4.a.3

With regard to either CCBHC or DCO services, consumers will have access to the CCBHC’s existing grievance procedures, which must satisfy the minimum requirements of Medicaid and other grievance requirements such as those that may be mandated by relevant accrediting entities.

CR 1.01 At initial contact clients receive and are helped to understand a written summary of their rights and responsibilities, including:

a. a description of the client’s rights, including the obligations the organization has to the client;

b. basic expectations for use of the organization’s services;

c. hours that services are available; d. rules, expectations, and other factors that

can result in discharge or termination of





Interview: a. Relevant personnel


CCBHC Criteria



(Tables of Evidence) services; and

e. a clear explanation of how to lodge complaints, grievances, or appeals.

Interpretation: If a client is disoriented or suffering from impaired cognition at initial contact, the summary of client rights and responsibilities should be provided at an appropriate time. When working with individuals who have been deemed incapacitated by the court, the depth or content of information provided may vary based on the individual’s assessed capacity to understand the information, the court order, and state law. Interpretation: The organization’s explanation of how to lodge complaints, grievances, or appeals should include informing clients about their right to file a complaint with the appropriate public authority or regulatory body. Interpretation: For networks, when the scope of a network’s services includes service authorization and placement decisions, the client’s right to appeal placement and authorization decisions are outlined in written network client rights and responsibilities material available to clients, and in the provider manual or other document outlining network operational procedures. Interpretation: Organizations that use web-based technologies, telephonic, or electronic communications to deliver services shall implement a system for assuring and documenting that clients receive and understand their rights and responsibilities.

b. Individuals or families served

Review case records

Facility Observation Table of Evidence for CR 3

Grievance policy or procedures for individuals and families served

Grievance reports for the last two quarters



CCBHC Criteria



(Tables of Evidence) CR 3: Grievance Procedures The organization maintains a formal mechanism through which applicants, clients, and other stakeholders can express and resolve grievances, including denial of service, which includes:

a. the right to file a grievance without interference or retaliation;

b. timely written notification of the resolution and an explanation of any further appeal, rights or recourse; and

c. at least one level of review that does not involve the person about whom the complaint has been made or the person who reached the decision under review.

Interpretation: Organizations providing Adult Guardianship should ensure that an advocate is appointed to assist the individual in navigating the grievance process.


Criteria 4.A: General Service Provisions (Continued)

4.a.4

DCO-provided services for CCBHC consumers must meet the same quality standards as those provided by the CCBHC.

RPM 9: Contracts and Service Agreements The organization enters into contracts and service agreements with due regard for practices that promote efficient use of resources. Interpretation: The standards in RPM 9 apply to all contracts entered into by the organization in which it acts as a purchaser or vendor of social and human services as well as to contracts for the purchase of support services, such as maintenance or transportation services.


Contracting procedures

Network list of contracts/service agreements/memoranda of understanding (MOU) between the network and providers

Contracts/service agreements/MOUs

Proof of accreditation, licensure, or certification for outside providers operating adventure-based activities


CCBHC Criteria



(Tables of Evidence) RPM 9 is not applicable to contracts with individual consultants and independent contractors, which are addressed in Human Resources Management (HR). RPM 9.01 The pursuit of contracts for services is consistent with the organization’s mission and purpose, and the organization:

a. establishes a system of standardized contracting practices;

b. conducts due diligence in contracting activities, including review of possible risks; and

c. assigns a qualified individual to oversee contracts.

Interpretation: The organization assigns each contract to a specific qualified individual who is charged with monitoring the progress and outcomes of each service contract. RPM 9.02 Written contracts contain all significant terms and conditions in accordance with applicable law. Interpretation: “Significant terms” include, as appropriate to the type of contract: roles and responsibilities of participating organizations;

a. services to be provided; b. clearly defined performance goals; c. measurable outcomes; .service

authorization, including eligibility criteria; d. provisions for training and technical support,

as necessary; e. duration of contract, including delineation of

Interview: a. Governing Body b. CEO/CFO c. Contract manager(s) d. Vendors



CCBHC Criteria



(Tables of Evidence) follow-up services;

f. policies and procedures for sharing information;

g. methods for resolving disputes; h. a plan and procedure for timely payment,

and consequences for failure to pay; i. documentation necessary for, and means of

reporting to, funding or oversight bodies; and

j. conditions for termination of the contract. RPM 9.04 Non-contractual service agreements include, as appropriate:

a. services exchanged or provided, and/or the goals and objectives of such collaborations;

b. roles and responsibilities of each organization, including reporting responsibilities;

c. procedures for sharing information; d. confidentiality protections, including signed

written consent forms; e. assignment of case coordination

responsibilities; f. service authorization procedures, including

accepting or rejecting cases; and g. how to resolve communication difficulties.

Interpretation: This standard applies to non-contractual arrangements, also known as Memorandums of Understanding (MOUs), in which organizations collaborate with providers to deliver specific services to a person or persons. For example, a service in which a provider voluntarily comes into the host organization’s facility to provide weekly smoking cessation classes.


CCBHC Criteria




4.a.5

The entities with which the CCBHC coordinates care and all DCOs, taken In 4.a.5 conjunction with the CCBHC itself, satisfy the mandatory aspects of these criteria.

RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations. Interpretation: The organization is expected to be familiar with all applicable, federal, state, and local legal and regulatory requirements. When necessary, the organization consults legal counsel to provide comprehensive necessary information regarding codes, regulations, licensure requirements, employment laws, and general guidance regarding legal compliance. Interpretation: The network management entity annually verifies that member organizations, subcontracting organizations, and independent practitioners meet the legal and regulatory requirements to provide the services that they provide on behalf of the network. Interpretation: Non profit credit counseling organizations are required to meet IRS 501 q regulations RPM 9: Contracts and Service Agreements The organization enters into contracts and service agreements with due regard for practices that promote efficient use of resources. Interpretation: The standards in RPM 9 apply to all contracts entered into by the organization in which it acts as a purchaser or vendor of social and human services as well as to contracts for the purchase of support services, such as maintenance or transportation services.









Contracting procedures

Network list of contracts/service agreements/memoranda of understanding (MOU) between the network and providers

Contracts/service agreements/MOUs

Proof of accreditation, licensure, or


CCBHC Criteria



(Tables of Evidence) RPM 9 is not applicable to contracts with individual consultants and independent contractors, which are addressed in Human Resources Management (HR). RPM 9.01 The pursuit of contracts for services is consistent with the organization’s mission and purpose, and the organization:

a. establishes a system of standardized contracting practices;

b. conducts due diligence in contracting activities, including review of possible risks; and

c. assigns a qualified individual to oversee contracts.

Interpretation: The organization assigns each contract to a specific qualified individual who is charged with monitoring the progress and outcomes of each service contract. RPM 9.04 Non-contractual service agreements include, as appropriate:

a. services exchanged or provided, and/or the goals and objectives of such collaborations;

b. roles and responsibilities of each organization, including reporting responsibilities;

c. procedures for sharing information; d. confidentiality protections, including signed

written consent forms; e. assignment of case coordination

responsibilities; f. service authorization procedures, including

certification for outside providers operating adventure-based activities

Interview: a. Governing Body b. CEO/CFO c. Contract manager(s) d. Vendors



CCBHC Criteria



(Tables of Evidence) accepting or rejecting cases;

g. how to resolve communication difficulties. Interpretation: This standard applies to non-contractual arrangements, also known as Memorandums of Understanding (MOUs), in which organizations collaborate with providers to deliver specific services to a person or persons. For example, a service in which a provider voluntarily comes into the host organization’s facility to provide weekly smoking cessation classes


Criteria 4.B: Requirement of Person-Centered and Family-Centered Care

4.b.1

The CCBHC ensures all CCBHC services, including those supplied by its DCOs, are provided in a manner aligned with the requirements of Section 2402(a) of the Affordable Care Act, reflecting person and family-centered, recovery-oriented care, being respectful of the individual consumer’s needs, preferences, and values, and ensuring both consumer involvement and self-direction of services received. Services for children and youth are family-centered, youth-guided, and developmentally appropriate. Note: See program requirement 3 regarding coordination of services and treatment planning. See criteria 4.K relating specifically to requirements for services for veterans.

RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations. Interpretation: The organization is expected to be familiar with all applicable, federal, state, and local legal and regulatory requirements. When necessary, the organization consults legal counsel to provide comprehensive necessary information regarding codes, regulations, licensure requirements, employment laws, and general guidance regarding legal compliance. Interpretation: The network management entity annually verifies that member organizations, subcontracting organizations, and independent practitioners meet the legal and regulatory requirements to provide the services that they provide on behalf of the network.






Network copies of relevant licenses and legal regulation documents, as applicable


CCBHC Criteria




Interpretation: Non profit credit counseling organizations are required to meet IRS 501 q regulations. ICHH 1.01 The organization is guided by a service philosophy that:

a. sets forth a logical approach for how program activities and interventions will meet the needs of persons served;

b. guides the development and implementation of the program based on program goals and the best available evidence of service effectiveness; and

c. establishes a holistic, person- or family-centered, resilience and recovery-focused approach to service delivery.

Interpretation: A practice model, or similar tool, guides program development and implementation by linking the organization’s service philosophy and mission with the strategies, practices, and tools needed to integrate these into daily work. A practice model can also help staff think systematically about how the program can make a measureable difference by drawing a clear connection between the service population’s needs, available resources, program activities and interventions, program outputs, and desired outcomes. MHSU 1: Service Philosophy, Modalities, and Interventions The service philosophy:


to the providers, at the office of the managing entity



Service Philosophy





Review case records

Observe health information technologies Table of Evidence for MHSU 1

Service philosophy




Interview: c. Clinical or program director d. Relevant personnel e. Individuals or families served

Review case records


CCBHC Criteria



(Tables of Evidence) b. ensures that services are strengths-based,

person- or family-centered, culturally and linguistically responsive, and trauma-informed;

c. guides the development and implementation of program activities and services based on the best available evidence of service effectiveness; and


Interpretation: A functional service philosophy, logic model, or similar framework guides program development and implementation by linking the organization’s mission or purpose with strategies, practices, or tools needed to integrate these into daily work. A well-defined and visible practice framework will help staff and stakeholders think systematically about how the program can make a measureable difference by drawing clear connections between program values, service population needs, available resources, program activities and interventions, program outputs, and desired outcomes. Interpretation: Organizational self-assessments can evaluate the extent to which organizations’ policies and practices are trauma-informed, as well as identify strengths and barriers in regards to trauma-informed service delivery and provision. For example, organizations can evaluate staff training and professional development opportunities and review supervision ratios to assess whether personnel are trained and supported on trauma-informed care practices. Organizations can also conduct an internal review of their assessments and service planning


CCBHC Criteria



(Tables of Evidence) processes to ensure that services are being delivered in a trauma-informed manner.


Criteria 4.B: Requirement of Person-Centered and Family-Centered Care

4.b.2

Person-centered and family-centered care includes care which recognizes the particular cultural and other needs of the individual. This includes but is not limited to services for consumers who are American Indian or Alaska Native (AI/AN), for whom access to traditional approaches or medicines may be part of CCBHC services. For consumers who are AI/AN, these services may be provided either directly or by formal arrangement with tribal providers.

ICHH 1.01 The organization is guided by a service philosophy that:

a. sets forth a logical approach for how program activities and interventions will meet the needs of persons served;

b. guides the development and implementation of the program based on program goals and the best available evidence of service effectiveness; and

c. establishes a holistic, person- or family-centered, resilience and recovery-focused approach to service delivery.

Interpretation: A practice model, or similar tool, guides program development and implementation by linking the organization’s service philosophy and mission with the strategies, practices, and tools needed to integrate these into daily work. A practice model can also help staff think systematically about how the program can make a measureable difference by drawing a clear connection between the service population’s needs, available resources, program activities and interventions, program outputs, and


Service Philosophy





Review case records



Service philosophy



CCBHC Criteria




desired outcomes. MHSU 1: Service Philosophy, Modalities, and Interventions The service philosophy:


b. ensures that services are strengths-based, person- or family-centered, culturally and linguistically responsive, and trauma-informed;

c. guides the development and implementation of program activities and services based on the best available evidence of service effectiveness; and


Interpretation: A functional service philosophy, logic model, or similar framework guides program development and implementation by linking the organization’s mission or purpose with strategies, practices, or tools needed to integrate these into daily work. A well-defined and visible practice framework will help staff and stakeholders think systematically about how the program can make a measureable difference by drawing clear connections between program values, service population needs, available resources, program activities and interventions, program outputs, and desired outcomes. Interpretation: Organizational self-assessments can evaluate the extent to which organizations’ policies and practices are trauma-informed, as well as




Review case records


CCBHC Criteria



(Tables of Evidence) identify strengths and barriers in regards to trauma-informed service delivery and provision. For example, organizations can evaluate staff training and professional development opportunities and review supervision ratios to assess whether personnel are trained and supported on trauma-informed care practices. Organizations can also conduct an internal review of their assessments and service planning processes to ensure that services are being delivered in a trauma-informed manner.


Criteria 4.C: Crisis Behavioral Health Services

4.c.1

Unless there is an existing state-sanctioned, certified, or licensed system or network for the provision of crisis behavioral health services that dictates otherwise, the CCBHC will directly provide robust and timely crisis behavioral health services. Whether provided directly by the CCBHC or by a state-sanctioned alternative acting as a DCO, available services must include the following: • 24 hour mobile crisis teams, • Emergency crisis intervention services, and • Crisis stabilization. PAMA requires provision of these three crisis behavioral health services. As part of the certification process, the states will clearly define each term as they are using it but services provided must include suicide crisis response and services capable of addressing






appropriate. ICHH 4.10 Persons served and their families are connected with peer support services appropriate to their request or need for service.



Assessment tool






Review case records


CCBHC Criteria



(Tables of Evidence) crises related to substance abuse and intoxication, including ambulatory and medical detoxification. States may elect to require the employment of peers on crisis teams. CCBHCs will have an established protocol specifying the role of law enforcement during the provision of crisis services. Note: See program requirement 2 related to crisis prevention, response and post-vention services and criterion 3.c.5 regarding coordination of services and treatment planning, including after discharge from a hospital or ED following a psychiatric crisis.

MHSU 6.04 Service recipients and their families are connected with peer support services appropriate to their request or need for service. Interpretation: Peer support refers to services provided by individuals who have shared, lived experience. Services promote resiliency and recovery and can include peer recovery groups, peer-to-peer counseling, peer mentoring or coaching, family and youth peer support or other consumer-run services. Interpretation: Organizations may provide peer support services directly or have a referral system in place to ensure that service recipients have access to peer support services when needed. Peer support workers may also be part of the treatment team. MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services.













