CCBHC Terms and Definitions

CCBHC Terms and Definitions Terms and definitions listed below are meant to provide guidance in understanding the CCBHC certification criteria. These terms and definitions are not intended to replace DMH definitions which are more specific, or, conversely which are more broadly defined. A. Agreement: As used in the context of CCBHC, care coordination is an arrangement between the CCBHC and external entities with which care is coordinated. Such an agreement is evidenced by a contract, Memorandum of Agreement (MOA), or Memorandum of Understanding (MOU) with the other entity, or by a letter of support, letter of agreement, or letter of commitment from the other entity. The agreement describes the parties’ mutual expectations and responsibilities related to care coordination. B. Behavioral health: Behavioral health is a general term that encompasses the promotion of emotional health; the prevention of mental illnesses and substance use disorders; and treatments and services for mental and/or substance use disorders. (Reference Source: Glossary of Terms and Acronyms for SAMHSA Grants – SAMHSA.) C. Care coordination: CCBHCs establish activities within their organization and with care coordination partners that promote clear and timely communication, deliberate coordination, and seamless transition. This may include (but is not limited to): 1. Establishing accountability and agreeing on responsibilities between care coordination partners. 2. Engaging and supporting people receiving services in, and subject to, appropriate consent, their family, and caregivers, to participate in care planning and delivery and ensuring that the supports and services that the person and family receive are provided in the most seamless manner that is practical. 3. Communicating and sharing knowledge and information, including the transfer of health records and prescriptions, within care teams and other care coordination partners, as allowable and agreed upon with the person being served. 4. Coordinating and supporting transitions of care that include tracking of admission and discharge and coordination of specific services if the person receiving services presents as a potential suicide or overdose risk. 5. Assessment of the needs and goals of the person receiving services to create a proactive treatment plan and linkage to community resources. 6. Monitoring and follow-up, including adapting supports and treatment plans as needed to respond to changes in the needs and preferences of people being served. 7. Coordinating directly with external providers for appointment scheduling and follow up after appointment for any prescription changes or care needs (i.e., “closing the loop”). 8. Communicating and sharing knowledge and information to the full extent permissible under HIPAA and ONC and CMS interoperability regulations on information blocking without additional requirements unless based on state law. As utilized in this context, care coordination applies to activities by CCBHCs that have the purpose of coordinating and managing the care and services furnished to each person receiving services as required by PAMA (including both behavioral and physical health care), regardless of whether the care and services are provided directly by the CCBHC or through referral or other affiliation with care providers and facilities outside the CCBHC. Care coordination is regarded as an activity rather than a service. D. Case management: Case management may be defined in many ways and can encompass services ranging from basic to intensive. The National Association of State Mental Health Program Directors (NASMHPD) defines case management as “a range of services provided to assist and support people in developing skills to gain access to needed medical, behavioral health, housing, employment, social, educational, and other services essential to meeting basic human services; linkages and training for people served in the use of basic community resources; and monitoring of overall service delivery.” E. Certified Community Behavioral Health Clinic (CCBHC) or Clinic: A CCBHC is a qualifying clinic that is responsible for providing all nine (9) services in a manner that meets or exceeds CCBHC criteria described in the CCBHC standards. The qualifying clinic may deliver the nine (9) required services directly or through formal agreements with DCOs. F. CCBHC directly provides: When the term, “CCBHC directly provides” is used within these criteria, it means employees or contract employees within the management structure and, under the direct supervision of the CCBHC, deliver the service. G. Community Needs Assessment: A systematic approach to identifying community needs and determining program capacity to address the needs of the population being served. DMH requires CCBHCs to conduct a county-level Community Needs Assessment survey every two (2) years. DMH will secure a third-party vendor to develop a survey tool with input from the Community Stakeholder Engagement Committee and the Community Mental Health Center (CMHC) Association. The survey will be sent to CCBHCs for distribution according to the DMH CCBHC Community Needs Assessment distribution guidelines. The results will be gathered and distributed to the CCBHCs to meet their Community Needs Assessment Requirements. 