Introducing Quality Measurement for 

Certified Community Behavioral Health 

Clinics (CCBHCs) and CCBHC-PDIs and 

CCBHC-IAs 

May 11, 2023

Peggy O’Brien, PhD

Center for Behavioral Health Statistics & Quality, Office of 

Evaluation

Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services
This webinar is being recorded and closed captioning is 

provided. Slides and the recording will be available 

about a week after the presentation. They will posted 

on the SAMHSA CCBHC website for later reference.

Please mute your lines (Thank you!).

Please turn off your cameras to conserve bandwidth.

We will have time for questions at the end. Please feel 

free to put questions in the chat as we go and we will 

address them at the end.

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Logistics
• Shweta Palakkode, SAMHSA, Center for 

Behavioral Health Statistics & Quality 

(CBHSQ), Office of Evaluation

• The CCBHC SAMHSA team in the Center for 

Mental Health Services (CMHS)

• The National Council for Mental Wellbeing 

• A-G Associates

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Acknowledgements
Agenda 

Introduction 

to Quality 

Measures 

Quality 

Measures 

and CCBHCs 

ClinicCollected 

Measures 

StateCollected 

Measures 

Timeframes 

for 

Reporting 

Previews of 

Future 

Webinars 

Questions 

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Please select the options that accurately describe your role:

1. Potential CCBHC demonstration state

2. Existing CCBHC demonstration state

3. Potential CCBHC demonstration clinic

4. Existing CCBHC demonstration clinic

5. Independent state CCBHC initiative

6. CCBHC-PDI grantees

7. CCBHC-IA grantees

8. Other (feel free to identify your role if not listed above)

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Poll #1: Who is in the audience today? 

This Photo by Unknown Author is licensed under CC BY-SA
1. Prospective and existing CCBHC Section 223 

Demonstration state staff

2. Prospective and existing CCBHC Section 223 

Demonstration CCBHCs or prospective CCBHCs

3. Independent state CCBHC initiative personnel

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

clinics and SAMHSA GPOs

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Intended audience for this webinar
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Introduction to Quality Measures

This Photo by Unknown Author is licensed under CC BY-SA
• Quality measures are standards for measuring 

the performance of healthcare providers to 

care for patients and populations. 

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What is a quality measure? 

Source: Centers for Medicare & Medicaid Services. Measures Management System Homepage
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Some purposes of quality measurement generally
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Three types of quality measures

Source: Agency for Healthcare Research and Quality. Talking Quality: Types of Health Care Quality Measures
rate =

Numerator

Denominator

=

(NNNNNNNNNNNN NNNNNNmmmmmmmm ssmmssmmssssNNss)

TTTTmmssTT NNTTmmmmmmNNTTNN ppTTppNNTTssmmmmTTmm

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Formula to calculate quality measure
Rate of 7 Day Follow-Up After Emergency Department 

(ED) Visit for Mental Illness 

# of follow-up visits within 7 days of ED visit

= ____________________________________

# of ED visits for adults and children 6 years of 

age and older with a diagnosis of mental illness

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Example of the formula with a real measure
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Types of data used for quality measurement
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Quality Measures and CCBHCs
1. The authorizing statute for the CCBHCs requires 

“reporting of encounter data, clinical outcomes data, 

quality data, and such other data as the Secretary 

requires.” Section 223 (a)(2)(E) of PAMA.

2. The certification criteria, as updated in 2023, provide 

additional detail about what is required.

