CCBHC Readiness: Updates and Strategies to Prepare for Implementation

1. CCBHC Readiness: Updates and Strategies to Prepare for Implementation Rebecca C. Farley, MPH National Council for Behavioral Health

2. The Vision Certified Community Behavioral Health Clinics • Improve overall health by bolstering community-based mental health and addiction treatment • Advance behavioral health care to the next stage of integration with physical health care • Assimilate and utilize evidence-based practices on a more consistent basis

3. What makes CCBHCs so different? • New provider type in Medicaid • Distinct service delivery model: trauma-informed recovery outside the traditional four walls • New prospective payment system (PPS) methodology • Care coordination and service delivery requirements necessitate new relationships with partner entities

4. Your CCBHC Guidebook… The SAMHSA CCBHC criteria: http://www.samhsa.gov/sites/default/files/programs_campaigns/ccbhc-criteria.pdf

5. Today’s Agenda • Current CCBHC implementation activities in the states • Key readiness steps and current decision points for providers • Discussion: prioritizing your efforts

6. Current CCBHC Activities in the States

7. Timeline SAMHSA has granted a 6-month extensionfor states that are selected to participate in the demonstration • The demonstration start date may be between Jan. 1 and July 1, 2017

8. Community Needs Assessment • State conducts community needs assessment • Identified needs inform: • Required CCBHC services • Evidence-based practices • Cultural/linguistic competency requirements • Staffing requirements

9. CCBHC Certification • State develops CCBHC selection process • Training and technical assistance provided to CCBHCs or potential CCBHCs • CCBHCs plan for & expand service array • Establish DCO relationships • Establish care coordination relationships • Bring on (or plan for) new service capacity to meet required services

10. CCBHC Rate Setting • State selects PPS-1 or PPS-2 • State decides how to address quality bonus payments (optional for PPS-1, required for PPS-2) • For PPS-2, state decides how to address outliers and special populations • CCBHCs prepare cost report • May include actual and anticipated costs • CCBHCs work with state to set rates

11. Application and Program Start • State applies to participate by October 31, 2016 • Selected states notified by Jan. 2017 • Selected states have an additional 6 months to prepare for and begin their demonstration

12. Key Readiness Steps for Providers

13. Readiness Steps: Educating and Reorganizing the Workforce • Educating boards around governing change and opportunities • Preparing the C-suite • Educating and expanding management and supervision capacity • Staff training plan & implementation

14. Decision Point: Board Governance • Governing board must have “meaningful participation” by those served • How will you meet this criteria? • 51% consumer representation? • Other? • Talk to your board about these changes • Educate and enlist the C-suite

15. Decision Point: Staffing • What staff do you already have on board? What staff do you need to hire? What staff do you need to reassign? • Staffing plan must include: • Medicaid-enrolled providers who are credentialed, certified, and/or licensed as determined by the state • Substance abuse specialists • Staff with trauma expertise • Staff with expertise in child & teen care • A medical director who is a psychiatrist • Culturally competent providers, including for veterans/military • And more… • CCBHCs must have a staff training plan

16. Readiness Steps: Clinical Excellence • Expanding clinical services • Managing clinical relationship w/ DCOs • Adapting clinical workflow & caseloads in alignment with quality reporting standards, required CCBHC service array, etc.

17. States have flexibility: • In establishing scope of required services • Informed by community needs assessment • In establishing treatment modalities • Use of telehealth, online treatment platforms, remote monitoring, etc. • In determining what constitutes a patient “visit” vs. what activities are not a visit but are built into the payment rate • Your readiness preparation must be informed by states’ decisions on these issues!