1. The CCBHC community needs assessment is comprised of the following elements: (a) A description of the physical boundaries and size of the service area, including identification of sites where services are delivered by the CCBHC, including through DCOs. (b) Information about the prevalence of mental health and substance use conditions and related needs in the service area, such as rates of suicide and overdose. (c) Economic factors and social determinants of health affecting the population’s access to health services, such as percentage of the population with incomes below the poverty level, access to transportation, nutrition, and stable housing. (d) Cultures and languages of the populations residing in the service area. (e) The identification of the underserved population(s) within the service area. (f) A description of how the staffing plan does and/or will address findings. (g) Plans to update the community needs assessment every two (2) years. 2. CCBHC Community Needs Assessments gather input regarding: (a) Cultural, linguistic, physical health, and behavioral health treatment needs. (b) Evidence-based practices and behavioral health crisis services. (c) Access and availability of CCBHC services including days, times, and locations, and telehealth options. (d) Potential barriers to care such as geographic barriers, transportation challenges, economic hardship, lack of culturally responsive services, and workforce shortages. 3. Community Needs Assessment input should come from the following entities if they are in the CCBHC service area: (a) People with lived experience of mental and substance use conditions and people who have received/are receiving services from the clinic conducting the needs assessment. (b) Health centers (including FQHCs in the service area). (c) Local health departments (Note: these departments also develop community needs assessments that may be helpful). (d) Inpatient psychiatric facilities, inpatient acute care hospitals, and hospital outpatient clinics. (e) One or more Department of Veterans Affairs facilities. (f) Representatives from local K-12 school systems. (g) Crisis response partners such as hospital emergency departments, emergency responders, crisis stabilization settings, crisis call centers and warmlines. 4. CCBHCs must engage with other community partners, especially those who also work with people receiving services from the CCBHC and populations that historically are not engaging with health services, such as: (a) Organizations operated by people with lived experience of mental health and substance use conditions. (b) Other mental health and SUD treatment providers in the community. (c) Residential programs. (d) Juvenile justice agencies and facilities. (e) Criminal justice agencies and facilities. (f) Indian Health Service or other tribal programs such as Indian Health Service youth regional treatment centers as applicable. (g) Child welfare agencies and state licensed and nationally accredited child placing agencies for therapeutic foster care service. (h) Crisis response partners such as hospital emergency departments, crisis stabilization settings, crisis call centers and warmlines. (i) Specialty providers of medications for treatment of opioid and alcohol use disorders. (j) Peer-run and operated service providers. (k) Homeless shelters and housing agencies. (l) Employment services systems. (m) Services for older adults, such as Area Agencies on Aging. (n) Aging and Disability Resource Centers. (o) Other social and human services (e.g., domestic violence centers, pastoral services, grief counseling, Affordable Care Act navigators, food, and transportation programs). H. Cultural and linguistic competency: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse consumers. (Reference Source: Cultural Competency - The Office of Minority Health). I. Designated Collaborating Organization (DCO): A DCO is an entity that is not under the direct supervision of the CCBHC but is engaged in a formal relationship with the CCBHC to deliver one (1) or more (or elements of) of the required services. CCBHC services provided through a DCO must conform to the relevant applicable CCBHC criteria. The formal relationship is evidenced by a contract, Memorandum of Agreement (MOA), Memorandum of Understanding (MOU), or such other formal, legal arrangements describing the parties’ mutual expectations and establishing accountability for services to be provided and funding to be sought and utilized. The formal relationship between CCBHCs and DCOs creates the platform for seamlessly integrated services delivered across providers under the umbrella of a CCBHC. DCO agreements shall include provisions that assure that the required CCBHC services that DCOs provide under the CCBHC umbrella are delivered in a manner that meets the standards set in the CCBHC certification criteria. To this end, DCOs are more than care coordination or referral partners, and there is an expectation that relationships with DCOs will include more regular, intensive collaboration across organizations than would take place with other types of care coordination partners. From the perspective of the person receiving services and their family members, services received through a DCO should be part of a coordinated package with other CCBHC services and not simply accessing services through another provider organization. To this end, the DCO agreement shall take active steps to reduce administrative burden on people receiving services and their family members when accessing DCO services through measures such as coordinating intake process, coordinated treatment planning, information sharing, and direct communication between the CCBHC and DCO to prevent the person receiving services or their family from having to relay information between the CCBHC and DCO. CCBHCs and their DCOs are further directed to work towards inclusion of additional integrated care elements (e.g., including DCO providers on CCBHC treatment teams, collocating services). Regardless of DCO relationships developed, the CCBHC maintains responsibility for