3. Why else? Quality improvement, Quality Bonus 

Payments (for demonstration CCBHCs), evaluation

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Why require quality measures for CCBHCs? 
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Broad sets of quality measure requirements for CCBHCs
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Categories of BHC quality measures

BHC Quality Measures

State-Collected

2016:

Required for CCBHC 

States (13)

Not Required (5)

2023:

Required for CCBHC 

States (13)

Optional (2)

Clinic-Collected

2016:

Required for 

CCBHCs (9)

Not Required (5)

2023:

Required for CCBHCs 

(5)

Optional (5)
• To update the specifications for measures we retained

• To strengthen our focus on access (including crisis 

response), social determinants/drivers of health 

(SDOH), and Medications for Opioid Use Disorder 

(MOUD)

• To reduce burden on clinics by requiring fewer clinic- reported measures (5 vs. 9)

• To remove or make optional some of the existing 

quality measures that have been problematic and to 

offset new measures 

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Why we made changes
19 This Photo by Unknown Author is licensed under CC BY

Clinic-Collected Measures
The clinic-collected 

measures are based on 

clinical data typically 

derived from EHRs or 

other electronic 

administrative sources.

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Data sources for clinic-collected measures
Calculating and reporting clinic-collected measures 

 For Demonstration clinics, clinic-collected quality 

measures are calculated by the clinic and sent to the 

state 9 months after the end of the Measurement 

Year. 

 For CCBHC-IAs and CCBHC-PDIs, the measures are 

calculated by the clinic and sent to SAMHSA. 

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Updated clinic-collected quality measures

Measure Steward Changes

Required

Time to Services(I-SERV) SAMHSA Replaces I-EVAL, includes average time to: Initial Evaluation, 

Initial Clinical Services, and Crisis Services

Depression Remission at Six Months (DEP-REM-6) MNCM Changed from the 12- month version, with updates

Preventive Care and Screening: Unhealthy AlcoholUse: Screening 

and Brief Counseling (ASC)

NCQA Updated

Screening for Depression and Follow-Up Plan (CDF-CH and CDF-AD) CMS Updated, based on the Medicaid Core Measure Set (MCMS) 

(2023)

Screening for Social Drivers of Health (SDOH) CMS Updated, based on the MCMS (2023)

Optional

Preventive Care & Screening: Tobacco Use: Screening & 

Cessation Intervention (TSC)

NCQA Updated

Child and Adolescent Major Depressive Disorder (MDD): Suicide

Risk Assessment(SRA)

(SRA-C)

Mathematica Updated

Adult Major Depressive Disorder: Suicide Risk Assessment (SRA) 

(SRA-A)

Mathematica Updated

Weight Assessment and Counseling for Nutrition and Physical 

Activity for Children/Adolescents(WCC-CH)

NCQA Updated, based on the MCMS (2023)

ControllingHigh Blood Pressure (CBP-AD) NCQA Updated, based on the MCMS (2023)
23

State-Collected Measures
The state-collected 

measures are based on 

administrative claims, 

encounter, and pharmacy 

data, and, to a limited 

extent, surveys already 

being collected.

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Data sources for state-collected measures
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Calculating and reporting state-collected measures

A state-collected measure is calculated by the 

state for each CCBHC, and sent to SAMHSA, along 

with the clinic-collected results, 12 months after 

the end of the Measurement Year.
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Updated state-collected quality measures (slide 1)

Measure Steward Changes

Required

Patient Experience of Care Survey SAMHSA Updated

Youth/Family Experience of Care Survey SAMHSA Updated

Adherence to Antipsychotic MedicationsforIndividuals

with Schizophrenia (SAA-AD)

CMS Updated, based on the Medicaid Core Measure Set (MCMS) 

(2023)

Follow-UpAfter Hospitalization for Mental Illness, ages 

18+ (adult) (FUH-AD)

NCQA Updated, based on the MCMS (2023)

Follow-UpAfter Hospitalization for Mental Illness, ages 6 

to 17 (child/adolescent) (FUH-CH)

NCQA Updated, based on the MCMS (2023)

Initiation and Engagement of Substance Use Disorder 

Treatment (IET-AD)

NCQA Updated, based on the MCMS (2023)

Follow-Up After Emergency Department Visit for Mental 

Illness(FUM-CH and FUM-AD)

NCQA Updated, based on the MCMS (2023)

Follow-Up After Emergency Department Visit for 

Substance Use (FUA-CH and FUA-AD)

NCQA Updated, based on the MCMS (2023)
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Updated state-collected quality measures (slide 2)

Measure Steward Changes

Required (cont’d from prior slide)

