CBHC Site Leadership Staff-site interview

ATTACHMENT A

Site Interview Protocol
Ccbhc Leadership

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site visit Interview questions- ccbhc leadership

On-site interviews will be conducted with program leadership, providers, and administrative staff from CCBHC demonstration sites in 4 states. The interviews will address specific factors that shape CCBHC policies, and will be tailored based on the information already gathered through applications and other sources—or gaps in that information—regarding participating sites’ program characteristics. The interviewer will transfer the information gathered from the interviews into a Debrief Template that organizes data by criteria domain and corresponding research questions. The general protocol for site visit interviews with CCBHC leadership is presented below.

A. Introduction

1. We would like to learn about your current role/position.

a. For how long have you held this position?

b. What are your key responsibilities in the CCBHC?

c. If you were at this agency prior to CCBHC certification, how has your role changed with CCBHC certification?

B. CCBHC characteristics

1. Please describe your organization [questions will be tailored to reflect information gathered from demonstration applications and other sources]:

a. What type of organization is your CCBHC? (e.g., non-profit, local government, Indian Health Service, etc.)?

Probe for:

-Prior to CCBHC certification, was your clinic a FQHC? RHC? Provider-based clinic owned by a hospital? Other? [If other, describe.]

b. Is your organization part of a larger health-care system or regional network?

• If yes, how does larger system influence CCBHC policies?

c. What location/geographic region(s) does your CCBHC serve?

• Urban/rural/highly rural/frontier and remote [note: categories refer to federal definitions]?

d. How many unique clients does your organization serve (e.g., per year)?

e. Please describe your client demographics

• Percent of clients under age 18? Over age 65?

• Percent of clients experiencing homelessness?

f. Please describe your client population (e.g., case mix; common problems/types of diagnoses; co-occurring disorders).

• Percent of clients with serious mental illness or serious emotional disturbance? Adults vs. children (<18 years)?

• Percent of clients with substance use disorder? Adults vs. children (<18 years)?

• Percent of clients who are armed service members or veterans? Adults vs. children (<18 years)?

• Percent of clients who are dually eligible or enrolled (Medicare/Medicaid)?

g. Please describe your CCBHC’s facility (e.g., size and space, number of locations)

h. Please describe the socio-demographics of the area/community where the CCBHC is located

2. What are the major differences between the way that CCBHCs are administered and the way non-CCBHC community behavioral health clinics (e.g., CMHCs) are administered in your state?

3. What are some things that make your CCBHC unique or different from other behavioral health organizations in your area?

a. What is unique about your client population (e.g., healthcare needs, barriers to care, types of diagnoses, demographics, etc.)?

b. Are there any unique programs, services, or other resources that are geared specifically toward the types of clients that you serve?

C. Staffing

1. Please describe the structure of your CCBHC management team.

a. Does the team include a designated CCBHC CEO/Executive Director/Project Director? Psychiatrist as Medical Director?

b. How many non-clinical and clinical staff are part of your management team?

2. Does the staff composition of your CCBHC include the following?

Probe about:

• Providers with expertise in addressing trauma and promoting the recovery of children and adolescents with serious emotional disturbance (SED)

• Providers with expertise in addressing trauma and promoting recovery in adults with serious mental illness

• Providers with credentialed substance abuse specialists promoting recovery in individuals with substance use disorders

• Medically trained BH provider able to prescribe and manage medication

3. Please describe the number and types of clinical services providers (defined as staff who interact directly with clients in a clinical capacity) employed by the CCBHC.

a. What is the FTE distribution for CCBHC clinical service providers in the following disciplines? We’ll discuss them one by one.

