A study of the Certified Community Behavioral Health Clinic demonstration to inform future investments in a new model of care: synthesizing a story across a range of voices and data sources

Abstract Information: This presentation explores how evaluators can synthesize a story from a range of qualitative and quantitative data sources – interviews; site visits; clinic, patient, and youth/family surveys; and medical claims data – to support the implementation of a new model of accessible and equitable community-based behavioral health (BH) care. Community BH clinics function as safety-net providers for people with mental and substance use disorders, providing critical services and helping people live independently in the community. The Certified Community Behavioral Health Clinic (CCBHC) demonstration allows state Medicaid programs to test a new strategy to deliver and reimburse services in BH clinics. The demonstration is designed to address inequities in access to care across communities by requiring that participating clinics provide a common set of comprehensive services to all individuals who seek care. In two of the three states included in this mixed-methods study, Medicaid beneficiaries who received care from CCBHCs had a statistically significant reduction in BH emergency department (ED) visits and hospitalizations, compared with beneficiaries who received care from other community behavioral health clinics. The findings from surveys, interviews, and site visits identified the strategies that CCBHCs used to increase access to care, coordinate care, expand service offerings, and expand and diversify staffing that may have led to these changes in service use.

Relevance Statement: This study highlights the important role evaluators play in uncovering the value of new models of health care, using diverse data sources to synthesize complex findings. Community behavioral health (BH) clinics provide critical services and function as safety-net providers for people with mental and substance use disorders. States have increasingly relied on these clinics to help people live independently in the community and avoid institutional care (1). In the absence of federal licensing or accreditation standards, these clinics vary in the types of services they provide and populations they serve (2). Without comprehensive Medicaid funding, clinics have turned to a patchwork of state and local funding and philanthropy to supplement costs for Medicaid beneficiaries and people without insurance (3). Such variation in funding and the services available from these clinics could contribute to disparate access to care across communities. In 2017, Congress authorized the Certified Community Behavioral Health Clinic (CCBHC) demonstration, which allows states to test a new strategy to deliver and reimburse services in BH clinics; eight states initially implemented the demonstration. We evaluated the first two years of the demonstration to provide objective, unbiased information on the implementation experiences and impacts of this innovative approach to delivering care. The mixed-methods evaluation analyzed findings from interviews with state Medicaid and BH officials, site visits to the clinics, a clinic survey, and Medicaid claims data from three of the demonstration states. By synthesizing across these diverse voices and perspectives, we told the story of the demonstration through evaluation reports produced at every stage of the evaluation process, exploring both the implementation of the demonstration and its impacts on the accessibility, quality, and equity of community-based BH care for federal policymakers, including by translating the evaluation reports into Reports to Congress. We found that Medicaid beneficiaries who received care from CCBHCs had a statistically significant reduction in BH emergency department visits and hospitalizations compared with beneficiaries who received care from other community behavioral health clinics. In addition, implementation of the CCBHC model required capacity building and technical assistance for participating states and clinics, and was supported by changes to Medicaid payment rates and policies. Other states and clinics can learn from the experiences of these states to inform their policy decisions and implementation approach. The story told by the evaluation increased federal policymakers’ confidence in the demonstration’s ability to improve the accessibility, quality, and equity of community-based behavioral health care, resulting in Congress extending the demonstration and allowing additional states to participate. 1. Rosenbaum S: Using the courts to shape Medicaid policy: Olmstead v LC by Zimring and its community integration legacy. J Health Polit Policy Law 2016; 41:585–597 2. Wishon A, Brown J: Variation in Services Offered by Certified Community Behavioral Health Clinics and Community Mental Health Centers. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2021. https://www.mathematica.org/publications/variation-in-services-offered-by-certified-community-behavioralhealth-clinics-and-community-mental. 3. Excellence in Mental Health Act: An Introduction. Rockville, MD, Substance Abuse and Mental Health Services Administration, National Council for Behavioral Health, 2015. http://www.thenationalcouncil.org/wp-content/uploads/2015/11/Fact-Sheet_Excellence-in-mental-health-act-an-introduction-FINAL.pdf