Plan All-Cause Readmissions Rate (PCR-AD) NCQA Updated, based on the Medicaid Core Measure Set (MCMS) 

(2023)

Follow-Up Care for Children Prescribed Attention-Deficit 

Hyperactivity Disorder(ADHD) Medication (ADD-CH)

NCQA Updated, based on the MCMS (2023)

AntidepressantMedication Management (AMM-AD) NCQA Updated, based on the MCMS (2023)

Use of Pharmacotherapy for OpioidUse Disorder(OUDAD)

CMS Added, based on the MCMS (2023)

Hemoglobin A1c Control for Patientswith Diabetes

(HBD-AD)

NCQA Added, based on the MCMS (2023)

Optional

Use of First-Line Psychosocial Care for Children and

Adolescents on Antipsychotics (APP-CH)

NCQA Updated, based on the MCMS (2023)

Metabolic Monitoring for Children and Adolescents on 

Antipsychotics (APM-CH)

NCQA Added, based on the MCMS (2023)
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Timeframes for Quality Measure Reporting
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Anticipated Timelines for Quality Measure Reporting, Existing Demo States & 

Clinics (including those that are also CCBHC-Es and already reporting)
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Anticipated Timelines for Quality Measure Reporting, New Demo States & 

Clinics (including those that are also 2022 or later CCBHC-Es)
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Anticipated Timelines for Quality Measure Reporting, 2022 CCBHC-IA & 

CCBHC-PDIs (including those in the demonstration)

Grant Year Measurement Year for 

Updated Measures (the 

period being considered)

Report Due Dates for 

Grant Purposes

CCBHC-IAs

Began Sept. 30, 2022; 1st

relevant GY = 2025

Jan. 1, 2025-Dec. 31, 2025 

and annually thereafter

Most recent complete data 

no later than 90 days after 

the end of each 12-month 

grant budget period

CCBHC-PDIs

Began Sept. 30, 2022; 1st

relevant GY = 2025

Jan. 1, 2025-Dec. 31, 2025 

and annually thereafter

Most recent complete data 

no later than 90 days after 

the end of each 12-month 

grant budget period
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Anticipated Timelines for Quality Measure Reporting, 2023 CCBHC-IA & 

CCBHC-PDIs (including those in the demonstration)

Grant Year Measurement Year for 

Updated Measures (the 

period being considered)

Report Due Dates for 

Grant Purposes

CCBHC-IAs

Begin Sept. 30, 2023; 1st

relevant GY = 2025

Jan. 1, 2025-Dec. 31, 2025 

and annually thereafter

Most recent complete data 

no later than 90 days after 

the end of each 12-month 

grant budget period

CCBHC-PDIs

Begin Sept. 30, 2023; 1st

relevant GY = 2025

Jan. 1, 2025-Dec. 31, 2025 

and annually thereafter

Most recent complete data 

no later than 90 days after 

the end of each 12-month 

grant budget period
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Upcoming Webinars
June 

‒ Quality measurement as a tool for continuous quality improvement 

at CCBHCs

July

‒ Preparing CCBHCs for quality measure data collection and reporting 

(administrative, technical, and clinical)

September-November

‒ Five measure-specific webinars

December

‒ Introduction to the reporting template

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Preview of future webinars in 2023
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Preview of Webinar 2: How measures can improve quality
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Preview of Webinar 3: How clinics can prepare to collect data
Please select all measurement-related factors contributing to 

that anxiety:

1. Not knowing what the specifications look like

2. Concerns about having adequate workforce to both provide care 

and do quality measure data collection and reporting

3. Worry that staff will not readily accept changes 

4. Concerns about cost

5. Concerns that we will be judged negatively if our rates are low

6. Math anxiety

7. Other (please specify)

8. Nothing, I am calm, cool, and collected.

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Poll #2: What may be causing you anxiety about quality measurement?
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Questions
SAMHSA’s mission is to reduce the impact of substance 

abuse and mental illness on America’s communities.

www.samhsa.gov

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

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Thank You