# Redline Edits of the 2014 Certified Community Behavioral Health Clinic (CCBHC) Criteria

This document is locked in “read only” mode.  Track changes show how the original criteria was updated in 2023. Only the criteria and Appendix A are included. Changes to the introduction and quality measures appendix were extensive, and are not included in the redline version. Also see ***The Summary of Changes*** for additional information and rationale for changes.

## Program Requirement 1: Staffing

### Criteria 1.A: General Staffing Requirements 

1.a.1 As part of the process leading to certification and recertification, and before certification or attestation, a community needs assessment (see Appendix A: Terms and Definitions for required components of the community needs assessment) and a staffing plan that is responsive to the community needs assessment are completed and documented., the state will prepare an assessment of the needs of the target consumer population and a staffing plan for prospective CCBHCs. The needs assessment will include cultural, linguistic and treatment needs. The needs assessment is performed prior to certification of the CCBHCs in order to inform staffing and services. After certification, the CCBHC will update the needs assessment and the staffing plan, including both consumer and family/caregiver input. The needs assessment and staffing plan will be updated regularly, but no less frequently than every three years.

	Certifying states may specify additional community needs assessment requirements.

1.a.2 The staff (both clinical and non-clinical) is appropriate for serving the consumer population receiving services, as determined by the community needs assessment, in terms of size and composition and providing the types of services the CCBHC is required to and proposes to offer. 

**Note:** See criteria 4.K relating to required staffing of services for veterans.

1.a.3 The Chief Executive Officer (CEO) of the CCBHC, or equivalent, maintains a fully staffed management team as appropriate for the size and needs of the clinic, as determined by the current community needs assessment and staffing plan. The management team will include, at a minimum, a CEO or equivalentExecutive Director/Project Director, and a psychiatrist as Medical Director. The Medical Director need not be a full-time employee of the CCBHC. Depending on the size of the CCBHC, both positions (CEO/Executive Director/Project Director and the Medical Director) may be held by the same person. The Medical Director will ensure the medical component of care and the integration of behavioral health (including addictions) and primary care are facilitated. 

Depending on the size**Note:** If a CCBHC is unable, after reasonable and consistent efforts, to employ or contract with a psychiatrist as Medical Director because of the CCBHC, both positions (CEO or equivalent and the Medical Director) may be held by the same person. The Medical Director will provide guidance regardinga documented behavioral health clinical service delivery, ensure the quality of the professional shortage in its vicinity (as determined by the Health Resources and Services Administration (HRSA) (Health Resources and Services Administration [2015]), psychiatric consultation will be obtained on the medical component of care, and provide guidance to foster the integration[footnoteRef:1] and coordination of behavioral health and primary care.  [1: 	While CCBHCs are not required to provide primary care services, they are required to provide Primary Care Screening and Monitoring (See 4.g). CCBHCs may not pay for primary care services under the Section 223 CCBHC Demonstration PPS beyond those defined under 4.g. CCBHCs should coordinate with primary care providers to support integrated provision of primary and behavioral health care.] 

***Note:****If a CCBHC is unable, after reasonable efforts, to employ or contract with a psychiatrist as Medical Director,*, and a medically trained behavioral health care *professional*provider with appropriate education and licensure with prescriptive authority *and appropriate education, licensure, and experience in*in psychopharmacology*, and* who can prescribe and manage medications independently*,* pursuant to state law*, may* will serve as the Medical Director.*In addition, if a CCBHC is unable to hire a psychiatrist and hires another prescriber instead, psychiatric consultation will be obtained regarding behavioral health clinical service delivery, quality of the medical component of care, and integration and coordination of behavioral health and primary care.*

1.a.4 The CCBHC maintains liability/malpractice insurance adequate for the staffing and scope of services provided.

### Criteria 1.B: Licensure and Credentialing of Providers 

1.b.1 All CCBHC providers who furnish services directly, and any Designated Collaborating Organization (DCO) providers that furnish services under arrangement with the CCBHC, are legally authorized in accordance with federal, state, and local laws, and act only within the scope of their respective state licenses, certifications, or registrations and in accordance with all applicable laws and regulations. This includes, including any applicable state Medicaid billing regulations or policies. Pursuant to the requirements of the statute (PAMA § 223 (a)(2)(A)), CCBHC providers must have and maintain all necessary state-required licenses, certifications, or other credentialing. When CCBHC, with providers are working toward licensure, and appropriate supervision must be provided in accordance with applicable state laws.law. 

1.b.2 The CCBHC staffing plan meets the requirements of the state behavioral health authority and any accreditation standards required by the state. The staffing plan, is informed by the communitystate’s initial needs assessment, and includes clinical, peer, and otherpeer staff. In accordance with the staffing plan, the CCBHC maintains a core workforcestaff comprised of employed and, as needed, contracted staff. Staffing shall be , as appropriate to address the needs of people receiving services at the CCBHC, consumers as reflectedstated in theirconsumers’ individual treatment plans, and as required to meetby program requirements 3 and 4 of these criteria.

CCBHC staffStates specify which staff disciplines they will require as part of certification but must include a medically trained behavioral health care provider, either employed or available through formal arrangement, who can prescribe and manage medications independently under state law, including buprenorphine and other FDA-approved medications used to treat opioid, and alcohol, and tobacco use disorders. This would not include methadone, unless the CCBHC is also an Opioid Treatment Program (OTP). If the CCBHC does not have the ability to prescribe methadone for the treatment of opioid use disorder directly, it shall refer to an OTP (if any exist in the CCBHC service area) and provide care coordination to ensure access to methadone. The CCBHC must have staff, either employed or under contractavailable through formal arrangements, who are licensed or certifiedcredentialed substance use treatment counselors orabuse specialists. If the Medical Director is not experienced with the treatment of substance use disorders, the CCBHC must have experienced[footnoteRef:2] addiction medicine physicians or specialists on staff, or arrangements that ensure access to consultation on addiction medicine for the Medical Director and clinical staff. The CCBHC must include staff Providers must include individuals with expertise in addressing trauma and promoting the recovery of children and adolescents with serious emotional disturbance (SED) and adults with serious mental illness (SMI).) and those with substance use disorders. Examples of staff the state might require include a combination of the following: (1) psychiatrists (including general adultchild, adolescent, and geriatric psychiatrists and subspecialists), (2) nurses trained to work with consumers across the lifespan, (3) licensed independent clinical social workers, (4) licensed mental health counselors, (5) licensed psychologists, (6) licensed marriage and family therapists, (7) licensed occupational therapists, (8) staff trained to provide case management, (9) certified/trained peer specialist(s)/recovery coaches, (10) licensed addiction counselors, (11) certified/staff trained to provide family peer specialistssupport, (12) medical assistants, and (13) community health workers. The CCBHC supplements its core staff, as necessary in order to adhere togiven program requirements 3 and 4 and individual treatment plans, through arrangements with and referrals to other providers. [2: 	CCBHCs should seek practitioners with experience in the assessment and diagnosis of SUD, substance intoxication and withdrawal; pharmacological management of intoxication, withdrawal, and SUDs; ambulatory withdrawal management; outpatient addiction treatment; toxicology testing; and pharmacodynamics of commonly used substances.] 

**Note:** Recognizing professional shortages exist for many behavioral health providers*[footnoteRef:3]*: (1) some services may be provided by contract or part-time *staff*or as needed; (2) in CCBHC organizations comprised of multiple *locations*clinics, providers may be shared *across locations*among clinics; and (3) *the CCBHC*CCBHCs may utilize telehealth/ telemedicine*, video conferencing, patient monitoring, asynchronous interventions,* and *other technologies, to the extent possible,*on-line services to alleviate shortages*, provided that these services are coordinated with other services delivered by the CCBHC. The CCBHC is*. CCBHCs are not precluded by anything in this criterion from utilizing providers working towards licensure*if*, provided they are working under the requisite supervision.  [3: 	Find Shortage Areas by State & County, see HPSA Find (hrsa.gov)] 

	Certifying states should specify which staff disciplines they will require as part of certification.

### Criteria 1.C: Cultural Competence and Other Training

1.c.1 The CCBHC has a training plan, for all CCBHC employed and contract staff, and for providers at DCOs who have direct contact with people receiving servicesCCBHC consumers or their families. The training plan, which satisfies and includes requirements of the state behavioral health authority and any accreditation standards on training which may be required by the state. At orientation and at reasonable intervals thereafter, the CCBHC must provide training on:

· Evidence-based practices

· Cultural competency (described below)

· Person-Training must address cultural competence; person- centered and family-centered, recovery-oriented planning , evidence-based and services

· Trauma-informed care

· The clinic’s policy; and procedures for continuity of operations/disasters 

· The clinic’s policy and procedures for integration and coordination with primary care

· Care for co-occurring mental/behavioral health and substance use disorders

At orientation and integration. This training, as well as training on the clinic’s continuity plan, occurs at orientation and thereafter at reasonable intervals as may be required by the state or accrediting agencies. At orientation and annually thereafter, the CCBHC must provideprovides training onabout: (1) risk assessment;, suicide and overdose prevention and suicide response; and(2) the roles of family and peer staff.families and peers; and (3) such other trainings as may be required by the state or accrediting agency on an annual basis. If necessary, trainings may be provided on-line.

