State mental health official-telephone interview

ATTACHMENT J

DEMONSTRATION END TELEPHONE INTERVIEW PROTOCOL
STATE BEHAVIORAL HEALTH OFFICIALS

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Demonstration END telephone Interview questions - state BEHAVIORAL HEALTH officials

In the spring of 2019, follow-up telephone interviews will be conducted with state behavioral health officials to obtain feedback regarding CCBHC implementation in their state. Telephone interviews will address specific factors that shape CCBHC policies and implementation, and will focus on changes in key CCBHC implementation domains since the second (demonstration midpoint) interview. 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 demonstration end telephone interviews is presented below.

A. Introduction

1. Please describe your current role/position and responsibilities.

B. Implementation successes and barriers

1. Have there been any changes to the way that non-CCBHC community behavioral health clinics are administered in your state since [insert month and year of baseline interview]? In our first interview we heard that non-CCBHC community behavioral health clinics in your state … (tailor summary of characteristics or examples based on responses provided in baseline interview). If yes, how?

a. What are the major differences between the way that CCBHCs are administered compared with how non-CCBHC community behavioral health clinics are currently administered in your state?

2. Overall, how do you think CCBHC demonstration implementation went in your state? Has anything changed since [insert month and year of midpoint interview]?

Probe for:

-Differences in implementation across CCBHCs within the state (e.g., urban vs. rural vs. frontier, type of clinic prior to CCBHC certification, populations served, etc.)

a. How did your experience compare with your expectations for the demonstration?

b. What kind of feedback have you received from CCBHCs since [insert month and year of midpoint interview]?

c. What are the key successes that CCBHCs have had?

• What factors have played a role in CCBHC successes?

d. What problems or barriers have CCBHCs in your state faced since [insert month and year of midpoint interview]? 

• Were these barriers anticipated or unexpected?

e. What steps have been taken to address or resolve these problems?

• Have these actions been effective?

• How could these problems be avoided or managed by other CCBHCs in the future?

C. Demonstration administration

1. In previous interviews, we heard that the state office(s) of mental health and substance abuse services were involved in monitoring compliance of CCBHCs with the certification criteria by [provide description based on midpoint interview].

Probe separately for:

• Differences in processes for monitoring compliance across different types of clinics that became CCBHCs (e.g., FQHCs, community mental health centers, substance use disorder clinics, etc.)?

a. Has this changed since [insert month and year of midpoint interview]?

b. Have any challenges arisen for CCBHCs in maintaining certification or continuing to meet all of the certification criteria?

• Were these challenges anticipated at the beginning of the demonstration?

• What steps were taken to resolve issues that arose?

2. How were consumers (including adults with SMI and those with long term and serious substance use disorders), family members (including of adults with SMI and children with serious emotional disturbances), providers, and other stakeholders (including American Indian/Native Alaskans, and other local and state agencies) involved in the demonstration implementation?

a. What were the critical issues they raised?

b. How did their input influence demonstration implementation?

D. Staffing and access to care

1. Since [insert month and year of midpoint interview], have there been any changes regarding staffing concerns of the CCBHCs in your state?

Probe about the following:

• Cultural competence for specific populations

• Workforce limitations

• Licensing

• Monitoring staff in designated collaborating organizations (DCOs)

• Staffing for new services offered at CCBHCs

2. In the second year of the demonstration, what have CCBHCs in your state done to improve access to care?

Probe about the following:

• Expanding hours of service

• Increasing number of locations for accessing care

• Outreach efforts (community-based; print advertising; online social networks; etc.) to specific underserved groups, such as children or homeless

• Telemedicine

• Internet/text/app based access

Probe separately for:

• Mental health services

• Substance use disorder services

3. Have CCBHCs attempted to expand access to other specific types of services?

Probe about the following:

a. Substance use disorder treatment

b. Services across the lifespan (e.g., child and adolescent; adult; geriatric)

c. Specific EBPs and evidence-based medications listed in the state demonstration application. For example:

• Motivational Interviewing; Cognitive Behavioral individual, group and on-line Therapies (CBT); Dialectical Behavior 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)

• Medications for psychiatric conditions; medication assisted treatment for alcohol and opioid substance use disorders; prescription long-acting injectable medications for both mental and substance use disorders; smoking cessation medications

• Community wrap-around services for youth and children; and specialty clinical interventions to treat mental and substance use disorders experienced by youth

2. What have CCBHCs in your state done to ensure access to services for consumers regardless of ability to pay?

Probe about:

• Duration of efforts to ensure access to services regardless of ability to pay (e.g., Are these programs/policies/procedures new or longstanding?)