• Psychiatrist

• Psychiatric nurse

• Child psychiatrist

• Adolescent psychiatrist

• Substance abuse specialist

• Case manager

• Recovery coach

• Peer specialist

• Family support specialist

• Licensed clinical social worker

• Licensed mental health counselor

• Mental health professional (trained and credentialed for psychological testing, such as licensed psychologists)

• Licensed marriage and family therapist

• Occupational therapist

• Interpreters or linguistic counselor

• General practice (performing CCBHC services)

• Other staff (such as pharmacy staff, medical assistants, community health workers, etc.)s

b. How many active staff (non-clinical are employed by the CCBHC?

c. How many clinical service providers are available to serve CCBHC clients through a designated collaborating organization (DCO)?

4. What type of cultural competencies do you seek in CCBHC service providers in order to work with your clients?

a. Do staff receive cultural competency training to ensure that they can meet the needs of the client population? If yes, please describe:

b. Are staff monitored to ensure they are providing culturally competent services?

D. Services

1. What services do CCBHC staff provide and who gets which services? We’ll discuss them one by one.

a. Services: [If yes, who are they available to?]

• Outpatient MH services

• Outpatient SUD services

• Assisted Outpatient Treatment

• Management of psychoactive drugs

• Medication assisted treatment

• Crisis planning services. If yes, who are they available to?

• Screening/assessment/diagnostic services. If yes, who are they available to?

• Crisis services/Urgent care

• Treatment planning services

• Psychiatric rehabilitation services

• Peer support services for clients

• Support services for families

• Targeted case management

• Primary health screening and monitoring

• Armed forces and veteran’s services

• Other (specify)

b. Evidence-based behavioral health practices

• Motivational Interviewing

• Cognitive Behavioral individual, group, and on-line therapies (CBT)

• Dialectical Behavioral 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)

• Medication evaluation and management

• Community wrap-around services for youth

• Specialty clinical interventions to treat youth

• Other (describe)

2. Has your CCBHC adopted any new evidence-based practices since CCBHC certification? Please describe.

a. Have you held/sponsored any new trainings in EBPs for providers? Please describe.

3. Please describe client flow in your CCBHC. What happens when a new client accesses services for the first time?

Probe about when the following occur and what staff are involved:

• Initial evaluation

• How do new clients access other CCBHC services when initial presentation was through crisis services?

• Person and family-centered evaluation and treatment planning

• Clinician assignment

• Ongoing treatment planning

4. The next set of questions are about screening for physical and behavioral health conditions. By screening, we mean the use of specific tools to assess or monitor physical or behavioral health conditions and symptoms. For each type of condition, we’d like to know who receives screenings and when, what tools you use, and what happens if an individual screens positive.

a. Are clients who receive care at your CCBHC screened for physical health conditions? (By screening, we mean the use of specific tools used to assess/monitor physical health symptoms.)

• What conditions are clients screened for?

• Which clients receive screenings?

• When are initial screenings provided?

• What screening tools do you use, and for which clients?

• What happens when someone screens positive for a physical health problem, such as hypertension?

b. Are clients who receive care at your CCBHC screened for mental health conditions? (By screening, we mean specific tools used to assess/monitor mental health symptoms.)

• Which clients receive screenings?

• When are initial screenings provided?

• What screening tools do you use, and for which clients?

• What happens when someone screens positive for a mental health condition, such as depression?

c. Are clients who receive care at your CCBHC screened for substance use? (By screening, we mean specific tools used to assess/monitor substance use.)

• Which clients receive screenings?

• When are initial screenings provided?

• What screening tools do you use, and for which clients?

• What happens when someone screens positive for substance use, such as opioid use?

5. Is repeat screening for CCBHC clients conducted at regular intervals? If so, what screenings and how often?

E. Program structure

1. Does your CCBHC have a Designated Collaborating Organization (DCO) or multiple DCOs?

a. Please list DCO(s)

b. Are relationships with DCO(s) new (since CCBHC certification), pre-existing informal, or pre-existing formal (i.e., prior contractual agreement with DCO)?

c. For each DCO, does the CCBHC-DCO service agreement include the following?

