Announcement Date: October 4, 2016

Payers and policymakers at all levels are exploring how to incentivize integrated care delivery, streamline patients’ transitions among care settings, and support proactive care management to address the drivers of poor outcomes and high costs. Certified Community Behavioral Health Clinics move beyond health homes to address these challenges and advance the movement toward integrated care.

The Excellence Act demonstration advances integrated care by imposing a number of requirements on CCBHCs related to direct provision of primary care services along with integrated care partnerships:

  • CCBHCs must ensure that all clients receive basic primary care screening and monitoring of health risk for selected chronic conditions. Key health indicators that must be monitored include tobacco use, weight/BMI, and diabetes risk; patients may also be monitored for high blood pressure, cholesterol, blood sugar, metabolic syndromes and heart disease.
  • CCBHCs must establish formal care coordination partnerships with primary care providers in their community (including federally qualified health centers and/or rural health centers), along with hospitals and other health system entities. Working with these partners, CCBHCs are responsible for leading an interdisciplinary care team that works together to coordinate the medical, psychosocial, emotional, therapeutic and recovery support needs of consumers.
  • CCBHCs must ensure seamless transitions for patients across the full spectrum of health services. For example, they must work with hospitals to ensure patients receive a “warm hand-off” to community-based care upon discharge. Through quality reporting requirements, CCBHCs are held accountable for ensuring that no patient falls through the cracks in their transitions between care settings.
  • CCBHCs must be able to exchange electronic patient health information with other entities involved in consumers’ care. In the framework of the demonstration, electronic health information exchange is the bedrock both of care coordination as well as quality tracking and reporting.

Experience with a variety of integrated care models has shown that care coordination activities alone are not enough to produce the improved health outcomes we desire. To meet the CCBHC requirements, clinics must move from merely connecting and coordinating among service providers, to proactively managing patients’ care. By formalizing and standardizing care coordination and care management as required elements of community-based behavioral health care, the Excellence Act demonstration establishes minimum expectations for integration and a foundation from which to build.

Moreover, unlike other initiatives, CCBHCs were specifically designed to address sustainability issues by paying clinics a Medicaid rate that is inclusive of their anticipated costs of expanding their service lines and integrated care activities

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