Training shall be aligned with the National Standards for Culturally and Linguistically Appropriate Services (CLAS)[footnoteRef:4] to advance health equity, improve quality of services, and eliminate disparities. To the extent active-Cultural competency training addresses diversity within the organization’s service population and, to the extent active duty military or veterans are being served, such training must also include information related to military culture. Examples of cultural competency training and materials that further the ability of the clinic to provide tailored training for a diverse population include, but are not limited to, those available through the HHS website, of the US Department of Health & Human Services (DHHS), the SAMHSA website,[footnoteRef:5] through the HHSwebsite of the DHHS, Office of Minority Health, or through the website of the DHHS, Health Resources and Services Administration.  [4: 	Access standards at, What is CLAS? - Think Cultural Health (hhs.gov) and Behavioral Health Implementation Guide for the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care at National Minority Mental Health Awareness Month — New CLAS Implementation Guide (hhs.gov). ]  [5: 	Suggested resources include the African American Behavioral Health Center of Excellence, LGBTQ+ Behavioral Health Equity Center of Excellence, Engage, Educate, Empower for Equity: E4 Center of Excellence for Behavioral Health Disparities in Aging, and Asian American, Native Hawaiian, and Pacific Islander Behavioral Health Center of Excellence.] 

**Note:** See criteria 4.K relating to cultural competency requirements in services for veterans.

1.c.2 The CCBHC regularly assessesassess the skills and competence of each individual furnishing services and, as necessary, provides in-service training and education programs. The CCBHC has written policies and procedures describing its method(s) of assessing competency and maintains a written accounting of the in-service training provided for the duration of employment of each employee who has direct contact with people receiving servicesduring the previous 12 months.

1.c.3 The CCBHC documents in the staff personnel records that the training and demonstration of competency are successfully completed. CCBHCs are encouraged to provide ongoing coaching and supervision to ensure initial and ongoing compliance with, or fidelity to, evidence-based, evidence-informed, and promising practices.

1.c.4 Individuals providing staff training are qualified as evidenced by their education, training, and experience.

### Criteria 1.D: Linguistic Competence

1.d.1 If the CCBHC serves individuals with Limited English Proficiency (LEP) or with language-based disabilities, the CCBHC takes reasonable steps to provide meaningful access to their services, such as language assistance, for those with Limited English Proficiency (LEP) and/or language-based disabilities.

1.d.2 Interpretation/translation service(s) are readily available andprovided that are appropriate and timely for the size/needs of the LEP CCBHC consumer population (e.g., bilingual providers, onsite interpreters, language video or telephone line). To the extent interpreters are used, such translation service providers are trained to function in a medical and, preferably, a behavioral health setting.

1.d.3 Auxiliary aids and services are readily available, Americans With Disabilities Act (ADA) compliant, and responsive to the needs of people receiving services with physical, cognitive, and/or developmentalconsumers with disabilities (e.g., sign language interpreters, teletypewriter (TTY) lines).

1.d.4 Documents or informationmessages vital to thea consumer’s ability of a person receiving services to access CCBHC services (e.g.,for example, registration forms, sliding scale fee discount schedule, after-hours coverage, signage) are available online and in paper format,for consumers in languages commonly spoken withincommon in the community served, taking account of literacy levels and the need for alternative formats. (for consumers with disabilities). Such materials are provided in a timely manner at intake and throughout the time a person is served. The requisite languages will be informed by the CCBHC.needs assessment prepared prior to certification, the needs assessment will inform which languages require language assistance, to be and as updated as needed.

1.d.5 The CCBHC’s policies have explicit provisions for ensuring all employees, affiliated providers, and interpreters understand and adhere to confidentiality and privacy requirements applicable to the service provider. These include,, including but are not limited to, the requirements of the Health Insurance Portability and Accountability Act (HIPAA) (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule allows routine – and often critical – communications between health care providers and a consumer's family and friends, so long as the consumer consents or does not object. If a consumer is amenable and has the capacity to make health care decisions, health care providers may communicate with a consumer's family and friends.

## Program Requirement 2: Availability and Accessibility of Services

### Criteria 2.A: General Requirements of Access and Availability

2.a.1 The CCBHC provides a safe, functional, clean, sanitary, and welcoming environment, for people receiving servicesconsumers and staff, conducive to the provision of services identified in program requirement 4. CCBHCs are encouraged to operate tobacco-free campuses.  

2.a.2 Informed by the community needs assessment, The CCBHC ensures thatprovides outpatient clinical services are provided during times that facilitateensure accessibility and meet the needs of the consumer population to be served by the CCBHC, including some eveningnights and weekend hours.

2.a.3 Informed by the community needs assessment, The CCBHC provides services at locations that ensure accessibility and meet the needs of the population to be served, such as settings in the community (e.g., schools, social service agencies, partner organizations, community centers) and, as appropriate and feasible, in the homes of people receiving services. consumer population to be served.

2.a.4 To the extent possible within the state Medicaid program or other funding or programs, The CCBHC provides transportation or transportation vouchers for people receiving services to the extent possible with relevant funding or programs in order to facilitate access to services in alignment with the person-centered and family-centered treatment planconsumers.

2.a.5 The CCBHC usesTo the extent possible within the state Medicaid program and as allowed by state law, CCBHCs utilize mobile in-home, telehealth/telemedicine, video conferencing, remote patient monitoring, asynchronous interventions, and other technologies, to the extent possible, in alignment with the preferences of the person receiving services to supportand on- line treatment services to ensure consumers have access to all required services.

2.a.6 Informed by the community needs assessment, The CCBHC conductsengages in outreach, and engagement, and retention activities to support inclusionassist consumers and families to access benefits, and formal or informal services to address behavioral health conditions and access for underserved individuals and populations.[footnoteRef:6]needs. [6: 	Underserved individuals and populations includes communities as defined in Federal Register: Advancing Racial Equity and Support for Underserved Communities Through the Federal Government as well as individuals or populations that have unmet needs for mental health and substance use disorder treatment and supports. ] 

2.a.7 Services are subject to all state standards for the provision of both voluntary and court-ordered services.

2.a.8 The CCBHC has a continuity of operations/disaster plan. The plan will ensure the CCBHC is able to effectively notify staff, people receiving services, and healthcare and community partners when a disaster/emergency occurs or services are disrupted. The CCBHC, to the extent feasible, has identified alternative locations and methods to sustain service delivery and access to behavioral health medications during emergencies and disasters. The plan also addresses health IT systems security/ransomware protection and backup and access to these IT systems, including health records, in case of disaster. 

2.a.9 CCBHCs have in place a continuity of operations/disaster plan.

### Criteria 2.B: General Requirements for Timely Access to Services and Initial and Comprehensive Evaluation for New Consumers

2.b.1 All people new to receiving services, whetherconsumers requesting or being referred for behavioral health services at the CCBHC, will, at the time of first contact, whether that contact is in-person, by telephone, or using other remote communication, receive a preliminary triage, including screening and risk assessment, to determine acuity of needs. That preliminary triagescreening may occur telephonically. The preliminary screening will be followed by: (1) an initial evaluation, and (2) a comprehensive person-centered and family-centered diagnostic and treatment planning evaluation, with the components of each specified in program requirement 4. Each evaluation builds upon what came before it. Subject to more stringent state, federal, or applicable accreditation standards:

· If the triagescreening identifies an emergency/crisis need, appropriate action is taken immediately (see 4.c.1 for crisis response timelines and detail about required services), including plans to reduce or remove risk of harm and to facilitate , including any necessary subsequent outpatient follow-up.

· If the triagescreening identifies an urgent need, clinical services are provided, including an and the initial evaluation completed within one business day of the time the request is made.

· If the triagescreening identifies routine needs, services will be provided and the initial evaluation completed within 10 business days.

· For those presenting with emergency or urgent needs, the initial evaluation may be conducted by phonetelephonically or through use of technologies for by telehealth/telemedicine and video conferencing, but an in-person evaluation is preferred. If the initial evaluation is conducted telephonically, once the emergency is resolved, the person receiving servicesconsumer must be seen in person at the next subsequent encounter and the initial evaluation reviewed.

The preliminary triage and risk assessment will be followed by: (1) an initial evaluation and (2) a comprehensive evaluation, with the components of each specified in program requirement 4. At the CCBHC’s discretion, recent information may be reviewed with the person receiving services and incorporated into the CCBHC health records from outside providers to help fulfill these requirements. Each evaluation must build upon what came before it. Subject to more stringent state, federal, or applicable accreditation standards, all new people receiving servicesconsumers will receive a more comprehensive person-centered and family-centered diagnostic and treatment planning evaluation to be completed within 60 calendar days of the first request for services. If the state has established independent screening and assessment processes for certain child and youth populations or other populations, the CCBHC should establish partnerships to incorporate findings and avoid duplication of effort. This requirement that the comprehensive evaluation be completed within 60 calendar days does not preclude either the initiation or completion of the comprehensive evaluation, or the provision of treatment during the 60 -day period.

**Note:** Requirements for these screenings and evaluations are specified in criteria 4.D.

2.b.2 The comprehensive person-centered and family-centered diagnostic and treatment planplanning evaluation is reviewed and updated as needed by the treatment team, in agreement with and endorsed by the person receiving services. The treatment plan will be updated consumer and in consultation with the primary care provider (if any), when changes occur within the consumer’s status of the person receiving services, based on, responses to treatment, or when there are changes in treatment goals.goal achievement have occurred. The treatment planassessment must be reviewed and updated no less frequently than every 6 months,90 calendar days unless the state has established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent.

2.b.3 People who are already receiving services from the CCBHC who are seeking routine Outpatient clinical services must be provided for established CCBHC consumers seeking an appointment for routine needs must be provided within 10 business days of the requestrequested date for an appointmentservice, unless the state has established a standard that meets the expectation of quality care and that renders this time frame unworkable, or state, federal, or applicable accreditation standards are more stringent. If a person receiving servicesIf an established consumer presents with an emergency/crisis need, appropriate action is taken immediately based on the needs of the person receiving services, including immediate crisis response if any necessary. If a person already receiving services subsequent outpatient follow-up. If an established consumer presents with an urgent, non-emergency need, clinical services are generally provided within one business day of the time the request is made or at a later time if that is the preference of the person receiving services. Same-day and open access scheduling are encouraged**.**.

