Clinic-Collected-Required Measures:

Time to Services (I-SERV) 

Social Drivers of Health (SDOH) 

Unhealthy Alcohol Use: Screening and Brief Counseling (ASC)

Peggy O’Brien and Shweta Palakkode

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

October 27, 2023

2:30-4:00 PM ET
2

Logistics

This webinar is being recorded and closed captioning is 

provided. The recording will be available about a week 

after the presentation and will be posted on the 

SAMHSA CCBHC website for later reference.

Please mute your lines (Thank you!).

We will have time for discussion and questions at the 

end. In the meantime, please feel free to put 

questions in the chat. We will address them at the end 

as well.
3

Intended audience for this webinar

1. Prospective and existing CCBHC Section 223 

Demonstration state staff and CCBHCs

2. Independent state CCBHC initiative personnel

3. CCBHC-Expansion (CCBHC-PDI and -IA) grant 

clinics and SAMHSA GPOs
4

Overview of Today’s Clinic-Collected Required Measures

I-SERV

Time to Services

Access

SDOH

Screening for Social 

Drivers of Health

Need

ASC

Unhealthy Alcohol 

Use: Screening and 

Brief Counseling

Need & 

Response
5

Time to Services (I-SERV)
6

Poll #1

1. Our clinic is prepared to track requests for 

service and actual time to delivery [please 

select one response]

a) Yes

b) No

c) Partly

d) I do not know
7

I-SERV Measure: Description and Source

The I-SERV measure calculates the average time 

for clients to access three different types of 

services at Behavioral Health Clinics (BHCs) 

reporting the measure.

 Time until provision of: (1) initial evaluation, (2) initial 

clinical services, and (3) crisis services

 Source: SAMHSA-developed metric
8

I-SERV Measure: Importance and Uses

 Importance: In 2021, only approximately 1/2 of adults with AMI and 

2/3 with SMI received mental health treatment, and, of those with 

SMI and a co-occurring SUD, 81% received only mental health 

services (SAMHSA, 2022a).

 Use for Quality Improvement: 

 Implement systematic tracking of requests for and receipt of CCBHC 

services

 Determine access needs based on requests and ability to deliver 

timely services

 Alter practices as needed to expedite services

 Use for evaluation of the CCBHC model

 Potential use for PPS
9

I-SERV Measure : Data Source and Measurement Period

 Medical records (example: electronic scheduling system)

 Measurement Period (aka, the time period that data must 

cover): 

 Denominator (submeasures 1&2): the first 11 months of the 

Measurement Year and six months prior (example: July 1, 2024- Nov. 30, 2025); (submeasure 3: Measurement Year (minus last 

day, plus one day before) (example: December 31, 2024- December 30, 2025)

 Numerator (all submeasures): the Measurement Year (example: 

Jan. 1, 2025-Dec. 31, 2025)

aka: also known as
10

I-SERV Submeasure #1 – Time to Initial Evaluation
11

I-SERV Measure: Calculation of Denominator #1

 Denominator is the number of all clients in

the Eligible Population:

All New Clients who contacted the CCBHC seeking CCBHC 

services during the first 11 months of the Measurement 

Year

Age 12 years or older at the end of the Measurement Year

Excluding: New Clients who never received an Initial 

Evaluation

 Stratification: age, payer, race, ethnicity

Bold indicates data need.

New Clients: Those seeking services who were not served by the CCBHC in the past 

six months.
12

I-SERV Measure: Calculation of Numerator #1 

Numerator is: 

Total number of days from First Contact

to Initial Evaluation for all members of the 

Denominator

Bold indicates data need.

