Stage 3 Certification and Data Collection

Written by Mary Givens, CCBHC Program Manager

Stage 3 Certification and Data Collection | Supporting the Five Stages of the CCBHC Experience

Stage 3 is where the rubber really meets the road. This is where the CCBHC firms up their data collection workflows and start to collect the data. It is an important time because this is when the CCBHC either self-attests to SAMHSA that they meet the CCBHC criteria OR they apply to get CCBHC certified with their state. Whether they attest or certify depends on which state they operate from.

Stage 3 is where the strategic plan for meeting the CCBHC criteria is now executed. This stage is where the strong foundation, new skills, hard decisions, clear thinking, and commitment to making, managing, and adapting your strategies and tactics will pay off, as you execute the challenging technical actions required to move forward.

With CCBHC data collection now underway, you will also be working to meet the remainder of the CCBHC criteria. The project plan has been updated a couple of times as some tasks took more time than planned. The supplemental deliverables have been built (marketing plan, communication plan) and executed. This is a time of great activity. Let’s look at each of the moving pieces in greater detail below.

Data Collection: You will be collecting data on specific clinical outcomes defined by the funding resource as well as operational key performance indicators (KPIs). For example, your CCBHC will be assessing clients for smoking, vaping, and tobacco use and, if positive, be delivering follow up intervention such as cessation counseling or possible medication. You will want to pull a report and see how often your providers are in fact delivering that follow-up intervention. In terms of operational data collection, your CCBHC will be collecting data on the race and ethnicity of your client base and pulling this data to be analyzed for possible disparities when that data is compared to the makeup of your catchment area. You still have time to revise, edit, rethink and restructure how and when the data is collected for all outcomes. Focus and commitment will be needed to execute needed adjustments. Celebrate what is working. Adjust and adapt for what needs fixing.

Certification Application: Your completed readiness assessment will guide you through the remaining tasks in completing your application. Qualifacts recommends that your team members strategically take responsibility for sections of the application where their expertise rests, while the project manager collects, coordinates, and synthesizes the individual contributions from your subject matter experts into one well-coordinated document. Here is a list of critical elements that will be included in your CCBHC attestation or certification application:

Staffing plan with personnel files-training records, credentials, experience, etc.
Procedure for Staff Skills and Competencies- Assessments to determine staff training needs
Training Plan- how, when, and what will you train on
Procedure for provision of services regardless of ability to pay- what should your intake people and billing SMES do in the scenario where individuals are uninsured or underinsured -what are the steps
Sliding Scale procedure and discount schedule – define the sliding scale procedure and discount schedule
Environment assessment of clinic- environmental and safety check of clinic
Disaster Plan and continuity of operations plan- documented plan of what your CCBHC will do if power or internet connection is lost, for example. If your geographical area is prone to other disasters (Tennesse = tornadoes) plan for maintaining the safety of clients as well.
Plan for managing integrated services- initial evaluation of risk and needs, referral process, sharing of information (interoperability), integrated treatment plan, etc. Procedures for meeting timelines for preliminary risk screening, Initial evaluation, comprehensive evaluation, required screenings, and Integrated treatment plan
Care Coordination Plan with a definition of how you will secure formal agreements with other entities of care such as social service agencies, schools, and judicial agencies.
HIT Plan to improve coordination of care-sending of C-CDA, custom integrations
Consumer grievance procedure- provide a copy of the procedure and how they are processed and resolved
Procedure for collecting data for quality measures- how workflows were established, training completed, reporting, analytics, sharing of information on the progress
A service grid that demonstrates your agency’s ability to meet the CCBHC service requirements
Procedure for independent financial audit
Narrative on how your agency engages in outreach activities – to the community, to referral sources, to jail diversion professionals, etc.
Narrative on how peer specialists are integrated into your clinic programming
Narrative on how you will address the needs of clients with limited English proficiency
Narrative on your access to care- hours and locations, call-in numbers, telehealth

If you are applying for certification through a state, you can expect a site visit and will need to prepare for that as well.

Attain Certification and Update Project Plan: In the step above you have authored your application for certification/self-attestation. This is a major step. The exercise of completing your application allows the CCBHC to assess where they are at and where they need to go next steps. By now, your CCBHC is meeting many of the CCBHC criteria and is working on meeting the remainder. Those results are the payoff for your early and ongoing efforts. As part of your application process for certification or self-attestation, you addressed how you meet each of the CCBHC criteria and listed which ones remain unmet. Your next step or actionable task here is to create a strategic plan for those criteria not yet met. This strategy will be broken down into tasks on your project plan with a resource assigned for driving towards the successful meeting of those remaining criteria. This is the time to update your project plan with new tasks and/or new due dates.

Hire Additional Staff: If the reconciliation of the criteria you meet versus the ones you still must address includes the hiring of new staff or the attainment of new credentials for current staff, now is the time to make that happen. This may require new job descriptions and additional types of training. Human Resources is best positioned to this task in terms of writing new job descriptions or modifying current job descriptions. New credential types may need to be attained so you will need to identify the certification process and associated costs for this new credential type.

Establish Outcome Baselines: Analytics and reporting now becomes critical. If you haven’t already done so, it is time to run outcomes reports to see where your team is performing on each measure. Be sure to share the results with the providers responsible for capturing the data. Transparency into performance and feedback is critical to success. This is the right time to establish a benchmark for each outcome and set goals for each provider to strive toward. The goals must be realistic with an end date assigned for reaching that goal. If you haven’t already, collaboratively develop and share with stakeholders your process for regularly repeating this exercise, as that will be a component of your ongoing commitment.