18. Decision Point: Scope of Services Must be delivered directly by CCBHC Delivered by CCBHC or a Designated Collaborating Organization (DCO)

19. Decision Point: Availability & Accessibility • What steps will you take to meet access requirements? • Access required at times and places convenient for those served • This includes weekend and evening hours • Prompt intake and engagement in services • Access regardless of ability to pay (sliding scale fees) and place of residence • Crisis management services available 24 hours per day

20. Decision Point: Service Locations & Modalities Services are not confined to delivery within the 4 walls of a clinic • Think creatively! • In-home services for newly placed foster youth? • Post-booking assessment in jails? • Outreach to homeless populations? • Innovative treatment modalities? • Identify the impact on your rate…

21. Readiness Steps: Environmental Readiness • CCBHC readiness assessment • Negotiating DCO contracts • Care coordination partnerships • Other community partnerships • Communications with state agencies, associations, payers and providers

22. Decision Point: Establishing Contracts with DCOs • What DCO relationships will you develop? • Keep in mind: • CCBHC maintains clinical and financial responsibility for care furnished by DCOs • Payment for DCO services included within scope of CCBHC PPS rate • CCBHC must serve as the Medicaid billing provider for DCO services

23. What does it mean for the CCBHC to be clinically responsible for DCOs? CCBHC ensures that services rendered by DCOs: • Meet cultural competency requirements • Are reflected in data reported by CCBHC • Meet SAMHSA CCBHC standards for accessibility of services (application of sliding fee scale; no denial of services based on ability to pay, regardless of insurance status; services rendered within specified time period after appointment request) • Meet all relevant SAMHSA program requirements applicable to the specific contracted service • Are rendered in keeping with State law, e.g., each clinician is acting within the scope of his/her license/certification and applicable supervision requirements are met

24. What does it mean for the CCBHC to be financially responsible for DCOs? The CCBHC: • Bears financial risk for collection of patient out-of-pocket liability (fees and cost-sharing) for CCBHC services rendered by DCO • Bears legal responsibility for coordination of benefits for services rendered by DCO • Is responsible for ensuring that DCO-related costs are included in CCBHC Medicaid cost report • Is responsible for billing Medicaid for services furnished by DCOs

25. DCO Contracting Considerations Does the DCO contract: • Establish fair market value for clinical services and other services rendered by DCO? • Require DCO to adhere to policies and protocols re: communication with CCBHC to improve patient care? • Require the DCO to observe all CCBHC requirements in delivering care? • Impose penalties on the DCO for care furnished in noncompliance with CCBHC service requirements, or require DCO to indemnify CCBHC against liability associated with noncompliance?

26. DCO Considerations, cont. Does the DCO contract: • Contain provisions for the DCO to indemnify the CCBHC for risks associated with the DCO relationship, such as malpractice liability or government audits or penalties? • Contain provisions to ensure protection of patient privacy? • Specify any obligations with respect to coordination of benefits to be delegated by the CCBHC to the DCO? • Specify how CCBHC will ensure that CCBHC consumers accessing DCO care are offered sliding fee discount?

27. Decision Point: Care Coordination Relationships • Partnerships or care coordination agreements required with: • FQHCs/rural health clinics • Inpatient psychiatry and detoxification • Post-detoxification step-down services • Residential programs • Other social services providers, including • Schools • Child welfare agencies • Juvenile and criminal justice agencies and facilities • Indian Health Service youth regional treatment centers • Child placing agencies for therapeutic foster care service • Department of Veterans Affairs facilities • Inpatient acute care hospitals and hospital outpatient clinics

28. Readiness Steps: Calculating and Reporting Costs • Understanding Medicaid PPS-reimbursement • Determining cost allocation plans • Strategy and structure for collecting and reporting costs

29. CCBHC Payment Establishment of a Prospective Payment System

30. What is a PPS… and what is it not? • Same rate is paid for each qualifying unit of service, regardless of the intensity of services provided • PPS is NOT cost reimbursement • Bears a rational relationship to the provider’s costs • May not equal costs for a given year and is not subject to cost settlement at the end of the year • States may choose to rebase in year 2 • You might be stuck with your rate – so get it right the first time!

