CCBHC site leadership staff-completion of report

ATTACHMENT l

demonstration year 1
Ccbhc annual progress report template

This page has been left blank for double-sided copying.

Certified Community Behavioral Health Clinic Demonstration
Annual Progress Report Template
Demonstration Year 1

Clinic name: Click here to enter clinic name.

Clinic address: Click here to enter full clinic address.

Clinic project director name: Click here to enter name.

Section A. CCBHC staffing

1. Which types of clinical staff are currently employed by your CCBHC? Please check all that apply: if staff were hired before the CCBHH certification process, as part of the certification process, or were hired after certification. For example, if one adult psychiatrist was on staff prior to certification and an additional adult psychiatrist was hired as part of certification, please check both categories. Do not report staff who are employed by collaborating agencies/organizations.
	Employed before Hired as part of Hired after certification certification certification
Medical director (psychiatrist)	☐ ☐ ☐
Medical director (other)	☐ ☐ ☐
Psychiatrist (other than Medical Director)	☐ ☐ ☐
Child/adolescent psychiatrists (not reported above)	☐ ☐ ☐
Pharmacy staff	☐ ☐ ☐
Other physicians	☐ ☐ ☐
Nurses (please enter nurse types; for example, psychiatric/mental health nurses, substance use disorder specialist nurses): Click here to enter nurse types.	☐ ☐ ☐
Licensed clinical social workers	☐ ☐ ☐
Licensed psychologists (please specify degree levels): Click here to enter degrees.	☐ ☐ ☐
Licensed marriage and family therapists	☐ ☐ ☐
Occupational therapists	☐ ☐ ☐
Substance abuse specialists	☐ ☐ ☐
Bachelor’s degree-level counselors	☐ ☐ ☐
Associate’s degree-level or non-degree counselors	☐ ☐ ☐
Mental health professionals (not reported above)	☐ ☐ ☐
Community health workers	☐ ☐ ☐
Medical/nursing assistants	☐ ☐ ☐
Case management staff	☐ ☐ ☐
Peer specialist(s)/recovery coaches	☐ ☐ ☐
Family support staff	☐ ☐ ☐
Interpreters or linguistic counselors	☐ ☐ ☐
Interns (not reported above)	☐ ☐ ☐
Other clinician types (specify): Click here to enter other clinician types.	☐ ☐ ☐
2. Have any of these staff positions gone unfilled for two months or longer during the past twelve months? ☐ Yes ☐ No If so, please describe why (for example, has a position been difficult to fill?): Click here to enter description.
3. Which of the following trainings have staff received during the past twelve months? Check all that apply.
☐ Risk assessment, suicide prevention, and suicide response training ☐ The role of family and peers in the delivery of care ☐ Person-centered and family-centered care ☐ Recovery-oriented care	☐ Evidence-based and trauma-informed care ☐ Cultural competency training to address diversity within the organization’s service population ☐ Primary and behavioral health care integration ☐ Other: Click here to describe other trainings.

Section B. CCBHC accessibility

1. How are clients referred to CCBHC services? Check all that apply.
☐ Self-referral ☐ Referred by provider ☐ Referred by courts/involuntary or assisted outpatient treatment order		☐ Referred by family ☐ Other (please describe): Click here to enter description.
2. Did your CCBHC make any changes to the organization’s physical space as a result of CCBHC certification? Check all that apply.
☐ Expansions or additions to the CCBHC building space ☐ Renovations to existing CCBHC facilities	☐ Improvements to facility safety features ☐ Other changes: Click here to enter description of changes.
3. Does the organization offer services in locations outside of the clinic (for example, in clients’ homes)? ☐ Yes ☐ No If yes, were services provided in the community: ☐ Offered before certification ☐ Offered to achieve/maintain certification If yes, where are services provided? Please describe: Click here to enter description of locations.
4. Does the organization offer services via telehealth? ☐ Yes ☐ No If yes, were telehealth services: ☐ Offered before certification ☐ Offered to achieve/maintain certification If yes, what telehealth services are available, and to whom? Click here to describe.
5. Does the organization offer translation services to clients? ☐ Yes ☐ No If yes, how are these services delivered? Please check all that apply: ☐ Staff interpreter ☐ Multilingual staff ☐ Other: Click here to describe.
6. Does the organization offer transportation or transportation vouchers? ☐ Yes ☐ No If yes, to whom are transportation/vouchers available? Click here to describe.
7. Has your CCBHC targeted any of the following populations with outreach or engagement efforts in the past twelve months?
☐ Consumers experiencing homelessness ☐ Members of the Armed Forces or Veterans ☐ Consumers who were previously incarcerated	☐ School-age youth ☐ Older adults ☐ Other populations (please specify): Click here to enter text.
8. Does your CCBHC offer a sliding fee schedule? ☐ Yes ☐ No If yes, is it published on your website or elsewhere? ☐ Yes ☐ No If available, please provide the web link to the schedule. Click here to enter web address.
9. Does your CCBHC provide services to clients unable to pay? ☐ Yes ☐ No Does your CCBHC provide services to clients with Medicare? ☐ Yes ☐ No Does your CCBHC provide services to clients with private insurance? ☐ Yes ☐ No Does your CCBHC provide services to clients who do not reside in its catchment area? ☐ Yes ☐ No

