Mental health modernization and reform is underway in Kansas. After what critics characterize as decades of underfunding, the state is making a huge transition to the Certified Community Behavioral Health Clinic, or CCBHC, model.
Kansas’ inpatient, institutional-based mental health services were largely replaced with outpatient, community-based services in the 1990s. Community Mental Health Centers, or CMHCs, became the safety-net providers for Kansas’ most vulnerable with 26 centers located across the state.
They also serve as gatekeepers for access to the state’s dwindling number of state hospital beds and are responsible for making Serious Emotional Disturbance (SED) determinations for children 4 to 18 to qualify for the Medicaid waiver. In Douglas County, Bert Nash Community Mental Health Center fills that role.
The effects of chronic underfunding of mental health services have affected rural areas and vulnerable people the most. Delays in mental health evaluations of individuals who face criminal charges in Kansas have led to lawsuits. In some cases, people have waited longer for a pretrial competency hearing than they would’ve served if convicted.
Some rural parts of Kansas are referred to as mental health deserts with many Kansans forced to drive long distances for mental health care. They also face limited access to broadband Internet services, which stifles their telehealth medicine options. And in Douglas County, obstacles accessing services and behavioral health medications reveal cracks in an overwhelmed system.
In 2021, Kansas became the first state to pass into law the transition of CMHCs to CCBHCs as a means of integrated health care for mental illness, addiction and substance use disorders.
Bert Nash was one of Kansas’ first nine to make the change.
Jeff Burkhead, spokesperson for Bert Nash, said in September the center had met 25 of the 39 elements for provisional CCBHC certification and staff were working to meet the additional 14 elements.
“Designation as a CCBHC is just the beginning of a transformative process that is expected to take months and years since the behavioral health system of care has been significantly neglected and (underfunded) for over 30 years,” Burkhead said in an email.
By July 2024, all 26 of Kansas’ CMHCs will have transitioned to the CCBHC model, if they follow the state’s timeline.
“Each center will undergo a baseline review to determine where gaps are present regarding service delivery and be given time to adjust and address those gaps prior to receiving full certification,” said Cara Sloan-Ramos, spokesperson for Kansas Department for Aging and Disability Services, in a September email.
Using multiple interviews and public information, we’ve compiled a list of questions and answers related to the CCBHC rollout with some of its initial effects for Douglas County.
But first, some helpful acronyms:
BHP – Behavioral Health Partners; established in 2020 by LMH Health and Bert Nash as a nonprofit organization to manage and operate the Treatment and Recovery Center of Douglas County.
CCBHC – Certified Community Behavioral Health Clinic; an outpatient, integrated care model designed to deliver community-based mental health and substance use disorder services.
CHIP – Children’s Health Insurance Program; in Kansas, the low-cost program for uninsured children and families whose income exceeds Medicaid qualification limits is known as KanCare.
CMHC – Community Mental Health Center; provides a safety net within Kansas for community-based public mental health services.
CMS – Centers for Medicare and Medicaid Services; a federal agency within the U.S. Department of Health and Human Services that administers Medicare and also works with states to administer Medicaid, the Children’s Health Insurance Program (CHIP), and health insurance portability standards such as HIPAA.
DCO – Designated Collaborating Organization; provides certain services with the CCBHC. Bert Nash submitted a DCO designation on behalf of Behavioral Health Partners Inc. for the Treatment and Recovery Center of Douglas County. The TRC is intended to provide the crisis services required within the CCBHC certification. DCO arrangements are approved by KDADS.
KDADS – Kansas Department for Aging and Disability Services; the agency that resulted from the merging in 2012 of the former Department on Aging with the Department for Social and Rehabilitation’s Disability and Behavioral Health Services Division and elements of the Health Occupations Credentialing Division within the Department of Health and the Environment. KDADS manages the remaining four state hospitals and institutions, administers the state’s home- and community-based services waiver programs under KanCare, directs health occupations credentialing, and administers services to older adults and behavioral health, addiction and prevention programs.
PPS – Prospective Payment System; method of Medicare and Medicaid health care services reimbursement where payment is based on a fixed and predetermined amount.
SAMHSA – Substance Abuse and Mental Health Services Administration; a branch of the U.S. Department of Health and Human Services that aims to reduce the impact of mental illness and substance abuse in communities. Its most recognized outreach program is the 988 Suicide and Crisis Lifeline.
TRC – Treatment and Recovery Center of Douglas County. Consisting of an Access Center, 23-hour Observation Unit, and 72-hour Stabilization Unit, the TRC‘s purpose is to help people experiencing crises in mental health, chemical use and addiction.
