CCBHCs can leverage quality data under new certification criteria

Certified Community Behavioral Health Clinics (CCBHCs) are working to meet timelines for compliance with new certification criteria based on their CCBHC expansion grant status and state demonstration pilot requirements.

Revised certification criteria was issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) in March 2023.

The revisions require new and enhanced clinic-collected quality outcomes measurement reporting, as well as the elimination of some previously required measures.

Technical specifications detailing the collection, calculation and reporting of these quality measures were outlined in the 2023 CCBHC Quality Measures Technical Specification Manual published in September of 2023.

Revisions include:

Required use of a Social Determinants of Health Screening Tool (SDOH) Changes to the collection timeframes of depression remission (DEP-REM-6) from one year to six months
New I-SERVE measurement including the I-EVAL measure, which measures the number of days between a new request for services and an initial evaluation, the number of days between first contact to first service and the measurement of response time for requests for crisis services
Clarification and separation of requirements for the Depression Screening and Follow-up measure (CDF-BH), creating one measure for adults and one for adolescents

Optional certification measures

Revised certification criteria have listed several quality outcomes measures as “Optional Measures.” They are:

Tobacco Use: Screening & Cessation (TSC)
Suicide Risk Assessment (SR-a and SRA-C)
Weight Assessment and Counseling (WCC-CH)

These measures were previously required for reporting and may still be required as part of a specific state’s demonstration pilot.

State demonstration pilot sites were established under the Protecting Access to Medicare Act of 2014 (PAMA, P.L. 113-93), Section 223, also known as the “Excellence in Mental Health Act.” Requirements may vary among these pilot sites. Timelines and requirements of collection of additional measures will be determined by a specific state’s guidance documents.

Data collection, calculation and reporting

Since the Technical Specifications Manual has been issued, SAMHSA has published revised timelines for clinics with CCBHC Planning, Development, and Implementation (PDI) and Improvement and Advancement (IA) grants to be in compliance with collection, calculation, and reporting requirements.

This will not be a simple task, as the data reporting, calculating and reporting is required for all required measures:

Time to Services (I-SERV)
Depression Remission at Six Months (DEP-REM-6)
Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling (ASC) (omitted preliminarily)
Screening for Social Drivers of Health (SDoH)
Screening for Clinical Depression and Follow-Up Plan (CDF-Ad and CDF-CH)

Important timeframes for look-back periods

Revisions to quality outcome measures will require considerable preparation and potential changes to data collection tools and workflow. This is why published timelines specify 2025 as the year reporting will begin for CCBHC PDI and IA grants. Specifically, the submission of outcome data reporting will begin in the measurement year of January 1, 2025 – December 31, 2025.

It is important to note, however, that because some of the measures include look-back periods, collecting the data required for the five outcome measures should commence no later than July 1, 2024.

Data collection, calculation and reporting of the quality outcome measures involve both clinical (activity dates/ times, screening tools and diagnosis) and administrative (demographic, coverage type, and claims) data that may currently be available in the clinic’s electronic health record, billing system or a combination of both. Readiness to collect, calculate and report on these measures may require changes to a clinic’s workflows, business processes and/or electronic medical record or other electronic scheduling or billing system.

Agencies may have multiple CCBHC clinics subject to different requirements based on each clinic’s funding status (PDI, IA or State Pilot), and some clinics may be utilizing a variety of electronic and manual (non-electronic) methods of collecting and calculating the measures.

SimiTree helps with data collection, calculation, and reporting

SimiTree’s clinical consultants, compliance experts, and data analysts work with all types of behavioral health providers, including CCBHCs, to provide guidance and support in standardized methods of collecting, calculating, and reporting the required quality outcomes within the specified timelines. This guidance goes one step further in working with clinics to leverage quality outcomes data to improve care, streamline workflow and drive performance.

If you’re looking for ways to improve service delivery, streamline workflow, identify innovative ideas for improved clinical delivery, and/or develop enhanced analytics and business intelligence, be sure to join two of our topnotch educators for a complimentary webinar Feb. 20.

Complimentary webinar

Kathy Dettling, VP of Clinical Strategy, and Melanie Elliott, PhD, VP of Analytics Strategy, will present a complimentary webinar to offer actionable insight to CCBHCs looking to get the most out of quality reporting under new CCBHC criteria.

They’ll explain the changes in criteria, and offer tips to make quality reporting more than a routine compliance chore. They’ll help you more effectively use the data your organization is tracking, by putting it to work on multiple levels.

“Are You Ready for the New CCBHC Measures?” begins at Noon EST on Tuesday, Feb. 20.

Next week: What your organization needs to know about Medicare’s new SDoH assessment billing code.

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J’non Griffin serves as Senior Vice President for the Compliance as well as Coding divisions at SimiTree. With a healthcare career that spans three decades, she has a track record of helping many provider types implement effective compliance programs. She has worked with organizations nationwide to develop compliant emergency preparedness and operation plans, implement fully compliant plans of care, and meet regulatory demands. As an AHIMA ambassador, Griffin was instrumental in preparing the coding community for the launch of ICD-10.