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pdfCertified Community Behavioral Health Clinics Criteria Compliance Checklist
Certified Community Behavioral
Health Clinic (CCBHC)
Page 1
Criteria Compliance Checklist
Updated July 2023
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Page ii
Table of Contents
Program Requirement 1: Staffing .......................................................................................................1
Criteria 1.A: General Staffing Requirements .......................................................................................... 1
Criteria 1.B: Licensure and Credentialing of Providers........................................................................... 5
Criteria 1.C: Cultural Competence and Other Training .......................................................................... 7
Criteria 1.D: Linguistic Competence ....................................................................................................... 9
Program Requirement 2: Availability and Accessibility of Services ..................................................... 11
Criteria 2.A: General Requirements of Access and Availability ............................................................ 11
Criteria 2.B: General Requirements for Timely Access to Services and Initial and Comprehensive
Evaluation ...................................................................................................................................... 13
Criteria 2.C: Access to Crisis Management Services ............................................................................. 15
Criteria 2.D: No Refusal of Services Due to Inability to Pay ................................................................. 16
Criteria 2.E: Provision of Services Regardless of Residence ................................................................. 17
Program Requirement 3: Care Coordination ..................................................................................... 18
Criteria 3.A: General Requirements of Care Coordination ................................................................... 18
Criteria 3.B: Care Coordination and Other Health Information Systems ............................................. 20
Criteria 3.C: Care Coordination Agreements ........................................................................................ 22
Criteria 3.D: Treatment Team, Treatment Planning, and Care Coordination Activities....................... 25
Program Requirement 4: Scope of Services ....................................................................................... 26
Criteria 4.A: General Service Provisions ............................................................................................... 26
Criteria 4.B: Person-Centered and Family-Centered Care ................................................................... 28
Criteria 4.C: Crisis Behavioral Health Services ...................................................................................... 29
Criteria 4.D: Behavioral Health Screening, Assessment, and Diagnosis ............................................... 31
Criteria 4.E: Person‐Centered and Family‐Centered Treatment Planning ........................................... 34
Criteria 4.F: Outpatient Mental Health and Substance Use Services ................................................... 36
Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring.............................................. 38
Criteria 4.H: Targeted Case Management Services .............................................................................. 40
Criteria 4.I: Psychiatric Rehabilitation Services .................................................................................... 41
Criteria 4.J: Peer Supports, Peer Counseling, and Family/Caregiver Supports .................................... 42
Criteria 4.K: Intensive, Community‐Based Mental Health Care for Members of the Armed Forces
and Veterans .................................................................................................................................. 43
Program Requirement 5: Quality and Other Reporting ...................................................................... 45
Criteria 5.A: Data Collection, Reporting, and Tracking ......................................................................... 45
Criteria 5.B: Continuous Quality Improvement (CQI) Plan ................................................................... 47
Program Requirement 6: Organizational Authority, Governance, and Accreditation .......................... 49
Criteria 6.A: General Requirements of Organizational Authority and Finances .................................. 49
Criteria 6.B: Governance ...................................................................................................................... 50
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
List of Acronyms
CCBHC: Certified Community Behavioral Health Clinic
CEO: Chief operating officer
CQI: Continuous Quality Improvement
DCO: Designated collaborating organizations
ED: Emergency department
HHS: Health and Human Services
HIPAA: Health Insurance Portability & Accountability Act
LEP: Limited English proficiency
SUD: Substance use disorder
VHA: Veterans Health Administration
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Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Instructions
For each of the criteria on the checklist, please indicate the number of CCBHCs in your state that fall
within each of the following categories:
1.
Ready to implement
• The CCHBC fully satisfies all elements under this Program Requirement Criteria.
2.
Mostly ready to implement
• The CCBHC satisfies almost all elements under this Program Requirement
Criteria although some minor adjustments are currently in process to fully
satisfy. The CCBHC has a plan to come into compliance within the required
timeframe.
3.
Ready to implement with remediation
• The CCBHC satisfies some elements but must make significant improvements in
other elements to fully satisfy this Program Requirement Criteria. The CCBHC is
responsive to implementing the needed changes and has begun to do so. The
CCBHC has a plan to come into compliance within the required timeframe.
4.
Unready to implement
• The CCBHC has not demonstrated capacity to meet the elements under this
Program Requirement Criteria and will be unable to come into compliance
within the required timeframe.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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CCBHC Criteria Compliance Checklist 2023
This compliance checklist identifies the criteria required for a Certified Community Behavioral Health
Clinic (CCBHC).
Program Requirement 1: Staffing
Criteria 1.A: General Staffing Requirements
1.a.1
Needs Assessment and Staffing Plan
Readiness Level
Criteria 1.a.1 1 2 3
# of Clinics
4
The CCBHC has completed a community needs assessment. The community needs assessment includes
the following components:
•
A description of the physical boundaries and size of the service area, including
identification of sites where services are delivered by the CCBHC, including through
DCOs
•
Information about the prevalence of mental health and substance use conditions and
related needs in the service area, such as rates of suicide and overdose
•
Economic factors and social determinants of health affecting the population's access to
health services, such as percentage of the population with incomes below the poverty
level, access to transportation, nutrition, and stable housing
•
Cultures and languages of the populations residing in the service area
•
The identification of the underserved population(s) within the service area
•
A description of how the staffing plan does and/or will address findings
•
Plans to update the community needs assessment every 3 years
•
Input with regard to:
Cultural, linguistic, physical health, and behavioral health treatment needs
Evidence-based practices and behavioral health crisis services
Access and availability of CCBHC services including days, times, and locations, and
telehealth options
Potential barriers to care such as geographic barriers, transportation challenges,
economic hardship, lack of culturally responsive services, and workforce shortages
•
Input gathered from the following entities in the service area:
People with lived experience of mental and substance use conditions and individuals
who have received/are receiving services from the clinic conducting the needs
assessment
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Health centers (including FQHCs)
Local health departments (Note: these departments also develop community needs
assessments that may be helpful)
Inpatient psychiatric facilities, inpatient acute care hospitals, and hospital outpatient
clinics
One or more Department of Veterans Affairs facilities
Representatives from local K-12 school systems
Other community partners
•
Input should also come from other community partners who work with people receiving
services from the CCBHC and populations that historically are not engaging with health
services, such as:
Organizations operated by people with lived experience of mental health and substance
use conditions
Residential programs
Juvenile justice agencies and facilities
Criminal justice agencies and facilities
Indian Health Service or other tribal programs such as Indian Health Service youth
regional treatment centers as applicable
Child welfare agencies and state licensed and nationally accredited child placing
agencies for therapeutic foster care service
Crisis response partners such as hospital emergency departments, crisis stabilization
settings, crisis call centers and warmlines
Specialty providers of medications for treatment of opioid and alcohol use disorders
Peer-run and operated service providers
Homeless shelters
Housing agencies
Employment services systems
Services for older adults, such as Area Agencies on Aging
Aging and Disability Resource Centers
Other social and human services (e.g., domestic violence centers, pastoral services, grief
counseling, Affordable Care Act navigators, food and transportation programs)
•
Additional state required community needs assessment requirements if any have been
established by the state.
•
The CCBHC has completed a staffing plan that reflects the findings of the needs
assessment.
•
(Recertification) The needs assessment and staffing plan updated in the past 3 years or
less.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
1.a.2
Page 3
Staff
Readiness Level
Criteria 1.a.2 1 2 3
# of Clinics
4
The CCBHC staff (both clinical and non-clinical) is appropriate in size and composition, and provides
services appropriate for the population served.
Staffing satisfies the requirements of criteria 4.K for services to veterans.
