Last month, we started to discuss Certified Community Behavioral Health Centers (CCBHCs). Among the goals of developing CCBHCs is the ability to improve access and outcomes, both of which require access to timely, information – in other words sophisticated and integrated data systems. For many traditional community mental health and substance use treatment centers, adoption of technology and data collection more specifically has been a challenge. Electronic health record adoption, for example, has been slower in behavioral health that in other healthcare sectors. In the ContinuumCloud technology survey earlier this year, many organizations conceded that they were not maximizing the potential of their existing technologies and not all had HRIS or EHRs. So, increasing demands for measurement and data aggregation will pose a significant barrier to full CCBHC implementation. This month we will look at the various issues the model will pose for organizations wanting to meet the CCBHC standards (the last blog had a link to the current standards).
The CCBHC standards include human resource tracking, process tracking, and outcome measurement. The aspirational aspect of CCBHCs also includes a transition to measurement-based care and shared decision-making. CCBHCs need to track staff credentials and be able to ensure that staff providing care are qualified, sufficient in number, and trained to provide specialized services based on EBPs. Organizations will be required to track not just staff and positions, but credentials, aggregating license/certification information and training in specific EBPs relevant to their work assignment. Furthermore, that information will have to link to the electronic health record to ensure that only credentialed and trained staff are assigned to a treatment team for specific clients. Clearly, HRIS and EHRs will have to be able to interface so that credentialing information can flow smoothly from one to the other.
Timely Access to Care
Another set of standards for CCBHCs deals with ensuring prompt access to care. Research has shown that delays in access are a significant driver of poor outcomes and a significant challenge across the country. One of the explicit goals of CCBHCs is improving time from first contact to initiation of treatment. There are subtleties with this measure affecting how accurately the timeframe is measured. Access is often characterized as “time to first” – but which time what first? Does the clock start ticking at the time a third-party (school, doctor, etc.) referral is made? Is it when the client first calls or walks in requesting services? Is a screening a “first” when the first counseling session is weeks away or a doctor visit is months away? Or, is first counted as the first actual treatment contact?
In addition, improving access to care will likely require that other processes be made more efficient. Scheduling practices, management of follow-up appointments, determining most effective services for a particular client will likely be processes that need improvement and, thus, must be measured. This will require data definition to ensure consistency and the ability to capture data from an EHR and translate that data into information that is clear and actionable for process redesign.
Outcome measurement, and relatedly measurement-based treatment, have long eluded behavioral health. Partly, this is due to the lack of concrete measures – there is no blood test or X-ray that makes for diagnostic clarity. The DSM only goes so far, and most patients meet the criteria for several different diagnoses. Outcomes depend on proxy measures such as symptom checklists, functional assessments, and patient and/or caregiver report. Reimbursement practices by third party payers often make incorporating those measures impractical because there is no reimbursement for the administration or interpretation of the results. CCBHCs prospective payment (only for the original projects) and grant-funded CCBHCs address this, but third-party payers have not. Most EHRs include many assessment tools, and many allow for the client to complete the instruments on a tablet to through a portal. The results can be reported and trended over time to reflect progress in treatment, or changes to the therapeutic relationship that signal the need to re-evaluate the treatment plan. A CCBHC will need to report on these measures and to do so at the client, clinician, program, and aggregate level to fully understand and communicate their impact at the patient and population level.
Still, the struggle to integrate these measures into treatment requires more than reporting. Clinicians have to become skilled at integrating these measures into how they practice and into their interactions with clients. This change may well require additional training and support for clinicians who have long “followed their gut” or used scripted treatment protocols rather than using diagnostic or outcome tools. EHRs and information systems, then, will need to ensure that the results of these clinical tools are visible to clinicians and patients in ways that are actionable and easily used to guide treatment. To be effective, measurement-based care also leads to shared decision-making wherein the clinician’s expertise and the client’s needs and wishes are determinative of how treatment proceeds.
The Path Forward for CCBHCs
In sum, the CCBHC model has the potential to improve outcomes for patients through better access and better practice. Getting there will require new skill sets and integrated information systems that facilitate the deployment of human resources and the utilization and integration of measurement all along the treatment process.
This is the second in a three-part blog series examining the CCBHC model, requirements, and cultural shifts that are leading to progress in service delivery and outcomes. View part 1, CCBHC: Promise and Challenges, and part 3, CCBHC and Culture: There and Back Again to learn more.
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