Interview: f. Clinical or program director g. Relevant personnel h. Individuals or families served


CCBHC Criteria




Review case records


Criteria 4.D: Screening, Assessment, and Diagnosis

4.d.1

The CCBHC directly provides screening, assessment, and diagnosis, including risk assessment, for behavioral health conditions. In the event specialized services outside the expertise of the CCBHC are required for purposes of screening, assessment or diagnosis (e.g., neurological testing, developmental testing and assessment, eating disorders), the CCBHC provides or refers them through formal relationships with other providers, or where necessary and appropriate, through use of telehealth telemedicine services. Note: See program requirement 3 regarding coordination of services and treatment planning.

ICHH 2.06 The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments. MHSU 3.05 The comprehensive assessment includes:




d. natural supports and helping networks. Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks.



Assessment tool






Review case records Table of Evidence MHSU 3


List of standardized assessment tools


CCBHC Criteria



(Tables of Evidence) Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history. Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 3.07 Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:

used




Review case records


CCBHC Criteria



(Tables of Evidence) a. medication monitoring and management; b. physical examinations or other physical


Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring. Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff, or available through a contract or formal arrangement. All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional. Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the organization for counseling or prevention. In such cases, the organization is not responsible for addressing the medical aspects of treatment, but must coordinate services with the physician.


CCBHC Criteria




.


Criteria 4.D: Screening, Assessment, and Diagnosis (Continued)

4.d.2

Screening, assessment, and diagnosis are conducted in a time frame responsive to the individual consumer’s needs and are of sufficient scope to assess the need for all services required to be provided by CCBHCs.

ICHH 2.02 Assessments are conducted within established timeframes using a standardized assessment tool to identify:




needs on the family unit. Interpretation: Basic needs such as food, clothing, and shelter should be considered when identifying the person’s service needs. For organizations serving children, the assessments should take into account systems involvement including education, child welfare and juvenile justice. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for conducting assessments.



Assessment tool






Review case records






CCBHC Criteria



(Tables of Evidence) Organizations serving children in the child welfare system should also be aware of any assessment timeframe requirements applicable to that population. Note: See ICHH 3.03 for more information on keeping the assessment up-to-date as part of the case review process. MHSU 2: Screening and Intake The organization’s screening and intake practices ensure that service recipients receive prompt and responsive access to appropriate services.


Review case records

4.d.3

The initial evaluation (including information gathered as part of the preliminary screening and risk assessment), as required in program requirement 2, includes, at a minimum, (1) preliminary diagnoses; (2) the source of referral; (3) the reason for seeking care, as stated by the consumer or other individuals who are significantly involved; (4) identification of the consumer’s immediate clinical care needs related to the diagnosis for mental and substance use disorders; (5) a list of current prescriptions and over-the-counter medications, as well as other substances the consumer may be taking; (6) an assessment of whether the consumer is a risk to self or to others, including suicide risk factors; (7) an assessment of whether the consumer has other concerns for their safety; (8) assessment of need for medical care (with





needs on the family unit. Interpretation: Basic needs such as food, clothing, and shelter should be considered when identifying the person’s service needs. For organizations serving children, the assessments should take into account systems involvement including education, child



Assessment tool






Review case records



CCBHC Criteria



(Tables of Evidence) referral and follow-up as required); and (9) a determination of whether the person presently is or ever has been a member of the U.S. Armed Services. As needed, releases of information are obtained.

welfare and juvenile justice. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for conducting assessments. Organizations serving children in the child welfare system should also be aware of any assessment timeframe requirements applicable to that population. Note: See ICHH 3.03 for more information on keeping the assessment up-to-date as part of the case review process. ICHH 2.03 The assessment incorporates applicable information from a variety of sources, which include, but are not limited to:

a. the person; b. the person’s family; c. medical and/or clinical case records; d. the results of screening tools; e. content of assessments completed by

partnering or referring providers; f. other providers; and g. members of the care planning team.

Interpretation: Information received through assessments completed by partnering or referring providers should be reviewed to identify:

a. gaps in information; b. out-of-date information; and c. information that can be used to minimize

duplication of effort.







Review case records


CCBHC Criteria



(Tables of Evidence) MHSU 3: Assessment Service recipients participate in a comprehensive, individualized, trauma-informed, strengths-based, family-focused, culturally and linguistically responsive assessment to determine an appropriate level of service. Interpretation: For an assessment to be trauma-informed, the organization understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the service recipient rather than personal deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the organization actively prevents instances that could potentially re-traumatize service recipients. MHSU 3.04 Each service recipient receives an individualized, comprehensive assessment, which includes a summary of symptoms and diagnoses based on a standardized diagnostic tool. Interpretation: The standardized diagnostic tool should be used to match the needs of the service recipient with the appropriate level care. Assessment tools will vary depending on the age and developmental level of the service population. Examples of standardized instruments or protocols include: the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), the Addiction Severity Index, Treatment Services Review,


CCBHC Criteria



(Tables of Evidence) the American Society of Addiction Medicine (ASAM) patient placement criteria, the Institute of Medicine (IOM), the Child and Adolescents Needs and Strengths (CANS), criteria required by federal or state oversight authorities, and criteria required for participation in managed care delivery systems. Interpretation: Assessments are completed within timeframes established by the organization. Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes. MHSU 3.05 The comprehensive assessment includes:




d. natural supports and helping networks.

Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks. Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-


CCBHC Criteria



(Tables of Evidence) being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history. Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 3.06 The organization engages service recipients in a risk assessment to assess their risk of suicide, self-injury, neglect, exploitation, and violence towards others. Interpretation: Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with


CCBHC Criteria



(Tables of Evidence) employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents.



4.d.4

As required in program requirement 2, a comprehensive person-centered and family-centered diagnostic and treatment planning evaluation is completed within 60 days by licensed behavioral health professionals who, in conjunction with the consumer, are members of the treatment team, performing within their state’s scope of practice. Information gathered as part of the preliminary screening and initial evaluation may be considered a part of the comprehensive evaluation. This requirement that the comprehensive evaluation be completed within 60 calendar days does not preclude either the initiation or completion of the comprehensive evaluation or the provision of treatment during the intervening 60 day period.



and his or her family.

Interpretation: Care planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and gradually assume more responsibility for making decisions independently. When the person receiving services is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring the involvement or consent of the person’s legal guardian. Interpretation: Generally, care plans should be developed following completion of all necessary assessments and reviewed with the person at their next visit.









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CCBHC Criteria



(Tables of Evidence) Note: The organization should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for completing care plans. ICHH 3.03 The care coordinator and the care planning team actively review the case according to established timelines to assess:

a. continued accuracy of the assessment; b. care plan implementation; c. the person’s continued engagement in his or

her treatment; d. the person’s progress toward achieving

goals and desired outcomes; and e. the continuing appropriateness of agreed

upon service goals. Interpretation: Timeframes for the review should be defined by the person and the care coordinator and take into consideration the issues and needs of the person and the frequency and intensity of services provided. Traumatic events or other significant life changes such as changes in housing, disclosure of abuse, hospitalization, or contact with the criminal justice system should trigger an immediate review of the case. ICHH 3.04 The care coordinator and the individual or family regularly review progress toward achievement of agreed upon goals and make revisions to service goals and plans as needed. Interpretation: The individual’s or family’s involvement in updating the plan should be


CCBHC Criteria



(Tables of Evidence) documented. MHSU 4: Service Planning and Monitoring Service recipients and their families participate in the development and ongoing review of an individualized, person- or family-centered service plan that is the basis for delivery of appropriate services and support. Interpretation: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law. Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child and can include the child’s birth, foster, adoptive, or kinship caregivers as appropriate. MHSU 4.02 The service plan is based on the assessment, and includes:


b. .services and supports to be provided, and by whom; and


Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain


CCBHC Criteria



(Tables of Evidence) employment, while outcomes for children and youth may focus on school performance and social and emotional well-being. MHSU 4.06 The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, at minimum, to assess:



agreed upon service goals. Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard. Interpretation: Timeframes for review should be adjusted depending upon the issues and needs of persons receiving services and the frequency and intensity of the services being provided. Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for service recipients with substance use disorders at high risk for relapse. Individuals with acute or complex needs (e.g., service recipients receiving medications for diagnosed symptoms and conditions) may require that their service plan be reviewed and updated every 30 days.


CCBHC Criteria




4.d.5

Although a comprehensive diagnostic and treatment planning evaluation is required for all CCBHC consumers, the extent of the evaluation will depend on the individual consumer and on existing state, federal, or applicable accreditation standards. As part of certification, states will establish the requirements for these evaluations; factors states should consider requiring include:(1) reasons for seeking services at the CCBHC, including information regarding onset of symptoms, severity of symptoms, and circumstances leading to the consumer’s presentation to the CCBHC; (2) a psychosocial evaluation including housing, vocational and educational status, family/caregiver and social support, legal issues, and insurance status; (3) behavioral health history (including trauma history and previous therapeutic interventions and hospitalizations); (3) a diagnostic assessment, including current mental status, mental health (including depression screening) and substance use disorders (including tobacco, alcohol, and other drugs); (4) assessment of imminent risk (including suicide risk, danger to self or others, urgent or critical medical conditions, other immediate risks including threats from another person); (5) basic competency/cognitive impairment screening (including the consumer’s ability to understand and participate in their own care); (6) a drug profile including the consumer’s prescriptions, over-the-counter medications, herbal remedies, and other treatments or substances that could affect

ICHH 2: Assessment The person and his or her family participate in a comprehensive, strengths-based, individualized assessment to identify service needs and goals. ICHH 2.02 Assessments are conducted within established timeframes using a standardized assessment tool to identify:




needs on the family unit. Interpretation: Basic needs such as food, clothing, and shelter should be considered when identifying the person’s service needs. For organizations serving children, the assessments should take into account systems involvement including education, child welfare and juvenile justice. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for conducting assessments. Organizations serving children in the child welfare system should also be aware of any assessment timeframe requirements applicable to that population. Note: See ICHH 3.03 for more information on keeping



Assessment tool










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List of identified medical referral sources,


CCBHC Criteria



(Tables of Evidence) drug therapy, as well as information on drug allergies; (7) a description of attitudes and behaviors, including cultural and environmental factors, that may affect the consumer’s treatment plan; (8) the consumer’s strengths, goals, and other factors to be considered in recovery planning;(9) pregnancy and parenting status; (10) assessment of need for other services required by the statute (i.e., peer and family/caregiver support services, targeted case management, psychiatric rehabilitation services, LEP or linguistic services); (11) assessment of the social service needs of the consumer, with necessary referrals made to social services and, for pediatric consumers, to child welfare agencies as appropriate; and (12) depending on whether the CCBHC directly provides primary care screening and monitoring of key health indicators and health risk pursuant to criteria 4.G, either: (a) an assessment of need for a physical exam or further evaluation by appropriate health care professionals, including the consumer’s primary care provider (with appropriate referral and follow-up), or (b) a basic physical assessment as required by criteria 4.G. All remaining necessary releases of information are obtained by this point.

the assessment up-to-date as part of the case review process. ICHH 2.03 The assessment incorporates applicable information from a variety of sources, which include, but are not limited to:

a. the person; b. the person’s family; c. medical and/or clinical case records; d. the results of screening tools; e. content of assessments completed by

partnering or referring providers; f. other providers; and g. members of the care planning team.

Interpretation: Information received through assessments completed by partnering or referring providers should be reviewed to identify:

a. gaps in information; b. out-of-date information; and c. information that can be used to minimize

duplication of effort. ICHH 2.04 Assessments are conducted in a culturally responsive manner to identify resources that can increase service participation, support the achievement of agreed upon goals, and promote recovery and resilience. Interpretation: Culturally responsive assessments can include attention to geographic location, language of choice, and the person’s religious, racial, ethnic, and cultural background. Other important factors that contribute to a responsive assessment

if applicable (MHSU 3.07)


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CCBHC Criteria



(Tables of Evidence) include attention to age, gender identity, sexual orientation, immigration status, and developmental level. ICHH 2.05 Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:





appropriate. ICHH 2.06 The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments. MHSU 2.01 Service recipients are screened at intake and informed about:



c. rules and expectations of the program. Interpretation: Screenings will vary based on the program’s target population and services offered,


CCBHC Criteria



(Tables of Evidence) and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, and/or risk of harm to self or others. Interpretation: For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program. MHSU 2.02 Prompt, responsive intake practices:






desired. Interpretation: Screening and intake procedures should direct staff on how to identify and respond to individuals or families experiencing emergency situations to ensure that they receive expedited treatment planning and are connected to more intensive services. Organizations should have the capacity to refer individuals in crisis to the appropriate services, which may include 24-hour mobile crisis teams, emergency crisis intervention services, or crisis stabilization.


CCBHC Criteria



(Tables of Evidence) Urgent situations can also include those in which an individual has a child in the child welfare system. Interpretation: Wait times are a major barrier to individuals and families receiving services. Organizations can monitor waitlists and standardize their referral process to improve accessibility. MHSU 3.04 Each service recipient receives an individualized, comprehensive assessment, which includes a summary of symptoms and diagnoses based on a standardized diagnostic tool. Interpretation: The standardized diagnostic tool should be used to match the needs of the service recipient with the appropriate level care. Assessment tools will vary depending on the age and developmental level of the service population. Examples of standardized instruments or protocols include: the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), the Addiction Severity Index, Treatment Services Review, the American Society of Addiction Medicine (ASAM) patient placement criteria, the Institute of Medicine (IOM), the Child and Adolescents Needs and Strengths (CANS), criteria required by federal or state oversight authorities, and criteria required for participation in managed care delivery systems. Interpretation: Assessments are completed within timeframes established by the organization. Organizations should review state Medicaid plans or


CCBHC Criteria



(Tables of Evidence) other third party reimbursement requirements to ensure they are meeting required timeframes. MHSU 3.05 The comprehensive assessment includes:




d. natural supports and helping networks. Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks. Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history. Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions.


CCBHC Criteria



(Tables of Evidence) If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 3.06 The organization engages service recipients in a risk assessment to assess their risk of suicide, self-injury, neglect, exploitation, and violence towards others. Interpretation: Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents.


CCBHC Criteria



(Tables of Evidence) MHSU 3.07 Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:


health services; c. medical detoxification; d. laboratory testing and toxicology screens; or

other diagnostic procedures. Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring. Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff, or available through a contract or formal arrangement. All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional. Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the organization for counseling or prevention. In such cases, the organization is not responsible for addressing the medical aspects of


CCBHC Criteria



(Tables of Evidence) treatment, but must coordinate services with the physician.



4.d.6

Screening and assessment by the CCBHC related to behavioral health include those for which the CCBHC will be accountable pursuant to program requirement 5 and Appendix A of these criteria. The CCBHC should not take non-inclusion of a specific metric in Appendix A as a reason not to provide clinically indicated behavioral health screening or assessment and the state may elect to require specific other screening and monitoring to be provided by the CCBHCs beyond those listed in criterion 4.d.5 or Appendix A.