1.a.3
Management Staffing
Readiness Level
Criteria 1.a.3 1 2 3
# of Clinics
4
CCBHC management staffing is adequate for the needs of CCBHC, as determined by the needs
assessment and staffing plan.
The Chief Executive Officer (CEO) or equivalent of the CCBHC maintains a fully staffed management
team appropriate for the needs and size of the clinic, as determined by the current needs assessment
and staffing plan.
The management team includes a CEO or equivalent/Project Director and a psychiatrist as Medical
Director.
•
For a CCBHC without a psychiatrist, provisions are made for psychiatric consultation and
a medically trained behavioral health provider with appropriate education and licensure
to independently prescribe as the Medical Director.
The Medical Director provides guidance regarding behavioral health clinical service delivery, ensures the
quality of the medical component of care, and provides guidance to foster the integration and
coordination of behavioral health and primary care.
•
1.a.4
If the CCBHC is unable to hire a psychiatrist and hires another prescriber instead
psychiatric consultation is obtained regarding behavioral health clinical service delivery,
quality of the medical component of care, and integration and coordination of
behavioral health and primary care.
Liability/Malpractice Insurance
Readiness Level
Criteria 1.a.4 1 2 3
# of Clinics
4
The CCBHC maintains adequate liability/malpractice insurance.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
General Staffing Requirements Notes
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Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 1.B: Licensure and Credentialing of Providers
1.b.1
Appropriate Licensure and Credentialing
Readiness Level
Criteria 1.b.1 1 2 3
# of Clinics
4
CCBHC practitioners providing direct services furnish them within their scope of practice in accordance
with all applicable federal, state, and local laws and regulations, including Medicaid billing regulations or
policies.
Appropriate supervision is provided for CCBHC providers that are working towards licensure.
1.b.2
Required Staffing
Readiness Level
Criteria 1.b.2 1 2 3
# of Clinics
4
The CCBHC staffing plan meets requirements of the state behavioral health authority and any
accreditation or other standards required by the state.
The staffing plan is informed by the community needs assessment and is appropriate to the needs of
people receiving CCBHC service.
The staffing plan includes clinical, peer, and other staff and core staff comprised of employed and as
needed, contracted staff. Staffing is appropriate to the needs of people receiving services at the CCBHC,
reflected in individual treatment plans, and as required to meet program requirements of these criteria.
The CCBHC has a medically trained behavioral health care provider, either employed or available
through formal arrangement, who can prescribe and manage medications independently under state
law, including buprenorphine and other FDA-approved medications used to treat opioid, alcohol, and
tobacco use disorders.
If the CCBHC does not have the ability to prescribe methadone for the treatment of opioid use disorder
directly, it refers to an opioid treatment program (if any exist in the CCBHC service area) and provides
care coordination to ensure access to methadone.
The CCBHC has staff, either employed or under contract, who are licensed or certified substance use
treatment counselors or specialists.
The Medical Director has experience in the assessment and diagnosis of SUD, substance intoxication and
withdrawal; pharmacological management of intoxication, withdrawal, and SUDs; ambulatory
withdrawal management; outpatient addiction treatment; toxicology testing; and pharmacodynamics of
commonly used substances.
•
If the Medical Director is not experienced with the treatment of substance use
disorders, the CCBHC has experienced addiction medicine physicians or specialists on
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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staff, or arrangements that ensure access to consultation on addiction medicine for the
Medical Director and clinical staff.
The CCBHC has credentialed substance use treatment specialists either employed or under contract.
The CCBHC has staff with expertise in addressing trauma and promoting the recovery of children and
adolescents with serious emotional disturbance and adults with serious mental illness.
The CCBHC supplements its core staff as necessary in order to adhere to program requirements 3 and 4
and individual treatment plans, through arrangements with, and referrals to, other providers.
The CCBHC has staff disciplines as required (if any) by the certifying state.
Licensure and Credentialing of Providers Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 1.C: Cultural Competence and Other Training
1.c.1
Training Plans
Readiness Level
Criteria 1.c.1 1 2 3
# of Clinics
4
The CCBHC has a training plan for all employees and contract staff who have direct contact with people
receiving services or their families.
The training plan satisfies and includes requirements of the state behavioral health authority and any
accreditation standards on training required by the state.
At staff orientation and at reasonable intervals, the CCBHC provides training on:
•
•
•
•
•
•
Evidence‐based practice
Cultural competency
Person‐centered and family‐centered, recovery‐oriented planning and services
Trauma‐informed care
The clinic’s policy and a continuity plan for operations/disasters
The clinic’s policy and procedures for integration and coordination with primary care
integrated care of mental health and substance use disorders
At orientation and annually thereafter, the CCBHC provides training on:
•
•
•
Risk assessment
Suicide and overdose prevention and response
The roles of families and peer staff
Trainings are aligned with the National Standards for Culturally and Linguistically Appropriate Services to
advance health equity, improve quality of services, and eliminate disparities.
Trainings include information related to military culture, to the extent active-duty military or veterans
are being served.
1.c.2 - 1.c.4
Skills and Competence
Readiness Level
Criteria 1.c.2-4 1
2 3
# of Clinics
4
The CCBHC regularly assesses and has written policies and procedures that describe the methods used
for assessing skills and competencies of providers and keeps track of training provided for each
employee.
The CCBHC maintains documentation of completion of training and demonstration of competencies
within staff personnel records.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Individuals providing training to CCBHC staff have the qualifications to do so as evidenced by their
education, training, and experience.
Cultural Competence and Other Training Notes
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Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 1.D: Linguistic Competence
1.d.1 - 1.d.4 Meaningful Access
Readiness Level
1 2 3
# of Clinics
Criteria 1.d.1-4
4
The CCBHC takes reasonable steps to provide meaningful access to people with Limited English
Proficiency (LEP) or with language-based disabilities.
Interpretation/translation service(s) are readily available, appropriate and timely for the size/needs of
the LEP CCBHC consumer population (e.g., bilingual providers, onsite interpreters, language video or
telephone line). To the extent interpreters are used, such translation service providers are trained to
function in a medical and, preferably, a behavioral health setting.
CCBHC auxiliary aids and services are available, ADA compliant, and responsive to the needs of people
with physical, cognitive, and/or developmental disabilities (e.g., sign language interpreters, teletype
[TTY] lines) receiving services.
Documents or messages vital to the ability of a person receiving services to access CCBHC services (e.g.,
registration forms, sliding scale fee discount schedule, after-hours coverage, signage) are available
online and in paper format, in languages commonly spoken within the community served, taking
account of literacy levels and the need for alternative formats, and provided in a timely manner at
intake and throughout the time a person is served by the CCBHC.
The community needs assessment has informed which languages require language assistance.
1.d.5
Meaningful Access and Privacy
Readiness Level
Criteria 1.d.5 1 2 3
# of Clinics
4
CCBHC policies have explicit provisions for ensuring that all employees, affiliated providers, and
interpreters understand and adhere to confidentiality and privacy requirements applicable to the
service provider, including but not limited to the requirements of the Health Insurance Portability and
Accountability Act (HIPAA), 42 CFR Part 2 (Confidentiality of Alcohol and Drug Abuse Patient Records),
patient privacy requirements specific to care for minors, and other state and federal laws.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Linguistic Competence Notes
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Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Program Requirement 2: Availability and Accessibility of
Services
Criteria 2.A: General Requirements of Access and Availability
2.a.1 - 2.a.8
Access and Availability
Readiness Level
Criteria 2.a.1-8 1
2 3
# of Clinics
4
The CCBHC provides a safe, functional, clean, sanitary, and welcoming environment for people receiving
services and staff.