### Criteria 2.C: 24/7 Access to Crisis Management Services

2.c.1 In accordance with the requirements of program requirement 4.c, the CCBHC provides crisis management services that are available and accessible 24- hours a day, seven days a week.   and delivered within three hours.

2.c.2 A description of The methods for providing a continuum of crisis prevention, response, and postvention services shall be includedare clearly described in the policies and procedures of the CCBHC and madeare available to the public.

2.c.3 Individuals who are served by the CCBHC are educated about crisis planning, psychiatric advanced directives,management services and Psychiatric Advanced Directives and how to access crisis services, including the 988 Suicide & Crisis Lifeline (by call, chat,suicide or text) and other area crisis hotlines and warmlines, and overdose prevention, if risk is indicated, at the time of the initial evaluation meeting following the preliminary triage. Please see 3.a.4. for further information on crisis planning. This includes individuals with LEP or disabilities (i.e., CCBHC provides instructions on how to access services in the appropriate methods, language(s), and literacy levels in accordance with program requirement 1.d).

2.c.4 In accordance with the requirements of program requirement 3, the CCBHC maintainsCCBHCs maintain a working relationship with local hospital emergency departments (EDs).. Protocols are established for CCBHC staff to address the needs of CCBHC people receiving servicesconsumers in psychiatric crisis who come to those EDs.

2.c.5 Protocols, including thoseprotocols for the involvement of law enforcement, are in place to reduce delays for initiating services during and following a behavioral health crisis. Shared protocols are designed to maximize the delivery of recovery-oriented treatment and services. The protocols should minimize contact with law enforcement and the criminal justice system, while promoting individual and public safety, and complying with applicable state and local laws and regulations. psychiatric crisis.

**Note:** See criterion 3.c.5 regarding specific care coordination requirements related to discharge from hospital or ED following a psychiatric crisis.

2.c.6 Following a psychiatric emergency or crisis involving a CCBHC consumer, in conjunction with the person receiving servicesconsumer, the CCBHC creates, maintains, and follows a crisis plan to prevent and de-escalate future crisis situations, with the goal of preventing future crises.  for the consumer and their family.

**Note:** See criterion 3.a.4 where precautionary crisis planning is addressed.	

### Criteria 2.D: No Refusal of Services due to Inability to Pay

2.d.1 The CCBHC ensures: (1) no individuals are denied behavioral health care services, including but not limited to crisis management services, because of an individual’s inability to pay for such services (PAMA § 223 (a)(2)(B));)), and (2) any fees or payments required by the clinic for such services will be reduced or waived to enable the clinic to fulfill the assurance described in clause (1).

2.d.2 The CCBHC has a published sliding fee discount schedule(s) that includes all services the CCBHC offersproposes to offer pursuant to these criteria. Such fee schedulesschedule will be included on the CCBHC website, posted in the CCBHC waiting room and readily accessible to people receiving servicesconsumers and families. The sliding fee discount schedule is communicated in languages/formats appropriate for individuals seeking services who have LEP, literacy barriers, or disabilities.

2.d.3 The fee schedules, to the extent relevant, conform to state statutory or administrative requirements or to federal statutory or administrative requirements that may be applicable to existing clinics; absent applicable state or federal requirements, the schedule is based on locally prevailing rates or charges and includes reasonable costs of operation.

2.d.4 The CCBHC has written policies and procedures describing eligibility for and implementation of the sliding fee discount schedule. Those policies are applied equally to all individuals seeking services.

### Criteria 2.E: Provision of Services Regardless of Residence

2.e.1 The CCBHC ensures no individual is denied behavioral health care services, including but not limited to crisis management services, because of place of residence, or homelessness, or lack of a permanent address.

2.e.2 The CCBHC hasCCBHCs have protocols addressing the needs of individualsconsumers who do not live close to thea CCBHC or within the CCBHC servicecatchment area. The CCBHC is as established by the state. CCBHCs are responsible for providing, at a minimum, crisis response, evaluation, and stabilization services in the CCBHC service area regardless of place of residence. The required protocols should address management of the individual’s on-going treatment needs beyond that. Protocols may provide for agreements with clinics in other localities, allowing the CCBHCCCBHCs to refer and track individualsconsumers seeking non-crisis services to the CCBHC or other clinicsclinic serving the individual’s areaconsumer’s county of residence. For individuals and families who livedistant consumers within the CCBHC’s service area but live a long distance from CCBHC clinic(s), the CCBHCcatchment area, CCBHCs should consider use of technologies for telehealth/telemedicine, video conferencing, remote patient monitoring, asynchronous interventions, and other technologies  to the extent practicable. In no circumstances (and in alignmentaccordance with the preferences of the person receivingPAMA § 223 (a)(2)(B)), may any consumer be refused services, and to the extent practical. These criteria do not require the CCBHC to provide continuous services including telehealth to individuals who live outside because of place of the CCBHC service area. CCBHCS may consider developing protocols for populations that may transition frequently in and out of the services area such as children who experience out-of-home placements and adults who are displaced by incarceration or housing instability.  residence.

## Program Requirement 3: Care Coordination

### Criteria 3.A: General Requirements of Care Coordination

3.a.1 Based on a person-centered and family-centered treatment plan of care aligned with the requirements of Section 2402(a) of the Affordable Care ActACA and aligned with state regulations and consistent with best practices, the CCBHC coordinates care across the spectrum of health services. This includes, including access to high-quality physical health (both acute and chronic) and behavioral health care, as well as social services, housing, educational systems, and employment opportunities as necessary to facilitate wellness and recovery of the whole person. The CCBHC also coordinates with other systems to meet the needs of the people they serve, including criminal and juvenile justice and child welfare.[footnoteRef:7]  [7: 	For additional information on care coordination, see Care Coordination | Agency for Healthcare Research and Quality (ahrq.gov)] 

**Note:** See criteria 4.K relating to care coordination requirements for veterans.

3.a.2 The CCBHC maintains the necessary documentation to satisfy the requirements of HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state privacy laws, including patient privacy requirements specific to the care of minors. To promote coordination of care, the CCBHC will obtain necessary consents for sharing information with community partners where information is not able to be shared under HIPAA and other federal and state laws and regulations. If the CCBHC isThe HIPAA Privacy Rule allows routine – and often critical – communications between health care providers and a consumer's family and friends. Health care providers may always listen to a consumer’s family and friends. If a consumer consents and has the capacity to make health care decisions, health care providers may communicate protected health care information to a consumer's family and friends. Given this, the CCBHC ensures consumers’ preferences, and those of families of children and youth and families of adults, for shared information are adequately documented in clinical records, consistent with the philosophy of person and family-centered care. Necessary consent for release of information is obtained from CCBHC consumers for all care coordination relationships. If CCBHCs are unable, after reasonable attempts, to obtain consent for any care coordination activity specified in program requirement 3, such attempts must be documented and revisited periodically

***Note:****CCBHCs are encouraged to explore options for electronic documentation of consent where feasible and responsive to the needs and capabilities of the person receiving services. See standards within the Interoperability Standards Advisory.[footnoteRef:8]* [8: 	The Interoperability Standards Advisory (ISA) process represents the model by which the Office of the National Coordinator for Health Information Technology (ONC) will coordinate the identification, assessment, and determination of "recognized" interoperability standards and implementation specifications for industry use to fulfill specific clinical health IT interoperability needs. More information can be found at Interoperability Standards Advisory (ISA) | HealthIT.gov. ] 

3.a.3 Consistent with requirements of privacy, confidentiality, and the preferences and needs of people receiving servicesconsumer preference and need, the CCBHC assists people receiving servicesconsumers and the families of children and youth, referred to external providers or resources, in obtaining an appointment and tracking participation in services to ensureconfirms the appointment was kept.Care coordination and receipt of supports.

3.a.4 The CCBHC shall coordinate care activities are carried out in keeping with the consumer’s preferences of the person receiving services and theirneeds for care needs.and, to the extent possible, care coordination should be provided, as appropriate, in collaboration and in accordance with the consumer’s expressed preferences, with the consumer’s family/caregiver of the person receiving services and other supports identified by the person. To identify theconsumer. So as to ascertain in advance the consumer’s preferences of the person in the event of psychiatric or substance use crisis, the CCBHC developsCCBHCs develop a crisis plan with each person receiving services. At minimum, people receiving services should be counseled about the use of the National Suicide & Crisis Lifeline, local hotlines, warmlines, mobile crisis, and stabilization services should a crisis arise when providers are not in their office. consumer. Examples of crisis plans may support the development ofinclude a Psychiatric Advanced Directive, if desired by the person receiving services.[footnoteRef:9] Psychiatric Advance Directives, if developed, are entered in the electronic health record of the person receiving services so that the information is available to providers in emergency care settings where those electronic health records are accessible.  or Wellness Recovery Action Plan. [9: 	Psychiatric Advance Directives are legal instruments that may be used to document a competent person’s specific instructions or preferences regarding future mental health treatment. Psychiatric Advance Directives can be used to plan for the possibility that someone may lose capacity to give or withhold informed consent to treatment during acute episodes of psychiatric illness. For more information visit NRC PAD | National Resource Center on Psychiatric Advance Directives (nrc-pad.org)] 

3.a.5 Appropriate care coordination requires the CCBHC to make and document reasonable attempts to determine any medications prescribed by other providers. To the extent that state laws allow, the state Prescription Drug Monitoring Program (PDMP) must be consulted before prescribing medications. The PDMP should also be consulted during the comprehensive evaluation. for CCBHC consumers and, upon appropriate consent to release of information, the CCBHC is also required to provide such information to other providers not affiliated with the CCBHC to the extent necessary for safe and quality care.