assuring that people receiving services from the CCBHC receive all nine (9) services as needed in a manner that meets the requirements of the CCBHC certification criteria. To the extent that services are needed by a person receiving services or their family that cannot be provided by either the CCBHC directly or by a DCO, referrals may be made to other providers or entities. The CCBHC retains responsibility for care coordination including services to which it refers consumers. Payment for those referred services is not through the PPS but is made through traditional mechanisms within Medicaid or other funding sources. J. Engagement: Engagement includes a set of activities connecting people receiving services with needed services and supporting their retention services. This involves the process of making sure people receiving services and families are informed about and can access needed services. Activities such as outreach and education can serve the objective of engagement. Conditions such as accessibility, provider responsiveness, availability of culturally and linguistically competent care, and the provision of quality care also promote persons receiving services engagement. K. Family: Involvement of families of both adults and children receiving services is important to treatment planning, treatment, and recovery. Families come in different forms and, to the extent possible, the CCBHC should respect the person’s view of what constitutes their family. Families can be organized in a wide variety of configurations regardless of social or economic status. Families can include biological parents and their partners, adoptive parents and their partners, foster parents and their partners, grandparents and their partners, siblings and their partners, extended family members, care givers, friends, and others as defined by the person. The CCBHC respects the view of what constitutes the family of the person receiving services. L. Family-centered: The Health Resources and Services Administration defines family- centered care, sometimes referred to as “family-focused care,” as “an approach to the planning, delivery, and evaluation of health care whose cornerstone is active participation between families and professionals. Family-centered care recognizes families are the ultimate decision-makers for their children, with children gradually taking on more and more of this decision-making themselves as developmentally appropriate. When care is family-centered, services not only meet the physical, emotional, developmental, and social needs of children, but also support the family’s relationship with the child’s health care providers and recognize the family’s customs and values.” Family-centered services should be both developmentally appropriate and youth guided. M. Formal relationships: As used in the context of scope of services and the relationships between the CCBHC and DCOs, a formal relationship is evidenced by a contract, Memorandum of Agreement (MOA), Memorandum of Understanding (MOU), or such other formal arrangements describing the parties’ mutual expectations and establishing accountability for services to be provided and payment to be sought and utilized. This formal relationship does not extend to referrals for services outside either the CCBHC or DCO, which are not encompassed within the reimbursement provided by the PPS. N. Health Information Exchange (HIE): The electronic movement of health-related information among organizations according to nationally recognized standards. The Mississippi Hospital Association (MHA) implements the statewide Mississippi HIE. O. Home and Community Based Services (HCBS): Provide opportunities for Medicaid beneficiaries to receive services in their own home or a community setting rather than moving to a facility for care or other isolated settings. These programs provide person- centered services to people with intellectual or developmental disabilities. P. Limited English Proficiency (LEP): LEP describes a characteristic of people who do not speak English as their primary language or who have a limited ability to read, write, speak, or understand English and who may be eligible to receive language assistance with respect to the service, benefit, or encounter. Q. Lived Experience: People with lived experience are persons directly impacted by a social issue or combination of issues who share similar experiences or backgrounds and can bring the insights of their experience to inform and enhance systems, research, policies, practices, and programs that aim to address the issue(s). R. Measurement-Based Care: For purposes of these criteria, measurement-based care (MBC) is the systematic use of patient-reported information to inform clinical care and shared decision-making among clinicians and patients and to individualize ongoing treatment plans. S. Peer Support Provider: A self-identified person (or family member of a person) is a person who uses their lived experience of recovery from mental or substance use disorders or as a family member/caregiver of such a person, plus skills learned in formal training, to deliver services to promote recovery and resiliency. T. Peer Support Service: Peer Support Services are non-clinical activities with a rehabilitation and resiliency/recovery focus that allow people receiving mental health services and substance use services and their family members the opportunity to build skills for coping with and managing psychiatric symptoms, substance use issues and challenges associated with various disabilities while directing their own recovery. Peer support may be provided in behavioral health, health, and community settings (e.g., mobile crisis outreach, psychiatric