Any who receive an Initial Evaluation after the last day of the MY are treated as having been 

evaluated 31 days after First Contact.
13

I-SERV Submeasure #1: Practice Example

Denominator

Number of New Clients 

requesting CCBHC services 

during MY

2,000

Of those, requested service 

during last month of MY

-500

Of those, 11 years or younger on 

last day of MY

-150

Of those, never received Initial 

Evaluation

-125

Denominator 1,225

Numerator

Total number of days between 

request for services and Initial 

Evaluation for all clients in 

Denominator

9,889

Numerator 9,889

I-SERV submeasure #1 = 9,889/1,225 = 8 

This means it was an average of 8 days 

until Initial Evaluation at this CCBHC during 

this MY.
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I-SERV Submeasure #2 – Time to Initial Clinical 

Services
15

I-SERV Measure: Calculation of Denominator #2

 Denominator is the number of all clients in

the Eligible Population:

All New Clients who contacted the CCBHC seeking CCBHC 

services during the first 11 months of the Measurement 

Year

Age 12 years or older at the end of the Measurement Year

Excluding: New Clients who never received a Clinical 

Service

 Stratification: age, payer, race, ethnicity

Bold indicates data need.

New Clients: Those not served by the CCBHC in the past six months.
16

I-SERV Measure: Calculation of Numerator #2 

Numerator is: 

Total number of days from First Contact

to Initial Clinical Service for all members of the 

Denominator

Bold indicates data need.

Any who receive an Initial Clinical Service after the last day of the MY are treated as having received 

services 31 days after First Contact.
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I-SERV Submeasure #2: Practice Example

Denominator

Number of New Clients 

requesting CCBHC services

2,000

Of those, requested service 

during last month of MY

-500

Of those, 11 years or younger 

on last day of MY

-150

Of those, never received Initial 

Clinical Services

-100

Denominator 1,250

Numerator

Total number of days between 

request for services and Initial 

Clinical Services for all clients in 

Denominator

7,789

Numerator 7,789

I-SERV submeasure #2 = 7,789 /1,250 = 6.23

This means it was an average of 6 days until 

Initial Clinical Services at this CCBHC during 

this MY.
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I-SERV Submeasure #3 – Time to Crisis Services
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I-SERV Measure: Calculation of Denominator #3

Denominator is the number of all clients 

In the Eligible Population:

All Clients who contacted the CCBHC or its crisis 

DCO seeking CCBHC Crisis Services for a New Crisis 

Episode during the Measurement Year

Age 12 years or older at the end of the Measurement 

Year

Stratification: age, payer, race, ethnicity

Bold indicates data need.

A New Crisis Episode begins when an individual or someone acting on their behalf contacts the 

Crisis Service provider (whether a CCBHC or its crisis DCO) requesting Crisis Services for the first time 

in a 24-hour period. 
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I-SERV Measure: Calculation of Numerator #3 

Numerator is: 

Total number of hours from Crisis Episode 

contact to related provision of a Crisis Service for 

all members of the Denominator

Bold indicates data need.
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I-SERV Submeasure #3: Practice Example

Denominator

Number of Clients seeking Crisis 

Services from CCBHC or crisis 

DCO

600

Of those, also had requested 

crisis service during the prior 24 

hours

-100

Of those, 11 years or younger 

on last day of MY

-120

Of those, never received a Crisis 

Service

-8

Denominator 372

Numerator

Total number of hours between 

Crisis Episode contact and 

related provision of Crisis 

Service for all clients in 

Denominator

1,296

Numerator 1,296

I-SERV submeasure #3 = 1,296 /372 = 3.48

This means it was an average of 3 hours until 

Receipt of Crisis Services at this CCBHC during 

this MY.
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I-SERV Measure: To Do in 2024

Needed for the I-SERV Measure:

1. Prepare to and begin using a way to identify clients 

served, no later than July 1, 2024.

2. Begin preparation for being able to track the date 

services are requested (date and time, if crisis services), 

and the date initial evaluation and initial clinical 

services are provided (date and time, if crisis services). 

Implement NLT December 15, 2024.

3. Train staff regarding documentation needed to record 

date and time of receipt of request and provision of 

services.
23

Screening for Social Drivers of 

Health (SDOH)
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Poll #2

1. Our clinic is prepared to screen for social 

determinants/drivers of health (SDOH) [please 

select one response]

a) Yes

b) Yes AND refer to services

c) No

d) Partly

e) I do not know
25

SDOH Measure: Description and Source

The SDOH measure calculates the percentage of 

clients 18 years and older screened for food 

insecurity, housing instability, transportation 

needs, utility difficulties, and interpersonal 

safety. 