3.a.6 Nothing about a CCBHC’s agreements for care coordination should limit thea consumer’s freedom of a person receiving services to choose their provider withinwith the CCBHC, with or its DCOs, or with any other provider.

3.a.7 The CCBHC assists people receiving services and families to access benefits, including Medicaid, and enroll in programs or supports that may benefit them.

### Criteria 3.B: Care Coordination and Other Health Information Systems

3.b.1 The CCBHC establishes or maintains a health information technology (IT) system that includes, but is not limited to, electronic health records. The health IT system has the capability to capture structured information in consumer records (including demographic information, diagnoses, and medication lists), provide clinical decision support, and electronically transmit prescriptions to the pharmacy. To the extent possible, the CCBHC will use the health IT system to report on data and quality measures as required by program requirement 5.

3.b.2 The CCBHC uses its secureexisting or newly established health IT system(s) and related technology tools, ensuring appropriate protections are in place, to conduct activities such as population health management, quality improvement, quality measurement and reporting, reducing disparities, outreach, and for research. When CCBHCs use federal funding to acquire, upgrade, or implement technology to support these activities, systems should utilize nationally recognized, HHS-adopted standards, where available, to enable  and outreach. If the CCBHC is establishing a health information exchange.[footnoteRef:10] For example, this may include simply using common terminology mapped to standards adopted by HHS to represent a concept such as race, ethnicity, or other demographic information. While this requirement does not apply to incidental use of existing IT systems to support these activities when there is no targeted use of program funding, CCBHCs are encouraged to explore ways to support alignment with standards across data-driven activitiessystem, the system will have the capability to capture structured information in the health IT system (including demographic information, problem lists, and medication lists). CCBHCs establishing a health IT system will adopt a product certified to meet requirements in 3.b.1, to send and receive the full common data set for all summary of care records and be certified to support capabilities including transitions of care and privacy and security. CCBHCs establishing health IT systems will adopt a health IT system that is certified to meet the “Patient List Creation” criterion (45 CFR §170.314(a)(14)) established by the Office of the National Coordinator (ONC)4 for ONC’s Health IT Certification Program. [10:  Pursuant to HHS Health IT Alignment policy and Section 13112 of the HITECH Act, recipients and subrecipients of award funding which involves acquiring, upgrading and implementing health IT must utilize health IT that meets standards and implementation specifications adopted by HHS in 45 CFR part 170, Subpart B, if such standards and implementation specifications can support the award activity.] 

3.b.3 The CCBHC uses technology that has been certified to current criteria[footnoteRef:11] under the ONC Health IT Certification Program for the following required core set of certified health IT capabilities (see footnotes for citations to the required health IT certification criteria and standards) that align with key clinical practice and care delivery requirements for CCBHCs[footnoteRef:12] [11:  As of February 2023, current criteria are the 2015 Edition of health IT certification criteria, as updated according to the 2015 Edition Cures Update.]  [12:  Additional information about health IT products certified to these criteria is available on the Certified Health IT Product List (CHPL).] 

· Capture health information, including demographic information such as race, ethnicity, preferred language, sexual and gender identity, and disability status (as feasible).[footnoteRef:13] [13:  United States Core Data for Interoperability (USCDI) standard at 45 CFR 170.213 and “Demographics” criterion at § CFR 170.315(a)(5).] 

· At a minimum, support care coordination by sending and receiving summary of care records.[footnoteRef:14] [14:  “Transitions of care” criterion at § 170.315(b)(1)).] 

· Provide people receiving services with timely electronic access to view, download, or transmit their health information or to access their health information via an API using a personal health app of their choice.[footnoteRef:15] [15:  “Application access – patient selection” criterion at § 170.315(g)(7); “Application access – all data request” criterion at § 170.315(g)(9) and “Standardized API for patient and population services” criterion at § 170.315(g)(10).] 

· Provide evidence-based clinical decision support.[footnoteRef:16] [16:  “Clinical decision support” criterion at § 170.315(a)(9).] 

· Conduct electronic prescribing.[footnoteRef:17] [17:  “Electronic prescribing” criterion at § 170.215(b)(3).] 

***Note:****Under the CCBHC program, CCBHCs are not required to have all these capabilities in place when certified or when submitting their attestation but should plan to adopt and use technology meeting these requirements over time, consistent with any applicable program timeframes. In addition, CCBHCs do not need to adopt a single system that provides all these certified capabilities but can adopt either a single system or a combination of tools that provide these capabilities. Finally, CCBHC providers who successfully participate in the Promoting Interoperability Performance Category of the Quality Payment Program will already have health IT systems that successfully meet all the core certified health IT capabilities.*

3.b.4 The CCBHC will work with DCOs to ensure all steps are taken, including obtaining consumer consent from people receiving services, to comply with privacy and confidentiality requirements. These include,, including but are not limited to, those of HIPAA (Pub. L. No. 104- 191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors.

3.b.5 The CCBHC develops and implements a plan within two-years from CCBHC certification or submission of attestationWhether a CCBHC has an existing health IT system or is establishing a new health IT system, the CCBHC will develop a plan to be produced within the two-year demonstration program time frame to focus on ways to improve care coordination between the CCBHC and all DCOs using a health IT system. This plan includesshall include information on how the CCBHC can support electronic health information exchange to improve care transition to and from the CCBHC using the health IT system they have in place or are implementing for transitions of care. To support integrated evaluation planning, treatment, and care coordination, the CCBHC works with DCOs to integrate clinically relevant treatment records generated by the DCO for people receiving CCBHC services and incorporate them into the CCBHC health record. Further, all clinically relevant treatment records maintained by the CCBHC are available to DCOs within the confines of federal and/or state laws governing sharing of health records. 

### Criteria 3.C: Care Coordination PartnershipsAgreements

3.c.1 The CCBHC has a partnershipan agreement establishing care coordination expectations with Federally-Qualified Health Centers (FQHCs) (and, as applicable, Rural Health Clinics ([RHCs))]) to provide health care services, to the extent the services are not provided directly through the CCBHC. For people receiving servicesconsumers who are served by other primary care providers, including but not limited to FQHC Look-Alikes and Community Health Centers, the CCBHC has established protocols to ensure adequate care coordination.

***Note:****These partnerships should be supported by a formal, signed agreement detailing the roles of each party. If the partnering entity is unable to enter into a formal agreement, the CCBHC may work with the partner to develop unsigned joint protocols that describe procedures for working together and roles in care coordination. At a minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be developed. All partnership activities should be documented to support partnerships independent of any staff turnover.*

**Note:** If an agreement cannot be established with a FQHC or, as applicable, an RHC (e.g., a provider does not exist in their service area), or cannot be established within the time frame of the demonstration project, justification is provided to the certifying body and contingency plans are established with other providers offering similar services (e.g., primary care, preventive services, other medical care services).

**Note:** CCBHCs are expected to work toward formal contracts with entities with which they coordinate care if they are not established at the beginning of the demonstration project.

3.c.2 The CCBHC has partnerships that establishan agreement establishing care coordination expectations with programs that can provide inpatient psychiatric treatment, OTP services, medical withdrawal management facilities andwith ambulatory and medical withdrawal management providers for substance use disordersdetoxification, post-detoxification step-down services, and residential substance use disorder treatment programs (if any exist within the CCBHC service area). These include tribally operated mental health and substance use services including crisis services that are in the service area.programs to provide those services for CCBHC consumers. The clinic tracksCCHBC is able to track when people receiving CCBHC servicesconsumers are admitted to facilities providing the services listed above, as well as when they are discharged, unless there is a formal transfer of care to a non-CCBHC entity. The CCBHC has established protocols and procedures for transitioning individuals from EDs, inpatient psychiatric programs, medically monitored withdrawal management services, detoxification, and residential or inpatient facilities that serve children and youth such as Psychiatric Residential Treatment Facilities and other residential treatment facilities,settings to a safe community setting. This includes transfer of healthmedical records of services received (e.g., prescriptions), active follow-up after discharge, and, as appropriate, a plan for suicide prevention and safety, overdose prevention, and provision for peer services.

***Note:****These partnerships should be supported by a formal, signed agreement detailing the roles of each party. If the partnering entity is unable to enter into a formal agreement, the CCBHC may work with the partner to develop unsigned joint protocols that describe procedures for working together and roles in care coordination. At a minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be developed. All partnership activities should be documented to support partnerships independent of any staff turnover.*

	Certifying states are encouraged to find ways to incentivize inpatient treatment facilities to partner with CCBHCs to establish protocols and procedures for transitioning individuals, including real time notification of discharge and record transfers that support the seamless delivery of care, maintain recovery, and reduce the risk of relapse and injury during transitions.

3.c.3 The CCBHC has partnerships**Note:** For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.The CCBHC has an agreement establishing care coordination expectations with a variety of community or regional services, supports, and providers. Partnerships support joint planning for care and services, provide opportunities to identify individuals in need of services, enable the CCBHC to provide services in community settings, enable the CCBHC to provide support and consultation with a community partner, and support CCBHC outreach and engagement efforts. CCBHCs are required Services and supports to collaborate with which are identified by statute to develop partnerships with the following organizations that operate within the service areainclude:

· Schools;

· Child welfare agencies;

· Juvenile and criminal justice agencies and facilities (including drug, mental health, veterans, and other specialty courts));

· Indian Health Service[footnoteRef:18] youth regional treatment centers; [18:  The Indian Health Service is an Operating Division within HHS, responsible for providing federal health services to American Indians and Alaska Natives.] 

· State licensed and nationally accredited child placing agencies for therapeutic foster care service; and

· Other social and human services.