• Provision of services on a sliding scale basis or provision of services regardless of ability to pay

3. Are CCBHCs in your state conducting any outreach or other activities to ensure access to services for those who live outside a clinic’s service area or are experiencing homelessness?

Probe about:

• Protocols regarding addressing the needs of consumers who do not live close to a CCBHC or within the CCBHC catchment area as established by the state

4. In addition to the CCBHC, is your state implementing other delivery system reforms designed to improve access to or quality of mental health or substance use services?

Probe about the following:

• Crisis services

• Substance use disorder services, recovery-oriented care

• CMS or health reform demonstrations

• Health homes

• Behavioral health-related waiver or demonstration activity

• Olmstead

• Medicaid expansion

• ACA

a. What types of funding sources currently support these efforts (e.g., existing grants, county-specific services funded through county taxes, 1115 waivers, general revenue)?

b. Do efforts/funding vary by region within the state?

c. How do these efforts interact with CCBHC efforts?

E. Scope of services and coordination of care

1. What are some barriers that clinics in your state have faced in providing the full CCBHC scope of services over the course of the demonstration? Have any new barriers or issues come to light since [insert month and year of midpoint interview]? 

2. In previous interviews, we heard that [all/not all] services within the CCBHC scope of services are reimbursable by Medicaid in your state. Have there been any changes since [insert month and year of midpoint interview]? If yes, what changes?

[If not previously answered or if changes have occurred]

a. Which services required by the CCBHC criteria were not historically provided in community behavioral health clinics in your state?

b. Were DCO arrangements important to providing the full scope of services by CCBHCs? If so, which services in particular are being provided by DCOs?

c. What are the barriers that clinics in your state might face in providing the full CCBHC scope of services? 

d. Have CCBHCs experienced any challenges surrounding care coordination for

individuals who are dually eligible/enrolled in both Medicaid and Medicare?

e. Have CCBHCs experienced any challenges surrounding care coordination for

individuals who recipients of 1915(c) Waivers?

3. In previous interviews, we heard that the care coordination services in the CCBHCs [are/are not] substantially different from what is available in other CMHCs in your state. Has this changed since [insert month and year of midpoint interview]? If yes, how?

[If not previously answered or if changes have occurred]

a. If different, how are they different? What changes were required to meet the CCBHC standard?

b. If not different, how are those services paid for in other settings?

4. In previous interviews, we heard that CCBHCs established care coordination with community or regional supports and providers by [provide description from baseline and midpoint interviews]. Have there been any changes in these care coordination efforts since [insert month and year of midpoint interview]? If yes, what changes?

Probe about the following:

• Schools

• Hospitals (e.g., to obtain discharge notifications for inpatient/ED care)

• Child welfare agencies

• Juvenile and criminal justice agencies and facilities (including drug, mental health, veterans and other specialty courts)

• Active military/VA facilities

• Indian Health Service youth regional treatment centers

• State licensed and nationally accredited child placing agencies for therapeutic foster care service

• FQHCs

• Other social and human services

5. Have there been any changes to health IT systems requirements or utilization of IT systems by non-CCBHC community behavioral health clinics since [insert month and year of midpoint interview]? If yes, what changes?

a. How do CCBHCs compare with non-CCBHC community behavioral health clinics in use of electronic health records?