 Source: Based on MIPS CQMs #487 (2023), stewarded by CMS

MIPS: Merit-based Incentive Payment System; CQMs: Clinical Quality Measures; CMS: 

Centers for Medicare & Medicaid Services 
26

SDOH Measure: Importance and Uses

 Importance: It is estimated that about 80% of health care 

outcomes stem from socioeconomic, environmental and 

behavioral factors (drivers of health) and that the rest are 

attributable to actual health care (Magnan, 2017). 

 Use for Quality Improvement: 

 Implement basic SDOH screening into services

 Determine client needs

 Basis for referral and case management supports

 Use for evaluation of the CCBHC model

 Potential use for PPS
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SDOH Measure: Data Source and Measurement Period

Medical records (example: electronic health 

records)

Measurement Period (aka, the time period 

that data must cover): The entire 

Measurement Year (example: Jan. 1, 2025-

Dec. 31, 2025)

aka: also known as
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SDOH Measure: Calculation of Denominator

Denominator is all clients in the Eligible 

Population:

All clients receiving at least one CCBHC service 

(identified by one of the Current Procedural 

Terminology [CPT®] encounter codes in the 

specification) during the Measurement Year

Age 18 years or older on date of that service

Stratification: payer, race, ethnicity

Bold indicates data need.
29

SDOH Measure: Calculation of Numerator

Numerator is: 

All clients in the Denominator

Screened:

for food insecurity, housing instability, transportation needs, 

utility difficulties, and interpersonal safety, 

using a standardized screening instrument

at least once per Measurement Year

• Documentation that screening happened or did not 

happen: identified with code in specification or 

equivalent information source

Bold indicates data need.
30

SDOH Measure: Practice Example

Denominator

Number of people receiving 

CCBHC service in 

Measurement Year (MY)

2,500

Of those, service was one of 

the appropriate encounter 

codes

2,000

Of those, 18 or older at date of 

service

1,500

Denominator 1,500

Numerator

Number in Denominator 1,500

Screened for SDOH using 

standardized screener during MY

1,000

Not screened during MY 500

Numerator 1,000

SDOH rate = 1000/1500 = .67. This means 

67% of the eligible population were screened 

using a standardized screener of SDOH.
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SDOH Measure: Standardized Health-Related Social Needs (HRSN) Screening Tools

HRSN is the term used by HHS to refer to an individual's unmet, adverse social 

conditions that contribute to poor health as a result of the community’s underlying 

SDOH. Examples of standardized HRSN screening tools include but are not limited to: 

• Accountable Health Communities Health-Related Social Needs

Screening Tool (2017) 

• Accountable Health Communities Health-Related Social Needs

Screening Tool (2021)

• The Protocol for Responding to and Assessing Patients’ Risks and Experiences

(PRAPARE) Tool (2016) 

• WellRx Questionnaire (2014)

• American Academy of Family Physicians (AAFP) Screening Tool (2018)
32

SDOH Measure: To Do in 2024

Needed for the SDOH Measure:

1. Identify standardized SDOH screening tool you will use

2. Determine where, when, and how in the clinic workflow screening 

will be implemented and documented

3. Prepare documentation systems needed to capture whether 

screening has occurred

4. Train staff regarding screening and documentation

Also Important:

1. Prepare to provide needed referrals and case management based 

on findings from screening
33

Unhealthy Alcohol Use: Screening 

and Brief Counseling (ASC)
34

Poll #3

1. Our clinic is prepared to systematically screen

for problematic alcohol use and provide followup services if needed [please select one 

response]

a) Yes

b) No

c) Partly

d) I do not know
35

ASC Measure: Description and Source

The ASC measure calculates the percentage of 

clients aged 18 years and older who were screened 

for unhealthy alcohol use using a Systematic 

Screening Method at least once within the last 12 

months AND who received brief counseling if 

identified as an unhealthy alcohol user. 