Q. Why does this transition matter?
CCBHCs must serve all — not just Medicaid beneficiaries — and cannot refuse services based on an individual’s residence or ability to pay.
This transition will have an impact on multiple aspects of mental health and chemical use disorder treatment in Douglas County, including services outside the walls of Bert Nash.
Essentially, Bert Nash can leverage funding for different types of care against other services. For example, Bert Nash CEO Patrick Schmitz said in May, the gap caused by the city of Lawrence’s withdrawal of funding for the Working to Recognize Alternative Possibilities (WRAP) program in schools could be filled by the new Prospective Payment System, or PPS.
“ … since nearly every service the Bert Nash Center provides can be included in the CCBHC model Cost Report and subsequent PPS, the overall support for care will be significantly impacted for the positive,” Schmitz said in an email.
“By drawing down more state/federal funds through Medicaid to support delivery of care, we can extend and compound funding from other sources to better serve uninsured and under-insured, and use local resources to implement new services that may eventually be included in the CCBHC model or may not have another funding stream, but nevertheless are determined to be an important service our community needs toward its goal of becoming the best place to live, work, play and receive care,” Schmitz said.
Another scenario that would leverage CCBHC funding for the county’s mobile response team was presented to the Douglas County Commission during its Oct. 19 meeting.
Q. What does the CCBHC designation mean for mental health and substance use services in Douglas County?
Here are six key areas the CCBHC model will affect:
Access: All CCBHCs are required to serve anyone who requests care for mental health or substance use, regardless of their age, ability to pay, or where they live, and care must be high quality and evidence-based whenever possible. Crisis services must be available 24/7. CCBHCs are required to provide care coordination across systems plagued by fragmentation, including behavioral and physical health care, and social services.
Collaborations: The TRC will provide crisis services for Bert Nash through a DCO with BHP.
Dr. George Thompson, who was serving as medical director and executive director for the TRC, said a significant amount of the center’s funding, quality standards and goals are tied to Bert Nash.
He said some of the philosophies of care that are required by the CCBHC are required at the TRC, such as patient-centered care and trauma-informed care. “We also have the same training,” Thompson said during a tour of the TRC last month.
Funding: The county will reap financial benefits from Bert Nash’s provisional certification as a CCBHC, said Douglas County Administrator Sarah Plinsky.
“It will bring a massive amount of state and federal resources associated with folks that are qualified for Medicaid to this community,” Plinsky said. “In a state without Medicaid expansion, this is a real game changer, so it’s huge.”
Representation: As a part of the CCBHC model, at least 50% of Bert Nash’s board must be made up of consumers of mental health services with lived experience, Emily Farley, director of community engagement, told attendees at a Bert Nash listening session in September.
Staffing: With CCBHC, PPS allows reimbursement based on the cost of providing a particular service rather than on a fee structure that can limit income potential, according to Andy Brown, commissioner of behavioral services for KDADS.
“CCBHCs can hire the staff that they want to hire to provide the services that they feel like their community needs the most and be reimbursed based on the cost of providing that service, rather than on a fee structure that sort of limits what their income is, or income potential is,” Brown said.
In turn, CCBHCs can offer more competitive salaries to allow communities to address workforce shortages across the state, according to Brown.
Wait lists: CCBHCs must meet standards for a range of services and are required to provide care for people quickly. CCBHCs must “provide routine outpatient care within 10 business days after an initial contact to prevent people from languishing on waiting lists,” according to an October SAMHSA news release.
Q. What services must CCBHCs provide?
There are nine core service areas that clinics must provide or coordinate with a DCO to qualify as a CCBHC, according to criteria issued by the SAMHSA:
- Mental health crisis, including 24-hour mobile crisis teams, emergency crisis intervention services and crisis stabilization
- Screenings, assessments and diagnoses in mental health, including risk assessment
- Outpatient treatment for mental health/substance use disorders
- Patient-centered treatment planning, including risk assessment and crisis planning
- Outpatient primary care health screening/monitoring of key health indicators and health risk
- Targeted case management
- Psychiatric rehabilitation
- Peer/mentor support, counselor services and family support
- Intensive services for veterans/members of the armed forces, particularly those in rural areas
Q. What’s the financial impact of the transition from the CMHC model to the CCBHC model for Medicaid?
Once fully implemented across the state, the CCBHC model will increase Medicaid payments to CMHCs statewide by $40-$70 million per year, according to an estimate by the Kansas Department of Health and Environment for the “Report of the Special Committee on Kansas Mental Health Modernization and Reform to the 2022 Kansas Legislature.”