ICHH 2.06 The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments. MHSU 2: Screening and Intake The organization’s screening and intake practices ensure that service recipients receive prompt and responsive access to appropriate services. MHSU 2.02 Prompt, responsive intake practices:








Assessment tool






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CCBHC Criteria



(Tables of Evidence) desired.

Interpretation: Screening and intake procedures should direct staff on how to identify and respond to individuals or families experiencing emergency situations to ensure that they receive expedited treatment planning and are connected to more intensive services. Organizations should have the capacity to refer individuals in crisis to the appropriate services, which may include 24-hour mobile crisis teams, emergency crisis intervention services, or crisis stabilization. Urgent situations can also include those in which an individual has a child in the child welfare system. Interpretation: Wait times are a major barrier to individuals and families receiving services. Organizations can monitor waitlists and standardize their referral process to improve accessibility.


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4.d.7

The CCBHC uses standardized and validated screening and assessment tools and, where appropriate, brief motivational interviewing techniques.





needs on the family unit. Interpretation: Basic needs such as food, clothing, and shelter should be considered when identifying



Assessment tool







CCBHC Criteria



(Tables of Evidence) the person’s service needs. For organizations serving children, the assessments should take into account systems involvement including education, child welfare and juvenile justice. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for conducting assessments. Organizations serving children in the child welfare system should also be aware of any assessment timeframe requirements applicable to that population. Note: See ICHH 3.03 for more information on keeping the assessment up-to-date as part of the case review process. MHSU 3.04 Each service recipient receives an individualized, comprehensive assessment, which includes a summary of symptoms and diagnoses based on a standardized diagnostic tool. Interpretation: The standardized diagnostic tool should be used to match the needs of the service recipient with the appropriate level care. Assessment tools will vary depending on the age and developmental level of the service population. Examples of standardized instruments or protocols include: the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), the Addiction Severity Index, Treatment Services Review,







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CCBHC Criteria



(Tables of Evidence) the American Society of Addiction Medicine (ASAM) patient placement criteria, the Institute of Medicine (IOM), the Child and Adolescents Needs and Strengths (CANS), criteria required by federal or state oversight authorities, and criteria required for participation in managed care delivery systems. Interpretation: Assessments are completed within timeframes established by the organization. Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes.

4.d.8

The CCBHC uses culturally and linguistically appropriate screening tools, and tools/approaches that accommodate disabilities (e.g., hearing disability, cognitive limitations), when appropriate.

CR 4: The Rights of Persons with Developmental Disabilities Children, youth, and adults with developmental disabilities receive services that help them achieve full integration and inclusion in the mainstream, make choices, exert control over their lives, and fully participate in, and contribute to, their communities. Interpretation: Throughout CR 4 the term "person" is defined to include children, youth, and adults with developmental disabilities. In instances where the person cannot make his or her own decisions, sign documents, or is otherwise limited in his/her ability to provide informed consent, the term, "person" may be understood to also include an advocate or legal guardian, as in "...the person, his/her advocate, or legal guardian..." CR 4.03 The organization works in partnership with the person, and his or her team according to the wishes of the person, to develop and implement a service plan that enables the fullest and most independent life possible in the community and promotes self-


Include service philosophy in the Narrative of each applicable service section (CR 4.01, CR 4.02, and CR 4.07)

Procedures for use of interventions that limit movement, diminish sensory experience, limit personal freedom, or cause personal discomfort

Include service planning procedures with the service planning and monitoring evidence of each applicable service section (CR 4.03, CR 4.04, and CR 4.05)

Procedures for helping persons access assistive technology

Procedures for providing or making referrals for family support services

Training curricula, educational material and/or other material provided to persons served regarding sexuality and relationships



CCBHC Criteria



(Tables of Evidence) determination. Interpretation: Persons with limited ability to make independent decisions receive help from the team in making choices and/or assuming responsibility for making decisions. "Team" is defined to include the person’s family, friends and other natural supports, circle of support, support/service broker, service coordinator, or others chosen by the person. It is essential that members of the person’s team are, to the extent possible, chosen by and the preference of the person. Interpretation: Service planning for persons with developmental disabilities can address, as appropriate to the person:

a. health and safety issues; b. degree of supervision needed; c. independent living, social, and daily living

skills; d. nutritional and dietary needs; e. leisure and vocational interests, aptitudes,

and need for greater social inclusion; f. screening and treatment for co-occurring

psychiatric disorders or substance use conditions;

g. the need for assistive technology, auxiliary aids, and other special accommodations;

h. positive behavior support planning; i. medication needs; j. issues related to adaptive, behavior, and

cognitive functioning, including concrete and abstract reasoning;

k. specialized supports such as physical, speech, and occupational therapy;

l. ancillary services;


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Assessment tool













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CCBHC Criteria



(Tables of Evidence) m. end of life planning; and n. the need for hospice or palliative care.

ICHH 2.04 Assessments are conducted in a culturally responsive manner to identify resources that can increase service participation, support the achievement of agreed upon goals, and promote recovery and resilience. Interpretation: Culturally responsive assessments can include attention to geographic location, language of choice, and the person’s religious, racial, ethnic, and cultural background. Other important factors that contribute to a responsive assessment include attention to age, gender identity, sexual orientation, immigration status, and developmental level. MHSU 3: Assessment Service recipients participate in a comprehensive, individualized, trauma-informed, strengths-based, family-focused, culturally and linguistically responsive assessment to determine an appropriate level of service. Interpretation: For an assessment to be trauma-informed, the organization understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the service recipient rather than personal deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the organization actively prevents instances that could potentially re-traumatize service recipients.


CCBHC Criteria




4.d.9

If screening identifies unsafe substance use including problematic alcohol or other substance use, the CCBHC conducts a brief intervention and the consumer is provided or referred for a full assessment and treatment, if applicable.





and/or crisis plan; and contacting emergency responders as appropriate.

ICHH 2.06 The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments. MHSU 2.02 Prompt, responsive intake practices:






desired. Interpretation: Screening and intake procedures



Assessment tool










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CCBHC Criteria



(Tables of Evidence) should direct staff on how to identify and respond to individuals or families experiencing emergency situations to ensure that they receive expedited treatment planning and are connected to more intensive services. Organizations should have the capacity to refer individuals in crisis to the appropriate services, which may include 24-hour mobile crisis teams, emergency crisis intervention services, or crisis stabilization. Urgent situations can also include those in which an individual has a child in the child welfare system. Interpretation: Wait times are a major barrier to individuals and families receiving services. Organizations can monitor waitlists and standardize their referral process to improve accessibility.


Criteria 4.E: Person-Centered and Family-Centered Treatment Planning

4.e.1

The CCBHC directly provides person-centered and family-centered treatment planning or similar processes, including but not limited to risk assessment and crisis planning. Person-centered and family-centered treatment planning satisfies the requirements of criteria 4.e.2 – 4.e.8 below and is aligned with the requirements of Section 2402(a) of the Affordable Care Act, including consumer involvement and self-direction. Note: See program requirement 3 related to coordination of care and treatment planning.





and/or crisis plan; and e. ontacting emergency responders as

appropriate.



Assessment tool





Interview:


CCBHC Criteria



(Tables of Evidence) ICHH 3: Care Planning and Monitoring The person and his or her family participate in the development and ongoing monitoring of a care plan that is the basis for delivery of needed services. MHSU 4: Service Planning and Monitoring Service recipients and their families participate in the development and ongoing review of an individualized, person- or family-centered service plan that is the basis for delivery of appropriate services and support. Interpretation: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law. Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child and can include the child’s birth, foster, adoptive, or kinship caregivers as appropriate. MHSU 4.01 An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient, and expedited service planning is available when crisis or urgent need is identified. Interpretation: Service planning is conducted so that

a. Program director b. Relevant personnel c. Persons served




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CCBHC Criteria



(Tables of Evidence) the individual retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for completing service plans. MHSU 4.05 The organization engages service recipients and involved family members in crisis planning, as needed. Interpretation: While each individual service recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary. The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. Depending on the needs of the individual, crisis plans may reference an advanced mental health directive,


CCBHC Criteria



(Tables of Evidence) also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care.

4.e.2

An individualized plan integrating prevention, medical and behavioral health needs and service delivery is developed by the CCBHC in collaboration with and endorsed by the consumer, the adult consumer’s family to the extent the consumer so wishes, or family/caregivers of youth and children, and is coordinated with staff or programs necessary to carry out the plan. Note: States may wish to access additional resources related to person-centered treatment planning found in the CMS Medicaid Home and Community Based Services regulations at 42 C.F.R. Part 441, Subpart M, or in the CMS Medicare Conditions of Participation for Community Mental Health Centers regulations at 42 C.F.R. Part 485.



and his or her family. Interpretation: Care planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and gradually assume more responsibility for making decisions independently. When the person receiving services is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring the involvement or consent of the person’s legal guardian. Interpretation: Generally, care plans should be developed following completion of all necessary assessments and reviewed with the person at their next visit. Note: The organization should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required









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CCBHC Criteria



(Tables of Evidence) timeframes for completing care plans. ICHH 3.02 The care plan is based on the assessment and includes:







g. documentation of the individual’s or family’s involvement in care planning

Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. MHSU 4.01 An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient, and expedited service planning is available when crisis or urgent need is identified. Interpretation: Service planning is conducted so that the individual retains as much personal responsibility


CCBHC Criteria



(Tables of Evidence) and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians. Note: Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for completing service plans. MHSU 4.02 The service plan is based on the assessment, and includes:




Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being.


Criteria 4.E: Person-Centered and Family-Centered Treatment Planning (Continued)


CCBHC Criteria




4.e.3

The CCBHC uses consumer assessments to inform the treatment plan and services provided.









Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. Note: Regarding element g, the organization should review state regulations governing the documentation of the individual’s or family’s involvement to ensure documentation meets all applicable requirements. MHSU 4.02 The service plan is based on the assessment, and includes:









Interview: d. Clinical or program director e. Relevant personnel f. Individuals or families served

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CCBHC Criteria



(Tables of Evidence) b. services and supports to be provided, and by

whom; and c. the service recipient or legal guardian’s

signature. Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being. Note: For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and wishes of the client. Research has shown that this population is often unsure of the services to which they are entitled and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible.

4.e.4

Treatment planning includes needs, strengths, abilities, preferences, and goals, expressed in a manner capturing the consumer’s words or ideas and, when appropriate, those of the consumer’s family/caregiver.







f. agreed upon timelines for conducting







CCBHC Criteria



(Tables of Evidence) regular case reviews; and


Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. Note: Regarding element g, the organization should review state regulations governing the documentation of the individual’s or family’s involvement to ensure documentation meets all applicable requirements. MHSU 4.01 An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient, and expedited service planning is available when crisis or urgent need is identified. Interpretation: Service planning is conducted so that the individual retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians. MHSU 4.02 The service plan is based on the assessment, and



Interview: g. Clinical or program director h. Relevant personnel i. Individuals or families served

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Networks a. Managing entity screening,



Network Interview: d. Provider personnel e. Provider supervisors f. Provider program directors


CCBHC Criteria



(Tables of Evidence) includes:




Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being. Note: For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and wishes of the client. Research has shown that this population is often unsure of the services to which they are entitled and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible. RPM 7.06 Service recipients may add a statement to their case records, and:

a. any response by personnel is added with the service recipient’s knowledge; and

b. the service recipient is given the opportunity to review and comment on such additions.


CCBHC Criteria




4.e.5

The treatment plan is comprehensive, addressing all services required, with provision for monitoring of progress towards goals. The treatment plan is built upon a shared decision-making approach.









Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. Note: Regarding element g, the organization should review state regulations governing the documentation of the individual’s or family’s involvement to ensure documentation meets all applicable requirements. ICHH 3.03 The care coordinator and the care planning team actively review the case according to established timelines to assess:

COA meets the intent of the CCHBC standard. Table of Evidence for ICHH 3








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CCBHC Criteria



(Tables of Evidence) a. continued accuracy of the assessment; b. care plan implementation; c. c. the person’s continued engagement in his

or her treatment; d. the person’s progress toward achieving

goals and desired outcomes; and e. the continuing appropriateness of agreed

upon service goals. Interpretation: Timeframes for the review should be defined by the person and the care coordinator and take into consideration the issues and needs of the person and the frequency and intensity of services provided. Traumatic events or other significant life changes such as changes in housing, disclosure of abuse, hospitalization, or contact with the criminal justice system should trigger an immediate review of the case. ICHH 3.04 The care coordinator and the individual or family regularly review progress toward achievement of agreed upon goals and make revisions to service goals and plans as needed. Interpretation: The individual’s or family’s involvement in updating the plan should be documented. MHSU 4.02 The service plan is based on the assessment, and includes:



c. the service recipient or legal guardian’s


CCBHC Criteria



(Tables of Evidence) signature.

Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being. Note: For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and wishes of the client. Research has shown that this population is often unsure of the services to which they are entitled and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible. MHSU 4.04 The service plan addresses, as appropriate:

a. unmet service and support needs; b. possibilities for maintaining and

strengthening family relationships; and c. the need for support of the service

recipient’s informal social network.

Note: While the involvement of family and significant others can support the development of an effective, individualized service plan, Medicaid requires that all goals, services and interventions be for the exclusive benefit of the client. MHSU 4.06 The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, at minimum, to assess:


CCBHC Criteria



(Tables of Evidence) a. service plan implementation; b. progress toward achieving service goals and


agreed upon service goals. Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard. Interpretation: Timeframes for review should be adjusted depending upon the issues and needs of persons receiving services and the frequency and intensity of the services being provided. Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for service recipients with substance use disorders at high risk for relapse. Individuals with acute or complex needs (e.g., service recipients receiving medications for diagnosed symptoms and conditions) may require that their service plan be reviewed and updated every 30 days. MHSU 4.07 The worker and service recipient or legal guardian regularly review progress toward achievement of agreed upon goals and document revisions to service goals and plans. Interpretation: In regards to documentation, any revisions to the service plan or service goals should be signed by a member of the treatment team and the service recipient, or a legal guardian when the service recipient is a minor, or otherwise documented in a manner that is consistent with the


CCBHC Criteria



(Tables of Evidence) organizations service planning and monitoring procedures. MHSU 4.08 Family members and significant others, as appropriate, and with the consent of the service recipient, are advised of ongoing progress and invited to participate in case conferences. Interpretation: The organization facilitates the participation of family and significant others by, for example, helping arrange transportation, and including them in scheduling decisions.


Criteria 4.E: Person-Centered and Family-Centered Treatment Planning (Continued)

4.e.6

Where appropriate, consultation is sought during treatment planning about special emphasis problems, including for treatment planning purposes (e.g., trauma, eating disorders).

ICHH 2.06 The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments. ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. Interpretation: This includes coordination of any services provided directly by the organization as well as those provided through linkages to community providers.