Outcomes can have practical consequences – including penalties and benefits – for organizational success, as well as being measures that track clinical progress.

In Minnesota, for example, CCBHCs must meet minimum thresholds on 6 measures to qualify for a bonus payment. In order to make thresholds fair and attainable, Minnesota set the performance thresholds will be capped at 95%. This means clinics will be considered to have met performance expectations on a measure of 95%. If a provider is currently performing on a particular measure at 38%, you wouldn’t set the benchmark at the ultimate goal of 95%. Instead, you might set a more realistic goal for that provider on that measure of 55%.

Qualifacts recommends that you work strategically to personalize benchmarks by program and provider, based on your programs and services. You will personalize each benchmark so each provider and team can gain insights into what is working and where additional efforts or resources could be focused. The organization can then benefit from visibility into each provider’s benchmarks and progress by measuring, by rolling them up into program-wide, service-wide, and organizational metrics. Be sure and celebrate your successes as well as provide feedback on outcomes that need to improve. Regular feedback is helpful in keeping people engaged. Good news should be shared, and teams should know that the process is there to reward people for their work, as well as to guide strategic decision-making.

Tweak Workflows and Retrain: By now your providers have been collecting CCBHC data for a little while. Running the outcomes reports will give you early indications on where each provider is performing in terms of success. Less than ideal indications are an alert that it is time to analyze your workflows and organize your leadership and staff to rethink current processes and manage for improvement.

Workflows can be redirected and enhanced to increase the effectiveness and efficiency of data collection, to provide data consistently. Workflows must be sustainable over time: Maximizing the efficiency of your workflows will increase the consistency of how accurately providers collect the needed data. Providers will always prioritize the quality of their clinical “face to face” interventions, and the workflows should support that while also accommodating data collection as seamlessly as possible.

Your goal is to make data collection as natural as part of the clinical workflow as possible, so that reportable information is gathered as part of how providers would document care. Technically, this means that data needs to be available in discrete fields. The more efficient your workflows, the stronger your reporting tool and the smarter your forms, the easier it will be to pull valuable data from your EHR. Bad data in, bad data out.

Issues that can interfere with clinical success can also include forms and if the issue is not the workflow, it’s the form or service document. Can you make the service document more user friendly by replacing text boxes with drops down descriptors or radio buttons, for example? Finally, if you feel confident in the workflows and the forms, you may need to deliver refresher training. Consistency in data collection is critical if you want to have a true picture of how your agency is performing on the CCBHC outcome measures. You can gain consistency through the following steps:

Ensure each frontline staff knows exactly what data needs to be collected and when
- Many outcome measures define when the data should be collected such as “during the same encounter” or “the same day”.
Ensure the frontline staff understand why this data is important and why it must be collected in a manner designed.
- This is where your full understanding of the specifications and rationale for each of the measures becomes so important. Share this information with the providers who are collecting the data. This will ensure greater “buy in”.
The third step is effective training. Training one time may not be sufficient. Refresher training may be required. Now is a suitable time to do refresher training on measures where outcomes are marginal and there is room for improvement.

Establish Health of the CCBHC: Just as important as looking at the clinical outcomes at the provider level is to look at the health of the CCBHC. Below are some of the types of key performance indicators you may want to look at to assess how well your CCBHC is doing overall.

Number of new CCBHC program intakes per month- utilization
The average number of days from the first point of contact to initial evaluation – compliance and access to care
The average number of days from intake to completion of the first integrated treatment plan – compliance
Average BMI and BP for clients in CCBHC program (include race, ethnicity, age)-overall health. Will look for improvement over time.
Percentage of clients with a positive smoking /tobacco/vape use assessment who have had follow up- quality indicator
Percentage of clients with a positive alcohol screen who have had follow up -quality indicator
Percentage of clients with a positive depression screen who have had follow up-quality indicator
The average number of services per client per day- utilization
If you have introduced a new service (i.e., MAT) the number of clients utilizing that service in a specific period of time- utilization
Number of services (intakes, therapy, etc.) delivered in the community and the service location code- utilization

Stage 3 is a stage of a lot of activity. Getting certified or attesting as a CCBHC is a major step. The activities described above will require the effort of many individuals. The staff who reassess and possibly re-engineer the workflows would be a different staff than the one who updates the project plan to reflect the goals of the strategic plan. Who trains on the new workflow may be a third person and the staff responsible for pulling together all the parts of the certification application is a different person still. This stage also requires report writers and analysts as well as other professionals.

It really does “take a village” and no one staff should try to accomplish all this work alone. There can still be a lot of “change” or “revision” in Stage 3.

In Stage 4 we will look in depth at how you can succeed with your CCBHC reporting, metrics and analytics, and the stabilization of processes and workflows. The changes needed here are less transformational, and more based on solidifying the new processes you have already established and continuing to build and support reporting that aligns with your compliance to the CCBHC criteria and that gives you visibility into your clinical tracking and your organizational success.

Mary Givens, MRA
CCBHC Program Manager
Qualifacts

Mary Givens has been with Qualifacts for 13 years. She has a Masters in Rehabilitation Administration from the University of San Francisco. Before coming to Qualifacts, Mary was the CEO of a non-profit organization that served IDD, she was the Director of Client Services and a Director of Supported Employment for people with SPMI. Since coming to Qualifacts, she has been a Project Manager for Implementation and a Program Manager of Meaningful Use, and is currently the CCBHC Program Manager.