F. Quality of care

1. How were quality measures data collected during demonstration?

Probe for the following:

a. CCBHC reported measures (9 required)

• New clients – days until initial evaluation/percent of new clients evaluated within 10 days

• Preventive care and screening: BMI

• Preventive care and screening: Tobacco

• Preventive care and screening: Alcohol

• Weight assessment/nutrition counseling; Phys Activity for child/adolescent

• Child/adolescent: MDD-Suicide risk

• Adult: MDD-Suicide risk

• Depression screening and follow-up plan

• Depression remission- 12 months

b. State reported measures (12 required)

• Housing status

• Follow-up after discharge from ED for mental health

• Follow-up after discharge from ED for substance use disorders

• Plan all-cause readmission rate

• Diabetes screening for individuals with schizophrenia or bipolar disorder using antipsychotic meds

• Adherence to antipsychotic medication for individuals with schizophrenia

• Adult (21+): Follow-up after hospitalization for mental illness

• Child/adolescent: Follow-up after hospitalization for mental illness

• Follow-up for children prescribed ADHD medication

• Antidepressant medication management

• Initiation/engagement of substance use disorder treatment

• Patient/family experience of care (Survey Measures)

c. Who is responsible for collecting quality data when care is covered by an MCO or provided by a DCO?

2. How has your state used CCBHC information on quality of care in the last year?

a. Reporting to CCBHC?

b. Compliance monitoring?

c. Quality bonus payment?

d. Public reporting?

e. Other benchmarking

3. Since [insert month and year of midpoint interview], how has information on CCBHC quality measures been shared among various state agencies, with CCBHCs and with the public?

a. How has CCBHC quality data been shared between clinics, managed care organizations, state Medicaid offices and state mental health departments?

4. In previous interviews, we heard that your state [does/does not] require CMHCs or other behavioral health providers to report quality measures? Has this changed since [insert month and year of midpoint interview]? If yes, how?

Probe about changes in:

• Which measures

• Which providers

• What is done with the information

5. In previous interviews, we heard that your state [does/does not] analyze claims data to help improve the quality of behavioral health care. Has this changed since [insert month and year of midpoint interview]?

a. If so, how?

b. Which measures are monitored?

c. How is the information used?

d. How does your state collect data on the National Outcomes Measures (NOMs) to meet your block grant reporting obligations?

6. In previous interviews, we heard that the state office of mental health [monitors/does not monitor] utilization of care in the CCBHCs. Has this changed since [insert month and year of midpoint interview]?

a. What are the data sources for the Office of Mental Health (OMH)?

b. Who receives information on the CCBHCs and how do they respond?

c. Does monitoring for CCBHCs differ from other community behavioral health clinics in the state?

d. Does the state OMH monitor utilization of care at DCOs?

7. How has your state used CCBHC information on utilization? Has this changed since [insert month and year of midpoint interview]? If yes, how?

G. Cost and payment

1. Since [insert month and year of midpoint interview], have you received any feedback from CCBHCs regarding use of the prospective payment system? Please describe.

a. How burdensome was the PPS been for CCBHCs in your state?

b. Did CCBHCs encounter any issues regarding use of the PPS (e.g., payment of DCOs)?

c. If yes, what steps were taken to address/resolve these issues? Please describe.

2. Since [insert month and year of midpoint interview], have CCBHC costs been consistent with your expectations? Please describe.

a. How did costs compare with those under the previous payment system?

b. How did costs vary across CCBHCs? Was the PPS appropriate/fair for different CCBHCs in your state?

H. Data availability

1. In previous interviews, we heard [provide description of NOMs data collection from baseline and midpoint interviews]. Has this changed since [insert month and year of midpoint interview]? If yes, how?

2. Have you identified any new sources of comparison data since [insert month and year of midpoint interview]?

I. Sustainability

1. What are your plans regarding sustaining any aspects of the CCBHCs after the demonstration ends?

a. What barriers or challenges might affect CCBHC sustainability?

b. How might those barriers/challenges be overcome?

c. What factors might facilitate sustainability?

J. Governance

1. Since [insert month and year of midpoint interview], have there been any changes to state requirements surrounding accreditation for CCBHCs?

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

b. Did CCBHCs encounter any issues with accreditation?

2. Have there been any changes to the process for ensuring that CCBHC boards are “reasonably” representative of the communities they serve (e.g., demographically, consumer perspectives, etc.)?

Probe for the following:

a. Perspectives of behavioral health consumers, families, and communities are represented in CCBHC governance?

b. Representation of consumer/family/community perspectives in CCBHCs?

K. 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 from the state office(s) of mental health and substance abuse services who should be included in these interviews?

3. Is there anyone else from the state office(s) of Medicaid who should be included in these interviews?