COA meets the intent of the CCBHC standard. COA expects the approach to treatment planning to align directly with the assessment process and address special emphasis problems either directly or via consultation. Table of Evidence for ICHH 2


Assessment tool







CCBHC Criteria



(Tables of Evidence) ICHH 4.02 The care planning team includes at a minimum:
















Review case records Table of Evidence MHSU 3







CCBHC Criteria



(Tables of Evidence) on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual. ICHH 4.05 The organization facilitates access to the full array of community and social support, behavioral health care, and physical health care services by:


b. maintaining a comprehensive, up-to-date referral list; removing barriers to the initiation of needed services including procedures for providing a warm hand off when needed services are provided directly by the program or on-site through a partnering provider; and

c. assisting the person with system navigation. Interpretation: Examples of community and social support services and behavioral and physical health care services that should be made available to persons served include:





MHSU 3.05 The comprehensive assessment includes:

c. Individuals or families served Review case records


CCBHC Criteria



(Tables of Evidence) a.the service recipient’s behavioral health, physical health, and community and social support service needs and goals; b.trauma history and recent incidents of trauma; c.individual and family strengths, risks, and protective factors; and d.natural supports and helping networks. Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks. Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history. Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health


CCBHC Criteria



(Tables of Evidence) professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 3.06 The organization engages service recipients in a risk assessment to assess their risk of suicide, self-injury, neglect, exploitation, and violence towards others. Interpretation: Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents. MHSU 3.07 Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:


health services;


CCBHC Criteria



(Tables of Evidence) c. medical detoxification; d. laboratory testing and toxicology screens; or e. other diagnostic procedures.

Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The organization is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring. Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff, or available through a contract or formal arrangement. All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional. Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the organization for counseling or prevention. In such cases, the organization is not responsible for addressing the medical aspects of treatment, but must coordinate services with the physician.


CCBHC Criteria




4.e.7

The treatment plan documents the consumer’s advance wishes related to treatment and crisis management and, if the consumer does not wish to share their preferences, that decision is documented.









Interpretation: The care plan should address any unmet basic needs, such as housing, as these needs can limit engagement and successful achievement of service goals. Note: Regarding element g, the organization should review state regulations governing the documentation of the individual’s or family’s involvement to ensure documentation meets all applicable requirements. MHSU 4.07 The worker and service recipient or legal guardian regularly review progress toward achievement of agreed upon goals and document revisions to service goals and plans.









Review case records




Review case records


Networks


CCBHC Criteria



(Tables of Evidence) Interpretation: In regards to documentation, any revisions to the service plan or service goals should be signed by a member of the treatment team and the service recipient, or a legal guardian when the service recipient is a minor, or otherwise documented in a manner that is consistent with the organizations service planning and monitoring procedures. RPM 7: Case Records Case records contain sufficient, accurate information to:

a. identify the consumer; b. support decisions about interventions or

services; and c. document the delivery of services.

Interpretation: In addition to supporting the delivery of services, case records are an important risk management tool. Well-maintained records can help shield the organization from allegations of misconduct and negligence, while poorly-maintained records and improper documentation are a known liability. Independent contractors who provide direct services to organization clients, maintain records for those clients in accord with RPM 7. RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including:

a. demographic and contact information; b. the reason for requesting or being referred

a. Managing entity screening, assessment, and authorization staff, if these services are provided


Network Interview: g. Provider personnel h. Provider supervisors i. Provider program directors


CCBHC Criteria



(Tables of Evidence) for services;

c. up-to-date assessments; d. the service plan, including mutually

developed goals and objectives; e. copies of all signed consent forms; f. a description of services provided directly or

by referral; g. routine documentation of ongoing services; h. documentation of routine supervisory

review; i. discharge or aftercare plan; j. recommendations for ongoing and/or future


k. a closing summary entered within 30 days of termination of service.

Interpretation: RPM 7.02 describes the basic elements to be included in individual case records. COA recognizes that in some cases not all listed information is obtainable for a person or family. In these cases, an explanation should be placed in the case record. The listed information may not be routinely available due to the nature of the service, e.g., a low demand shelter or drop-in center. Interpretation: Case records and signatures can be paper, electronic, or a combination of paper and electronic. When using electronic signatures, organizations should take appropriate measures to verify the individual’s identity and ensure that each electronic signature is unique to the individual. Electronic signatures (by both personnel and service recipients) can include, for example, a digitalized signature via tablet or two identifying components such as a user identification code (ID) and


CCBHC Criteria



(Tables of Evidence) password/personal identification number (PIN). Procedures or protocols for electronic signatures should be included in the organization’s record content and maintenance procedures. Interpretation: To most effectively collect information on trends and outcomes, consistent terminology and structured data should be used within the electronic records system. Interpretation: In EAPs case records contain appropriate information to demonstrate the status of the case and whether it is open or closed.

4.e.8

Consistent with the criteria in 4.e.1 through 4.e.7, states should specify other aspects of consumer, person-centered and family-centered treatment planning they will require based upon the needs of the population served. Treatment planning components that states might consider include: prevention; community inclusion and support (housing, employment, social supports); involvement of family/caregiver and other supports; recovery planning; safety planning; and the need for specific services required by the statute (i.e., care coordination, physical health services, peer and family support services, targeted case management, psychiatric rehabilitation services, accommodations to ensure cultural and linguistically competent services).





needs on the family unit. Interpretation: Basic needs such as food, clothing, and shelter should be considered when identifying the person’s service needs. For organizations serving children, the assessments should take into account systems involvement including education, child welfare and juvenile justice. Note: Organizations should review state Medicaid plans or other third party reimbursement

COA meets the intent of the CCBHC standard. COA requires that treatment planning be aligned with assessments and that organizations/agencies are compliant with state laws and regulations with regard to the parameters around service provision. Table of Evidence for ICHH 2


Assessment tool






Review case records


CCBHC Criteria



(Tables of Evidence) requirements to ensure they are meeting required timeframes for conducting assessments. Organizations serving children in the child welfare system should also be aware of any assessment timeframe requirements applicable to that population. Note: See ICHH 3.03 for more information on keeping the assessment up-to-date as part of the case review process. ICHH 2.05 Assessment procedures include mechanisms to identify and respond to individuals or families in crisis including:





appropriate. MHSU 3.02 Assessments are conducted in a culturally and linguistically responsive manner, and:

a. identify resources that can increase service participation and achievement of agreed-upon goals; and

b. address issues of special relevance to various groups, such as women, older adults, young children, or adolescents, as applicable.

Interpretation: Culturally responsive assessments







Review case records






Review case records



Copies of agreements with cooperating service providers and/ or an up-to-date referral list of identified community-


CCBHC Criteria



(Tables of Evidence) can include attention to geographic location, language of choice, the person’s religious, racial, ethnic, and cultural background, and military status. Other important factors that contribute to a responsive assessment include attention to age, sexual orientation, gender identity, developmental level and level of literacy attainment. Interpretation: For organizations serving children, assessments should take into account systems involvement including education, child welfare and juvenile justice. MHSU 3.05 The comprehensive assessment includes:




d. natural supports and helping networks. Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks. Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-

based providers, as applicable












CCBHC Criteria



(Tables of Evidence) being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history. Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms. MHSU 4.05 The organization engages service recipients and involved family members in crisis planning, as needed. Interpretation: While each individual service recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary.


Review case records









CCBHC Criteria



(Tables of Evidence) The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. Depending on the needs of the individual, crisis plans may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care. MHSU 6.01 Services are delivered in a holistic, trauma-informed, and culturally and linguistically responsive manner, and focus on the treatment of mental health and/or substance use disorders. MHSU 6.02 Therapeutic and educational interventions may include individual, family, or group service modalities that are:

a. based on research or clinical practice guidelines where they exist; and

b. matched with the assessed needs, age, developmental level, and personal goals of the service recipient.

MHSU 6.03 Service recipients receive goal-directed, psychosocial


CCBHC Criteria



(Tables of Evidence) treatments, including:

a. psychotherapy; b. illness management and psychoeducation

interventions; c. medication education; d. coping skills training; e. relapse prevention; and f. support groups and self-help referrals.

MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services. MHSU 9.04 In collaboration with the service recipient, the organization coordinates with, as needed:



a. work-related services and job placement; b. supported housing; c. transportation; d. social skills training;


CCBHC Criteria



(Tables of Evidence) e. public benefits; f. educational services; and g. respite care.

Note: Service members and veterans should be linked to any services or benefits for which they may be eligible, including Veterans Affairs health services. RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations.


Criteria 4.F: Outpatient Mental Health and Substance Use Services

4.f.1

CCBHC also provides or makes available through formal arrangement traditional practices/treatment as appropriate for the consumers served in the CCBHC area. Note: See also program requirement 3 regarding coordination of services and treatment planning.

MHSU 6.02 Therapeutic and educational interventions may include individual, family, or group service modalities that are:







Review case records


CCBHC Criteria




4.f.2

Based upon the findings of the needs assessment as required in program requirement 1, states must establish a minimum set of evidence-based practices required of the CCBHCs. Among those evidence-based practices states might consider are the following: Motivational Interviewing; Cognitive Behavioral individual, group and on-line Therapies (CBT); Dialectical Behavior 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 (e.g., buprenorphine, methadone, naltrexone (injectable and oral), acamprosate, disulfiram, naloxone), prescription long-acting injectable medications for both mental and substance use disorders, and smoking cessation medications); community wrap-around services for youth and children; and specialty clinical interventions to treat mental and substance use disorders experienced by youth (including youth in therapeutic foster care). This list is not intended to be all-inclusive and the states are free to determine whether these or other evidence-based treatments may be appropriate as a condition of certification.









services; and long-term care supports and services. MHSU 6.02 Therapeutic and educational interventions may include individual, family, or group service modalities that are:











Review case records





Review case records


CCBHC Criteria



(Tables of Evidence) b. matched with the assessed needs, age,

developmental level, and personal goals of the service recipient.

MHSU 6.03 Service recipients receive goal-directed, psychosocial treatments, including:



MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services.


Criteria 4.F: Outpatient Mental Health and Substance Use Services (Continued)


CCBHC Criteria




4.f.3

Treatments are provided that are appropriate for the consumer’s phase of life and development, specifically considering what is appropriate for children, adolescents, transition age youth, and older adults, as distinct groups for whom life stage and functioning may affect treatment. Specifically, when treating children and adolescents, CCHBCs provide evidenced-based services that are developmentally appropriate, youth guided, and family/caregiver driven with respect to children and adolescents. When treating older adults, the individual consumer’s desires and functioning are considered and appropriate evidence-based treatments are provided. When treating individuals with developmental or other cognitive disabilities, level of functioning is considered and appropriate evidence-based treatments are provided. These treatments are delivered by staff with specific training in treating the segment of the population being served.




MHSU 13.03 Clinical personnel and personnel who conduct assessments are competent, qualified by education, training, supervised experience, licensure or the equivalent, and able to recognize individuals and families with special needs. Interpretation: Clinical personnel qualifications will vary depending on the services provided and program design. Clinical personnel may also include individuals who are license-eligible and supervised by experienced, licensed staff. MHSU 13.05 Clinical personnel demonstrate competency in:




d. working with difficult to reach, traumatized, or disengaged individuals and families;


f. recognizing and working with individuals





Review case records



List of program personnel that includes: g. name; h. title; i. degree held and/or other

credentials; j. FTE or volunteer; k. length of service at the

organization; l. time in current position




Job descriptions

Training curricula



CCBHC Criteria



(Tables of Evidence) with co-occurring physical health, mental health, and substance use conditions; and


Interpretation: When the organization serves military or veteran populations, it is essential that staff have the competencies needed to effectively support and assist service members, veterans, and their families, including sufficient knowledge regarding: military culture, values, policies, structure, terminology, unique barriers to service, traumas and signature injuries, co-occurring conditions, effective and evidence-based interventions, applicable regulations, benefits, and other relevant issues. When providers possess the requisite military competency, they are capable of supporting improved communication and more effective care. Signature injuries and co-occurring conditions include post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance abuse, and intimate partner violence. Personnel serving military and veteran populations should have the competencies to identify, assess, and develop a treatment plan for these injuries and conditions. Interpretation: In addition to having the knowledge and skills to identify co-occurring mental health and substance use disorders, clinical personnel should also be able to recognize physical health issues commonly associated with mental health or substance use disorders.

Interview: d. Supervisors e. Relevant personnel f. Review case records


Criteria 4.F: Outpatient Mental Health and Substance Use Services (Continued)


CCBHC Criteria




4.f.4

Children and adolescents are treated using a family/caregiver-driven, youth guided and developmentally appropriate approach that comprehensively addresses family/caregiver, school, medical, mental health, substance abuse, psychosocial, and environmental issues.









Note: Service members and veterans should be linked to any services or benefits for which they may be eligible, including Veterans Affairs health services.










Review case records


CCBHC Criteria





Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring

4.g.1

The CCBHC is responsible for outpatient clinic primary care screening and monitoring of key health indicators and health risk. Whether directly provided by the CCBHC or through a DCO, the CCBHC is responsible for ensuring these services are received in a timely fashion. Required primary care screening and monitoring of key health indicators and health risk provided by the CCBHC include those for which the CCBHC will be accountable pursuant to program requirement 5 and Appendix A of these criteria. The CCBHC should not take non-inclusion of a specific metric in Appendix A as a reason not to provide clinically indicated primary care screening and monitoring and the state may elect to require specific other screening and monitoring to be provided by the CCBHCs. The CCBHC ensures children receive age appropriate screening and preventive interventions including, where appropriate, assessment of learning disabilities, and older adults receive age appropriate screening and preventive interventions. Prevention is a key component





needs on the family unit. Interpretation: Basic needs such as food, clothing, and shelter should be considered when identifying the person’s service needs. For organizations serving children, the assessments should take into account systems involvement including education, child welfare and juvenile justice. ICHH 2.04 Assessments are conducted in a culturally responsive manner to identify resources that can increase service participation, support the achievement of



Assessment tool












CCBHC Criteria



(Tables of Evidence) of primary care services provided by the CCBHC. Nothing in these criteria prevent a CCBHC from providing other primary care services. Note: See also program requirement 3 regarding coordination of services and treatment planning.

agreed upon goals, and promote recovery and resilience. Interpretation: Culturally responsive assessments can include attention to geographic location, language of choice, and the person’s religious, racial, ethnic, and cultural background. Other important factors that contribute to a responsive assessment include attention to age, gender identity, sexual orientation, immigration status, and developmental level. ICHH 2.06 The organization promptly provides or makes arrangements for specialized screenings, assessments, or tests as needed based on information collected during initial and ongoing assessments. ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. Interpretation: This includes coordination of any services provided directly by the organization as well as those provided through linkages to community providers. MHSU 2.01 Service recipients are screened at intake and informed about:














professional


CCBHC Criteria



(Tables of Evidence) b. what services will be available and when;

and c. rules and expectations of the program.