The CCBHC provides services during times that facilitate accessibility and meet the needs of the
population served, including some evening and weekend hours as informed by the community needs
assessment.
The CCBHC provides services at locations that are accessible to and meet the needs of the population to
be served, such as community settings as informed by the community needs assessment.
The CCBHC provides transportation or transportation vouchers for people receiving services to the
extent possible with relevant funding or programs in order to facilitate access to services in alignment
with the person-centered and family-centered treatment plan.
The CCBHC utilizes telehealth/telemedicine, video conferencing, digital therapeutics, remote patient
monitoring, asynchronous interventions, and/or other technologies to the extent possible in alignment
with the preferences of the person receiving services to support access to all required services.
The CCBHC conducts outreach, engagement, and retention activities to support inclusion and access for
underserved individuals and populations as informed by the community needs assessment.
CCBHC services conform to state or county/municipal court standards for the provision of voluntary and
court‐ordered services.
The CCBHC has a continuity of operations/disaster plans in place that:
•
•
•
Ensures the CCBHC is able to effectively notify staff, people receiving services, and
healthcare and community partners when a disaster/emergency occurs or services are
disrupted
Identifies alternative locations and methods to sustain service delivery and access to
behavioral health medications during emergencies and disasters
Addresses health IT systems security/ransomware protection and backup and access to
these IT systems, including health records, in case of disaster
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
General Requirements of Access and Availability Notes
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Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 2.B: General Requirements for Timely Access to Services and Initial and
Comprehensive Evaluation
2.b.1
Timing of Screening, Evaluation and Provision of Services to People Receiving
Services New CCBHC
Readiness Level
Criteria 2.b.1 1 2 3
# of Clinics
4
All new people requesting or referred for services receive, at the time of first contact, a preliminary
triage (whether in-person, by telephone, or other remote communication) to determine acuity of needs.
•
•
•
If the triage identifies an emergency/crisis need, appropriate action is taken
immediately (see 4.c.1 for crisis response timelines and detail about required services),
including plans to reduce or remove risk of harm and to facilitate any necessary
subsequent outpatient follow-up.
If triage identifies an urgent need, clinical services and initial evaluation are to be
provided within one (1) business day of the time the request is made.
If triage identifies routine needs, services are provided, including the initial evaluation
completed within 10 business days.
For those presenting with emergency or urgent needs, if the initial evaluation is conducted
telephonically, once the emergency is resolved, the person receiving services is seen in-person at the
next subsequent encounter and the initial evaluation reviewed.
The preliminary triage and risk assessment is followed by: (1) an initial evaluation and (2) a
comprehensive evaluation, with the components of each specified in program requirement 4.
All new people receiving services receive a comprehensive evaluation to be completed within 60
calendar days of the first request for services. If the state has established independent screening and
assessment processes for certain child and youth populations or other populations, the CCBHC should
establish partnerships to incorporate findings and avoid duplication of effort. This requirement does not
preclude the initiation or completion of the comprehensive evaluation, or the provision of treatment
during the 60-day period.
2.b.2
Updating Comprehensive Person‐Centered and Family‐Centered Diagnostic
and Treatment Planning Evaluation
Readiness Level
Criteria 2.b.2 1 2 3
# of Clinics
4
CCBHC treatment teams update the person‐centered and family‐centered diagnostic and treatment
plan, in agreement with and endorsed by the person receiving services, when changes occur with the
status of the person receiving services, based on responses to treatment, or when there are changes in
treatment goals.
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The treatment plan is reviewed and updated no less frequently than every 6 months unless the state,
federal, or applicable accreditation standards are more stringent.
2.b.3
Timing of Services for Established People Who Are Receiving Services
Readiness Level
Criteria 2.b.3 1 2 3
# of Clinics
4
Unless state, federal, or applicable accreditation standards are more stringent, appointments occur
within 10 business days from when the request for appointment is made for all people who are already
receiving services from the CCBHC and seeking routine outpatient clinical service.
If a person receiving services presents with an emergency/crisis need, the CCBHC takes appropriate and
immediate action that is consistent with the needs of the person receiving services. This includes
immediate crisis response.
If a person already receiving services presents with an urgent, non-emergency need, clinical services are
generally provided within one business day of the request, or at a later time if that is the preference of
the person receiving services.
General Requirements for Timely Access to Services and Initial and Comprehensive Evaluation
Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 2.C: Access to Crisis Management Services
Readiness Level
Criteria 2.C
1 2 3
# of Clinics
4
The CCBHC provides crisis management services in accordance with program requirement 4.c. that are
available and accessible 24 hours a day, seven days a week.
The CCBHC has policies or procedures in place requiring communication to the public of the methods for
providing a continuum of crisis prevention, response, and postvention services.
The CCBHC educates individuals served by the CCBHC about crisis planning; psychiatric advanced
directives; how to access crisis services, including the 988 Suicide & Crisis Lifeline and other area
hotlines and warmlines; and overdose prevention. This includes individuals with LEP or disabilities (i.e.,
CCBHC provides instructions on how to access services in the appropriate methods, language(s), and
literacy levels in accordance with program requirement 1.d).
Protocols established for CCBHC staff to address the needs of CCBHC people receiving services in
psychiatric crisis who come to emergency departments.
Protocols with law enforcement are in place to reduce delays for initiating services during and following
a behavioral health crisis.
The CCBHC has created, maintained, and followed crisis plans to prevent and de-escalate future crisis
situations, in conjunction with the person receiving services following a psychiatric emergency or crisis.
Access to Crisis Management Services Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 2.D: No Refusal of Services Due to Inability to Pay
Readiness Level
Criteria 2.D
1 2 3
# of Clinics
4
The CCBHC has policies that (1) services cannot be denied because of inability to pay and that (2) any
fees or payments required by the clinic for such services are reduced or waived for those unable to pay.
The CCBHC has published sliding fee discount schedule(s) on the CCBHC website, posted in the CCBHC
waiting room and that are readily accessible to people receiving services and their families. The sliding
fee discount schedule is communicated in languages/formats appropriate for individuals seeking
services who have LEP, literacy barriers, or disabilities.
The fee schedule(s) conform to state statutory or administrative requirements or to federal statutory or
administrative requirements that may be applicable. Absent applicable state or federal requirements,
the schedule is based on locally prevailing rates or charges and includes reasonable costs of operation.
The CCBHC has written policies and procedures describing eligibility for and implementation of the
sliding fee discount schedule and are applied equally to all individuals seeking services.
No Refusal of Services Due to Inability to Pay Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 2.E: Provision of Services Regardless of Residence
Readiness Level
Criteria 2.E
1 2 3
# of Clinics
4
The CCBHC has a policy that services cannot be refused due to residence, homelessness, or lack of a
permanent address.
The CCBHC has policies or protocols addressing services for those who do not live close to or within the
CCBHC service area.
The CCBHC provides, at a minimum, crisis response, evaluation, and stabilization services in the CCBHC
service area regardless of place of residence.
The CCBHC has protocols that address management of the individual’s on-going treatment needs
beyond crisis services. Protocols may provide for agreements with clinics in other localities, allowing the
CCBHC to refer and track individuals seeking non-crisis services to the CCBHC or other clinics serving the
individual’s area of residence.
Provision of Services Regardless of Residence Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Program Requirement 3: Care Coordination
Criteria 3.A: General Requirements of Care Coordination
Readiness Level
Criteria 3.A
1 2 3
# of Clinics
4
Care coordination is based on a person-centered and family-centered treatment plan aligned with the
requirements of Section 2402(a) of the Affordable Care Act and aligned with state regulations and
consistent with best practices.