Section C. CCBHC care coordination

1. Which of the following are involved in developing and updating a comprehensive treatment plan? Please check all that apply.
☐ Mental health clinicians ☐ Substance use disorder clinicians ☐ Case managers ☐ Consumers/clients		☐ Client family members ☐ Psychiatrists ☐ Primary care physicians ☐ Other: Click here to enter additional provider types.
2. Which of the following are included on treatment teams at your CCBHC? Check all that apply.
☐ Mental health clinicians ☐ Substance use disorder service providers ☐ Case managers ☐ Consumers ☐ Families		☐ Psychiatrists ☐ Primary care physicians ☐ Community support and social service providers ☐ Other: Click here to enter additional provider types.
Were all of the staff included on treatment teams prior to CCBHC certification? ☐ Yes ☐ No Have the members of the organization’s treatment teams changed as a result of CCBHC certification? If so, please describe: Click here to enter description.
3. Does your CCBHC provide on-site primary care services (in addition to primary care screening and monitoring)? ☐ Yes ☐ No If so, was your CCBHC providing these services before certification? ☐ Yes ☐ No Is your CCBHC also an FQHC? ☐ Yes ☐ No
4. How does your CCBHC learn of clients’ care transitions, such as hospitalizations or discharges? Check all that apply.
Receives notification when hospital treats a client for: ☐ Physical health condition ☐ Behavioral health condition Receives discharge summary from hospital after a client is treated for: ☐ Physical health condition ☐ Behavioral health condition Receives notification when emergency department treats a client for: ☐ Physical health condition ☐ Behavioral health condition Receives discharge summary from emergency department after a client is treated for: ☐ Physical health condition ☐ Behavioral health condition Receives notification by other means (for example, contacts by consumers or families) about: ☐ Physical health condition ☐ Behavioral health condition
5. Health information technology (HIT) and Electronic Health Records (EHRs) a. Did your clinic adopt a new HIT system or EHR as part of CCBHC certification? ☐ Yes ☐ No b. Has your clinic altered its HIT system or EHR to meet CCBHC certification requirements for coordination and data collection? ☐ Yes ☐ No c. Does your clinic use any form of electronic prescribing? ☐ Yes ☐ No d. Please provide the name of your EHR: Click here to enter name. e. Please provide the name of any other HIT system used by your CCBHC (for example, HIT systems for clinical regestries, scheduling, case management, etc.) Click here to enter name(s).
6. Which of the following functionalities does your EHR include? Check all that apply and indicate if the functionality is new as a result of CCBHC certification.
Contains mental health records			☐ Yes ☐ No			☐ New
Contains substance use disorder records			☐ Yes ☐ No			☐ New
Contains primary care records			☐ Yes ☐ No			☐ New
Contains case management or care coordination records			☐ Yes ☐ No			☐ New
Generates electronic care plan			☐ Yes ☐ No			☐ New
Communication with laboratory to request tests or receive results			☐ Yes ☐ No			☐ New
Incorporation of laboratory results into health record			☐ Yes ☐ No			☐ New
Clinical decision support			☐ Yes ☐ No			☐ New
Allows electronic exchange of clinical information with designated collaborative organizations (DCOs)			☐ Yes ☐ No			☐ New
Allows electronic exchange of clinical information with other external providers			☐ Yes ☐ No			☐ New
Quality measure reporting capabilities			☐ Yes ☐ No			☐ New
7. Does your CCBHC have relationships with any of the following types of facilities or providers? For each, indicate the type of relationship, or that there is no relationship.
DCO Formal relationship Informal relationship No relationship
Federally qualified health center	☐			☐	☐		☐
Rural health clinic	☐			☐	☐		☐
Primary care providers	☐			☐	☐		☐
Inpatient psychiatric facility	☐			☐	☐		☐
Medical detoxification facility	☐			☐	☐		☐
Ambulatory detoxification facility	☐			☐	☐		☐
Post-detoxification step-down facility	☐			☐	☐		☐
Hospital outpatient clinic	☐			☐	☐		☐
Psychiatric residential treatment facility	☐			☐	☐		☐
Substance use disorder residential treatment facility	☐			☐	☐		☐
Medication-assisted treatment providers for substance use	☐			☐	☐		☐
Suicide/crisis hotlines and warmlines	☐			☐	☐		☐
Residential (non-hospital) crisis settings	☐			☐	☐		☐
Schools	☐			☐	☐		☐
School-based health centers	☐			☐	☐		☐
Child welfare agencies	☐			☐	☐		☐
Juvenile justice agencies	☐			☐	☐		☐
Adult criminal justice agencies/courts	☐			☐	☐		☐
Mental health/drug courts	☐			☐	☐		☐
Law enforcement	☐			☐	☐		☐
Indian Health Service or other tribal programs	☐			☐	☐		☐
Indian Health Service youth regional treatment centers	☐			☐	☐		☐
Therapeutic foster care service agencies	☐			☐	☐		☐
Homeless shelters	☐			☐	☐		☐
Housing agencies	☐			☐	☐		☐
Employment services and/or supported employment	☐			☐	☐		☐
Older adult services	☐			☐	☐		☐
Other social and human service providers	☐			☐	☐		☐
Emergency departments	☐			☐	☐		☐
Urgent care centers	☐			☐	☐		☐
Consumer operated/peer service provider organizations	☐			☐	☐		☐
Department of Veterans Affairs treatment facilities	☐			☐	☐		☐
8. Does your CCBHC use any of the following to facilitate crisis planning? Psychiatric advance directives ☐ Yes ☐ No Wellness recovery action plan ☐ Yes ☐ No Other (please list): Click here to list others.
9. How are consumer and family preferences for care elicited and documented? Click here to describe.