Interpretation: Screenings will vary based on the program’s target population and services offered, and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, and/or risk of harm to self or others. Interpretation: For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program. MHSU 7.01 A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating persons with mental health and/or substance use disorders is responsible for the medical aspects of treatment. Interpretation: Medical aspects can include:




c. Relevant personnel d. Individuals or families served

Review case records


Table of Evidence for PCS 3

Description of clinical care services

Screening, assessment, and examination procedures

Clinical decision support tools

Interview: a. Program director b. Primary care providers c. Persons and families served

Review case records


CCBHC Criteria



(Tables of Evidence) d. seizure disorders; e. psychosomatic disorders; and f. other medical and psychiatric related issues


The organization ensures that medication management includes appropriate monitoring and administration of pharmacotherapy for individuals with co-occurring health, mental health, and substance use conditions. Interpretation: The qualifications and training of the physician should be appropriate to the program. For example, organizations that provide mental health services should have a board-eligible psychiatrist who is responsible for the medical aspects of treatment or a qualified health professional with the appropriate training, licensure, and/or credentials. Examples of qualified health professionals include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision. Interpretation: It is permissible under the standard to use a consulting psychiatrist or a community mental health center for psychiatric consultation, provided that the organization has a formal agreement or contract. PCS 3.02 Individuals are screened in accordance with clinical


CCBHC Criteria



(Tables of Evidence) decisions support tools and, when indicated, the organization:

a. obtains a medical history and conducts a physical screening to identify immediate needs;

b. assesses the individual for chronic physical health conditions associated with the population served; and

c. conducts a physical examination, as soon as feasible based on individual needs and preferences, but no less than annually.

Interpretation: The primary care service should determine the chronic physical health conditions associated with the population(s) served. Based on this information, or other evidence bases such as local health department data, the organization identifies the conditions for which all individuals will be routinely screened and, if indicated, assessed. Providers are not limited to these routine screening and assessment tools.


Criteria 4.H: Targeted Case Management Services

4.h.1

The CCBHC is responsible for high quality targeted case management services that will assist individuals in sustaining recovery, and gaining access to needed medical, social, legal, educational, and other services and supports. Targeted case management should include supports for persons deemed at high risk of suicide, particularly during times of transitions such as from an ED or psychiatric hospitalization. Based upon the needs of the population served, states should specify the

ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. Interpretation: This includes coordination of any services provided directly by the organization as well as those provided through linkages to community providers

COA meets the intent of the CCBHC standard. The standards listed in response to the CCBHC standard reflect targeted case management practices. Case management principles are embedded in each of COA’s service standard sections. Table of Evidence ICHH 2


Assessment tool


CCBHC Criteria



(Tables of Evidence) scope of other targeted case management services that will be required, and the specific populations for which they are intended.











a. coordinating information sharing and service






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CCBHC Criteria



(Tables of Evidence) provision with providers and the person;



Interpretation: Supported transitions can include, but are not limited to, transitioning from inpatient hospitalization, residential treatment, therapeutic group care, the juvenile justice system, foster care, and from pediatric to adult settings. MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical care, psychiatric rehabilitation and targeted case management services. MHSU 9: Care Coordination The organization coordinates services in order to promote continuity of care and whole-person wellness. Interpretation: The standards in MHSU 9 address the efforts an organization makes to promote information sharing and collaboration with the various systems touching a particular individual. Organizations are not required to provide integrated care to implement the standards in this section. Organizations that offer integrated behavioral health












CCBHC Criteria



(Tables of Evidence) and primary care services (e.g., health homes) will complete the Integrated Care; Health Home (ICHH) standards. Organizations directly providing primary care services will also complete the Primary Care Services (PCS) standards in addition to the Integrated Care; Health Home (ICHH) standards. MHSU 9.03 The organization supports the coordination of behavioral and physical health care to increase service recipients’ access to needed services. Interpretation: To meet the standard, organizations must demonstrate that they are working towards linking behavioral health and primary care services. Examples include: providing referrals to identified primary care providers, communicating with service recipients’ primary care doctor about treatment planning, and linking individuals to navigators to help service recipients navigate the health care system. MHSU 10.01 The organization provides, either directly or by referral, necessary support services which may include, as appropriate:

a. work-related services and job placement;. b. supported housing; c. transportation; d. social skills training; e. public benefits; f. educational services; and g. respite care.



Review case records


CCBHC Criteria



(Tables of Evidence) Note: Service members and veterans should be linked to any services or benefits for which they may be eligible, including Veterans Affairs health services


Criteria 4.I: Psychiatric Rehabilitation Services

4.i.1

The CCBHC is responsible for evidence-based and other psychiatric rehabilitation services. States should specify which evidence-based and other psychiatric rehabilitation services they will require based upon the needs of the population served. Psychiatric rehabilitation services that might be considered include: medication education; self-management; training in personal care skills; individual and family/caregiver psycho-education; community integration services; recovery support services including Illness Management & Recovery; financial management; and dietary and wellness education. States also may wish to require the provision of supported services such as housing, employment, and education, the latter in collaboration with local school systems. Note: See program requirement 3 regarding coordination of services and treatment

ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. ICHH 4.01 All individuals and their families receive:



ICHH 4.02 The care planning team includes at a minimum:


physician’s assistant or nurse practitioner with access to a physician for needed











CCBHC Criteria



(Tables of Evidence) planning.

consultation; c. a behavioral health professional such as a

social worker, psychologist, or other licensed clinician with access to a psychiatrist for needed consultation; and


Interpretation: The qualifications of the designated care coordinator will vary given the needs of the identified service population. For adults with serious and persistent mental health conditions, for example, a medical professional such as a nurse practitioner may be preferred given the high prevalence of comorbid, chronic, physical health conditions present in this population. For children, however, where chronic medical conditions are far less common, the coordination of behavioral health care and linkages to community and social support services might best be carried out by a behavioral health practitioner with experience working with children and families. Interpretation: Organizations should leverage alternative service delivery methods such as telehealth and telemental health when regional shortages of certain professional groups, such as psychiatrists, make in-person consultation impractical. Interpretation: Supports that might also be included on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual. MHSU 6.02 Therapeutic and educational interventions may

Review case records










Review case records


CCBHC Criteria



(Tables of Evidence) include individual, family, or group service modalities that are:


b. matched with the assessed needs, age, developmental level, and personal goals of the service recipient






Note: Service members and veterans should be linked to any services or benefits for which they may be eligible, including Veterans Affairs health services.


CCBHC Criteria





Criteria 4.J: Peer Supports, Peer Counseling and Family/Caregiver Supports

4.j.1

The CCBHC is responsible for peer specialist and recovery coaches, peer counseling, and family/caregiver supports. States should specify the scope of peer and family services they will require based upon the needs of the population served. Peer services that might be considered include: peer‐run drop‐in centers, peer crisis support services, peer bridge services to assist individuals transitioning between residential or inpatient settings to the community, peer trauma support, peer support for older adults or youth, and other peer recovery services. Potential family/caregiver support services that might be considered include: family/caregiver psycho-education, parent training, and family-to-family/caregiver support services. Note: See program requirement 3 regarding coordination of services and treatment planning.

ICHH 4.10 Persons served and their families are connected with peer support services appropriate to their request or need for service. MHSU 6.04 Service recipients and their families are connected with peer support services appropriate to their request or need for service. Interpretation: Peer support refers to services provided by individuals who have shared, lived experience. Services promote resiliency and recovery and can include peer recovery groups, peer-to-peer counseling, peer mentoring or coaching, family and youth peer support or other consumer-run services. Interpretation: Organizations may provide peer support services directly or have a referral system in place to ensure that service recipients have access to peer support services when needed. Peer support workers may also be part of the treatment team. MHSU 10.02 The organization works with the service recipient to










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CCBHC Criteria




identify natural supports and social networks to cultivate and sustain a supportive community. Interpretation: As appropriate, the organization should provide, refer, or direct service recipients to opportunities where they can participate in group activities to meet, support, and share experiences with peers. Opportunities can include: social, recreational, education, or vocational activities; religious or spiritual gatherings; or neighborhood and community events.









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Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the Armed Forces and Veterans


CCBHC Criteria




4.k.1

The CCBHC is responsible for intensive, community-based behavioral health care for certain members of the U.S. Armed Forces and veterans, particularly those Armed Forces members located 50 miles or more (or one hour’s drive time) from a Military Treatment Facility (MTF) and veterans living 40 miles or more (driving distance) from a VA medical facility, or as otherwise required by federal law. Care provided to veterans is required to be consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration (VHA), including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration. The provisions of these criteria in general and, specifically, in criteria 4.K, are designed to assist CCBHCs in providing quality clinical behavioral health services consistent with the Uniform Mental Health Services Handbook. Note: See program requirement 3 regarding coordination of services and treatment planning.





Interpretation: Fair and equitable treatment includes the provision of effective, equitable, understandable, and respectful services that are responsive to: diverse cultural beliefs and practices, including the freedom to express and practice religious and spiritual beliefs; preferred languages; and other communication needs. Organizations’ policies, procedures, and practices should recognize, respect, and respond to the unique, culturally-defined needs of persons and families being served. For example, program information, signs, posters, and other printed material, as well as electronic and multimedia communications and training are available and presented:

a. in the language(s) of the major population groups served; and

b. in a manner that is non-discriminatory and non-stigmatizing.

MHSU 1.01 The program is guided by a philosophy that provides a logical basis for services and support to be

COA meets the intent of the CCBHC standard. In sections that do not specify that services are specifically provided to Veterans or members of the armed forces, COA calls for services to be tailored to the demographic in question which is inclusive of this population. Table of Evidence for ASE 3

Relevant licenses

Documentation of compliance with regulations and codes

Interview: a. Program director b. Facility management

Table of Evidence for CR 1




Interview: c. Relevant personnel d. Individuals or families served e. Review case records



Service philosophy



Documentation of training and/or certification related to therapeutic


CCBHC Criteria



(Tables of Evidence) delivered in a trauma-informed and culturally and linguistically responsive manner, based on program goals and the best available evidence of service effectiveness. Interpretation: Services and support should be tailored to meet the individualized needs and goals of service recipients. MHSU 5.04 If a service recipient is a victim of violence, abuse, neglect, or other known trauma, the organization provides:

a. a protection or safety plan, as needed; b. more intensive services; c. trauma-informed care; d. more frequent monitoring of progress

toward service goals; and e. a referral.

Interpretation: Service members and veterans who are trauma survivors may need services uniquely tailored to their needs. Service members and veterans often experience a complex nexus of post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance abuse, and intimate partner violence. MHSU 6.02 Therapeutic and educational interventions may include individual, family, or group service modalities that are:


b. matched with the assessed needs, age,

interventions

Interview: f. Clinical or program director g. Relevant personnel h. Individuals or families served

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A description of clinical counseling services

Procedures for evaluating level and intensity of care (MHSU 5.05)


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CCBHC Criteria



(Tables of Evidence) developmental level, and personal goals of the service recipient.


Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the Armed Forces and Veterans (Continued)

4.k.2

All individuals inquiring about services are asked whether they have ever served in the U.S. military. Current Military Personnel: Persons affirming current military service will be offered assistance in the following manner: (1) Active Duty Service Members (ADSM) must use their servicing MTF, and their MTF Primary Care Managers (PCMs) are contacted by the CCBHC regarding referrals outside the MTF. (2) ADSMs and activated Reserve Component (Guard/Reserve) members who reside more than 50 miles (or one hour’s drive time) from a military hospital or military clinic enroll in TRICARE PRIME Remote and use the network PCM, or select any other authorized TRICARE provider as the PCM. The PCM refers the member to specialists for care he or she cannot provide; and works with the regional managed care support contractor for referrals/authorizations. (3) Members of the Selected Reserves, not on Active Duty (AD) orders, are eligible for TRICARE Reserve Select and can schedule an appointment with

Interpretation: Organizations that rent facilities should obtain relevant documentation from their landlord. If the organization cannot obtain access to the required documentation from their landlord or from relevant public or private health and safety authorities the organization may also solicit a recognized expert to verify compliance with applicable laws and safety codes MHSU 2: Screening and Intake The organization’s screening and intake practices ensure that service recipients receive prompt and responsive access to appropriate services. MHSU 2.01 Service recipients are screened at intake and informed about:



c. rules and expectations of the program.

COA’s language is designed to capture services to a broad range of demographic groups and meets the intent of the CCBHC standard. COA does not have precise language around classes of military service recipients or military eligibility for service based on proximity to dedicated service providers or classification. Table of Evidence for ASE 3

Relevant licenses

Documentation of compliance with regulations and codes

Interview: a. Program director b. Facility management

Table of Evidence MHSU 2





CCBHC Criteria



(Tables of Evidence) any TRICARE-authorized provider, network or non-network. Veterans: Persons affirming former military service (veterans) are offered assistance to enroll in VHA for the delivery of health and behavioral health services. Veterans who decline or are ineligible for VHA services will be served by the CCBHC consistent with minimum clinical mental health guidelines promulgated by the VHA, including clinical guidelines contained in the Uniform Mental Health Services Handbook as excerpted below (from VHA Handbook 1160.01, Principles of Care found in the Uniform Mental Health Services in VA Centers and Clinics). Note: See also program requirement 3 requiring coordination of care across settings and providers, including facilities of the Department of Veterans Affairs.

Interpretation: Screenings will vary based on the program’s target population and services offered, and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, and/or risk of harm to self or others. Interpretation: For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program. MHSU 3: Assessment Service recipients participate in a comprehensive, individualized, trauma-informed, strengths-based, family-focused, culturally and linguistically responsive assessment to determine an appropriate level of service. Note: Refer to the Assessment Matrix - Private, Public, Canadian, Network for additional assessment criteria. The elements of the matrix can be tailored according to the needs of specific individuals or service design (elements of the Assessment Matrix include military status) MHSU 6.05 The organization directly provides or makes referrals for a comprehensive range of prevention and treatment services, including acute care services when necessary. Interpretation: Services may include detoxification, inpatient care, intensive outpatient care, medical







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Procedures for care coordination, including strategies for identifying and engaging other community-based


CCBHC Criteria



(Tables of Evidence) care, psychiatric rehabilitation and targeted case management services. MHSU 9.02 Service recipients with co-occurring mental health and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider. Note: This standard is applicable to all programs regardless of the services offered. Organizations that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and organizations that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders.

providers



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4.k.3

In keeping with the general criteria governing CCBHCs, CCBHCs ensure there is integration or coordination between the care of substance use disorders and other mental health conditions for those veterans who experience both and for integration or coordination between care for behavioral health conditions and other components of health care for all veterans.