The CCBHC coordinates care across the spectrum of health services, including access to high‐quality
physical health (both acute and chronic) and behavioral health care, as well as social services, housing,
educational systems, and employment opportunities as necessary to facilitate wellness and recovery of
the whole person.
The CCBHC coordinates with other systems to meet the needs of the people they serve, including
criminal and juvenile justice and child welfare.
The CCBHC maintains the necessary documentation to satisfy the requirements of HIPAA, 42 CFR Part 2,
requirements specific to minors, and other privacy and confidentiality requirements of state or federal
law addressing care coordination and in interactions with the DCOs.
The CCBHC obtains necessary consents for sharing information with community partners where
information is not able to be shared under HIPAA and other federal and state laws and regulations.
•
If the CCBHC is unable, after reasonable attempts, to obtain consent for any care
coordination activity specified in program requirement 3, such attempts are
documented and revisited periodically.
Consistent with requirements of privacy, confidentiality, and the preferences and needs of people
receiving services, the CCBHC assists people receiving services and the families of children and youth
referred to external providers or resources in obtaining an appointment and tracking participation in
services to ensure coordination and receipt of supports.
The CCBHC coordinates care in keeping with the preferences of the person receiving services and their
care needs.
The CCBHC develops a crisis plan with each person receiving services. Crisis plans may support the
development of a Psychiatric Advanced Directive, if desired by the person receiving services. Psychiatric
Advance Directives are entered in the electronic health record of the person receiving services so that
the information is available to providers in emergency care settings.
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The CCBHC has procedures to coordinate care in collaboration with the family/caregiver of the person
receiving services. The CCBHC develops a crisis plan with each person receiving services to identify the
preferences of the person in the event of psychiatric or substance use crisis.
•
At minimum, people receiving services should be counseled about the use of the
National Suicide & Crisis Lifeline, local hotlines, warmlines, mobile crisis, and
stabilization services should a crisis arise when providers are not in their office.
The CCBHC has procedures to coordinate care for medication reconciliation with other providers.
CCBHC agreements for care coordination do not limit the freedom of a person receiving services to
choose their provider within the CCBHC, its DCOs, or any other provider.
The CCBHC assists people receiving services and families to access benefits, including Medicaid, and
enroll in programs or supports that may be beneficial to them.
General Requirements of Care Coordination Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 3.B: Care Coordination and Other Health Information Systems
Readiness Level
Criteria 3.B
1 2 3
# of Clinics
4
The CCBHC has a health information technology system in place that includes electronic health records.
The CCBHC uses its secure health IT system and related technology tools to conduct activities such as
population health management, quality improvement, quality measurement and reporting, disparity
reduction, outreach, and research.
The CCBHC (CCBHCs are not required to have all these capabilities in place when certified or when
submitting their attestation) uses technology that has been certified to current criteria under the ONC
Health IT Certification Program for the following required core set of certified health IT capabilities that
align with key clinical practice and care delivery requirements for CCBHCs:
•
•
•
•
•
Capture health information, including demographic information such as race, ethnicity,
preferred language, sexual and gender identity, and disability status (as feasible)
At a minimum, support care coordination by sending and receiving summary of care
records
Provide people receiving services with timely electronic access to view, download, or
transmit their health information or to access their health information via an API using a
personal health app of their choice
Provide evidence-based clinical decision support
Conduct electronic prescribing
The CCBHC works with DCOs to ensure all steps are taken, including obtaining consent from people
receiving services, to comply with privacy and confidentiality requirements. These include, but are not
limited to, those of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal
and state laws, including patient privacy requirements specific to the care of minors.
Within two years from CCBHC certification or submission of attestation the CCBHC produces a plan to
focus on ways to improve care coordination between the CCBHC and all DCOs using a health IT system.
This plan includes:
•
•
•
Information on how the CCBHC can support electronic health information exchange to
improve care transition to and from the CCBHC using the health IT system they have in
place or are implementing for transitions of care
Integrating clinically relevant treatment records (evaluation planning, treatment, and
care coordination) generated by the DCO for people receiving CCBHC services and
incorporating them into the CCBHC health record
All clinically relevant treatment records maintained by the CCBHC are available to DCOs
within the confines of federal and/or state laws governing sharing of health records
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Care Coordination and Other Health Information Systems Notes
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Certified Community Behavioral Health Clinics Criteria Compliance Checklist
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Criteria 3.C: Care Coordination Agreements
Readiness Level
Criteria 3.C
1 2 3
# of Clinics
4
The CCBHC has a partnership 1 establishing care coordination with Federally Qualified Health Centers
and, where relevant, Rural Health Clinics, unless health care services are provided by the CCBHC.
For people receiving services who are served by other primary care providers, including but not limited
to FQHC Look-Alikes and Community Health Centers, the CCBHC has established protocols to ensure
adequate care coordination.
The CCBHC has partnerships1 that establish care coordination expectations with programs that can
provide inpatient psychiatric treatment, OTP services, medical withdrawal management facilities and
ambulatory medical withdrawal management providers for substance use disorders, and residential
substance use disorder treatment programs (if any exist within the CCBHC service area). These include
tribally operated mental health and substance use services including crisis services that are in the
service area. The CCBHC tracks when people receiving services are admitted to and discharged from
these facilities (unless there is a formal transfer of care to a non-CCBC entity).
The CCBHC has established protocols and procedures for transitioning individuals from EDs, inpatient
psychiatric programs, medically monitored withdrawal management services, and residential or
inpatient facilities that serve children and youth such as Psychiatric Residential Treatment Facilities and
other residential treatment facilities, to a safe community setting. This includes transfer of health
records of services received (e.g., prescriptions), active follow-up after discharge, and, as appropriate, a
plan for suicide prevention and safety, overdose prevention, and provision for peer services.
The CCBHC has partnerships 2 (with a variety of community or regional services, supports, and providers.
CCBHCs are required to develop partnerships with the following organizations operating within the
service area:
•
•
•
Schools
Child welfare agencies
Juvenile and criminal justice agencies and facilities, including drug, mental health,
veterans and other specialty courts
These partnerships should be supported by a formal, signed agreement detailing the roles of each party. If the
partnering entity is unable to enter into a formal agreement, the CCBHC may work with the partner to develop
unsigned joint protocols that describe procedures for working together and roles in care coordination. At a
minimum, the CCBHC has developed written protocols for supporting coordinated care undertaken by the CCBHC
and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be
developed. All partnership activities should be documented to support partnerships independent of any staff
turnover.
2
These partnerships should be supported by a formal, signed agreement detailing the roles of each party or
unsigned joint protocols that describe procedures for working together and roles in care coordination. At a
minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and
efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be
developed. All partnership activities should be documented to support partnerships independent of any staff
turnover.
1
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•
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•
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Indian Health Service youth regional treatment centers
State licensed and nationally accredited child placing agencies for therapeutic foster
care service
The 988 Suicide & Crisis Lifeline call center serving the area in which the CCBHC is
located
Additional partners as required by certifying states
CCBHCs may develop partnerships based on the population served, the needs and
preferences of people receiving services, and/or needs identified in the community
needs assessment (see 3.c.3 for examples)
The CCBHC has partnerships1 in place with the nearest Department of Veterans Affairs' medical center,
independent clinic, drop‐in center, or other facility of the Department.
The CCBHC has care coordination partnerships1 establishing expectations with inpatient acute-care
hospitals in the area served by the CCBHC and their associated services/facilities including emergency
departments, hospital outpatient clinics, urgent care centers, and residential crisis settings.
