Preparing Certified Community Behavioral 

Health Clinics (CCBHCs) for Quality Measure 

Data Collection and Reporting 

July 20, 2023

Peggy O’Brien, PhD & Shweta Palakkode, MPH 

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!).

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.

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Logistics
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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Agenda

Areas of 

opportunity 

Cliniccollected 

measure 

screening 

requirements

Lessons from 

the field Recap

Upcoming 

quality 

measure 

webinars
Recap of What & Why

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• 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
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? 
Preparing CCBHCs for 

Quality Measure Data 

Collection and 

Reporting 

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Areas of opportunity as you prepare for reporting

Infrastructure

State and Clinic 

Relationships

Staffing

Mutual Support
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Infrastructure

• IT infrastructure and EHR vendor relationships

• Billing and shadow billing/coding to capture services

• Workflow systems and supporting infrastructure to facilitate 

care coordination, screening and follow-up, alerts, and other 

needs

Infrastructure

Staffing
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Staffing

• Clinical, administrative, data/IT staffing roles

• Sufficiency of staffing 

• Willingness and motivation to effect change

• Training that addresses change, including in workflow

• Interdepartmental collaboration 

Staffing
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State and clinic relationships for demonstration

• Regular communication between states and clinics

• Technical assistance 

• Supporting electronic Admission, Discharge, Transfer Notifications 

(ADT) 

• Supporting other Health Information Exchanges

State and clinic 

relationships
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Mutual support

• Formal learning collaboratives assembled by SAMHSA and others 

• Informal peer learning groups within or across states 

• Sharing of questions and answers by SAMHSA and CMS for 

common knowledge 

Mutual Support
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Clinic-collected measure screening requirements
•

Why are certain screening instruments required?

Nearly all of our measures are based on 

existing measures which incorporate specific 

requirements related to evidence-based or 

best practices.

• Among those requirements are ones related 

to screening, some more prescriptive than 

others.

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Measure

Screening or Assessment Instruments for Required Clinic-Collected 

Measures (1)

Instrument

Screening for Social 

Drivers of Health 

Standardized Health-Related Social Needs (HRSN) Screening, some examples of 

which are:

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)

Preventive Care and 

Screening: Unhealthy 

Alcohol Use: Screening 

& Brief Counseling 

AUDIT Screening Instrument; 

AUDIT-C Screening Instrument; or 

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? 

Depression Remission at 

Six Months 

PHQ-9 or PHQ-9M

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Measure Instrument

Screening for Depression 

and Follow-Up Plan 

(Adult/Child) (R)

A normalized and validated depression screening tool developed for the population in which it is 

being utilized. Examples of depression screening tools include but are not limited to: 

Adult Screening Tools (age 18 and older)

Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for 

Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke AnxietyDepression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale for Depression in 

Dementia (CSDD), PRIME MD-PHQ2, Hamilton Rating Scale for Depression (HAM-D), Quick 

Inventory of Depressive Symptomatology Self-Report (QID-SR), Computerized Adaptive Testing 

Depression Inventory (CAT-DI), and Computerized Adaptive Diagnostic Screener (CAD-MDD).

Perinatal Screening Tools

Edinburgh Postnatal Depression Scale, Postpartum Depression Screening Scale, Patient Health 

Questionnaire 9 (PHQ-9), Beck Depression Inventory, Beck Depression Inventory–II, Center for 

Epidemiologic Studies Depression Scale, and Zung Self-rating Depression Scale.

Adolescent Screening Tools (12–17 years)

Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care 

Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies 

Depression Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric Symptom Checklist 

(PSC-17), and PRIME MD-PHQ2

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Screening or Assessment Instruments for Required Clinic-Collected 

Measures (2)
Measure

Screening or Assessment Instruments for Optional Clinic-Collected 

Measures

Instrument

Preventive Care & Screening: Tobacco Use: 

Screening & Cessation Intervention 

Screen for tobacco use

Adult Major Depressive Disorder (MDD): 

Suicide Risk Assessment (SRA) & 

Child and Adolescent Major Depressive 

Disorder (MDD): Suicide Risk Assessment 

(SRA)

The specific type and magnitude of the standardized SRA is at the discretion of the 

clinician and should be specific to the needs of the client. At a minimum, SRA 

should evaluate:

Adult SRA:

1) Suicidal ideation

2) Patient’s [Client's] intent of initiating a suicide attempt

AND, if either is present,

3) Patient [Client] plans for a suicide attempt

4) Whether the patient [client] has means for completing suicide

Low burden tools to track suicidal ideation and behavior such as the ColumbiaSuicide Severity Rating Scale (C-SSRS) and the Suicide Assessment Five-Step

Evaluation and Triage (SAFE-T) can also be used

Child and Adolescent SRA:

1. Risk (e.g., age, sex, stressors, comorbid conditions, hopelessness, impulsivity)

and protective factors (e.g., religious belief, concern not to hurt family) that may

influence the desire to attempt suicide.

2. Current severity of suicidality.

3. Most severe point of suicidality in episode and lifetime.

Low burden tools to track suicidal ideation and behavior such as

the Columbia-Suicidal Severity Rating Scale can also be used. 19
• Based on the approach used with I-EVAL

• It calculates the average time for clients to access three different types of service, 

specifically: (1) initial evaluation, (2) initial clinical services, and (3) crisis services. 

These are all services with time frames in the criteria. The actual calculations are:

a. For initial evaluation and initial clinical services: The eligible population are 

new clients ages 12 and older (not served in the past six months), and the 

measure is just the average number of days until those services from the time 

of first contact.

b. For crisis services: The eligible population is clients who contact the crisis 

provider for a new crisis episode (first time in 24 hours), and the measure is 

just the average number of hours until those services from the time of first 

contact.

• Details in the technical specs on new clients, first contact, etc.

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Basics of I-SERV (Time to Services)
Lessons from the 

Field 

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CCBHC Medicaid Policy Analyst

Health Systems Division

Oregon Health Authority

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Thoughts from the Field: Preparing for Quality Measure Data Collection and 

Reporting 

Q&A with Katie Rosenthal, M.Ed 
Putting yourself back at the beginning, what 

would you have wanted to know as a new 

CCBHC to prepare for quality measure 

reporting as you were gearing up for the 

demo?

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Question 1
Thinking about it from a state’s perspective, 

what would you tell clinics they should focus 

on for quality measure reporting as they are 

preparing to collect and report?

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Question 2
As a clinic, once the specifications are released, 

how would you approach next steps?

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Question 3
What do you see as the biggest challenges 

around quality measure collection and 

reporting, and what potential solutions might 

you suggest? 

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Question 4
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Thoughts from the Field: Preparing for Quality Measure Data Collection and 

Reporting 

Open Discussion

With Other States and Clinics in the 

Audience
Upcoming Quality 

Measure Webinars

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September 2023 

‒ Two webinars on clinic-collected measures

October 2023 

‒ Two webinars: one each on clinic-collected measure and 

state-collected measures 

November 2023 

‒ Two webinars on state-collected measures

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Tentative schedule of measure-specific webinars 
December 2023 or January 2024

‒ One webinar on the reporting template and recap 

of major questions and concerns raised in earlier 

webinars in this series

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Tentative schedule for reporting format webinar 
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Questions
In the last hour, 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)

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Poll #2
Thank you

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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)