ICHH 4: Care Coordination All aspects of the person’s treatment are managed in accordance with the care plan to ensure access to and coordination of needed behavioral health care, physical health care, and community and social support services. Interpretation: This includes coordination of any services provided directly by the organization as well as those provided through linkages to community providers. MHSU 9.02 Service recipients with co-occurring mental health







Copies of agreements with community


CCBHC Criteria



(Tables of Evidence) and substance use disorders receive coordinated treatment either directly or through active involvement with a cooperating service provider. Note: This standard is applicable to all programs regardless of the services offered. Organizations that only treat substance use disorders are expected to have the core capability to address co-occurring mental health conditions, and organizations that only treat mental health disorders are expected to have the core capability to address co-occurring substance use disorders. MHSU 9.03 The organization supports the coordination of behavioral and physical health care to increase service recipients’ access to needed services. Interpretation: To meet the standard, organizations must demonstrate that they are working towards linking behavioral health and primary care services. Examples include: providing referrals to identified primary care providers, communicating with service recipients’ primary care doctor about treatment planning, and linking individuals to navigators to help service recipients navigate the health care system.

providers, as applicable







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4.k.4

Every veteran seen for behavioral health services is assigned a Principal Behavioral Health Provider. When veterans are seeing more than one behavioral health provider and when they are involved in more than one program, the identity of the Principal Behavioral Health Provider is made clear to the veteran and identified in the medical record. The Principal Behavioral Health Provider is identified on a consumer tracking

CR 1.07 Clients participate in all service decisions and have the right to:









CCBHC Criteria



(Tables of Evidence) database for those veterans who need case management. The Principal Behavioral Health Provider ensures the following requirements

are fulfilled: (1) Regular contact is maintained

with the veteran as clinically indicated as long as ongoing care is required. (2) A psychiatrist, or such other independent prescriber as satisfies the current requirements of the VHA Uniform Mental Health Services Handbook, reviews and reconciles each veteran’s psychiatric medications on a regular basis. (3) Coordination and development of the veteran’s treatment plan incorporates input from the veteran (and, when appropriate, the family with the veteran’s consent when the veteran possesses adequate decision-making capacity or with the veteran’s surrogate decision-maker’s consent when the veteran does not have adequate decision-making capacity). (4) Implementation of the treatment plan is monitored and documented. This must include tracking progress in the care delivered, the outcomes achieved, and the goals attained. (5) The treatment plan is revised, when necessary. (6) The principal therapist or Principal Behavioral Health Provider communicates with the veteran (and the veteran's authorized surrogate or family or friends when appropriate and when veterans with adequate decision-making capacity consent) about the treatment plan, and for addressing any of the veteran’s problems or concerns about their care. For veterans who are at high



Interpretation: When the client is a minor, or an adult under the care of a guardian, the organization follows applicable laws or regulations governing the right of the parent or legal guardian, to refuse service, treatment, or medication unless mandated by law or court order. Adult guardianship workers should refer to the court order and state law when determining an appropriate level of involvement for each service recipient. See AG 8 for more information on including the client in service decisions. ICHH 1.03 The organization has developed clear mechanisms for linking behavioral health and primary care services through:



c. systems for tracking referrals and needed follow-up.



information; and

Interview: d. Relevant personnel e. Individuals or families served f. Review case records



Service Philosophy




Interview: d. Program director e. Relevant personnel f. Persons served

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Observe health information technologies Table of Evidence for ICHH 3



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CCBHC Criteria



(Tables of Evidence) risk of losing decision-making capacity, such as those with a diagnosis of schizophrenia or schizoaffective disorder, such communications need to include discussions regarding future behavioral health care treatment (see information regarding Advance Care Planning Documents in VHA Handbook 1004.2). 7) The treatment plan reflects the veteran’s goals and preferences for care and that the veteran verbally consents to the treatment plan in accordance with VHA Handbook 1004.1, Informed Consent for Clinical Treatments and Procedures. If the Principal Behavioral Health Provider suspects the veteran lacks the capacity to make a decision about the mental health treatment plan, the provider must ensure the veteran’s decision-making capacity is formally assessed and documented. For veterans who are determined to lack capacity, the provider must identify the authorized surrogate and document the surrogate’s verbal consent to the treatment plan.

c. satisfy applicable reporting requirements. ICHH 3.01 A care plan is developed:


and his or her family.

Interpretation: Care planning is conducted such that individuals and families retain as much personal responsibility and self-determination as possible or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and gradually assume more responsibility for making decisions independently. When the person receiving services is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring the involvement or consent of the person’s legal guardian. Interpretation: Generally, care plans should be developed following completion of all necessary assessments and reviewed with the person at their next visit ICHH 3.04 The care coordinator and the individual or family regularly review progress toward achievement of agreed upon goals and make revisions to service goals and plans as needed. Interpretation: The individual’s or family’s involvement in updating the plan should be documented.












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CCBHC Criteria



(Tables of Evidence) ICHH 4.02 The care planning team includes at a minimum:







CCBHC Criteria



(Tables of Evidence) on the care planning team can include, but are not limited to, peer mentors and natural supports as appropriate to the needs of the individual. ICHH 4.03 The roles and responsibilities of each team member are clearly defined. ICHH 4.04 The organization has established communication procedures for collaboration:

a. across disciplines, both internal and external; and

b. with the person and his or her family. MHSU 4.05 The organization engages service recipients and involved family members in crisis planning, as needed. Interpretation: While each individual service recipient may not require a crisis plan, the organization should have a process in place for determining whether or not a crisis plan is necessary. The crisis plan should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. Depending on the needs of the individual, crisis plans may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be


CCBHC Criteria



(Tables of Evidence) incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care.



4.k.5

In keeping with the general criteria governing CCBHCs, behavioral health services are recovery-oriented. The VHA adopted the National Consensus Statement on Mental Health Recovery in its Uniform Mental Health Services Handbook. SAMHSA has since developed a working definition and set of principles for recovery updating the Consensus Statement. Recovery is defined as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” The following are the 10 guiding principles of recovery: • Hope • Person-driven • Many pathways • Holistic • Peer support • Relational • Culture • Addresses trauma • Strengths/responsibility • Respect (Substance Abuse and Mental Health Services Administration [2012]). As implemented in VHA recovery, the recovery principles also include the following: • Privacy • Security • Honor Care for veterans must conform to that definition and to those principles in order to satisfy the statutory

MHSU 13.08 Individuals who provide peer support received pre- and in-service training on:

a. how to recognize the need for more intensive services and how to make an appropriate referral;

b. established ethical guidelines including setting appropriate boundaries; and

c. skills, concepts, and philosophies related to recovery and peer support.

Interpretation: Peer support workers should receive ongoing education to remain current on wellness support methods, trauma-informed care practices, and recovery resources as the field of recovery and peer support is rapidly evolving. Interpretation: Peer support workers establish relationships with service recipients that are based on mutual respect and trust and support bidirectional learning and reciprocity. One of the greatest perceived challenges of delivering peer support services is peers’ ability to handle confidentiality and boundaries. Clearly defining and communicating the

The COA standard used to respond conveys the recovery-centered focus that COA promotes in the training of staff who provide services for mental health and/or substance use conditions. The standard also includes research that speaks directly to the guiding principles described in the CCBHC standard. Table of Evidence for MHSU 13









CCBHC Criteria



(Tables of Evidence) requirement that care for veterans adheres to guidelines promulgated by the VHA.

roles of the peer worker is critical when establishing the peer-to-peer relationship. Research Note: A national network of researchers, health care professionals, behavioral health experts, and individuals in recovery developed a set of universal recovery principles. The ten guiding principles of recovery include:

a. hope; b. person-centered/self-directed; c. individualized/many pathways; d. holistic; e. peer support; f. relational; g. cultural competence; h. trauma-informed; i. strengths-based/responsibility; and j. respect

Job descriptions

Training curricula



4.k.6

In keeping with the general criteria governing CCBHCs, all behavioral health care is provided with cultural competence. (1) Any staff who is not a veteran has training about military and veterans’ culture in order to be able to understand the unique experiences and contributions of those who have served their country. (2) All staff receives cultural competency training on issues of race, ethnicity, age, sexual orientation, and gender identity.

MHSU 13.04 Clinical personnel receive ongoing training and education in the following areas:

a. delivering culturally and linguistically responsive care ;














Job descriptions

Training curricula


CCBHC Criteria



(Tables of Evidence) Interpretation: Ecological or person-in-environment perspectives view social, economic, and environmental factors as critical in the development and resolution of personal and family problems. Factors may include:

a. poverty and lack of employment opportunities;

b. local mores; c. language and cultural differences; and d. alternative medicine and traditional healing

processes. TS 2.05 Training for direct service personnel addresses differences within the organization’s service population, including:

a. interventions that address cultural and socioeconomic factors in service delivery;

b. the role cultural identity plays in motivating human behavior; and

c. understanding bias or discrimination. Interpretation: Credit counseling organizations should implement cultural competence training that demonstrates the importance of sensitivity to matters as outlined in the elements the standard. This intent of the training is to help staff understand and be sensitive to how people of varying cultures think about and handle financial situations. TS 2.06 Personnel demonstrate competence in, or receive training on, the needs of special populations within the defined service population, such as the need for normalizing experiences and social inclusion.







Training curricula



CCBHC Criteria



(Tables of Evidence) Interpretation: “Special populations” include, but are not limited to, those who are abused and neglected, those with a developmental disability, and those with mental health and substance use disorders. Depending on the services provided and the population served, the organization’s training may vary from different treatment approaches, to procedures for referring individuals to other providers when those needs cannot be addressed by the organization. For example, staff at a credit counseling agency may encounter individuals with substance abuse or mental health disorders. In such situations, staff should be aware of the agency’s protocols and how to refer those individuals to appropriate services.

4.k.7

In keeping with the general criteria governing CCBHCs, there is a behavioral health treatment plan for all veterans receiving behavioral health services. (1) The treatment plan includes the veteran’s diagnosis or diagnoses and documents consideration of each type of evidence-based intervention for each diagnosis. (2) The treatment plan includes approaches to monitoring the outcomes (therapeutic benefits and adverse effects) of care, and milestones for reevaluation of interventions and of the plan itself. (3) As appropriate, the plan considers interventions intended to reduce/manage symptoms, improve functioning, and prevent relapses or recurrences of episodes of illness. (4) The plan is recovery oriented, attentive to the veteran’s values and preferences, and evidence-based regarding what constitutes effective and safe treatments. (5) The

MHSU 3: Assessment Service recipients participate in a comprehensive, individualized, trauma-informed, strengths-based, family-focused, culturally and linguistically responsive assessment to determine an appropriate level of service. Interpretation: For an assessment to be trauma-informed, the organization understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the service recipient rather than personal deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the organization actively prevents instances that could potentially re-traumatize service recipients. MHSU 3.04 Each service recipient receives an individualized,







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Service planning and monitoring procedures, including strategies for


CCBHC Criteria



(Tables of Evidence) treatment plan is developed with input from the veteran, and when the veteran consents, appropriate family members. The veteran’s verbal consent to the treatment plan is required pursuant to VHA Handbook 1004.1. 52

comprehensive assessment, which includes a summary of symptoms and diagnoses based on a standardized diagnostic tool. Interpretation: The standardized diagnostic tool should be used to match the needs of the service recipient with the appropriate level care. Assessment tools will vary depending on the age and developmental level of the service population. Examples of standardized instruments or protocols include: the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), the Addiction Severity Index, Treatment Services Review, the American Society of Addiction Medicine (ASAM) patient placement criteria, the Institute of Medicine (IOM), the Child and Adolescents Needs and Strengths (CANS), criteria required by federal or state oversight authorities, and criteria required for participation in managed care delivery systems. Interpretation: Assessments are completed within timeframes established by the organization. Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes. MHSU 4.01 An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient, and expedited service planning is available when crisis or urgent need is identified.

active family participation when appropriate

Crisis and safety planning procedures



Review case records Table of Evidence for RPM 7



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Network Interview: a. Provider personnel b. Provider supervisors c. Provider program directors


CCBHC Criteria



(Tables of Evidence) Interpretation: Service planning is conducted so that the individual retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians. MHSU 4.02 The service plan is based on the assessment, and includes:




Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being. MHSU 4.03 During service planning, the organization explains:

a. available options; b. how the organization can support the

achievement of desired outcomes; and c. the benefits, alternatives, and risks or

consequences of planned services.


CCBHC Criteria



(Tables of Evidence) MHSU 4.04 The service plan addresses, as appropriate:

a. unmet service and support needs; b. possibilities for maintaining and

strengthening family relationships; and c. the need for support of the service

recipient’s informal social network.

PROGRAM REQUIREMENT 5: QUALITY AND OTHER REPORTING

Criteria 5.A: Data Collection, Reporting and Tracking

5.a.1

The CCBHC has the capacity to collect, report, and track encounter, outcome, and quality data, including but not limited to data capturing: (1) consumer characteristics; (2) staffing; (3) access to services; (4) use of services; (5) screening, prevention, and treatment; (6) care coordination; (7) other processes of care; (8) costs; and (9) consumer outcomes. Data collection and reporting requirements are elaborated below and in Appendix A.

PQI 4: Performance and Outcomes Measures The PQI system identifies measures to build organizational capacity, improve services, and meet contracting and reporting requirements, by evaluating:

a. the impact of services on clients; b. quality of service delivery; and c. management and operations performance.

COA meets the intent of the CCBHC standard. Table of Evidence for PQI 4

See PQI plan re: description of what is being measured. Response must address and include PQI 4.02, PQI 4.03, and PQI 4.04, and include:

a. outcomes b. outputs c. data sources d. indicators e. targets

Documentation of stakeholder involvement in selection of outcomes, indicators, etc. (work group/committee meeting minutes, agendas)

See response to Narrative Question #4

See also PQI outcomes/outputs documentation provided in the Service Narratives

Networks Only

Networks provide network-specific


CCBHC Criteria



(Tables of Evidence) performance measures

Regulatory/licensing or other external reviews/reports (PQI 4.05)

For organizations seeking re-accreditation:

a. Pre-Commission Review Report (PCR)

b. Final Accreditation Report (FAR) c. Maintenance of Accreditation

(MOA) Reports for the three most recent years

Interview: a. PQI personnel b. Relevant staff c. Other relevant stakeholders


Criteria 5.A: Data Collection, Reporting and Tracking (Continued)

5.a.2

Reporting is annual and data are required to be reported for all CCBHC consumers, or where data constraints exist (for example, the measure is calculated from claims), for all Medicaid enrollees in the CCBHCs.