31. PPS-2 Guidelines • CCBHCs receive afixed monthly reimbursement for each individual who has at least one visit in the month • CCBHCs do NOT get paid in months when the patient does not receive any services • Allows CCBHCs to establish separate reimbursement rates for distinct populations • E.g. adults with serious mental illness, children and youth with serious emotional disorders, individuals with serious substance use disorders, etc. • Must implement a quality bonus payment system • Must create a system for “outlier payments”

32. Decision Point: Rate Setting for Special Populations • CCBHCs must calculate a different rate for the general CCBHC patient population and each special population: Total allowable costs of providing services to population Payment rate for each unduplicated monthly visit Total number of unduplicated monthly visits each year

33. What goes into the numerator? • “Allowable costs” for the population (either general CCBHC population or special subpopulation) • Costs related to CCBHC services • Includes overhead, indirect costs • Includes anticipated costs • Does NOT include non-CCBHC services • ALL allowable costs for that population are included (not just for Medicaid-covered patients)

34. What goes into the denominator? • “Unduplicated monthly visits” for the population (either general CCBHC population or special subpopulation) • This is not a per-member per-month rate! • ALL unduplicated monthly visits are included (not just Medicaid patients) • Your state defines what constitutes a “visit” • E.g. in-person encounter with clinician • Telehealth encounter? Call to crisis line? Other?

35. When is a payment triggered? • Payment is only received for CCBHC patients who are covered under Medicaid… • …When that patient has a qualifying visit • This includes DCO visits

36. How does the rate change over time? • PPS rates are typically trended forward from year to year based on an inflation factor such as the Medicare Economic Index (MEI) • Creates incentive for provider to provide care efficiently • States have the option to rebase during demonstration year 2

37. Additional CMS Guidelines • PPS rates are CCBHC-specific • Within a CCBHC, they can be organization-wide or site-specific • CCBHCs will be required to develop annual cost reports • The cost of DCO services is included in the CCBHC prospective payment rate, and DCO encounters are treated as CCBHC encounters for purposes of the prospective payment.

38. Decision Point: Cost Report Preparation • Assemble your team • Develop a plan and timetable • Know the regulations • Compile all required records • Keep and provide all backup supporting statistical records

39. Decision Point: Reporting Actual vs. Anticipated Costs • Anticipated costs are additional costs for services needed to be a CCBHC • Costs expected to increase as a result of offering CCBHC services • Allowed only in Demonstration Year 1 • What costs of becoming a CCBHC can be taken on in the base year (i.e. before Oct.) and what must be included as “anticipated”? • What steps will you take after certification to ensure anticipated costs are actually incurred?

40. Get it Right! • Why Get it Right? • You may have to live with the rate you establish • When setting your rate consider: • Budgeting for growth • Potential new staffing requirements • New documentation or collaboration requirements

41. Quality Measures Required Measures for Quality Bonus Payments • Follow-Up after Hospitalization for Mental Illness (adult age groups) • Follow-Up after Hospitalization for Mental Illness (child/adolescents) • Adherence to Antipsychotics for Individuals with Schizophrenia • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment • Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

42. Quality Measures Eligibile Measures for Quality Bonus Payments • Follow-Up Care for Children Prescribed Attention Deficit Hyperactivity Disorder (ADHD) Medication • Screening for Clinical Depression and Follow-Up Plan • Antidepressant Medication Management • Plan All-Cause Readmission Rate • Depression Remission at Twelve Months-Adults

43. Outlier Payments • States establish threshold over which service costs excluded (e.g., $10,000 annually per patient; three standard deviations above average costs) • “Outlier” costs segregated; states make payments equaling a portion of outlier costs • Significant State discretion – watch for guidance

44. More PPS-2 Key Decision Points • How will you identify costs for groups of patients with specific conditions? • How will your state establish the outlier threshold, and how will you collect and report costs in accordance with those requirements? • What data/system changes do you need to put in place to produce required cost report elements by condition level?

45. Readiness Steps: Calculating and Reporting Costs, cont. • Managing the financial arrangements with DCOs • Developing sliding fee schedules • Compliance issues under cost-based reimbursement • Payroll reporting and tracking

46. How do I prioritize my efforts?

47. Questions? Rebecca FarleyDirector, Policy and AdvocacyRebeccaF@thenationalcouncil.org http://www.thenationalcouncil.org/topics/certified-community-behavioral-health-clinics/