Attachment A. CCBHC State Official Interview Protocol_Year 2

EVALUATION YEAR TWO TELEPHONE INTERVIEW QUESTIONS – STATE OFFICIALS

In each evaluation year, we will conduct semi-structured telephone interviews with state Medicaid and behavioral health officials in each demonstration state to gather information on demonstration progress at different stages of implementation. The focus of interviews will be adapted based on which evaluation questions will be answered during that evaluation year, and questions will vary between new and original demonstration states. We will tailor the interview protocol in advance of each interview to reflect information about the demonstration in that state. We have identified by name and color-coded questions or parts of questions below that are specific to new states (blue text) and original states (red text). We will ask the COVID-19 questions if still applicable. The interviewer will transfer the information gathered from the interviews into an Excel template that organizes data by PAMA topic and corresponding research questions. The general protocol for telephone interviews with state officials is presented below.

A. Introduction

1. Interviewer introduction

1. Obtain verbal consent to record

2. Please describe your current role(s)/position(s) and responsibilities.

2. Demonstration Oversight

1. Could you please briefly share how implementation has been going for your state and its CCBHCs since we spoke in Spring 2022?

   1. Does the state still have [number] CCBHCs participating in the demonstration? [If no] Why has the number changed?

   2. What have been the key challenges and successes for the state agency in the last year? What about for CCBHCs?

2. Has the state’s role in demonstration implementation evolved since we spoke with you in Spring 2022? Please describe if so.

3. Do you have any updates to share since we spoke in Spring 2022 regarding expansion of the CCBHC model through other funding mechanisms (or any new plans to do so)? (e.g., State Plan Amendments, 1115 waivers, CCBHC Expansion grants, state legislative efforts/initiatives) What is the status/timing of these?

   1. [For new SPAs/1115 waivers/other state-level initiatives]: Have you made any changes to the requirements of the CCBHC model? Are you retaining all of the required services and types of staff? Why?

   2. [For new SPAs/1115 waivers/other state-level initiatives]: How will CCBHC financing and payment work under [initiative]? How will this compare to the current PPS?

3. Access to Care

   1. Could you please update us on state and CCBHC activities to increase access to care since we spoke with you in Spring 2022?

1. What kinds of technical assistance or guidance have the state or other groups provided this past year (if any)?

2. Has the state changed any requirements related to access since we last spoke?

3. How, if at all, has access changed?

2. [Kentucky and Michigan] Could you please share some of the key successes that demonstration CCBHCs have had in increasing access to care?

3. [Kentucky and Michigan] What challenges have demonstration CCBHCs encountered in increasing access to care? For example, CCBHCs may have encountered challenges in retaining staff to meet increased demands for services or encountered challenges engaging consumers in services.

[Potential probes]:

• Can you think of any statewide or regional challenges? What about challenges for specific clinics?

• Do you recall any activities that CCBHCs considered, but did not end up implementing due to challenges?

• Have CCBHCs discontinued any activities to increase access? Why?

• Have there been any access challenges specific to certain populations? (For example, consumers with disabilities, homeless, children, adolescents, Veterans, Indigenous people, rural)

1. How, if at all, is the state supporting the CCBHC(s) to address these issues?

2. How are CCBHCs working to overcome these challenges? What have been some of the more successful strategies to date?

1. How has the COVID-19 pandemic affected access to care at CCBHCs since we last spoke?

1. How did the state support clinics’ efforts to maintain access?

1. [Kentucky and Michigan] We understand that the state expected to serve [number of individuals from initial conversation with the state] consumers in the first year of the demonstration. Did the state reach that number? What is the state’s projection for the second year of the demonstration?

1. Were the characteristics of clients served by CCBHCs what you expected in the first year? (Characteristics such as age, race/ethnicity, gender, insurance status, and housing status.)

4. Scope of Services

1. Has the state established any new requirements or changed any existing requirements related to the scope of CCBHC services since we spoke in spring 2022? Why?

2. Have there been any major changes in the scope of services provided by CCBHCs? For example, have CCBHCs struggled to maintain any of the required services? Please describe if so.

3. Has the state provided any new guidance or support or made any new investments to help CCBHCs provide the required services since we last spoke with you?

1. [If yes]: What prompted those actions?

4. How has the COVID-19 pandemic affected CCBHCs’ delivery of required services since we last spoke?

1. Did the state provide any support or guidance specific to COVID-19-related challenges to help CCBHCs maintain the required services in the last year?

5. [Original states] Have CCBHCs generally been able to maintain case management and care coordination activities that they were engaging in during the first two years of the demonstration? We will talk about activities to coordinate care between internal and external providers and partners in more depth in a minute, but we are after your broad impressions of case management and care coordination first. This would include coordination activities with clients’ families as well.

   1. In what ways, if any, have clinics been able to make further strides since then?

   2. Have they made any major changes to the way they provide case management and care coordination?

6. [Kentucky and Michigan] How are case management and care coordination activities going for CCBHCs?

   1. What are some early challenges and successes of this work?

7. What investments, support, or guidance has the state provided [for original states: since the end of the second demonstration year] to help CCBHCs provide case management and care coordination?

8. Have there been any new policies or programs that have affected CCBHCs’ case management and care coordination activities?

9. Have clinics used any innovative technologies to provide case management and care coordination? (e.g., registries, dashboards, patient portals, care management software)

   1. What have been some of the challenges or successes of using these technologies for this work?

10. Have you begun to see the effects of care management activities and care coordination on client outcomes?

11. [Original states] Have CCBHCs generally been able to maintain activities to coordinate care across providers within the CCBHC that they were engaging in during the first two years of the demonstration?