PQI 4.01 Staff throughout the organization and stakeholders work together to identify key outputs and outcomes, and related:

a. quantitative and qualitative indicators; b. data sources, including measurement tools

and instruments for each identified output and outcome; and

c. performance targets. PQI 4.02 On an ongoing basis, each of the organization’s programs measures client outcomes, including two of the following areas:

a. change in clinical status; b. change in functional status;






CCBHC Criteria



(Tables of Evidence) c. health, welfare, and safety; d. permanency of life situation; e. quality of life; f. achievement of individual service goals; and g. other outcomes as appropriate to the

program or service population. PQI 4.03 At least annually, the organization examines its service delivery processes to plan, manage, and evaluate the quality of its services, including:

a. outreach, intake, assessment, and service planning and delivery processes;

b. review of immediate and ongoing risks related to service delivery; and

c. consumer satisfaction. PQI 4.04 The organization collects and monitors data on management and operational performance to:

a. strengthen and build organizational capacity;

b. measure progress toward achieving its strategic goals and objectives;

c. evaluate operational functions that influence the capacity to deliver services; and

d. identify and mitigate risk. PQI 4.05 The organization reviews and addresses the findings and recommendations of external review processes, including, as applicable:

a. licensing and other reviews related to federal, state, and local requirements;

b. government and other funder audits;



Networks Only

Networks provide network-specific performance measures







Table of Evidence for PQI 6

Data analyses/reports related to the elements in PQI 6.02

Summary documents or reports provided to internal and external stakeholders, e.g.,

a. performance dashboards, b. annual reports c. reports of gains made against

goals d. annual scorecards, etc. (PQI

6.03)

PQI data management procedures

Procedures for reviewing and


CCBHC Criteria



(Tables of Evidence) c. accreditation reviews; and d. other reviews, where appropriate.

PQI 6: Analyzing and Reporting Information The organization systematically collects, aggregates, analyzes, and maintains data.

aggregating PQI data

Additional analyses/reports related to the elements in PQI 6.02.

PQI committees/work group minutes for analyzing PQI information

Documentation of stakeholder review and discussion of PQI results, including meeting minutes and agendas

Governing body meeting minutes regarding review of PQI data

Interview: a. PQI personnel b. Relevant staff

Review of management information system regarding collecting, aggregating, analyzing, and maintaining data

5.a.3

To the extent possible, these criteria assign to the state responsibility for data collection and reporting where access to data outside the CCBHC is required. Data to be collected and reported and quality measures to be reported, however, may relate to services CCBHC consumers receive through DCOs. Collection of some of the data and quality measures that are the responsibility of the CCBHC may require access to data from DCOs and it is the responsibility of the CCBHC to arrange for access to such data as legally permissible upon creation of the relationship with DCOs and to ensure adequate consent as appropriate and that releases of information are obtained for each affected consumer.

PQI 6.01 Procedures for reviewing and aggregating PQI data:

a. ensure data integrity and reliability; and b. facilitate the development of aggregate data

reports for analysis. PQI 6.02 The organization analyzes PQI data to:

a. track and monitor identified measures; b. identify patterns and trends; c. compare performance over time; d. compare data against the results of internal

benchmarks; and e. compare data against the results of external

benchmarks, if available. PQI 6.03 Summary reports of PQI information: a. are distributed in a timeframe and format that


Data analyses/reports related to the elements in PQI 6.02

Summary documents or reports provided to internal and external stakeholders, e.g.,

a. performance dashboards, b. annual reports c. reports of gains made against

goals d. annual scorecards, etc. (PQI

6.03)

PQI data management procedures

Procedures for reviewing and aggregating PQI data

Additional analyses/reports related to the elements in PQI 6.02.

PQI committees/work group minutes for


CCBHC Criteria




facilitates review and analysis; and b. consider concerns related to the confidentiality of service recipients. PQI 6.04 Internal and external stakeholders review performance data and outcome results in order to:

a. identify strengths and areas of positive practice; and

b. provide feedback about areas in need of improvement.

analyzing PQI information

Documentation of stakeholder review and discussion of PQI results, including meeting minutes and agendas

Governing body meeting minutes regarding review of PQI data

Interview: a. PQI personnel b. Relevant staff

Review of management information system regarding collecting, aggregating, analyzing, and maintaining data



5.a.4

As specified in Appendix A, some aspects of data reporting will be the responsibility of the state, using Medicaid claims and encounter data. States must provide CCHBC-level Medicaid claims or encounter data to the evaluators of this demonstration program annually. At a minimum, consumer and service-level data should include a unique consumer identifier, unique clinic identifier, date of service, CCBHC-covered service provided, units of service provided and diagnosis. These data must be reported through MMIS/T-MSIS in order to support the state’s claim for enhanced federal matching funds made available through this demonstration program. For each consumer,

RPM 7: Case Records Case records contain sufficient, accurate information to:

a. identify the consumer; b. support decisions about interventions or

services; and c. document the delivery of services

RPM 7.01 The organization maintains a case record for each person or family. RPM 7.02 Case records comply with all legal requirements and contain information necessary to provide services, including:




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assessment, and authorization staff, if these services are


CCBHC Criteria



(Tables of Evidence) the state must obtain and link the consumer level administrative Uniform Reporting System (URS) information to the claim (or be able to link by unique consumer identifier). CCBHC consumer claim or encounter data must be linkable to the consumer’s pharmacy claims or utilization information, inpatient and outpatient claims, and any other claims or encounter data necessary to report the measures identified in Appendix A. These linked claims or encounter data must also be made available to the evaluator. In addition to data specified in this program requirement and in Appendix A that the state is to provide the state will provide such other data, including Treatment Episode Data Set (TEDS) data and data from comparison settings, as may be required for the evaluation to HHS and the national evaluation contractor annually. To the extent CCBHCs are responsible for provision of data, the data will be provided to the state and, as may be,

a. demographic and contact information; the reason for requesting or being referred for services;

b. up-to-date assessments; c. the service plan, including mutually

developed goals and objectives; d. copies of all signed consent forms; e. a description of services provided directly or

by referral; f. routine documentation of ongoing services;

documentation of routine supervisory review;

g. discharge or aftercare plan; h. recommendations for ongoing and/or future


i. a closing summary entered within 30 days of termination of service.

RPM 7.04 Case record entries are made by authorized personnel only, and are:

a. specific, factual, relevant, and legible; kept up to date from intake through case closing;

b. completed, signed, and dated by the person who provided the service; and

c. signed and dated by supervisors, where appropriate.

RPM 7.05 Progress notes comply with legal requirements and are entered:

a. at least quarterly; or b. monthly, or as required by law or regulation

for individuals receiving protective services, out-of-home care, day treatment, or

provided b. Providers who request

authorizations from the managing entities

Network Interview: d. Provider personnel e. Provider supervisors f. Provider program directors


CCBHC Criteria



(Tables of Evidence) frequent or intensive counseling or treatment.



5.a.5

CCBHCs annually submit a cost report with supporting data within six months after the end of each demonstration year to the state. The state will review the submission for completeness and submit the report and any additional clarifying information within nine months after the end of each demonstration year to CMS. Note: In order for a clinic to receive payment using the CCBHC PPS, it must be certified as a CCBHC.

FIN 6: Financial Accountability The organization is accountable for the management and performance of its finances to its governing body, the community, and applicable regulatory bodies. FIN 6.01 The organization makes available an annual report of fiscal, statistical, and service data that includes summary information regarding its financial position that is provided upon request.

COA meets the intent of the CCBHC standard. Table of Evidence for FIN 6

Most recent audit and management letter

List of Audit Committee members and Finance Committee members

Annual report of fiscal, statistical, and service data

IRS Form 990 (FIN 6.04)

Governing Body minutes

Minutes of audit and finance committees



Criteria 5.B: Continuous Quality Improvement (CQI) Plan


CCBHC Criteria




5.b.1

The CCBHC develops, implements, and maintains an effective, CCBHC-wide data-driven continuous quality improvement (CQI) plan for clinical services and clinical management. The CQI projects are clearly defined, implemented, and evaluated annually. The number and scope of distinct CQI projects conducted annually are based on the needs of the CCBHC’s population and reflect the scope, complexity and past performance of the CCBHC’s services and operations. The CCBHC-wide CQI plan addresses priorities for improved quality of care and client safety, and requires all improvement activities be evaluated for effectiveness. The CQI plan focuses on indicators related to improved behavioral and physical health outcomes, and takes actions to demonstrate improvement in CCBHC performance. The CCBHC documents each CQI project implemented, the reasons for the projects, and the measurable progress achieved by the projects. One or more individuals are designated as responsible for operating the CQI program.

PQI Purpose Standard An organization-wide Performance and Quality Improvement system advances efficient, effective service delivery, effective management practices, and the achievement of strategic and program goals. PQI 2: Infrastructure A PQI system has an infrastructure that has the capacity to:

a. identify organization-wide and program-specific issues;

b. implement solutions that improve overall efficiency; and

c. deliver accessible, effective services in all regions and sites.

PQI 2.01 The PQI system includes each of the organization’s regions and sites, and covers all persons and families served. PQI 2.02 A written PQI plan operationalizes the organization’s PQI system, and:

a. articulates the organization’s approach to quality improvement;

b. describes the PQI system’s structure and activities;

c. defines staff roles and assigns responsibility for implementing and coordinating the PQI program (PQI 3);

d. identifies what is being measured; (PQI 4, PQI 5)

e. defines data collection processes and applicable timeframes (PQI 6); and

f. outlines processes for reporting findings and


PQI plan / PQI operational procedures

Document or chart that describes the organization's PQI structure including committees, work groups, and member lists, as appropriate

PQI meeting/activity schedule for the next twelve months

Networks Only

Network contracts with network service providers

Interview: a. CEO Senior management b. PQI personnel c. Staff at all levels







Networks Only

Networks provide network-specific


CCBHC Criteria



(Tables of Evidence) monitoring results (PQI 7).

PQI 2.03 The PQI plan:

a. defines the organization’s stakeholders; and b. specifies how a broad range of internal and

external stakeholder groups will be involved in the PQI process.

PQI 2.04 The PQI plan describes an improvement cycle which includes mechanisms for:

a. obtaining feedback about findings from stakeholders; taking action in response to PQI findings and feedback; and

b. determining if an implemented change is an improvement.

PQI 4.02 On an ongoing basis, each of the organization’s programs measures client outcomes, including two of the following areas:

a. change in clinical status; b. change in functional status; c. health, welfare, and safety; d. permanency of life situation; e. quality of life; f. achievement of individual service goals; and g. other outcomes as appropriate to the

program or service population PQI 4.03 At least annually, the organization examines its service delivery processes to plan, manage, and evaluate the quality of its services, including:

a. outreach, intake, assessment, and service

performance measures








Annual PQI Report


Evidence of improvements made from the analysis and use of PQI data, including data related to the standards in PQI 4, PQI 5, and PQI 6, and any related corrective action/improvement plans.

PQI meeting minutes, agendas, attendance lists

Governing body meeting minutes reflecting review of PQI data / annual PQI report

Interview: a. PQI personnel b. Personnel at all levels c. External stakeholder groups


CCBHC Criteria



(Tables of Evidence) planning and delivery processes; review of immediate and ongoing risks related to service delivery; and

b. consumer satisfaction. PQI 4.04 The organization collects and monitors data on management and operational performance to:

a. strengthen and build organizational capacity;

b. measure progress toward achieving its strategic goals and objectives;

c. evaluate operational functions that influence the capacity to deliver services; and

d. identify and mitigate risk. PQI 4.05 The organization reviews and addresses the findings and recommendations of external review processes, including, as applicable:

a. licensing and other reviews related to federal, state, and local requirements;

b. government and other funder audits; c. accreditation reviews; and d. other reviews, where appropriate.

PQI 7.04 The organization develops an annual PQI Report for the governing body and staff that:

a. summarizes key PQI activities that are ongoing, have been resolved, or that need further intervention;

b. reviews holdover issues from prior PQI annual reports; and

c. identifies PQI priorities and goals for the


CCBHC Criteria



(Tables of Evidence) coming year.

PQI 7.03 Organization leaders, senior managers, program directors, and supervisors:

a. keep PQI on the agenda of board, management, and staff meetings;

b. regularly evaluate the need for and uses of data; and

c. evaluates the PQI system, infrastructure, processes and procedures.


Criteria 5.B: Continuous Quality Improvement (CQI) Plan (Continued)

5.b.2

Although the CQI plan is to be developed by the CCBHC and reviewed and approved by the state during certification, specific events are expected to be addressed as part of the CQI plan, including: (1) CCBHC consumer suicide deaths or suicide attempts; (2) CCBHC consumer 30 day hospital readmissions for psychiatric or substance use reasons; and (3) such other events the state or applicable accreditation bodies may deem appropriate for examination and remediation as part of a CQI plan.

PQI 4.03 At least annually, the organization examines its service delivery processes to plan, manage, and evaluate the quality of its services, including:

a. outreach, intake, assessment, and service planning and delivery processes;

b. review of immediate and ongoing risks related to service delivery; and

c. cconsumer satisfaction. RPM 2.02 The organization conducts a quarterly review of immediate and ongoing risks that includes a review of incidents, critical incidents, accidents, and grievances including the following, as appropriate to the program or service:

a. facility safety issues; b. serious illness, injuries, and deaths; c. situations where a person was determined

to be a danger to himself/herself or others; d. service modalities or other organizational


See PQI plan re: description of what is being measured. Response must address and include PQI 4.02, PQI 4.03, and PQI 4.04, and include: a. outcomes

b. outputs

c. data sources

d. indicators

e. targets




Networks Only


CCBHC Criteria



(Tables of Evidence) practices that involve risk or limit freedom of choice; and

e. the use of restrictive behavior management interventions, such as seclusion and restraint.

RPM 2.03 The organization conducts an independent review of each incident, serious occurrence, accident, and grievance that involves the threat of or actual harm, serious injury, or death, and review procedures:

a. require that the investigation be initiated within 24 hours of the incident and/or accident being reported and establish timeframes for review;

b. require solicitation of statements from all involved individuals;

c. ensure an independent review; d. require timely implementation and

documentation of all actions taken; e. address ongoing monitoring if actions are

required and determine their effectiveness; and

f. address applicable reporting requirements.

Networks provide network-specific performance measures


For organizations seeking re-accreditation: a. Pre-Commission Review Report (PCR)

b. Final Accreditation Report (FAR)

c. Maintenance of Accreditation (MOA) Reports for the three most recent years



Procedures for conducting annual assessments of potential organizational risks

Procedures for quarterly review of immediate and ongoing risks

Procedures for investigation and review of critical incidents (RPM 2.03)

Quarterly (RPM 2.02) and annual (RPM 2.01) risk management reports, including analyses and improvement action plans, as applicable

Governing body and management meeting minutes where risk prevention and management activities are reviewed, improvement actions discussed, and implemented, as applicable

Policy for legal assistance to personnel against whom claims are made (RPM 2.06)

Contract or other documentation of


CCBHC Criteria



(Tables of Evidence) agreement with organizations permitted to use facilities

Interview: a. Governing Body CEO/CFO b. Risk management personnel

PROGRAM REQUIREMENT 6: ORGANIZATIONAL AUTHORITY, GOVERNANCE AND ACCREDITATION

Criteria 6.A: General Requirements of Organizational Authority and Finances

6.a.1

The CCBHC maintains documentation establishing the CCBHC conforms to at least one of the following statutorily established criteria: • Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United States Internal Revenue Code; • Is part of a local government behavioral health authority; • Is operated under the authority of the Indian Health Service, an Indian tribe, or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian

GOV 1: Legal Authorization to Operate The organization is legally authorized to operate as:

a. a nonprofit organization with a governing body incorporated or authorized to conduct business in the state where it operates or is headquartered and has a duly promulgated charter, constitution, and/or bylaws;

b. a nonprofit organization organized as an identified sub-unit of a religious body that has legal status or is an identified sub-unit of another legal entity recognized under state law; or

c. a corporation sole.