D. CCBHC scope of services

1. Which of the services below does your CCBHC or DCO(s) currently provide? For each service, please indicate the following: a. If the service is provided by your CCBHC or a DCO b. The time of day/week the service is available. Record the number of months each service was available during the past twelve months. c. If your clinic added this service as a result of CCBHC certification a. Provided by: b. Available: c. Added
		CCBHC DCO Business hours Evenings Weekends Overnight Duration
a. Crisis Behavioral Health Services
24-hour mobile crisis teams		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Emergency crisis intervention		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Crisis stabilization		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
b. Screening, Assessment, and Diagnosis
Mental health screening, assessment, diagnostic services		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
SUD screening, assessment, diagnostic services		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
c. Person- and Family-centered Teatment Planning Services		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
d. Outpatient Mental Health and SUD Services
Outpatient mental health counseling		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Outpatient substance use disorder treatment		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Motivational interviewing		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Individual cognitive behavioral therapy (CBT)		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Group CBT		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Online CBT		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Dialectical behavioral therapy		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
First episode/early intervention for psychosis		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Multi-systemic therapy		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Assertive community treatment (ACT)		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Forensic ACT		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Evidence-based medication evaluation and management		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Medication-assisted treatment for alcohol and opioid use		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Therapeutic foster care		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Community wraparound services for youth/children		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Specialty MH/SUD services for children and youth		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
e. Psychiatric Rehabilitation Services
Medication education		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Self-management		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Skills training		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Psychoeducation		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Community integration services		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Illness management and recovery		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Financial management		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Wellness education services (diet, nutrition, exercise, tobacco cessation, etc.		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Supported housing		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Supported employment		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Supported education		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
f. Peer Support Services
Peer support services for consumers/clients		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Peer support services for families		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
g. Targeted Case Management		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
h. Primary Care Screening and Monitoring		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
i. Intensive Community-based Mental Health Services for Armed Forces and Veterans		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
Please describe any specific activities or services that are targeted to members of the Armed Forces or Veterans: Click here to enter description.
j. Other required CCBHC services (please describe): 1. Click here to enter additional service. 2. Click here to enter additional service. 3. Click here to enter additional service.		☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐ ☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐ ☐ ☐ ☐ ☐ ☐ ☐ Enter # of months ☐
2. If your CCBHC has made any changes to the scope of services provided in the past 12 months, please briefly explain those changes and why you made them. Click here to enter text.

E. CCBHC quality and other reporting

1. Does your CCBHC collect any of the following information as described in Program Requirement 5 of the CCBHC criteria? For each category, please indicate whether this information is stored in an EHR, clinical registry, or other database. If other, please describe.
Staffing	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Consumer characteristics	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Access to services	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Use of CCBHC services	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Screening	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Prevention	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Treatment	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Care coordination	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Other processes of care	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Costs	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
Consumer outcomes	☐ EHR ☐ Clinical registry ☐ Other: Click here to describe.
2. Please list any current Continuous Quality Improvement projects underway and the length of time they have been implemented. Click here to list.
3. In the past 12 months, has your CCBHC used the information collected on quality of care to change clinical practice? ☐ Yes ☐ No If so, please describe what measures these efforts were based on and the nature of the changes to your clinical practice: Click here to enter description.
4. Is your CCBHC accredited? ☐ Yes ☐ No If so, please describe the type of accreditation/accrediting agency: Click here to enter description.