• Guidelines on how rapidly clients will be seen

• Policies detailing communication (i.e. sharing of clinical information about clients in a timely fashion)

• Sharing of the clinical records for DCO visits

• Policies detailing coordination (e.g., scheduling CCBHC and DCO visits on the same day, which group is responsible for providing certain services, etc.)

• Policies detailing payment mechanism to DCO(s)

• Specific instructions on the proper procedure for scheduling a PC consult

d. Are DCOs part of a larger health-care system or regional network? If yes, how does larger system influence CCBHC policies?

e. Please describe the DCO’s facilities.

2. Describe the services that your DCO(s) provide(s) for CCBHC clients, and reasons why they are provided by a DCO rather than provided in CCBHC.

a. If multiple DCOs, which DCOs provide which services?

b. Staff: Who provides what services?

c. Services: Are regular visits scheduled?

3. What has been challenging or successful about these relationships with DCOs?

4. Please describe the relationship between the CCBHC and DCO(s) (if applicable):

a. What is the distance between CCBHC and DCO(s)?

b. How do clients get from one location to another?

• Does the program CCBHC assist with transportation between locations [note: transportation of clinic users is not an allowed cost under the CCBHC demonstration]?

c. How is information shared between CCBHC and DCO?

d. How many clients have been referred to DCO? How are they identified?

e. How does CCBHC monitor quality of care at DCO?

5. Does your CCBHC have arrangements with other organizations that are not formally designated as DCOs? If yes, please describe:

Probe about:

• Types of services provided

• Description of any formal service agreements. Would it be possible for us to obtain a copy of the agreement(s)?

• If not previously mentioned, probe about coordination with hospitals regarding client discharge notifications.

F. Care coordination

1. How is client care coordinated (i.e., designated care manager, case manager, care coordinator; direct communication between providers)?

Probe for:

-Challenges regarding care coordination?

-Challenges regarding care coordination for dual eligible patients? Patients who are recipients of 1915(c) Waivers

2. What types of staff are involved in care management for CCBHC clients?

3. What types of staff are involved in person- and family-centered planning?

4. What is done to manage CCBHC clients’ medications across different prescribers?

a. Does the program keep up-to-date lists of clients’ current medications?

5. Are CCBHC clients expected to select a personal PC physician (e.g., for primary health screening and monitoring)? If yes, please describe:

a. Is their choice documented?

b. Does the program monitor the percentage of client visits with a specific clinician or team?

c. How are physical health conditions monitored at CCBHC?

6. What is the average CCBHC client caseload for full-time care managers and other providers?

G. Referral practices

1. Please describe the process for referrals to external healthcare services:

a. What is the process for referring clients to services at a DCO (if applicable)?

b. What is the process for receiving referrals to the CCBHC (e.g., from crisis center, hospital, etc.)?

c. How are referrals to external services (e.g., specialists) managed? Are Care Managers involved, or other staff?

d. How are referrals tracked, with follow-up? [e.g., paper or electronically, sharing clinical information, tracking status of referrals, following up to obtain specialist reports] How often?

e. Which staff are responsible for follow-up with referrals?

2. Please describe your CCBHC’s standard discharge procedures and continuity of care processes. What exchanges of information regarding discharges do you initiate or receive?

3. Please describe the process for referrals to non-healthcare community or social services.

a. How are client’s non-healthcare needs (e.g., housing authority, transportation, child care, legal etc.) managed, and by whom?

b. How often are clients linked to community resources? Are these referrals tracked?

c. What kinds of partnerships does your organization have with community organizations? How does the integrated care team interface with other organizations in the community?

H. Data sharing

1. Please describe your CCBHC’s use of electronic health records.

a. Does your CCBHC use an EHR?

b. Did your CCBHC use an EHR prior to certification?

c. Are electronic records shared between MH and PC providers? What information is shared and how?

d. Who uses records (mental health providers, primary care providers, care managers, consumers)?

e. Describe the flow of information in the record system. Who collects what data, and when? Who enters data? Who checks data? Who is responsible for sharing data (e.g., with DCOs)?