Care coordination partnerships with these entities include:
•
•
•
•
•
Procedures and services, such as peer recovery specialist/coaches, to help individuals
successfully transition from ED or hospital to CCBHC and community care to ensure
continuity of services and to minimize the time between discharge and follow up
Tracking when people receiving CCBHC services are admitted to facilities providing the
services listed above, as well as when they are discharged
The transfer of health records of services received (e.g., prescriptions) and active followup after discharge
For all people receiving CCBHC services being discharged from such facilities who are at
risk for suicide or overdose, a requirement to coordinate consent and follow-up services
with the person receiving services within 24 hours of discharge and that continues until
the individual is linked to services or assessed to be no longer at risk
The CCBHC requests that notification be provided through the Admission-DischargeTransfer (ADT) system of relevant inpatient and outpatient facilities, for people
receiving CCBHC services
The CCBHC makes and documents reasonable attempts to contact all people receiving CCBHC services
who are discharged from these settings within 24 hours of discharge.
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Care Coordination Agreements Notes
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Criteria 3.D: Treatment Team, Treatment Planning, and Care Coordination
Activities
Readiness Level
Criteria 3.D
1 2 3
# of Clinics
4
CCBHC treatment teams include the person receiving CCBHC services, their family/caregivers to the
extent the person receiving CCBHC services chooses, and any other people the person receiving CCBHC
services desires to be involved in their care. All CCBHC treatment planning and care coordination are
person‐centered and family‐centered and align with the requirements of Section 2402(a) of the
Affordable Care Act.
All treatment planning and care coordination activities comply with HIPAA (Pub. L. No. 104-191, 110
Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy
requirements specific to the care of minors.
The CCBHC designates interdisciplinary treatment teams that is responsible, with the person receiving
services and their family/caregivers/legal guardians, to the extent the person receiving services desires
their involvement for directing, coordinating, and managing care and services.
The interdisciplinary team is composed of individuals who work together to coordinate the medical,
psychiatric, psychosocial, emotional, therapeutic, and recovery support needs of people receiving
services traditional approaches to care for people receiving services who are American Indian or Alaska
Native or from other cultural and ethnic groups.
The CCBHC coordinates care and services provided by DCOs in accordance with the current treatment
plan.
Treatment Team, Treatment Planning, and Care Coordination Activities Notes
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Program Requirement 4: Scope of Services
Criteria 4.A: General Service Provisions
Readiness Level
Criteria 4.A
1 2 3
# of Clinics
4
Whether delivered directly or through a DCO agreement, the CCBHC is responsible for ensuring access
to all care specified in the Protecting Access to Medicare Act. This includes the following required
services: crisis services; screening, assessment, and diagnosis; person-centered and family-centered
treatment planning; outpatient behavioral health services; outpatient primary care screening and
monitoring; targeted case management; psychiatric rehabilitation; peer and family supports; and
intensive community-based outpatient behavioral health care for members of the U.S. Armed Forces
and veterans.
The CCBHC organization directly delivers the majority (51% or more) of encounters across the required
services (excluding Crisis Services) rather than through DCOs.
All CCBHC services, if not available directly through the CCBHC, are provided through a DCO.
The CCBHC or DCO make outside referrals if a needed specialty service is unavailable through the CCBHC
or DCO entities.
People receiving CCBHC services have freedom to choose providers within the CCBHC and its DCOs.
People receiving CCBHC services will be informed of and have access to CCBHC grievance procedures,
including for CCBHC services provided by a DCO.
With regard to CCBHC or DCO services, the grievance process satisfies the minimum requirements of
Medicaid and other grievance requirements such as those that may be mandated by relevant
accrediting entities.
CCBHC services provided by DCOs meet the same quality standards as those required of the CCBHC.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
General Service Provisions Notes
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Criteria 4.B: Person-Centered and Family-Centered Care
Readiness Level
Criteria 4.B
1 2 3
# of Clinics
4
The CCBHC ensures all CCBHC services, including those supplied by its DCOs, are provided in a manner
aligned with the requirements of Section 2402(a) of the Affordable Care Act. The CCBHC and its DCOs
provide services that reflect person‐centered and family‐centered and recovery oriented, being
respectful of the needs, preferences, and values of the person receiving CCBHC services, and ensuring
both involvement of the person receiving CCBHC services and self‐direction of services received.
The services that the CCBHC and its DCOs provide for children and adolescents are family‐centered,
youth-guided, and developmentally appropriate.
CCBHC services are responsive to the race, ethnicity, sexual orientation, and gender identity of the
person receiving CCBHC services and are culturally and ethically appropriate, as indicated in the needs
assessment, including services for people who are American Indian or Alaska Native.
Person-Centered and Family-Centered Care Notes
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Criteria 4.C: Crisis Behavioral Health Services
Readiness Level
Criteria 4.C
1 2 3
# of Clinics
4
The CCBHC provides crisis services directly or through a DCO agreement with existing state-sanctioned,
certified, or licensed system or network for the provision of crisis behavioral health services as identified
in these criteria.
•
•
The CCBHC has received approval from HHS to have a DCO relationship with a statesanctioned crisis system that operates under less stringent standards than those
identified in these criteria.
The certifying state has received approval from HHS to certify CCBHCs in its state that
has or seeks to have a DCO relationship with a state-sanctioned crisis system with less
stringent standards than those included in these criteria.
The CCBHC provides or coordinates with telephonic, text, and chat crisis intervention call centers that
meet 988 Suicide & Crisis Lifeline standards for risk assessment and engagement of individuals at
imminent risk of suicide.
Protocols have been established to track referrals made from the call center to the CCBHC or its DCO
crisis care provider to ensure the timely delivery of mobile crisis team response, crisis stabilization, and
post crisis follow-up care.
The CCBHC provides community-based behavioral health crisis intervention services using mobile crisis
teams twenty-four hours per day, seven days per week to adults, children, youth, and families anywhere
within the service area including at home, work, or anywhere else where the crisis is experienced.
Mobile crisis teams arrive in-person within one hour (2 hours in rural and frontier settings) from the
time that they are dispatched, with response time not to exceed 3 hours. Telehealth/telemedicine may
be used to connect individuals in crisis to qualified mental health providers during the interim travel
time. Technologies also may be used to provide crisis care to individuals when remote travel distances
make the 2-hour response time unachievable
•
The ability to provide an in-person response is available when it is necessary to assure
safety.
The CCBHC provides crisis receiving/stabilization services that includes at minimum, urgent care/walk-in
mental health and substance use disorder services for voluntary individuals.
Urgent care/walk-in services identify the individual’s immediate needs, de-escalate the crisis, and
connect them to a safe and least-restrictive setting for ongoing care.
Walk-in hours are informed by the community needs assessment and include evening hours that are
publicly posted.
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Services are available to individuals of any level of acuity, whether individuals present on their own, with
a concerned individual, such as a family member, or with a human service worker and/or law
enforcement in accordance with state and local laws.
Crisis services include suicide prevention and intervention and services capable of addressing crises
related to substance use including the risk of drug and alcohol related overdose and support following a
non-fatal overdose after the individual is medically stable.
Overdose prevention activities include the availability of naloxone for overdose reversal to individuals
who are at risk of opioid overdose, and as appropriate, to their family members.
The CCBHC has an established protocol specifying the role of law enforcement during the provision of
crisis services.
As a part of the requirement to provide training related to trauma-informed care, the CCBHC specifically
focuses on the application of trauma-informed approaches during crises.
Crisis Behavioral Health Services Notes
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Criteria 4.D: Behavioral Health Screening, Assessment, and Diagnosis
Readiness Level
Criteria 4.D
1 2 3
# of Clinics
4
The CCBHC directly, or through a DCO, provides screening, assessment, and diagnosis, including risk
assessment for behavioral health conditions. In the event specialized services outside the expertise of
the CCBHC are required for purposes of screening, assessment, or diagnosis, the CCBHC refers the
person to an appropriate provider.