 Three submeasures: (1) screening, (2) brief counseling, (3) 

screening and brief counseling

 Source: Based on MIPS CQMs #431 (2023), derived from a 

measure stewarded by NCQA

MIPS: Merit-based Incentive Payment System; CQMs: Clinical Quality Measures; NCQA: 

National Committee for Quality Assurance 
36

ASC Measure: Importance and Uses

 Importance: Alcohol Use Disorder is the most common SUD 

in the United States (SAMHSA, 2022b) and commonly co- occurs with other mental health disorders (NIAAA, 2022)

 Use for Quality Improvement: 

 Implement systematic screening for problematic alcohol use 

into services

 Determine client needs

 Provide brief counseling responsive to screening results

 Use for evaluation of the CCBHC model

 Potential use for PPS
37

ASC Measure: Data Source and Measurement Period

Medical records (example: electronic health 

records)

Measurement Period (aka, the time period that 

data must cover): 

Denominator: the Measurement Year (example: Jan. 

1, 2025-Dec. 31, 2025)

Numerator: the Measurement Year and the prior 

Calendar Year (example: Jan. 1, 2024-Dec. 31, 2025)

aka: also known as
38

ASC Submeasure #1 -- Screening
39

ASC Measure: Calculation of Denominator #1

 Denominator is all clients in the Eligible Population:

All clients receiving at least one CCBHC preventive service 

or two nonpreventive encounters (identified by the listed 

Current Procedural Terminology [CPT®] encounter codes in 

the specification) during the Measurement Year

Age 18 years or older on date of service during the 

Measurement Year

Excluding: specific requirements related to dementia, 

hospice use, and existing alcohol use disorder diagnosis

 Stratification: payer, race, ethnicity

Bold indicates data need.
40

ASC Measure: Calculation of Numerator #1 

Numerator is: 

All clients in the Denominator

Who, in the past 12 months: 

(a) screened positive using systematic screening method OR 

(b) screened negative using systematic screening method

• Documentation that screening happened (and the result (+/-)) 

or did not happen during the MY or in the 12 months before 

that visit: identified with code in specification or equivalent 

information source

Bold indicates data need.
41

ASC Submeasure #1: Practice Example

Denominator

Number of people receiving 

CCBHC service in Measurement 

Year (MY)

2,500

Of those, service was one of the 

appropriate encounter codes

2,000

Of those, 18 or older at date of 

service

1,500

Of those, no dementia, hospice 

use, or existing alcohol use 

disorder diagnosis

1,200

Denominator 1,200

Numerator

Number in Denominator 1,200

Screened positive using 

standardized alcohol screener 

(SAS) at or during 12 mos. before 

denominator visit(s)

250

Screened negative using SAS at 

or during 12 mos. before 

denominator visit(s)

400

Not screened at or during 12 

mos. before denominator visit(s)

550

Numerator 650

ASC rate #1 = 650/1200 = .54
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ASC Submeasure #1: Resources

For purposes of the ASC measure, one of the following 

systematic methods to assess unhealthy alcohol use 

must be used. Systematic Screening Methods and 

thresholds for defining unhealthy alcohol use include: 

 AUDIT Screening Instrument (score ≥ 8), available at WHO 

AUDIT Guidelines

 AUDIT-C Screening Instrument (score ≥4 for men; score ≥3 for 

women), available at NIDA CTN Common Data Elements

 Single Question Screening - How many times in the past year 

have you had 5 (for men) or 4 (for women and all adults older 

than 65 years) or more drinks in a day? (response ≥1)
43

ASC Submeasure #2 – Brief Counseling
44

ASC Measure: Calculation of Denominator #2

 Denominator is all clients in the Eligible Population:

 All clients receiving at least one CCBHC preventive service or two 

nonpreventive encounters (identified by the listed Current Procedural 

Terminology [CPT®] encounter codes in the specification) during the 

Measurement Year

 Age 18 years or older on date of service during the Measurement Year

 Excluding: specific requirements related to dementia, hospice use, 

and existing alcohol use disorder diagnosis

 Who were identified as an unhealthy alcohol user when screened for 

unhealthy alcohol use using a Systematic Screening Method in the 

numerator of Submeasure 1 

 Stratification: payer, race, ethnicity

Bold indicates data need.
45

ASC Measure: Calculation of Numerator #2 

Numerator is: 