As safety-net providers, CMHCs in Kansas receive Medicaid funds for many of the services they provide. Under that structure, some providers tend to focus their priorities on the most lucrative services for Medicaid reimbursement, Brown said during a May interview. Critics also say that a fee-for-service reimbursement rate incentivizes providers to order unnecessary care and testing.
Within the CCBHC model, PPS is used. PPS is a cost-based reimbursement system, and while the reimbursement rate is still pre-determined, it factors in a patient’s total cost of care, including operating and capital-related costs. In other words, CCBHCs such as Bert Nash receive a set reimbursement fee for providing a service to a client, regardless of the amount of care provided and at higher, more competitive rates than CMHCs.
According to Maureen Bonatch, a health care writer, the PPS fee structure “is intended to motivate health care providers to structure cost-effective, efficient patient care that avoids unnecessary services. The goal is to provide quality patient care that engages patients and strives for faster diagnosis and treatment, shorter hospital stays, and lower costs.”
Q. How is the PPS rate figured?
Bert Nash’s first cost report as a CCBHC runs July 1, 2022 through Dec. 31, 2023. From the report, the total approved expenses are divided by the total number of client visits. That number forms the PPS rate, which amounts to a per-client funding amount.
During a process known as rebase, or redetermination, state officials will examine Bert Nash’s total expenses and visits during the rate period. A difference in those numbers from the approved cost report could result in Bert Nash being asked to reconcile, or pay back, some of the revenue generated, according to Jeff Burkhead, Bert Nash spokesperson. The process of paying money back for Medicaid funding is known as recoupment.
Each year, there’s an opportunity for CCBHCs to review their costs and update their PPS rate based on their actual expenses or inflation.
Q. What are the CCBHC qualification requirements?
- Staffing: staff with diverse disciplinary backgrounds, the necessary state required license and accreditation, and are cultural and linguistically trained to serve the needs of patients
- Availability and access of services: crisis management services available and accessible 24 hours a day, a sliding scale for payment, and no rejection or limiting of services based on a patient’s ability to pay or place of residence
- Care coordination: coordination of care across settings and providers to ensure seamless transitions for patients across the health services’ spectrum, including acute, chronic and behavioral health needs
- Scope of services: must be available directly through the CCBHC or referred through formal relationships with other providers: mental health crisis; screenings, assessments and diagnoses; outpatient mental health/substance use disorder treatment; patient-centered treatment planning; outpatient primary care screening; targeted case management; psychiatric rehabilitation; peer/mentor support, counselor services, and family support; and intensive services for veterans/members of the armed forces
- Quality and other reporting: reporting of various data points, including data on encounters, clinical outcomes, and quality
- Organizational authority: CCBHCs must be a nonprofit, part of a local government behavioral health authority, or operated by the Indian Health Service, an Indian Tribe, or a Tribal organization
Q. Who oversees CCBHCs?
The Behavioral Health Services division within KDADS oversees CMHCs and the integration of CCBHCs across Kansas.
Q. Where did the CCBHC model originate?
The CCBHC model was developed by SAMHSA and CMS. It was tested during a federal demonstration project that launched in 2017 in eight states. Two more states were added in 2020. Kansas is not among the demonstration states.
In 2022, Congress approved $40 million to expand CCBHC demonstrations nationally via the Bipartisan Safer Communities Act with additional funds going to violence prevention and expansion of mental health and substance use disorder services in various community settings, including schools.
Q. What are Kansas’ goals for CCBHCs?
According to the KDADS website, the goals of the CCBHC program in Kansas are to:
- Increase access to community-based services for mental health and substance use disorder, especially in under-served communities.
- Advance holistic care by integrating behavioral health and physical health care.
- Improve evidence-based practices consistently. Evidence-based practices are therapies that have consistently been shown in scientific studies to improve client outcomes. Examples include cognitive behavioral therapy, Housing First, Assertive Community Treatment through the Treatment and Recovery Campus of Douglas County, and the employment program Individual Placement and Support, or IPS, according to Brown.
Q. How much money is Kansas investing in this transition?
Kansas is set to invest about $60 million for the transition of 26 centers to the CCBHC model, Brown said.
The initial round of nine centers making the transition, including Bert Nash, cost approximately $22 million, Brown said.
In October, Gov. Laura Kelly announced Kansas had received a SAMHSA grant of $12.6 million to help 13 CMHCs qualify as CCBHCs. Unlike other clinics that have made the transition, Bert Nash did so without similar grant funding.
Q. Will Bert Nash change its name?
No, Burkhead said in an email last week.
“We remain the designated Community Mental Health Center and the Certified Community Behavioral Health Clinic for Douglas County,” Burkhead said. “Our official name is the Bert Nash Community Mental Health Center.”