Screening, assessment, and diagnosis are conducted in a timeframe responsive to the needs and
preferences of the person receiving services and are of sufficient scope to assess the need for all
services required to be provided by the CCBHC.
The CCBHC’s initial evaluation of people receiving CCBHC services includes the following:
•
•
•
•
•
•
•
•
•
•
•
•
Preliminary diagnoses
Source of referral
Reason for seeking care, as stated by the person receiving CCBHC services or other
individuals who are significantly involved
Identification of the immediate clinical care needs related to the diagnoses for mental
and substance use disorders of the person receiving services
A list of current prescriptions and over‐the‐counter medications, herbal remedies and
dietary supplements and the indication for any medication
A summary of previous mental health and substance use disorder treatments with a
focus on which treatments helped and were not helpful
The use of any alcohol and/or other drugs the person receiving services may be taking
An assessment of whether the person receiving services is a risk to self or to others,
including suicide risk factors
An assessment of whether the person receiving services has other concerns for their
safety, such as intimate partner violence
An assessment of need for medical care (with referral and follow‐up as required)
A determination of whether the person presently is or ever has been a member of the
U.S. Armed Services
for children and youth, whether they have system involvement (such as child welfare
and juvenile justice)
All people receiving CCBHC services receive a comprehensive evaluation.
The comprehensive evaluation should gather the amount of information that is commensurate with the
complexity of their specific needs and prioritize preferences of people receiving services with respect to
the depth of evaluation and their treatment goals.
The comprehensive evaluation include:
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Page 32
Reasons for seeking services at the CCBHC, including information regarding onset of
symptoms, severity of symptoms, and circumstances leading to the presentation to the
CCBHC of the person receiving services
An overview of relevant social supports; social determinants of health and healthrelated social needs such as housing, vocational, and educational status;
family/caregiver and social support; legal issues; and insurance status
A description of cultural and environmental factors that may affect the treatment plan
of the person receiving services, including the need for linguistic services or supports for
people with LEP
Pregnancy and/or parenting status
Behavioral health history, including trauma history and previous therapeutic
interventions and hospitalizations with a focus on what was helpful and what was not
helpful in past treatments
Relevant medical history and major health conditions that impact current psychological
status
A medication list including prescriptions, over-the counter medications, herbal
remedies, dietary supplements, and other treatments or medications of the person
receiving services. Include those identified in a Prescription Drug Monitoring Program
(PDMP) that could affect their clinical presentation and/or pharmacotherapy, as well as
information on allergies including medication allergies
An exam that includes current mental status, mental health (including depression
screening, and other tools that may be used in ongoing measurement-based care) and
substance use disorders (including tobacco, alcohol, and other drugs)
Basic cognitive screening for cognitive impairment
Assessment of imminent risk, including suicide risk, withdrawal and overdose risk,
danger to self or others, urgent or critical medical conditions, and other immediate risks
including threats from another person
The strengths, goals, preferences, and other factors to be considered in treatment and
recovery planning of the person receiving services
Assessment of the need for other services required by the statute (i.e., peer and
family/caregiver support services, targeted case management, psychiatric rehabilitation
services)
Assessment of any relevant social service needs of the person receiving services, with
necessary referrals made to social services. For children and youth receiving services,
assessment of systems involvement such as child welfare and juvenile justice and
referral to child welfare agencies as appropriate
An assessment of need for a physical exam or further evaluation by appropriate health
care professionals, including the primary care provider (with appropriate referral and
follow-up) of the person receiving services
The preferences of the person receiving services regarding the use technologies such as
telehealth/telemedicine, video conferencing, digital therapeutics, remote patient
monitoring, and asynchronous interventions
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Page 33
Screening and assessment conducted by the CCBHC related to behavioral health include those for which
the CCBHC is accountable pursuant to program requirement 5 and Appendix B of the criteria.
Other screening and monitoring required (if any) by the certifying state.
The CCBHC uses standardized and validated and developmentally appropriate screening and assessment
tools appropriate for the person and, where warranted, brief motivational interviewing techniques to
facilitate engagement.
The CCBHC uses culturally and linguistically appropriate screening tools and approaches that
accommodate all literacy levels and disabilities (e.g., hearing disability, cognitive limitations), when
appropriate.
If screening identifies unsafe substance use, including problematic alcohol or other substance use, the
CCBHC conducts a brief intervention and the person receiving services is provided a full assessment and
treatment, if appropriate within the level of care of the CCBHC, or referred to a more appropriate level
of care. If the screening identifies more immediate threats to the safety of the person receiving services,
the CCBHC takes appropriate action as described in 2.b.1.
Behavioral Health Screening, Assessment, and Diagnosis Notes
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Criteria 4.E: Person‐Centered and Family‐Centered Treatment Planning 3
Readiness Level
Criteria 4.E
1 2 3
# of Clinics
4
The CCBHC directly, or through a DCO, provides person‐centered and family‐centered treatment
planning including but not limited to, risk assessment and crisis planning.
The CCBHC develops an individualized treatment plan based on information obtained through
comprehensive evaluation and the person receiving services’ goals and preferences.
The plan addresses the person’s prevention, medical, and behavioral health needs and is developed in
collaboration with and be endorsed by the person receiving services, their family (if the person receiving
services so wishes), and family/caregivers/legal guardians of youth and children.
The treatment plan development is coordinated with staff or programs necessary to carry out the plan
and supports care in the least restrictive setting possible.
All necessary releases of information are obtained and included in the health record as a part of the
development of the initial treatment plan.
The CCBHC uses the initial and comprehensive evaluations and ongoing screening assessments of the
person receiving services to inform the treatment plan and services provided.
Treatment planning includes needs, strengths, abilities, preferences, and goals, expressed in a manner
capturing the words or ideas of the person receiving services or their family if appropriate.
The treatment plan is comprehensive, addressing all services required, including recovery supports, with
provision for monitoring of progress towards goals and built upon a shared decision-making approach.
The CCBHC seeks consultation where appropriate during treatment planning (e.g., eating disorders,
traumatic brain injury, intellectual and developmental disabilities (I/DD), interpersonal violence and
human trafficking.
The person’s health record documents any advance directives related to treatment and crisis planning. If
the person receiving services does not wish to share their preferences, that decision is documented.
Please see 3.a.4., requiring the development of a crisis plan with each person receiving services.
Other aspects of person-centered and family-centered treatment planning required (if any) by the
certifying states.
For more information related to person-centered treatment planning see eCFR :: 42 CFR Part 485 Subpart J -Conditions of Participation: Community Mental Health Centers (CMHCs) and eCFR :: 42 CFR Part 441 Subpart M -State Plan Home and Community-Based Services for the Elderly and Individuals with Disabilities.
3
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Person‐Centered and Family‐Centered Treatment Planning Notes
Page 35
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Page 36
Criteria 4.F: Outpatient Mental Health and Substance Use Services
Readiness Level
Criteria 4.F
1 2 3
# of Clinics
4
The CCBHC directly, or through a DCO, provides outpatient behavioral health care including
psychopharmacological treatment that are evidence-based services using best practices for treating
mental health and substance use disorders across the lifespan with tailored approaches for adults,
children, and families.
SUD treatment and services are provided as described in the American Society for Addiction Medicine
Levels 1 and 2.1 and include treatment of tobacco use disorders.
In the event specialized or more intensive services outside the expertise of the CCBHC or DCO are
required for purposes of outpatient mental and substance use disorder treatment the CCBHC makes
them available through referral or other formal arrangement with other providers or, where necessary
and appropriate, through use of telehealth/telemedicine, in alignment with state and federal laws and
regulations.