COA meets the intent of the CCBHC standard. Table of Evidence for GOV 1

Bylaws/charter/articles of incorporation

Interview: a. CEO/Governing Body Chair


Criteria 6.A: General Requirements of Organizational Authority and Finances (Continued)


CCBHC Criteria




6.a.1

Self-Determination Act (25 U.S.C. 450 et seq.); • Is an urban Indian organization pursuant to a grant or contract with the Indian Health Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.). Note: A CCBHC is considered part of a local government behavioral health authority when a locality, county, region or state maintains authority to oversee behavioral health services at the local level and utilizes the clinic to provide those services.

GOV 1: Legal Authorization to Operate The organization is legally authorized to operate as:

a. a nonprofit organization with a governing body incorporated or authorized to conduct business in the state where it operates or is headquartered and has a duly promulgated charter, constitution, and/or bylaws;

b. a nonprofit organization organized as an identified sub-unit of a religious body that has legal status or is an identified sub-unit of another legal entity recognized under state law; or

c. a corporation sole.


Bylaws/charter/articles of incorporation

Interview: a. CEO/Governing Body Chair

6.a.2

To the extent CCBHCs are not operated under the authority of the Indian Health Service, an Indian tribe, or tribal or urban Indian organization, states, based upon the population the prospective CCBHC may serve, should require CCBHCs to reach out to such entities within their geographic service area and enter into arrangements with those entities to assist in the provision of services to AI/AN consumers and to inform the provision of services to those consumers. To the extent the CCBHC and such entities jointly provide services, the CCBHC and those collaborating entities shall, as a whole, satisfy the requirements of these criteria.













Copies of agreements with cooperating service providers and/ or an up-to-date referral list of identified community-


CCBHC Criteria



(Tables of Evidence) coordination, and transitional care;

d. chronic disease management, including self-management;

e. community, social support, and recovery services; and

f. long-term care supports and services.

based providers, as appropriate


Review case records


Criteria 6.A: General Requirements of Organizational Authority and Finances (Continued)

6.a.3

An independent financial audit is performed annually for the duration of the demonstration in accordance with federal audit requirements, and, where indicated, a corrective action plan is submitted addressing all findings, questioned costs, reportable conditions, and material weakness cited in the Audit Report.

FIN 6.02 An audit of the organization’s financial statements is conducted within 180 days of the end of each fiscal year by an independent, certified public accountant. Interpretation: An organization that is getting reaccredited can receive a 2 rating if it has completed an audit for the most recent auditable year but did not conduct an audit for any or all of the intervening years since their last accreditation. All new organizations must have an audit from their most recent auditable year in order to get accredited. FIN 6.03 The governing body has an independent audit committee that:

a. oversees the financial reporting process; b. selects an independent auditor; c. meets with the auditor to review the

findings of the audit, accompanying financial information, and any accompanying management letter;

d. formally accepts the auditor’s report within 180 days of the close of the fiscal year;

e. reports the findings and makes

COA meets the intent of the CCBHC standard. Table of Evidence for FIN 6

Most recent audit and management letter

List of Audit Committee members and Finance Committee members

Annual report of fiscal, statistical, and service data

IRS Form 990 (FIN 6.04)

Governing Body minutes

Minutes of audit and finance committees



Annual PQI Report


Evidence of improvements made from the analysis and use of PQI data, including data related to the standards in PQI 4, PQI 5, and PQI 6, and any related


CCBHC Criteria



(Tables of Evidence) recommendations at the next official meeting of the governing body;

f. assures that the executive director promptly acts upon recommendations in the management letter, if any; and

g. does not include organization staff or relatives of staff.

Interpretation: To receive a rating of 1 for FIN 6.03 the audit committee must be independent of the finance committee in order to minimize potential conflict of interest, and may not be a committee comprised of the entire governing body as a whole. If the audit committee is not independent of the finance committee, an organization may be able to receive a rating of 2 if:

a. the selection and oversight of the auditor (elements (b), (c), and (d)) is managed by a board sub-committee that: is chaired by a board member who is not also the chair of the finance or executive committee; and includes at least one person who is not a member of the finance committee; and

b. no organization staff, including the CEO and CFO, or relatives of staff, participate in selection of the auditor or oversight of the audit process.

See the interpretation for FIN 1 for a discussion of the functions of the audit and finance committees. The American Institute of CPAs recommends that an auditing firm not provide both auditing and non-auditing services, such as bookkeeping and actuarial services to the same organization.

corrective action/improvement plans.

PQI meeting minutes, agendas, attendance lists

Governing body meeting minutes reflecting review of PQI data / annual PQI report

Interview: a. PQI personnel b. Personnel at all levels c. External stakeholder groups


CCBHC Criteria



(Tables of Evidence) PQI 7.01 The organization takes action based on the findings and feedback to:

a. develop solutions; b. replicate good practice; c. recognize and motivate staff; d. improve organizational systems, processes,

polices, and procedures; e. improve services; and f. eliminate or reduce identified problems.

Interpretation: Corrective Action Plans or Improvement Plans should be implemented when issues have been identified that will involve ongoing effort and monitoring. Corrective Action Plans are implemented to correct problems or deficiencies, including those related to compliance with regulatory requirements (e.g., Medicaid documentation requirements). The need for a Corrective Action Plan suggests that the issue has moved beyond program improvement to the level of oversight by the organization’s leadership. Improvement Plans formally lay out the actions that will be taken to address areas in need of improvement that are identified by staff and stakeholders as crucial to meeting the organization’s goals and delivering quality services. Improvement plans should be implemented when it is necessary to monitor and address the issue over time.


Criteria 6.B: Governance


CCBHC Criteria




6.b.1

As a group, the CCBHC’s board members are representative of the individuals being served by the CCBHC in terms of demographic factors such as geographic area, race, ethnicity, sex, gender identity, disability, age, and sexual orientation, and in terms of types of disorders. The CCBHC will incorporate meaningful participation by adult consumers with mental illness, adults recovering from substance use disorders, and family members of CCBHC consumers, either through 51 percent of the board being families, consumers or people in recovery from behavioral health conditions, or through a substantial portion of the governing board members meeting this criteria and other specifically described methods for consumers, people in recovery and family members to provide meaningful input to the board about the CCBHC’s policies, processes, and services.

GOV 2.02 The governing body:

a. reflects the demographics of the community it serves;

b. represents the interests of the community it serves; and

c. serves as a link between the organization and the public or community.

GOV 2.04 Not-for-profit organizations that do not have a representative governing body, and networks, establish and maintain a stakeholder advisory group that serves as a bridge between the organization and the community and it:

a. includes representatives of relevant community groups, consumers, parents, service providers, advocates, and others with an interest in the success of the organization achieving its mission or purpose;

b. provides information and feedback to the organization about services, outcomes, the perception of the agency within the community, and other information that would help the organization better serve its defined population and the community; and

c. serves in an advisory capacity only and does not assume governing body or management responsibilities.


A list of Governing Body members, with brief bios, that includes qualifications per GOV 2.02 and 2.03


Stakeholder advisory group procedures (GOV 2.04)

Minutes of stakeholder advisory group meetings/ agendas/meeting schedule (GOV 2.04)

Interview: a. Governing Body b. Personnel

Network Interview: a. Members of stakeholder

advisory group


Criteria 6.B: Governance (Continued)


CCBHC Criteria




6.b.2

The CCBHC will describe how it meets this requirement or develop a transition plan with timelines appropriate to its governing board size and target population to meet this requirement.

GOV 6.05 The governing body’s responsibilities regarding the executive director include:

a. appointment of the executive director; b. collaboration with the executive director; c. delegation of the authority and

responsibility for organization management and policy implementation to the executive director;

d. oversight and annual evaluation of the executive director’s performance and compensation;

e. approval of the executive director’s employment activities outside of the organization to ensure they do not interfere with her/his administrative responsibilities;

f. development of a written plan for delegating authority in the absence of the chief executive officer and/or designating an interim chief executive officer, if necessary; and

g. evaluation of the effectiveness of its partnership with the executive director, at least every two years.


Governing Body and/or committee meeting minutes including record of policy decisions

Management letter from last two audits

Interview: a. Governing Body Chair b. CEO c. Governing Body d. CFO (GOV 6.04 and 6.05) e. Governing Body Treasurer (GOV

6.04 and 6.05) f. Management personnel (GOV

6.06)



6.b.3

To the extent the CCBHC is comprised of a governmental or tribal entity or a subsidiary or part of a larger corporate organization that cannot meet these requirements for board membership, the state will specify the reasons why the CCBHC cannot meet these requirements and the CCBHC will have or develop an advisory structure and other

GOV 2.04 Not-for-profit organizations that do not have a representative governing body, and networks, establish and maintain a stakeholder advisory group that serves as a bridge between the organization and the community and it:

a. includes representatives of relevant community groups, consumers, parents, service providers, advocates, and others



A list of Governing Body members, with brief bios, that includes qualifications per


CCBHC Criteria



(Tables of Evidence) specifically described methods for consumers, persons in recovery, and family members to provide meaningful input to the board about the CCBHC's policies, processes, and services.

with an interest in the success of the organization achieving its mission or purpose;



GOV 2.02 and 2.03





advisory group

6.b.4

As an alternative to the board membership requirement, any organization selected for this demonstration project may establish and implement other means of enhancing its governing body’s ability to insure that the CCBHC is responsive to the needs of its consumers, families, and communities. Efforts to insure responsiveness will focus on the full range of consumers, services provided, geographic areas covered, types of disorders, and levels of care provided.

GOV 4.02 The organization collaborates with community members and service recipients to advocate for issues of mutual concern consistent with the organization’s mission, such as:

a. making improvements to existing services and filling gaps in service;

b. the full and appropriate implementation of applicable laws and regulations regarding issues concerning the service population;

c. improved supports and accommodations for individuals with special needs;

d. addressing community-specific needs including cultural and linguistic diversity; and

e. service coordination. Interpretation: The standard requires the organization to actively advocate and work for the provision of a full array of community services, and to provide personnel with time to carry out advocacy activity. Advocacy activities comply with the legal and




Interview: a. Governing Body b. CEO

c. Program and clinical managers d. Community stakeholders e. Persons served


CCBHC Criteria



(Tables of Evidence) regulatory requirements governing such activities. The organization can work at several levels to advocate with, and on behalf of, persons, groups, and families served. Direct service personnel can advocate with persons and families served to solve problems related to their individual cases. Advisory board members, management, and other personnel, along with persons served, can engage in legislative and other system-wide advocacy activities. They also work collaboratively with other community organizations to monitor federal, state, and/or local activity that impacts the service population.



6.b.4

The state will determine if this alternative approach is acceptable and, if it is not, will require that additional or different mechanisms be established to assure that the board is responsive to the needs of CCBHC consumers and families. Each organization will make available the results of their efforts in terms of outcomes and resulting changes.

GOV 4.01 The organization conducts ongoing community outreach and education to: communicate its mission or purpose, role, functions, and capacities; provide information about the strengths, needs, and challenges of the individuals, families, and groups it serves; build community support and presence and maintain effective partnerships; and elicit feedback as to unmet needs in the community that can be addressed by the organization as its top advocacy priorities.






CCBHC Criteria




6.b.5

Members of the governing or advisory boards will be representative of the communities in which the CCBHC's service area is located and will be selected for their expertise in health services, community affairs, local government, finance and banking, legal affairs, trade unions, faith communities, commercial and industrial concerns, or social service agencies within the communities served. No more than one half (50 percent) of the governing board members may derive more than 10 percent of their annual income from the health care industry.

GOV 2: Governing Body and Community Representation The organization’s governing body is sufficiently active, capable, and diverse to guide, plan, and support the achievement of the organization’s mission and goals. GOV 2.01 The governing body sets a tone of responsible stewardship and ensures policies and performance uphold the public trust. GOV 2.02 The governing body:

a. reflects the demographics of the community it serves;

b. represents the interests of the community it serves; and

c. serves as a link between the organization and the public or community.

GOV 2.03 The governing body reflects:

a. governance expertise, including leadership ability and policy development skills;

b. relevant business experience; financial expertise; knowledge of consumer issues and trends; familiarity with and access to community leaders, political representatives and other relevant local organizations;

c. public recognition and respect; and commitment and ability to fundraise or to connect the organization with potential resources, as applicable.








advisory group


CCBHC Criteria



(Tables of Evidence) GOV 2.04 Not-for-profit organizations that do not have a representative governing body, and networks, establish and maintain a stakeholder advisory group that serves as a bridge between the organization and the community and it:

a. includes representatives of relevant community groups, consumers, parents, service providers, advocates, and others with an interest in the success of the organization achieving its mission or purpose;



Interpretation: The input and feedback provided by stakeholder advisory groups are vital to the functioning of a well-run organization. In order for advisory groups to function well the organization should:

a. establish clear and transparent recruitment and selection guidelines;

b. have reasonable expectations about what the group can accomplish within the parameters of its mission and available resources; and

c. actively consider and respond to the group’s input, feedback, or recommendations.


CCBHC Criteria



(Tables of Evidence) .

6.b.6

States will determine what processes will be used to verify that these governance criteria are being met.

RPM 1: Legal and Regulatory Compliance The organization possesses relevant licenses and complies with applicable federal, state, and local laws and regulations. Interpretation: The organization is expected to be familiar with all applicable, federal, state, and local legal and regulatory requirements. When necessary, the organization consults legal counsel to provide comprehensive necessary information regarding codes, regulations, licensure requirements, employment laws, and general guidance regarding legal compliance. Interpretation: The network management entity annually verifies that member organizations, subcontracting organizations, and independent practitioners meet the legal and regulatory requirements to provide the services that they provide on behalf of the network. Interpretation: Non profit credit counseling organizations are required to meet IRS 501 q regulations.










CCBHC Criteria




Criteria 6.C: Accreditation

6.c.1

CCBHCs will adhere to any applicable state accreditation, certification, and/or licensing requirements.








Interview: c. Governing Body d. CEO/CFO

6.c.2

States are encouraged to require accreditation of the CCBHCs by an appropriate nationally-recognized organization (e.g., the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities [CARF], the Council on Accreditation [COA], the Accreditation Association for Ambulatory Health Care



Provide a letter signed by the Governing Body Chair and CEO certifying the organization is presently in compliance with license requirements, regulations and decrees. Networks are to provide procedures for ensuring provider


CCBHC Criteria



(Tables of Evidence) [AAAHC]). Accreditation does not mean “deemed” status.

compliance with applicable licenses, regulations, and decrees for services provided by the network.






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