CCBHCs may develop partnerships with the following entities based onThe CCBHC has, to the extent necessary given the population served, and the needs and preferences of people receivingindividual consumers, an agreement with such other community or regional services, supports, and/or needs identified in the community needs assessment. Examples of providers as may be necessary, such partnerships include (but are not limited to)as the following:

· Specialty providers including those who prescribe of medications for the treatment of opioid and alcohol use disordersdependence;

· Suicide and /crisis hotlines and warmlines;

· Indian Health Service or other tribal programs;

· Homeless shelters;

· Housing agencies;

· Employment services systems;

· Peer-operated programs

· Services for older adults, such as Area Agencies on Aging 

· Aging and Disability Resource Centers; and

· State and local health departments and behavioral health and developmental disabilities agencies

· Substance use prevention and harm reduction programs

· Criminal and juvenile justice, including law enforcement, courts, jails, prisons, and detention centers

· Legal aid

· Immigrant and refugee services

· SUD Recovery/Transitional housing 

· Programs and services for families with young children, including Infants & Toddlers, WIC, Home Visiting Programs, Early Head Start/Head Start, and Infant and Early Childhood Mental Health Consultation programs

· Coordinated Specialty Care programs for first episode psychosis

· Other social and human services (e.g., intimate partnerdomestic violence centers, religiouspastoral services and supports, grief counseling, Affordable Care Act navigators, food and transportation programs) ).

In addition, the CCBHC has a care coordination partnership with the 988 Suicide & Crisis Lifeline call center serving the area in which the CCBHC is located.

***Note:****These partnerships should be supported by a formal, signed agreement detailing the roles of each party or unsigned joint protocols that describe procedures for working together and roles in care coordination. At a minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be developed. All partnership activities should be documented to support partnerships independent of any staff turnover.*

	Certifying states may require CCBHCs to establish additional partnerships.  

The CCBHC has partnerships**Note:** For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.

3.c.4 The CCBHC has an agreement establishing care coordination expectations with the nearest Department of Veterans Affairs' medical center, independent clinic, drop-in center, or other facility of the Department. To the extent multiple Department facilities of different types are located nearby, the CCBHC should work to establishexplore care coordination agreements with facilities of each type.

***Note:****These partnerships should be supported by a formal, signed agreement detailing the roles of each party. If the partnering entity is unable to enter into a formal agreement, the CCBHC may work with the partner to develop unsigned joint protocols that describe procedures for working together and roles in care coordination. At a minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be developed. All partnership activities should be documented to support partnerships independent of any staff turnover.*

**Note:** For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.

3.c.5 The CCBHC has care coordination partnershipsan agreement establishing care coordination expectations with inpatient acute-care hospitals in the area served by the CCBHC and their associated services/facilities, including emergency departments, hospital outpatient clinics, urgent care centers, and residential crisis settings., medical detoxification inpatient facilities and ambulatory detoxification providers, in the area served by the CCBHC, to address the needs of CCBHC consumers. This includes procedures and services, such as peer recovery specialist/coachesbridgers, to help transition individuals successfully transition from the ED or hospital to CCBHC and community care to ensure continuity of services and to minimize thecare and shortened time lag between discharge and follow up. Ideally, the CCBHC should work with the discharging facility ahead of discharge to assure a seamless transition. These partnerships shall support trackingassessment and treatment. The agreement is such that the CCBHC can track when people receiving CCBHC servicestheir consumers are admitted to facilities providing the services listed above, as well as when they are discharged. The partnerships shall also support the , unless there is a formal transfer of healthcare to another entity. The agreement also provides for transfer of medical records of services received (e.g., prescriptions) and active follow-up after discharge. CCBHCs should request of relevant inpatient and outpatient facilities, for people receiving CCBHC services, that notification be provided through the Admission-Discharge-Transfer (ADT) system.

The CCBHC will make and document reasonable attempts to contact all people receiving CCBHC servicesconsumers who are discharged from these settings within 24 hours of discharge. For all people receiving CCBHC servicesconsumers being discharged from such facilities who are at risk forpresented to the facilities as a potential suicide or overdoserisk, the care coordination agreement between these facilities and the CCBHC includes a requirement to coordinate consent and follow-up services with the person receiving servicesconsumer within 24 hours of discharge, and continues until the individual is linked to services or assessed to be no longer at risk.

***Note:****These partnerships should be supported by a formal, signed agreement detailing the roles of each party. If the partnering entity is unable to enter into a formal agreement, the CCBHC may work with the partner to develop unsigned joint protocols that describe procedures for working together and roles in care coordination. At a minimum, the CCBHC will develop written protocols for supporting coordinated care undertaken by the CCBHC and efforts to deepen the partnership over time so that jointly developed protocols or formal agreements can be developed. All partnership activities should be documented to support partnerships independent of any staff turnover.*

**Note:** For these services, if an agreement cannot be established, or cannot be established within the time frame of the demonstration project, justification is provided and contingency plans are developed and the state will make a determination whether the contingency plans are sufficient or require further efforts.

### Criteria 3.D: Care Treatment Team, Treatment Planning, and Care Coordination Activities 

3.d.1 The CCBHC treatment team includes the person receiving services and their consumer, the family/caregivers,caregiver of child consumers, the adult consumer’s family to the extent the person receiving services desires their involvement or when they are legal guardiansconsumer does not object, and any other people the person receiving services desires to be involved in their care.person the consumer chooses. All treatment planning and care coordination activities are person- and family-centered and alignfamily- centered and aligned with the requirements of Section 2402(a) of the Affordable Care Act. All treatment planning and care coordination activities are subject to HIPAA (Pub. L. No. 104-191, 110 Stat. 1936 (1996)), 42 CFR Part 2, and other federal and state laws, including patient privacy requirements specific to the care of minors. The HIPAA Privacy Rule does not cut off all communication between health care professionals and the families and friends of consumers. As long as the consumer consents, health care professionals covered by HIPAA may provide information to a consumer’s family, friends, or anyone else identified by a consumer as involved in their care.

3.d.2 As appropriate for the individual’s needs, the CCBHC designates an interdisciplinary treatment team that is responsible, with the person receiving services and their consumer or family/caregivers, to the extent the person receiving services desires their involvement or when they are legal guardianscaregiver, for directing, coordinating, and managing care and services. for the consumer. The interdisciplinary team is composed of individuals who work together to coordinate the medical, psychiatric, psychosocial, emotional, therapeutic, and recovery support needs of the people receiving servicesCCBHC consumers, including, as appropriate and desired by the person receiving services, traditional approaches to care for people receiving servicesconsumers who aremay be American Indian or Alaska Native or from other cultural and ethnic groups. .

**Note:** See criteria 4.K relating to required treatment planning services for veterans.

3.d.3 The CCBHC coordinates care and services provided by DCOs in accordance with the current treatment plan.

**Note:** See program requirement 4 related to scope of service and person- centered and family-centered treatment planning.

## Program Requirement 4: Scope of Services

### Criteria 4.A: General Service Provisions

4.a.1 Whether delivered directly or through a DCO agreement, the CCBHC isThe CCBHCs are responsible for ensuring access tothe provision of all care specified in PAMA. This includes, including, as more explicitly provided and more clearly defined below in criteria 4.cB through 4.K the following required services:, crisis services; screening, assessment and diagnosis; person-centered and family-centered treatment planning; outpatient behavioral health services; outpatient primary care screening and monitoring; targeted case management; psychiatric rehabilitation; peer and family supports; and intensive community-based outpatient behavioral health care for members of the U.S. Armed Forces and veterans.   US Armed Forces and veterans. As provided in criteria 4.B through 4.K, many of these services may be provided either directly by the CCBHC or through formal relationships with other providers that are DCOs. Whether directly supplied by the CCBHC or by a DCO, the CCBHC is ultimately clinically responsible for all care provided. The decision as to the scope of services to be provided directly by the CCBHC, as determined by the state and clinics as part of certification, reflects the CCBHC’s responsibility and accountability for the clinical care of the consumers. Despite this flexibility, it is expected CCBHCs will be designed so most services are provided by the CCBHC rather than by DCOs, as this will enhance the ability of the CCBHC to coordinate services.

The CCBHC organization will deliver directly the majority (51% or more) of encounters across the required services (excluding Crisis Services) rather than through DCOs. 

**Note:** See CMS PPS guidance regarding payment.

4.a.2 The CCBHC ensures all CCBHC services, if not available directly through the CCBHC, are provided through a DCO, consistent with the consumer’s freedom of the person receiving services to choose providers within the CCBHC and its DCOs. This requirement does not preclude the use of referrals outside the CCBHC or DCO if a needed specialty service is unavailable through the CCBHC or DCO entities.

4.a.3 With regard to either CCBHC or DCO services, people receiving services will be informed of andconsumers will have access to the CCBHC’s existing grievance procedures, which must satisfy the minimum requirements of Medicaid and other grievance requirements such as those that may be mandated by relevant accrediting entities or state authorities.

4.a.4 DCO-provided services for people receiving CCBHC servicesconsumers must meet the same quality standards as those provided by the CCBHC. The entities with which the CCBHC coordinates care and all DCOs, taken in conjunction with the CCBHC itself, satisfy the mandatory aspects of these criteria.

### Criteria 4.B: Requirement of Person-Centered and Family-Centered Care

4.b.1 The CCBHC ensures all CCBHC services, including those supplied by its DCOs, are provided in a manner aligned with the requirements of Section 2402(a) of the Affordable Care Act. These reflect, reflecting person-centered and family-centered, recovery-oriented care;, being respectful of the individual consumer’s needs, preferences, and values of the person receiving services;, and ensuring both consumer involvement of the person receiving services and self- direction of services received. Services for children and youth are family- centered, youth-guided, and developmentally appropriate. A shared decision-making model for engagement is the recommended approach.

**Note:** See program requirement 3 regarding coordination of services and treatment planning. See criteria 4.K relating specifically to requirements for services for veterans.