The CCBHC provides or makes available through a formal arrangement traditional practices/treatment
as appropriate for the people receiving services served in the CCBHC area.
The CCBHC delivers the evidence-based practices as required by certifying states.
Treatments are provided that are appropriate for the phase of life and development of the person
receiving services and delivered by staff with specific training in treating the segment of the population
being served.
•
•
•
When treating children and adolescents, CCBHCs provide evidenced-based services that
are developmentally appropriate, youth-guided, and family/caregiver-driven.
When treating older adults, the desires and functioning of the individual person
receiving services are considered, and appropriate evidence-based treatments are
provided.
When treating individuals with developmental or other cognitive disabilities, level of
functioning is considered, and appropriate evidence-based treatments are provided.
Supports for children and adolescents comprehensively address family/caregiver, school, medical,
mental health, substance use, psychosocial, and environmental issues.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Outpatient Mental Health and Substance Use Services Notes
Page 37
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Page 38
Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring
Readiness Level
Criteria 4.G
1 2 3
# of Clinics
4
The CCBHC monitors key health indicators and health risks, and coordinates care in a timely fashion. The
Medical Director has established protocols that conform to screening recommendations with scores of A
and B of the United States Preventive Services Task Force Recommendations for the following
conditions:
•
•
•
HIV and viral hepatitis
Primary care screening pursuant to CCBHC Program Requirement 5 Quality and Other
Reporting and Appendix B
Other clinically indicated primary care key health indicators of children, adults, and
older adults receiving services, as determined by the CCBHC Medical Director and based
on environmental factors, social determinants of health, and common physical health
conditions experienced by the CCBHC person receiving services population.
The Medical Director developed organizational protocols to ensure screening for common physical
health conditions experienced by CCBHC populations across the lifespan. Protocols include:
•
•
•
Identifying people receiving services with chronic diseases
Ensuring that people receiving services are asked about physical health symptoms
Establishing systems for collection and analysis of laboratory samples, fulfilling the
requirements of 4.g.
The CCBHC should have the ability to collect biologic samples directly, through DCO, or through a formal
agreement. Laboratory analyses can be done directly or through another arrangement with an
organization separate from the CCBHC.
The CCBHC provides ongoing primary care monitoring of health conditions as identified in 4.g.1 and
4.g.2., and as clinically indicated for the individual. Monitoring includes the following:
•
•
•
Ensuring individuals have access to primary care services
Ensuring ongoing periodic laboratory testing and physical measurement of health status
indicators and changes in the status of chronic health conditions
Coordinating care with primary care and specialty health providers including tracking
attendance at needed physical health care appointments; and promoting a healthy
lifestyle
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Outpatient Clinic Primary Care Screening and Monitoring Notes
Page 39
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Page 40
Criteria 4.H: Targeted Case Management Services
Readiness Level
Criteria 4.H
1 2 3
# of Clinics
4
The CCBHC provides directly, or through a DCO, targeted case management services that assists people
receiving services in sustaining recovery, and gaining access to needed medical, social, legal,
educational, housing, vocational, and other services and supports. CCBHC targeted case management
should include supports for people deemed at high risk of suicide or overdose, particularly during times
of transitions; individual with complex or serious mental health or substance use conditions and for
individuals who have a short-term need for support in a critical period.
The CCBHC provides the scope of targeted case management services to the specific populations for
which they are intended as specified (if any) by certifying states/
Targeted Case Management Services Notes
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Criteria 4.I: Psychiatric Rehabilitation Services
Readiness Level
Criteria 4.I
1 2 3
# of Clinics
4
The CCBHC or through a DCO provides evidence-based rehabilitation services for both mental health and
substance use disorders. Psychiatric rehabilitation services include:
•
Supported employment programs designed to provide those receiving services with ongoing support to obtain and maintain competitive, integrated employment (e.g.,
evidence-based supported employment, customized employment programs, or
employment supports that are run in coordination with Vocational Rehabilitation or
Career One-Stop services)
•
Services that help people to participate in supported education and other educational
services; achieve social inclusion and community connectedness; participate in
medication education, self-management, and/or individual and family/caregiver
psychoeducation; and find and maintain safe and stable housing
Evidence-based and other psychiatric rehabilitation services above the minimum requirements
described in 4.i as required (if any) by certifying states.
Psychiatric Rehabilitation Services Notes
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Criteria 4.J: Peer Supports, Peer Counseling, and Family/Caregiver Supports
Readiness Level
Criteria 4.J
1 2 3
# of Clinics
4
The CCBHC or through a DCO provides peer supports, including peer specialist and recovery coaches,
peer counseling, and family/caregiver supports.
The CCBHC or through a DCO provides the scope of peer and family services specified (if any) by
certifying states.
Peer Supports, Peer Counseling, and Family/Caregiver Supports Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Page 43
Criteria 4.K: Intensive, Community‐Based Mental Health Care for Members of
the Armed Forces and Veterans
Readiness Level
Criteria 4.K
1 2 3
# of Clinics
4
The CCBHC provides directly, or through a DCO, intensive, community‐based behavioral health care for
certain members of the U.S. Armed Forces and veterans, particularly those Armed Forces members
located 50 miles or more (or one hour’s drive time) from a Military Treatment Facility and veterans living
40 miles or more (driving distance) from a VA medical facility, or as otherwise required by federal law.
The CCBHC has demonstrated efforts to facilitate the provision of intensive community‐based
behavioral health services to veterans and active-duty military personnel.
With all individuals inquiring about services, the CCBHC documents whether they have ever served in
the U.S. military. For those affirming current or former service in the U.S. military, CCBHCs either directs
them to care or provides care through the CCBHC as required by criterion 4.k.2.
The CCBHC offers assistance with enrollment in the VHA for the delivery of health and behavioral health
services to persons affirming former military service.
The CCBHC ensures coordination for the care of substance use disorders and other mental health
conditions for veterans and active-duty military personnel who experience both, to the extent those
services are appropriately provided by the CCBHC in accordance with criteria 4.k.1 and 4.k.2.
The CCBHC provides for integration and coordination of care for behavioral health conditions and other
components of health care for all veterans and active-duty military personnel who experience both, to
the extent those services are appropriately provided by the CCBHC in accordance with criteria 4.k.1 and
4.k.2.
The CCBHC assigns a Principal Behavioral Health Provider to every veteran seen, unless the VHA has
already assigned a Principal Behavioral Health Provider. When veterans are seeing more than one
behavioral health provider and when they are involved in more than one program, the identity of the
Principal Behavioral Health Provider is made clear to the veteran and identified in the health record. The
Principal Behavioral Health Provider fulfills requirements in accordance with accordance with criteria
4.k.4.
The CCBHC provides behavioral health services for veterans that are recovery‐oriented and adhere to
the guiding principles of recovery (outlined in criteria 4.k.5), VHA recovery, and other VHA guidelines.
CCBHC staff who work with people receiving CCBHC services who are military or veterans are trained in
cultural competence, and specifically military and veterans’ culture.
The CCBHC develops a behavioral health treatment plan for all veterans receiving behavioral health
services compliant with provisions of Criteria 4.K.
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Page 44
Intensive, Community‐Based Mental Health Care for Members of the Armed Forces and Veterans
Notes
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Program Requirement 5: Quality and Other Reporting
Criteria 5.A: Data Collection, Reporting, and Tracking
Readiness Level
Criteria 5.A
1 2 3
# of Clinics
4
The CCBHC has the capacity to collect, report, and track encounter, outcome, and quality data,
including, but not limited to, data capturing of:
•
•
•
•
•
•
•
•
•
Characteristics of people receiving services
Staffing
Access to services
Use of services
Screening, prevention, and treatment
Care coordination
Other processes of care
Costs
Outcomes of people receiving services
The CCBHC collects and reports the Clinic-Collected quality measures identified as required in Appendix
B for all people receiving CCBHC services. CCBHCs report quality measures nine (9) months after the end
of the measurement year as that term is defined in the technical specifications.