    1. In what ways, if any, have clinics been able to make further strides since then?

    2. Have they made any major changes to the way they internally coordinate care?

12. [Kentucky and Michigan] How are activities to coordinate care across providers within the CCBHC going for CCBHCs?

    1. What are some early challenges and successes of this work?

13. What investments, support, or guidance has the state provided [for original states: since the end of the second demonstration year] to help CCBHCs coordinate care across providers within the CCBHC?

14. Have there been any new policies or programs that have affected CCBHCs’ coordination activities across providers within the CCBHC?

15. Have clinics used any innovative technologies to coordinate care internally (e.g., EHR functionalities, instant messaging)?

    1. What have been some of the challenges or successes of using EHRs or other technologies for this work?

16. Have you begun to see the effects of internal care coordination activities on client outcomes?

17. [Original states] Have CCBHCs generally been able to maintain activities to coordinate care externally that they were engaging in during the first two years of the demonstration? For example, we’re interested in hearing about coordination with external providers and partners, referrals to other levels of care, and coordination of care transitions.

    1. In what ways, if any, have clinics been able to make further strides since then?

    2. Have they made any major changes to the way they externally coordinate care?

[Probe on collaborating and sharing information with the following example entities]:

• Hospitals

• EDs

• Child/adolescent service providers

• Schools

18. [Kentucky and Michigan] How are external care coordination activities going for CCBHCs? We’re interested in hearing about coordination with external providers and partners, referrals to other levels of care, and coordination of care transitions.

    1. What are some early challenges and successes of this work?

19. What investments, support, or guidance has the state provided [for original states: since the end of the second demonstration year] to help CCBHCs coordinate care externally?

20. Have there been any new policies or programs that have affected CCBHCs’ external care coordination?

21. Original states: How do CCBHCs learn about clients’ care transitions, such as hospital admissions or discharges and ED visits?

    1. [If not addressed] What is the source of this information?

    2. Does your state provide CCBHCs with any information about clients’ care transitions? If yes:

1. What information does the state provide?

2. How is the information conveyed to the CCBHC?

22. How is health IT supporting CCBHCs’ care coordination efforts in the state?

    1. Do clinics have access to a health information exchange? How do they use this exchange to coordinate care? What are some of the challenges?

    2. Do clinics tend to receive alerts when a client is seen by another provider? Why or why not? How does technology support transitions of care for CCBHC clients in this state?

    3. What technologies do clinics tend to use for referring clients to other levels of care, such as inpatient, residential, or detoxification services? What are some of the challenges?

    4. To what extent are non-technological workflows being used?

23. Have you begun to see the effects of external care coordination activities on client outcomes?

5. Quality of Care

   1. What has the process been like for states and CCBHC in terms of reporting the required quality measures since we spoke in Spring 2022?

1. What has hindered reporting?

2. What has facilitated reporting?

3. Have you calculated the measures following the specifications?

1. How is the state supporting CCBHCs’ continuous QI activities?

   1. How has the state used performance on quality measures to help clinics improve quality [for original states: since we spoke with you in Spring 2022]?

   2. Have the state or other groups offered any technical assistance related to quality?

2. Has the state used quality measure performance to change any policies? Please describe if so.

3. Could you briefly share your reflections on how the quality of care delivered by CCBHCs compares to non-CCBHCs? How has the quality of care provided by CCBHCs changed [KY/MI: over time]/[original states: since the end of the second demonstration year]?

4. How has the COVID-19 pandemic affected the quality of care provided by the CCBHCs since we last spoke, particularly in relation to demonstration services?

6. Payment System Changes and Costs

   1. Did the state rebase its PPS rates or adjust them for inflation in the last year?

      1. [If yes]: What led to the decision to do so? Was the pandemic a factor? How did you use cost reports for rebasing?

2. Has the way the state approaches the rate setting process changed since we spoke with you in Spring 2022?

3. Did you need to make new appropriations to fund the demonstration since we last spoke? How much is currently allocated for the demonstration?

4. [Managed care states] Did the state fully incorporate PPS rates into capitation payments or elect to make wraparound payments to CCBHCs?

   1. [States that incorporated] Did the state make any adjustments to the portion of the state’s capitation rate associated with the CCBHC demonstration?

   2. [Wraparound payment states] Did the state make wraparound payments to CCBHCs in the past year?

5. Do CCBHCs submit Medicaid claims for services not covered by the PPS? What are examples of those services?

6. Have there been any challenges with paying CCBHCs or managed care plans that are covering CCBHC services?

7. Have there been any changes in the state that would affect the way CCBHCs are submitting Medicaid claims for clients in CCBHCs?

8. How has the COVID-19 pandemic affected costs since we last spoke?

   1. Did it affect costs of operating the CCBHCs?

   2. Did it affect costs of specific types of required CCBHC services?

   3. Did it affect staffing costs?

1. Cross-cutting

   1. Would you like to share any updates on how your state is integrating CCBHCs with other policy initiatives?

Probe for the following and implications for funding, overlap, and care coordination, as relevant:

1. 1115 waivers, health homes (and status/timing of these)

2. 988 (mental health crisis number)

3. Planning grants for mobile crisis intervention through the American Rescue Plan (KY, MO, NV, OK, OR) [Outcomes of these investments]

4. SAMHSA CCBHC grants

5. Increased funding for home and community-based services (HCBS) through the American Rescue Plan [Outcomes of these investments]

6. Individual Placement and Support services (model of supported employment for people with behavioral health needs)

8. Interviewee Feedback/Open Discussion

   1. What have we missed? What else do we need to know that we haven’t asked you? [Note: we will be covering additional topics with you in later years, but any brief updates would be helpful.]