4.b.2 Person-centered and family-centered care is responsive to the race, ethnicity, sexual orientation and gender identity of the person receiving services and includes care which recognizes the particular cultural and other needs of the individual. This includes, but is not limited to, services for peopleconsumers who are American Indian or Alaska Native (AI/AN) or other cultural or ethnic groups,), for whom access to traditional approaches or medicines may be part of CCBHC services. For people receiving servicesconsumers who are AI/AN, these services may be provided either directly or by formal arrangement with tribal organizations. providers.

### Criteria 4.C: Crisis Behavioral Health Services

4.c.1 The CCBHC shall provide crisis services directly or through a DCO agreement withUnless there is an existing state-sanctioned, certified, or licensed system or network for the provision of crisis behavioral health services. HHS recognizes that state-sanctioned crisis systems may operate under different standards than those identified in these criteria. If a CCBHC would like to have a DCO relationship with a state-sanctioned crisis system that operates under less stringent standards, they must request approval from HHS to do so.[footnoteRef:19]  that dictates otherwise, the CCBHC will directly provide robust and timely crisis behavioral health services. Whether provided directly by the CCBHC or by a state- sanctioned alternative acting as a DCO, available services must include the following: [19:  For questions about this process, please email ccbhc@samhsa.hhs.gov. ] 

	Certifying states must request approval from HHS to certify CCBHCs in their states that have or seek to have a DCO relationship with a state-sanctioned crisis system with less stringent standards than those included in these criteria.[footnoteRef:20]  [20:  For questions about this process, please email ccbhc@samhsa.hhs.gov.] 

· 24 hour mobile crisis teams,

· Emergency crisis intervention services, and

· Crisis stabilization.

PAMA requires provision of these three crisis behavioral health services, whether . As part of the certification process, the states will clearly define each term as they are using it but services provided directly by the CCBHC or by a DCO: 

· **Emergency crisis intervention services:** The CCBHC provides or coordinates with telephonic, text, and chatmust include suicide crisis intervention call centers that meet 988 Suicide & Crisis Lifeline standards for risk assessment and engagement of individuals at imminent risk of suicide. The CCBHC should participate in any state, regional, or local air traffic control (ATC)[footnoteRef:21] systems which provide quality coordination of crisis care in real-time as well as any service capacity registries as appropriate. Quality coordination means that protocols have been established to track referrals made from the call center to the CCBHC or its DCO crisis care provider to ensure the timely delivery of mobile crisis team response, crisis stabilization, and post crisis follow-up care. [21:  Air traffic control (ATC) serves as a conceptual model for real-time coordination of crisis care and linkage to crisis response services. It may involve real-time connection to GPS-enabled mobile teams, true system-wide access to available beds, and outpatient appointment scheduling through the integrated crisis call center. For more information see National Guidelines for Behavioral Health Crisis Care | SAMHSA] 

· **24-hour mobile crisis teams:** The CCBHC provides community-based behavioral health crisis intervention services using mobile crisis teams twenty-four hours per day, seven days per week to adults, children, youth, and families anywhere within the service area including at home, work, or anywhere else where the crisis is experienced. Mobile crisis teams are expected to arrive in-person within one hour (2 hours in rural and frontier settings) from the time that they are dispatched, with response time not to exceed 3 hours. Telehealth/telemedicine may be used to connect individuals in crisis to qualified mental health providers during the interim travel time. Technologies also may be used to provide crisis care to individuals when remote travel distances make the 2-hour response time unachievable, but the ability to provide an in-person response must be available when it is necessary to assure safety. The CCBHC should consider aligning their programs with the  if they are in a state that includes this option in their Medicaid state plan.[footnoteRef:22]  [22:  For information on crisis services for children and youth, please see National Guidelines for Child and Youth Behavioral Health Crisis Care (samhsa.gov) and A Safe Place to Be: Crisis Stabilization Services and Other Supports for Children and Youth (samhsa.gov) ] 

· **Crisis receiving/stabilization:** The CCBHC provides crisis receiving/stabilization services that must include at minimum, urgent care/walk-in mental health and substance use disorder services for voluntary individuals. Urgent care/walk-in services that identify the individual’s immediate needs, de-escalate the crisis, and connect them to a safe and least-restrictive setting for ongoing care (including care provided by the CCBHC). Walk-in hours are informed by the community needs assessment and include evening hours that are publicly posted. The CCBHC should have a goal of expanding the hours of operation as much as possible. Ideally, these services are available to individuals of any level of acuity; however, the facility need not manage the highest acuity individuals in this ambulatory setting. Crisis stabilization services should ideally be available 24 hours per day, 7 days a week, whether individuals present on their own, with a concerned individual, such as a family member, or with a human service worker, and/or law enforcement, in accordance with state and local laws. In addition to these activities, the CCBHC may consider supporting or coordinating with peer-run crisis respite programs. The CCBHC is encouraged to provide crisis receiving/stabilization services in accordance with the SAMHSA National Guidelines for Behavioral Health Crisis Care.

Services provided must include suicide prevention and intervention, and services capable of addressing crises related to substance use including the risk of drug and alcohol related overdose and support following a non-fatal overdose after the individual is medically stable. Overdose prevention activities must include ensuring access to naloxone for overdose reversal to individuals who are at risk of opioid overdose, and as appropriate, to their family members. The CCBHC or its DCO crisis care provider should offer developmentally appropriate responses, sensitive de-escalation supports, and connections to ongoing care, when needed. The CCBHCabuse and intoxication, including ambulatory and medical detoxification. States may elect to require the employment of peers on crisis teams. CCBHCs will have an established protocol specifying the role of law enforcement during the provision of crisis services. As a part of the requirement to provide training related to trauma-informed care, the CCBHC shall specifically focus on the application of trauma-informed approaches during crises. 

**Note:** See program requirement 2*.c regarding access* related to crisis prevention, response and postvention services and criterion 3.c.5 regarding coordination of services and treatment planning, including after discharge from a hospital *inpatient*or *emergency department*ED following a *behavioral health*psychiatric crisis.

### Criteria 4.D: Screening, Assessment, and Diagnosis

4.d.1 The CCBHC directly, or through a DCO, provides screening, assessment, and diagnosis, including risk assessment, for behavioral health conditions. In the event specialized services outside the expertise of the CCBHC are required for purposes of screening, assessment, or diagnosis (e.g., neuropsychologicalneurological testing or, developmental testing and assessment, eating disorders), the CCBHC provides or refers the person to an appropriate provider. Whenthem through formal relationships with other providers, or where necessary and appropriate screening, assessment and diagnosis can be provided, through use of telehealth/telemedicine services.

**Note:** See program requirement 3 regarding coordination of services and treatment planning.

4.d.2 Screening, assessment, and diagnosis are conducted in a time frame responsive to the individual consumer’s needs and preferences of the person receiving services and are of sufficient scope to assess the need for all services required to be provided by the CCBHCCCBHCs.

4.d.3 The initial evaluation (including information gathered as part of the preliminary triagescreening and risk assessment, with information releases obtained as needed), as required in program requirement 2, includes, at a minimum:

1. (1) Preliminary diagnoses;

2. (2) The source of referral; 

3. (3) The reason for seeking care, as stated by the person receiving servicesconsumer or other individuals who are significantly involved; 

4. (4) Identification of the consumer’s immediate clinical care needs related to the diagnosis for mental and substance use disorders of the person receiving services

5. (5) A list of all current prescriptions and over-the- counter medications, herbal remedies, and dietary supplements and the indication for any medications 

6. A summary of previous mental health and substance use disorder treatments with a focus on which treatments helped and were not helpful 

7. The use of any alcohol and/or as well as other drugssubstances the person receiving servicesconsumer may be taking and indication for any current medications 

8. (6) An assessment of whether the person receiving servicesconsumer is a risk to self or to others, including suicide risk factors; 

9. (7) An assessment of whether the person receiving servicesconsumer has other concerns for their safety, such as intimate partner violence 

10. (8) Assessment of need for medical care (with referral and follow-up as required)

11. ); and (9) A determination of whether the person presently is, or ever has been, a member of the U.S. Armed Services. As needed, releases of information are obtained.

12. For children and youth, whether they have system involvement (such as child welfare and juvenile justice)

4.d.4 As required in program requirement 2, A comprehensive person-centered and family-centered diagnostic and treatment planning evaluation is completed within 60 days by licensed behavioral health professionals who, in conjunction with the consumer, are members of the treatment team, performing within their state’s scope of practice. Information gathered as part of the preliminary screening and initial evaluation may be considered a part of the comprehensive evaluation. This requirement that the comprehensive evaluation be completed within 60 calendar days does not preclude either the initiation or completion of the comprehensive evaluation or the provision of treatment during the intervening 60 day period.

Although a comprehensive diagnostic and treatment planning evaluation is required for all people receiving CCBHC services. Subject to applicable consumers, the extent of the evaluation will depend on the individual consumer and on existing state, federal, or otherapplicable accreditation standards, clinicians. As part of certification, states will establish the requirements for these evaluations; factors states should use their clinical judgment with respect to the depth of questioning within the assessment so that the assessment actively engages the person receiving services around their presenting concern(s). The evaluation should gather the amount of information that is commensurate with the complexity of their specific needs, and prioritize preferences of people receiving services with respect to the depth of evaluation and their treatment goals. The evaluation shallconsider requiring include: 

1. (1) Reasons for seeking services at the CCBHC, including information regarding onset of symptoms, severity of symptoms, and circumstances leading to the consumer’s presentation to the CCBHC of the person receiving services.

2. An overview of relevant social supports; social determinants of health; and health-related social needs such as ; (2) a psychosocial evaluation including housing, vocational, and educational status;, family/caregiver and social support;, legal issues;, and insurance status.

3. A description of cultural and environmental factors that may affect the treatment plan of the person receiving services, including the need for linguistic services or supports for people with LEP.