CCBHCs participating in Section 223 Demonstration report the data to their states.
CCBHC-Es that are required to report quality measure data, report it directly to SAMHSA.
The CCBHC collects and reports any of the optional Clinic-Collected measures identified in Appendix B as
required (if any) by certifying states.
CCBHCs participating in the Section 223 Demonstration have arrangements with DCOs for access to
quality measures data for CCBHC services delivered by DCOs as legally permissible.
CCBHCs participating in the Section 223 Demonstration program participate in discussions with the
national evaluation team and other evaluation-related data collection activities if requested.
CCBHCs participating in the Section 223 Demonstration program annually submit a cost report with
supporting data within six months after the end of each Section 223 Demonstration year to the state.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Data Collection, Reporting, and Tracking Notes
Page 46
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Criteria 5.B: Continuous Quality Improvement (CQI) Plan
Readiness Level
Criteria 5.B
1 2 3
# of Clinics
4
The CCBHC develops, implements, and maintains an effective, CCBHC-wide continuous quality
improvement (CQI) plan for the services provided.
The CCBHC establishes a critical review process to review CQI outcomes and implement changes to
staffing, services, and availability that improves the quality and timeliness of services.
The CQI plan focuses on indicators related to improved behavioral and physical health outcomes and
takes actions to demonstrate improvement in CCBHC performance.
The Medical Director is involved in the aspects of the CQI plan that apply to the quality of the medical
components of care, including coordination and integration with primary care.
The CQI plan addresses how the CCBHC reviews known significant events including, at a minimum:
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•
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•
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Deaths by suicide or suicide attempts of people receiving services
Fatal and non-fatal overdoses
All-cause mortality among people receiving CCBHC services
30-day hospital readmissions for psychiatric or substance use reasons
Such other events the state or applicable accreditation bodies may deem appropriate
for examination and remediation as part of a CQI plan
The CQI plan is data-driven and the CCBHC considers the use of quantitative and qualitative data in their
CQI activities.
CCBHCs participating in the Section 223 Demonstration address the data resulting from the CCBHCcollected and, as applicable for the, State-Collected, quality measures that may be required as part of
the Demonstration.
The CQI plan includes an explicit focus on populations experiencing health disparities (including racial
and ethnic groups and sexual and gender minorities) and addresses how the CCBHC uses disaggregated
data from the quality measures and, as available, other data to track and improve outcomes for
populations facing health disparities.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Continuous Quality Improvement (CQI) Plan Notes
Page 48
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Page 49
Program Requirement 6: Organizational Authority,
Governance, and Accreditation
Criteria 6.A: General Requirements of Organizational Authority and Finances
Readiness Level
Criteria 6.A
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The CCBHC maintains documentation establishing the CCBHC conforms to at least one of the following
statutorily established criteria:
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Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United
States Internal Revenue Code
•
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Is part of a local government behavioral health authority
•
Is an urban Indian organization pursuant to a grant or contract with the Indian Health
Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.)
Is operated under the authority of the Indian Health Service, an Indian tribe, or tribal
organization pursuant to a contract, grant, cooperative agreement, or compact with the
Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 et
seq.)
To the extent CCBHCs are not operated under the authority of the Indian Health Service, an Indian tribe,
or tribal or urban Indian organization, CCBHCs has reached out to such entities within their geographic
service area and enter into arrangements with those entities to assist in the provision of services to
tribal members and to inform the provision of services to tribal members. To the extent the CCBHC and
such entities jointly provide services, the CCBHC and those collaborating entities, as a whole, satisfy the
requirements of these criteria.
An independent financial audit is performed annually for the duration that the clinic is designated as a
CCBHC in accordance with federal audit requirements, and, where indicated, a corrective action plan is
submitted addressing all findings, questioned costs, reportable conditions, and material weakness cited
in the Audit Report.
General Requirements of Organizational Authority and Finances Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Page 50
Criteria 6.B: Governance
Readiness Level
Criteria 6.B
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The CCBHC has identified how to integrate meaningful participation in leadership and decision-making
positions within their governance by individuals with lived experience of mental and/or substance use
disorders and their families, including youth.
•
Option 1. At least fifty-one percent of the CCBHC governing board is comprised of
individuals with lived experience of mental and/or substance use disorders and families.
OR
•
Option 2. Individuals with lived experience of mental and/or substance use disorders
and family members of people receiving services have representation in governance
that assures input into Identifying community needs and goals and objectives of the
CCBHC; service development, quality improvement, and the activities of the CCBHC;
fiscal and budgetary decisions; and governance (human resource planning, leadership
recruitment and selection, etc.).
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•
•
•
•
•
The governing board must establish protocols for incorporating input from
individuals with lived experience and family members
Board meeting summaries are shared with those participating in the alternate
arrangement and recommendations from the alternate arrangement are entered
into the formal board record
A member or members of the arrangement must be invited to board meetings; and
Representatives of the alternate arrangement must have the opportunity to
regularly address the board directly, share recommendations directly with the
board, and have their comments and recommendations recorded in the board
minutes
The CCBHC provides staff support for posting an annual summary of the
recommendations from the alternate arrangement under option 2 on the CCBHC
website
Opportunity to share recommendations directly with the board.
– The CCBHC provides staff support for posting an annual summary of the
recommendations from the alternate arrangement on the CCBHC website.
For Option 2, the certifying state or the federal grant funding agency determined that
the approach to achieve meaningful participation is acceptable.
•
If not acceptable, the CCBHC has made satisfactory progress in the process of
implementing additional mechanisms as required by the certifying state or federal
grant funding agency to fulfill this requirement. CCBHC makes available the results
of its efforts in terms of outcomes and resulting changes.
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Page 51
Note: See criteria 6.b.3 for CCBHC that are comprised of a governmental or tribal
organization, subsidiary, or part of a larger corporate organization that cannot meet these
requirements for board membership. Members of the governing or advisory boards are
representative of the communities in which the CCBHC's service area is located and are
selected for their expertise in health services, community affairs, local government, finance
and accounting, legal affairs, trade unions, faith communities, commercial and industrial
concerns, or social service agencies within the communities served. No more than one half
(50 percent) of the governing board members may derive more than 10 percent of their
annual income from the health care industry.
Governance Notes
Certified Community Behavioral Health Clinics Criteria Compliance Checklist
Page 52
Criteria 6.C: Accreditation
Readiness Level
Criteria 6.C
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The CCBHC is enrolled as a Medicaid provider and licensed, certified, or accredited provider of both
mental health and substance use disorder services including developmentally appropriate services to
children, youth, and their families, unless there is a state or federal administrative, statutory, or
regulatory framework that substantially prevents the CCBHC organization provider type from obtaining
the necessary licensure, certification, or accreditation to provide these services.
The CCBHC adheres to any applicable state accreditation, certification, and/or licensing requirements.
The CCBHC participates in SAMHSA Behavioral Health Treatment Locator.
Accreditation Notes
| File Type | application/pdf |
| File Title | Certified Community Behavioral Health Clinic (CCBHC) Criteria Compliance Checklist Updated March 2023 |
| Subject | Certified Community Behavioral Health Clinic (CCBHC) Certification Criteria |
| Author | Substance Abuse and Mental Health Services Administration (SAMHS |
| File Modified | 2024-01-09 |
| File Created | 2024-01-09 |