All clients in the Denominator

Who, in the past 12 months, received brief 

counseling

• Documentation that counseling happened or did not 

happen during the MY or in the 12 months before that 

visit: identified with code in specification or equivalent 

information source

Bold indicates data need.
46

ASC Submeasure #2: Practice Example

Denominator

Number receiving CCBHC service 

in Measurement Year (MY)

2,500

Of those, service was one of the 

appropriate encounter codes

2,000

Of those, 18 + at date of service 1,500

Of those, no dementia, hospice 

use, or existing AUD diagnosis

1,200

Of those, screened positive using 

standardized alcohol screener 

(SAS) at or during 12 mos. before 

denominator visit(s)

250

Denominator 250

Numerator

Number in Denominator 250

Received brief counseling 150

Numerator 150

ASC rate #2 = 150/250 = .60
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ASC Submeasure #2: Brief Counseling Defined

For purposes of the ASC measure, brief counseling for 

unhealth alcohol use refers to one or more counseling 

sessions, a minimum of 5 to 15 minutes, which may 

include: feedback on alcohol use and harms; 

identification of high-risk situations for drinking and 

coping strategies; increased motivation and the 

development of a personal plan to reduce drinking.
48

ASC Submeasure #3 – Screening & Brief 

Counseling

Providers are required to use only submeasures 1 and 2 unless they were reporting this 

measure as part of MIPS before 2017. Submeasure 3 is optional for others.
49

ASC Measure: Calculation of Denominator #3

 Denominator is all clients in the Eligible Population:

All clients receiving at least one CCBHC preventive service 

or two nonpreventive encounters (identified by the listed 

Current Procedural Terminology [CPT®] encounter codes in 

the specification) during the Measurement Year

Age 18 years or older on date of service during the 

Measurement Year

Excluding: specific requirements related to dementia, 

hospice use, and existing alcohol use disorder diagnosis

 Stratification: payer, race, ethnicity

Bold indicates data need.
50

ASC Measure: Calculation of Numerator #3 

Numerator is: 

All clients in the Denominator

Who, in the past 12 months: 

(a) screened positive using systematic screening method and 

received Brief Counseling OR (b) screened negative using 

systematic screening method

• Documentation that screening happened (and the result (+/-)); 

if positive, that Brief Counseling occurred, or screening and (if 

relevant, Brief Counseling) did not happen during the MY or in 

the 12 months before that visit: identified with code in 

specification or equivalent information source

Bold indicates data need.
51

ASC Submeasure #3: Practice Example

Denominator

Number of people receiving 

CCBHC service in Measurement 

Year (MY)

2,500

Of those, service was one of the 

appropriate encounter codes

2,000

Of those, 18 or older at date of 

service

1,500

Of those, no dementia, hospice 

use, or existing alcohol use 

disorder diagnosis

1,200

Denominator 1,200

Numerator

Number in Denominator 1,200

Screened positive using standardized 

alcohol screener (SAS) at or during 

12 mos. before denominator visit(s)

250

Screened positive and received Brief 

Counseling

150

Screened negative using SAS at or 

during 12 mos. before denominator 

visit(s)

300

Not screened at or during 12 mos. 

before denominator visit(s)

650

Numerator 450

ASC rate #3 = 450/1200 = .38
52

Additional Resources on SBIRT for All Three Submeasures

• Resources for Screening, Brief Intervention, and 

Referral to Treatment (SBIRT) | SAMHSA

• Alcohol Screening and Brief Intervention for Youth: 

A Practitioner’s Guide | NIH

• Luong J, Board A, Gosdin L, et al. Alcohol 

Use, Screening, and Brief Intervention 

Among Pregnant Persons — 24 U.S. 