4. Pregnancy and/or parenting status.

5. ; (3) Behavioral health history,  (including trauma history and previous therapeutic interventions and hospitalizations with a focus on what was helpful and what was not helpful in past treatments.

6. Relevant medical history and major health conditions that impact current psychological status.

7. A medication list); (3) a diagnostic assessment, including prescriptions, over-the counter medications, herbal remedies, dietary supplements, and other treatments or medications of the person receiving services. Include those identified in a Prescription Drug Monitoring Program (PDMP) that could affect their clinical presentation and/or pharmacotherapy, as well as information on allergies including medication allergies.

8. An examination that includes current mental status, mental health (including depression screening, and other tools that may be used in ongoing measurement-based care) and substance use disorders (including tobacco, alcohol, and other drugs).

9. Basic cognitive screening for cognitive impairment.

10. ); (4) Assessment of imminent risk,  (including suicide risk, withdrawal and overdose risk, danger to self or others, urgent or critical medical conditions, and other immediate risks including threats from another person.

11. The); (5) basic competency/cognitive impairment screening (including the consumer’s ability to understand and participate in their own care); (6) a drug profile including the consumer’s prescriptions, over-the- counter medications, herbal remedies, and other treatments or substances that could affect drug therapy, as well as information on drug allergies; (7) a description of attitudes and behaviors, including cultural and environmental factors, that may affect the consumer’s treatment plan; (8) the consumer’s strengths, goals, preferences, and other factors to be considered in treatment and recovery planning of the person receiving services.

12. Assessment of the; (9) pregnancy and parenting status; (10) assessment of need for other services required by the statute (i.e., peer and family/caregiver support services, targeted case management, psychiatric rehabilitation services).

13.  LEP or linguistic services); (11) Assessment of any relevantthe social service needs of the person receiving servicesconsumer, with necessary referrals made to social services. For children and youth receiving services, assessment of systems involvement such as child welfare and juvenile justice and referral, for pediatric consumers, to child welfare agencies as appropriate.

14. ; and (12) depending on whether the CCBHC directly provides primary care screening and monitoring of key health indicators and health risk pursuant to criteria 4.G, either: (a) An assessment of need for a physical exam or further evaluation by appropriate health care professionals, including the consumer’s primary care provider (with appropriate referral and follow-up)), or (b) a basic physical assessment as required by criteria 4.G. All remaining necessary releases of the person receiving servicesinformation are obtained by this point.

15. The preferences of the person receiving services regarding the use technologies such as telehealth/telemedicine, video conferencing, remote patient monitoring, and asynchronous interventions. 

4.d.5 Screening and assessment conducted by the CCBHC related to behavioral health include those for which the CCBHC will be accountable pursuant to program requirement 5 and Appendix BA of these criteria. The CCBHC should not take non-inclusion of a specific metric in Appendix BA as a reason not to provide clinically indicated behavioral health screening or assessment.and 

	The state may elect to require specific other screening and monitoring to be provided by the CCBHCs beyond those listed in criterion 4.d.45 or Appendix BA.

4.d.6 The CCBHC uses standardized and validated and developmentally appropriate screening and assessment tools appropriate for the person and, where warrantedappropriate, brief motivational interviewing techniques to facilitate engagement.

4.d.7 The CCBHC uses culturally and linguistically appropriate screening tools, and tools/approaches that accommodate all literacy levels and disabilities (e.g., hearing disability, cognitive limitations), when appropriate.

4.d.8 If screening identifies unsafe substance use including problematic alcohol or other substance use, the CCBHC conducts a brief intervention and the person receiving services is provided a full assessment and treatment, if appropriate within the level of care of the CCBHC, or referred to a more appropriate level of care. If the screening identifies more immediate threats to the safety of the person receiving services, the CCBHC will take appropriate action as described in 2.b.1. consumer is provided or referred for a full assessment and treatment, if applicable.

### Criteria 4.E: Person-Centered and Family-Centered Treatment Planning

4.e.1 The CCBHC directly, or through a DCO, provides person-centered and family-centered treatment planning or similar processes, including but not limited to, risk assessment and crisis planning (CCBHCs may work collaboratively with DCOs to complete these activities).. Person-centered and family-centered treatment planning satisfies the requirements of criteria 4.e.2 – 4.e.8 below and is aligned with the requirements of Section 2402(a) of the Affordable Care Act, including person receiving servicesconsumer involvement and self-direction.

**Note:** See program requirement 3 related to coordination of care and treatment planning.

4.e.2 The CCBHC develops an individualized treatment plan based on information obtained through the comprehensive evaluation and the person receiving services’ goals and preferences. The plan shall address the person’sintegrating prevention, medical, and behavioral health needs. The plan shall be  and service delivery is developed by the CCBHC in collaboration with and be endorsed by the person receiving services; theirconsumer, the adult consumer’s family (to the extent the person receiving servicesconsumer so wishes); and, or family/caregivers of youth and children or legal guardians. Treatment plan development shall be, and is coordinated with staff or programs necessary to carry out the plan. The plan shall support care in the least restrictive setting possible. Shared decision making is the preferred model for the establishment of **Note:** States may wish to access additional resources related to person- centered treatment planning goals. All necessary releases of information shall be obtained and included in the health record as a part of the development of the initial treatment plan. found in the CMS Medicaid Home and Community Based Services regulations at 42 C.F.R. Part 441, Subpart M, or in the CMS Medicare Conditions of Participation for Community Mental Health Centers regulations at 42 C.F.R. Part 485.

4.e.3 The CCBHC uses the initial evaluation, comprehensive evaluation, and ongoing screening and assessment of the person receiving servicesconsumer assessments to inform the treatment plan and services provided.

4.e.4 Treatment planning includes needs, strengths, abilities, preferences, and goals, expressed in a manner capturing the consumer’s words or ideas of the person receiving services and, when appropriate, those of the consumer’s family/caregiver of the person receiving services.  .

4.e.5 The treatment plan is comprehensive, addressing all services required, including recovery supports, with provision for monitoring of progress towards goals. The treatment plan is built upon a shared decision-making approach.

4.e.6 Where appropriate, consultation is sought during treatment planning as neededabout special emphasis problems, including for treatment planning purposes (e.g., trauma, eating disorders, traumatic brain injury, intellectual and developmental disabilities (I/DD), interpersonal violence and human trafficking).**).

4.e.7 The person’s health record treatment plan documents anythe consumer’s advance directiveswishes related to treatment and crisis planning.management and, if the person receiving servicesconsumer does not wish to share their preferences, that decision is documented. Please see 3.a.4., requiring the development of a crisis plan with each person receiving services*.*

	Consistent with the criteria in 4.e.1 through 4.e.7, certifying states should specify other aspects of consumer, person-centered and family-centered treatment planning they will require based upon the needs of the population served. Treatment planning components that certifying states might consider include: prevention; community inclusion and support (housing, employment, social supports); involvement of family/caregiver and other supports; recovery planning; safety planning; and the need for specific services required by the statute (i.e., care coordination, physical health services, peer and family support services, targeted case management, psychiatric rehabilitation services, tailored treatmentaccommodations to ensure cultural and linguistically appropriatecompetent services).

### Criteria 4.F: Outpatient Mental Health and Substance Use Services

4.f.1 The CCBHC directly, or through a DCO, provides outpatient behavioral health care, including psychopharmacological treatment. The CCBHC or the DCO must provide mental and substance use disorder services that are evidence-based services using or best practices for treating mental health and substance use disorders across the lifespan, consistent with tailored approaches for adults, children, and families. SUD treatment and services shall be provided as described in the American Society for Addiction Medicine Levels 1 and 2.1 and include treatment of tobacco use disorders.the needs of individual consumers as identified in their individual treatment plan. In the event specialized or more intensive services outside the expertise of the CCBHC or DCO are required for purposes of outpatient mental and substance use disorder treatment (e.g., treatment of sexual trauma, eating disorders, specialized medications for substance use disorders), the CCBHC makes them available through referral or other formal arrangement with other providers or, where necessary and appropriate, through use of telehealth/telemedicine, in alignment with state and federal laws and regulations. services. The CCBHC also provides or makes available through a formal arrangement traditional practices/treatment as appropriate for the people receiving servicesconsumers served in the CCBHC area. Where specialist providers are not available to provide direct care to a particular person receiving CCBHC services, or specialist care is not practically available, the CCBHC professional staff may consult with specialized services providers for highly specialized treatment needs. For people receiving services with potentially harmful substance use, the CCBHC is strongly encouraged to engage the person receiving services with motivational techniques and harm reduction strategies to promote safety and/or reduce substance use.  

**Note:** See also program requirement 3 regarding coordination of services and treatment planning.

	Based upon the findings of the community needs assessment as required in program requirement 1, certifying states must establish a minimum set of evidence-based practices required of the CCBHCs. Among those evidence-based practices states might consider are the following: Motivational Interviewing; Cognitive Behavioral Therapyindividual, group and on-line Therapies (CBT); Dialectical Behavior Therapy (DBT); Coordinated Specialty Care (CSC) for First Episode Psychosis (FEP); Seeking Safety; addiction technologies; recovery supports; first episode early intervention for psychosis; Multi-Systemic Therapy; Assertive Community Treatment (ACT); Forensic Assertive Community Treatment (FACT);F- ACT); evidence-based medication evaluation and management (including but not limited to medications for psychiatric conditions, medication assisted treatment for alcohol and opioid substance use disorders (e.g., buprenorphine, methadone, naltrexone (injectable and oral), acamprosate, disulfiram, naloxone), prescription long-acting injectable medications to treatfor both mental and substance use disorders; Multi-Systemic Therapy; Trauma-Focused Cognitive Behavioral Therapy (TF-CBT); Cognitive Behavioral Therapy for psychosis (CBTp); High-Fidelity Wraparound; Parent Management Training; Effective but underutilized medications such as clozapine and FDA-approved medications for substance use disorders including , and smoking cessation. medications); community wrap-around services for youth and children; and specialty clinical interventions to treat mental and substance use disorders experienced by youth (including youth in therapeutic foster care). This list is not intended to be all-inclusive. Certifying and the states are free to determine whether these or other evidence-based treatments may be appropriate as a condition of certification.