Probe specifically for:

-Sharing of cost/billing data

f. Are electronic records shared between CCBHC and DCO providers?

• Describe the process for sharing data between CCBHCs and DCOs.

g. Does the EHR have a clinical registry function or tool included in EHR that is utilized?

If yes:

• What types of information does the embedded registry function/tool include?

• Describe the flow of information for the registry. Who collects what data, and when? Who enters data? Who checks data?

• Who uses the registry, and for what purpose?

• How often is the registry checked for accuracy and by whom?

If no:

Does the CCBHC have a standalone clinical registry—a system for tracking client information—used for documenting CCBHC clients’ PC and/or MH conditions? If so:

• Is the registry electronic or paper?

• What types of information are included?

• Describe the flow of information for the registry. Who collects what data, and when? Who enters data? Who checks data?

• Who uses the registry, and for what purpose?

• How often is the registry checked for accuracy and by whom?

2. What information and/or services are available to CCBHC clients through a secure electronic system? (e.g., health information, clinical visit summaries, 2-way communication with the practice, emails to notify clients about needs.) Does the CCBHC have an interactive website or patient portal to support CCBHC client access?

3. Does your CCBHC have a system to track and follow-up on lab test or imaging orders?

a. If yes, is the system paper or electronic? Please describe.

b. Does the system have a documented process for notifying CCBHC clients of normal and abnormal results?

c. Does the system have a documented process to flag and follow-up on results that are overdue to be shared with a client?

I. Accessibility

1. What hours/days are various services available for clients at your CCBHC, in person? We’ll discuss them one by one.

• Outpatient MH services

• Outpatient SUD services

• Assisted Outpatient Treatment

• Management of psychoactive drugs

• Medication assisted treatment

• Crisis planning services

• Screening/assessment/diagnostic services

• Crisis services/Urgent care

• Treatment planning services

• Psychiatric rehab

• Peer support services for clients

• Support services for families

• Targeted case management

• Primary health screening and monitoring

• Armed forces and veteran’s services

• Other (specify)

2. Can appointments for MH and PC visits (if applicable) be made during the same call, or scheduled for the same day?

a. What is the approximate time between an appointment request and the appointment/ receipt of services?

b. Are services available on a walk-in basis? If yes, what types of services?

c. Are there waiting lists for services or visits?

d. How are appointments made and coordinated with DCOs?

3. What services (e.g., MH / PC advice, community or social supports) are available to clients by phone or electronically? During what hours?

a. If clinical advice is provided by phone or electronically, does the program have relevant written policies, defined standards, and performance monitoring about the timeliness of this advice?

4. What happens if clients seek routine or urgent-care MH or PC appointments outside regular business hours (e.g., weekends / evenings)?

a. If after-hours care is available at a site other than an ER, does the CCBHC have written policies, defined standards, and performance monitoring about after-hours access?

b. Is medical record information for care and advice after hours integrated with business hours records [or systematically shared with daytime staff]?

c. Is there a 24-hour hotline available for CCBHC clients?

5. How accessible is the clinic by public transportation?

a. Do you offer support to clients in accessing clinic, such as shuttle service, Medicaid cab?

6. Are you carrying out any outreach activities to reach clients who are not engaged in services?

a. What kinds of outreach (e.g., developing relationships with community organizations, advertising, etc.)?

b. Specific target population(s)?

7. Are any Internet, text messaging, or mobile device applications being used to reach clients or improve clients’ access to the CCBHC?

Probe for:

-Telehealth services

-Care delivery via computer contact

-Off-site interpreter and translation services

J. Quality and other reporting

1. How do you monitor the performance of your CCBHC? [Open-ended, then prompt with the following:]

a. What sources of data do you use?

b. How are quality measures calculated and reported?

c. Do you track CCBHC clients’ utilization information related to health care costs? (e.g., ER visits, hospital admissions, generic vs. prescription medications)?

d. Do you solicit and/or receive feedback from CCBHC clients about their experiences with the program and care? In what format?

e. Do you use any of the data you collect for the CCBHC in any additional ways? How? And how often? (e.g., quarterly, bi-annual or annual presentations to the team?)