rehabilitation, outpatient mental health/substance use treatment, emergency rooms, wellness programs, peer-operated programs). Peer Support is a helping relationship between peers and/or family member(s) that is directed toward the achievement of specific goals defined by the person. Peer Support Services are provided by a Certified Peer Support Specialist Professional. U. Person or People Receiving Services: Within the CCBHC standards, person or people receiving services refers to people of all ages (i.e., children, adolescents, transition age youth, adults, and older adults) who are receiving services. In many places in the Certification Criteria, the person receiving services has a role in directing, expressing preferences, planning, and coordinating services. In these situations, when there is a legal guardian for the person receiving services, these roles shall also be filled by the legal guardian. V. Person-Centered Care: Person-Centered Care is aligned with the requirements of the applicable section of the Patient Protection and Affordable Care Act, as implemented by the Department of Health and Human Services. This guidance defines “person-centered planning” as a process directed by the person with service needs which identifies recovery goals, objectives, and strategies. If the person receiving services wishes, this process may include a representative whom the person has freely chosen, or who is otherwise authorized to make personal or health decisions for the person. Person-centered planning also includes family members, legal guardians, friends, caregivers, and others whom the person wishes to include. Person-centered planning involves the person receiving services to the maximum extent possible. Person-centered planning also involves self-direction, which means the person receiving services has control over selecting and using services and supports, including control over the amount, duration, and scope of services and supports, as well as choice of providers. W. Practitioner or Provider: Any individual (practitioner) or entity (provider) engaged in the delivery of health care services and who is legally authorized to do so by the state in which the individual or entity delivers the services. X. Recovery: A process of change through which people improve their health and wellness, live a self-directed life, and strive to reach their full potential. Y. Recovery-oriented care: Recovery-oriented care is oriented toward promoting and sustaining a person's recovery from a behavioral health condition. Care providers identify and build upon everyone’s assets, strengths, and areas of health and competence to support the person in managing their condition while regaining a meaningful, constructive sense of membership in the broader community. Z. Required services: The nine (9) service areas identified in PAMA, which CCBHCs must provide to people receiving services based on their needs: (1) Crisis Services; (2) Screening, Assessment, and Diagnosis; (3) Person-Centered and Family-Centered Treatment Planning; (4) Outpatient Mental Health and Substance Use Services; (5) Primary Care Screening and Monitoring; (6) Targeted Case Management Services; (7) Psychiatric Rehabilitation Services; (8) Peer Supports and Family/Caregiver Supports; and (9) Community Care for Uniformed Service Members and Veterans. AA.Satellite Facility: A satellite facility of a CCBHC is a facility that is established by the CCBHC, operated under the governance and financial control of that CCBHC, and provides the following services: crisis services; screening, diagnosis, and risk assessment; person and family-centered treatment planning; and outpatient mental health and substance use services as specified in CCBHC certification criteria. For CCBHCs participating in the Section 223 Demonstration only, the Protecting Access to Medicare Act of 2014 stipulates that “no payment shall be made to a satellite facility of a CCBHC established after April 1, 2014, under this Demonstration.” This definition does not limit the provision of services in non-clinic settings such as shelters and schools or at other locations managed by the CCBHC that do not meet the definition of a satellite facility. BB.Shared Decision-Making (SDM): Shared decision-making is a best practice in behavioral and physical health that aims to help people in treatment and recovery have informed, meaningful, and collaborative discussions with providers about their health care services. It involves tools and resources that offer objective information upon which people in treatment and recovery incorporate their personal preferences and values. Shared decision- making tools empower people who are seeking treatment or in recovery to work together with their service providers and be active in their own treatment. (Reference Source: Substance Abuse and Mental Health Services Administration. Shared Decision-Making Tools - SAMHSA). CC.Sliding Fee Scale: Sliding scale fees are fees for services that are adjusted depending on a person’s income to allow for fairness and to address income inequality. DD.Trauma-informed: A trauma-informed approach to care realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in people receiving services, their families, staff, and others involved in the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization. The six (6) key principles of a trauma-informed approach include: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical and gender issues. EE.Underserved people and populations: This group includes communities as defined in the Federal Register: as well as people or populations that have unmet needs for mental health and substance use disorder treatment and supports.