Jurisdictions, 2017 and 2019. MMWR Morb

Mortal Wkly Rep 2023;72:55–62. 
53

ASC Measure: To Do in 2024

Needed for the ASC Measure:

1. Begin preparation for and using one of the three identified systematic screening methods 

and, if needed, brief counseling

2. Determine where, when, and how in the clinic workflow screening and, if needed, brief 

counseling, will be implemented and documented

3. Prepare documentation systems needed to capture whether screening and, if needed, brief 

counseling has occurred

4. Train staff regarding screening, brief counseling, and documentation

5. Begin collecting data for the numerator in 2024

6. Determine if you fall into a category that does not need to report submeasure 3 and, if so, 

whether you will calculate it anyway

Also Important:

1. Prepare to provide further assessment and treatment when problematic alcohol use is 

revealed by screening and additional services beyond brief counseling are needed.

2. Prepare to more appropriately screen special populations, such as youth, pregnant people, 

or those taking medication where alcohol use is particularly contraindicated.
54

Stratification Overview
55

Stratification

Stratification of measures may be by age, payer, race, or 

ethnicity. 

1. Age (only I-SERV): 12-17 years, 18 years or older

2. Payer: Medicaid only; Other (including those dually 

eligible for Medicare and Medicaid)

3. Race: White or Caucasian, Black or African American, 

American Indian or Alaska Native, Asian, Native Hawaiian 

or Pacific Islander, More than one race, or Unknown

4. Ethnicity: Not Hispanic or Latino, Hispanic or Latino, or 

Unknown
56

Lookback Periods Overview
57

Lookback Periods

Lookback periods can mean you need data from 

prior to the Measurement Year (if a Measurement 

Period calls for earlier data). Examples today:

• I-SERV: Last six months of 2024 to see if an 

individual is a New Client

• ASC: All of 2024 to see if clients were screened 

for problematic alcohol use in the 12 months 

before a visit during 2025
58

Upcoming Quality Measure Webinars

Upcoming Quality 

Measure Webinars
59

Schedule of Clinic-Collected Measure-Specific Webinars 

Friday, October 27, 2023 (TODAY)

‒ Clinic-Collected-Required Measures: I-SERV, SDOH, ASC

Wednesday, November 1, 2023 

‒ Clinic-Collected-Required Measures: CDF-AD & CH, DEP-REM-6

Thursday, November 9, 2023 

‒ Clinic-Collected-Optional Measures: TSC, SRA-A & C, CBP, WCC
60

Subsequent Technical Assistance

November or December 2023, Office Hours for Clinic-Collected 

Measures

January 18, 2024, State-Collected-Required Measures Part 1

February 15, 2024, State-Collected-Required Part 2 and Optional 

Measures

Late February or March 2024, Reporting Template and Commonly 

Asked Quality Measure Questions

March 2024, Office Hours for State-Collected Measures
61

Questions and Discussion
62

Poll #4

In the last 90 minutes, I have learned (please 

select the best option):

A. A lot of useful new information

B. Some useful new information

C. Very little new information

D. Not sure

E. Other (please add comments to the chat 

box)
63

References

• Magnan, 2017: Cited in Quality ID #487: Screening for Social Drivers of Health, 

MIPSCQM

• NIAAA, 2022: National Institute on Alcohol Abuse and Alcoholism. The 

Healthcare Professional’s Core Resource on Alcohol Knowledge. Impacts. 

Strategies. 

• SAMHSA, 2022a: Highlights for the 2021 National Survey on Drug Use and 

Health. 

• SAMHSA, 2022b: Substance Abuse and Mental Health Services Administration. 

(2022). Key substance use and mental health indicators in the United States: 

Results from the 2021 National Survey on Drug Use and Health (HHS 

Publication No. PEP22-07-01-005, NSDUH Series H-57). Center for Behavioral 

Health Statistics and Quality, Substance Abuse and Mental Health Services 

Administration. 
Thank You

64

SAMHSA’s mission is to lead public health and service delivery 

efforts that promote mental health, prevent substance misuse, 

and provide treatments and supports to foster recovery while 

ensuring equitable access and better outcomes.

Direct Quality Measure Questions to: 

CCBHCMeasuresSubmission@samhsa.hhs.gov

www.samhsa.gov

1-877-SAMHSA-7 (1-877-726-4727) ● 1-800-487-4889 (TDD)