2. Are the required quality measures appropriate for measuring and improving the quality of your CCBHC/quality of the care that your CCBHC provides?

a. Why or why not?

b. Does your CCBHC collect and use additional performances measures?

c. Are you able to calculate the quality measures for the entire CCBHC population? If so, have you experienced any difficulties?

3. How do you ensure person-centered care in the CCBHC?

a. How is person-centered care monitored?

b. What data sources does your CCBHC use to assess person-centered care? How is this data used (e.g., for CQI)?

4. How does your CCBHC share data on quality measures with other parties (e.g., state agencies, other clinics, public)?

5. How are staff qualifications for contracted providers or providers at DCOs who have contact with CCBHC clients assessed and monitored?

a. How is information on quality of care used to improve performance?

6. Does your CCBHC have a quality improvement plan in place? If yes, please describe.

a. Do clinicians receive feedback on care for individual consumers?

b. Is information on quality used in care team meetings?

c. Do quality measures inform changes in clinic policies?

d. Can you provide us with a copy of the written quality improvement plan?

K. CCBHC implementation successes and barriers

1. How has your organization changed since CCBHC implementation?

a. What have been your CCBHC implementation successes to date?

2. What barriers have you faced in implementing the steps for CCBHC certification? (If necessary, prompt with: types of barriers may include problems hiring qualified staff, coordinating MH and DCO leadership, billing/financing issues, collecting outcome data, and lack of client interest in the program.) What strategies have you used to overcome them?

3. What aspects of becoming a CCBHC or maintaining certification is your CCBHC still working toward?

a. What plans do you have for maintenance and sustainability of the program?

b. What policies have driven the way that you provide and sustain CCBHC services and processes (e.g., services offered, collaboration with DCOs, etc.)? These could include federal, state, local or agency-level policies.

4. How is your CCBHC paying for CCBHC client care?

a. What payment system is used at your CCBHC?

b. How have Medicaid reimbursement levels changed?

Probe for:

-Prior to CCBHC demonstration, was payment PPS or FFS?

5. How is the payment system working for your clinic?

a. Have you encountered any difficulties with the following?

• Cost reports?

(1) Difficult to produce or update?

(2) Personnel to complete them?

• Setting rates?

• Coordination with managed care?

b. How accurate or fair do you think the PPS rates are for your clinic?

c. Have you received any feedback from staff or clients?

d. What steps have been taken to address these issues?

e. How does the clinic handle billing if a client is receives services from more than one DCO in a single day?

f. If PPS2: How are the various components of the rate mechanism working at your clinic (i.e., stratification of rates by patient severity, outlier payments and quality bonus payments)?

L. Governance

1. Is your CCBHC accredited?

a. What type/agency (e.g., CARF, COA, TJC)?

b. Were you encouraged or required to seek accreditation by your state as part of CCBHC certification?

2. Please describe the composition/membership of your CCBHC board.

a. What factors determined the composition of the board? How are board members selected?

Probe for:

- If the clinic is dually certified as a FQHC and CCBHC, do the same board members serve for both lines of business?

b. How engaged/active are board members in decision-making for the CCBHC? What kinds of input do board members provide?

c. For how long do board members serve? Is turnover/retention a problem?

d. What challenges have you encountered in selecting and retaining board members?

3. How do you ensure that your CCBHC board is “reasonably” representative of the communities that your clinic serves (e.g., demographically, patient/consumer perspectives, etc.)?

a. How do you ensure that perspectives of behavioral health consumers, families, and communities are represented in your CCBHC governance?

b. Has this requirement posed any challenges for your CCBHC?

M. Interviewee feedback/open discussion

1. What have we missed? What else do we need to know that we haven’t asked you?

2. Is there anyone else in CCBHC leadership who should be included in these interviews?

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