4.f.2 Treatments are provided that are appropriate for the consumer’s phase of life and development of the person receiving services, specifically considering what is appropriate for children, adolescents, transition -age youth, and older adults, as distinct groups for whom life stage and functioning may affect treatment. Specifically, when treating children and adolescents, CCBHCs mustCCHBCs provide evidenced-based services that are developmentally appropriate, youth -guided, and family/caregiver -driven. with respect to children and adolescents. When treating older adults, the individual consumer’s desires and functioning of the individual person receiving services are considered, and appropriate evidence-based treatments are provided. When treating individuals with developmental or other cognitive disabilities, level of functioning is considered, and appropriate evidence-based treatments are provided. These treatments are delivered by staff with specific training in treating the segment of the population being served. CCBHCs are encouraged to use evidence-based strategies such as measurement-based care (MBC)[footnoteRef:23] to improve service outcomes.    [23:  Measurement-based care (MBC) is the systematic use of patient-reported information to inform clinical care and shared decision-making among clinicians and patients and to individualize ongoing treatment plans: Measurement-Based Mental Health Care (va.gov) ] 

4.f.3 Supports for Children and adolescents mustare treated using a family/caregiver-driven, youth guided and developmentally appropriate approach that comprehensively addressaddresses family/caregiver, school, medical, mental health, substance useabuse, psychosocial, and environmental issues.

### Criteria 4.G: Outpatient Clinic Primary Care Screening and Monitoring

4.g.1 The CCBHC is responsible for outpatient clinic primary care screening and monitoring of key health indicators and health risk. Whether directly provided by the CCBHC or through a DCO, the CCBHC is responsible for ensuring these services are received in a timely fashion. Prevention is a key component of primary care screening and monitoring services provided by the CCBHC. The Medical Director establishes protocols that conform to screening recommendations with scores of A and B, of the United States Preventive Services Task Force Recommendations (these recommendations specify for which populations screening is appropriate) for the following conditions: Required primary care screening and monitoring of key health indicators and health risk provided by the CCBHC include those for which the CCBHC will be accountable pursuant to program requirement 5 and Appendix A of these criteria. The CCBHC should not take non-inclusion of a specific metric in Appendix A as a reason not to provide clinically indicated primary care screening and monitoring and the state may elect to require specific other screening and monitoring to be provided by the CCBHCs. The CCBHC ensures children receive age appropriate screening and preventive interventions including, where appropriate, assessment of learning disabilities, and older adults receive age appropriate screening and preventive interventions. Prevention is a key component of primary care services provided by the CCBHC. Nothing in these criteria prevent a CCBHC from providing other primary care services.

· HIV and viral hepatitis 

· Primary care screening pursuant to CCBHC Program Requirement 5 Quality and Other Reporting and Appendix B

· Other clinically indicated primary care key health indicators of children, adults, and older adults receiving services, as determined by the CCBHC Medical Director and based on environmental factors, social determinants of health, and common physical health conditions experienced by the CCBHC person receiving services population.**

4.g.2 The Medical Director will develop organizational protocols to ensure that screening for people receiving services who are at risk for common physical health conditions experienced by CCBHC populations across the lifespan. Protocols will include:

· Identifying people receiving services with chronic diseases; 

· Ensuring that people receiving services are asked about physical health symptoms; and 

· Establishing systems for collection and analysis of laboratory samples, fulfilling the requirements of 4.g.

In order to fulfill the requirements under 4.g.1 and 4.g.2 the CCBHC should have the ability to collect biologic samples directly, through a DCO, or through protocols with an independent clinical lab organization. Laboratory analyses can be done directly or through another arrangement with an organization separate from the CCBHC. The CCBHC must also coordinate with the primary care provider to ensure that screenings occur for the identified conditions. If the person receiving services’ primary care provider conducts the necessary screening and monitoring, the CCBHC is not required to do so as long as it has a record of the screening and monitoring and the results of any tests that address the health conditions included in the CCBHCs screening and monitoring protocols developed under 4.g.

4.g.3 The CCBHC will provide ongoing primary care monitoring of health conditions as identified in 4.g.1 and 4.g.2., and as clinically indicated for the individual. Monitoring includes the following:

(1) ensuring individuals have access to primary care services; 

(2) ensuring ongoing periodic laboratory testing and physical measurement of health status indicators and changes in the status of chronic health conditions; 

(3) coordinating care with primary care and specialty health providers including tracking attendance at needed physical health care appointments; and 

(4) promoting a healthy behavior lifestyle.

***Note****: The provision of primary care services, outside of primary care screening and monitoring as defined in 4.g., is not within the scope of the nine required CCBHC services. CCBHC organizations may provide primary care services outside the nine required services, but these primary care services cannot be reimbursed through the Section 223 CCBHC demonstration PPS.*

**Note:** See also program requirement 3 regarding coordination of services and treatment planning.

	Certifying states may elect to require specific other screening and monitoring to be provided by the CCBHCs in addition to the those described in 4.g.

### Criteria 4.H: Targeted Case Management Services[footnoteRef:24] [24:  CCBHC targeted case management services are separate from and do not follow state targeted case management rules under the Medicaid state plan or waivers.] 

4.h.1 The CCBHC is responsible for providing directly, or through a DCO,high quality targeted case management services that will assist people receiving services individuals in sustaining recovery, and gaining access to needed medical, social, legal, educational, housing, vocational, and other services and supports. CCBHC targeted case management provides an intensive level of support that goes beyond the care coordination that is a basic expectation for all people served by the CCBHC. CCBHC Targeted case management should include supports for peoplepersons deemed at high risk of suicide or overdose, particularly during times of transitions such as from a residential treatment, hospital emergency department,an ED or psychiatric hospitalization. CCBHC targeted case management should also be used accessible during other critical periods, such as episodes of homelessness or transitions to the community from jails or prisons. CCBHC targeted case management should be used for individual with complex or serious mental health or substance use conditions and for individuals who have a short-term need for support in a critical period, such as an acute episode or care transition. Intensive case management and team-based intensive services such as through Assertive Community Treatment are strongly encouraged but not required as a component of CCBHC services

	Based upon the needs of the population served, states should specify the scope of other CCBHC targeted case management services that will be required, and the specific populations for which they are intended.

### Criteria 4.I: Psychiatric Rehabilitation Services

4.i.1 The CCBHC is responsible for providing directly, or through a DCO, evidence-based rehabilitation services for both mental health and substance use disorders. Rehabilitative services include services and recovery supports that help individuals develop skills and functioning to facilitate community living; support positive social, emotional, and educational development; facilitate inclusion and integration; and support pursuit of their goals in the community. These skills are important to addressing social determinants of health and navigating the complexity of finding housing or employment, filling out paperwork, securing identification documents, developing social networks, negotiating with property owners or property managers, paying bills, and interacting with neighbors or co-workers.[footnoteRef:25] Psychiatric rehabilitation services must include supported employment programs designed to provide those receiving services with on-going support to obtain and maintain competitive, integrated employment (e.g., evidence-based supported employment, customized employment programs, or employment supports run in coordination with Vocational Rehabilitation or Career One-Stop services). Psychiatric rehabilitation services must also support people receiving services to: [25:  For more information, see Social Determinants of Health (SDOH) State Health Official (SHO) Letter (medicaid.gov)] 

· Participate in supported education and other educational services;

· Achieve social inclusion and community connectedness;

· Participate in medication education, self-management, and/or individual and family/caregiver psycho-education; and

· Find and maintain safe and stable housing.

Other psychiatric rehabilitation services that might be considered include training in personal care skills; community integration services; cognitive remediation; facilitated engagement in substance use disorder mutual help groups and community supports; assistance for navigating healthcare systems; and other recovery support services including Illness Management & Recovery, financial management, and dietary and wellness education. These services may be provided or enhanced by peer providers.

***Note:****See program requirement 3 regarding coordination of services and treatment planning.*

	CertifyingThe CCBHC is responsible for evidence-based and other psychiatric rehabilitation services. States should specify which evidence-based and other psychiatric rehabilitation services they will require based upon the needs of the population served above the minimum requirements described in 4.i. . Psychiatric rehabilitation services that might be considered include: medication education; self-management; training in personal care skills; individual and family/caregiver psycho-education; community integration services; recovery support services including Illness Management & Recovery; financial management; and dietary and wellness education. States also may wish to require the provision of supported services such as housing, employment, and education, the latter in collaboration with local school systems.

**Note:** See program requirement 3 regarding coordination of services and treatment planning.

### Criteria 4.J: Peer Supports, Peer Counseling, and Family/Caregiver Supports

4.j.1 The CCBHC is responsible for directly providing, or through a DCO, peer supports, including peer specialist and recovery coaches, peer counseling, and family/caregiver supports. Peer services may include: peer‐run wellness and recovery centers; youth/young adult peer support; recovery coaching; peer-run crisis respites[footnoteRef:26]; warmlines; peer-led crisis planning; peer navigators to assist individuals transitioning between different treatment programs and especially between different levels of care; mutual support and self-help groups; peer support for older adults; peer education and leadership development; and peer recovery services. Potential family/caregiver support services that might be considered include: community resources education; navigation support; behavioral health and crisis support; parent/caregiver training and education; and family-to-family caregiver support.’ [26:  For more information, see National Guidelines for Behavioral Health Crisis Care] 

***Note:****See program requirement 3 regarding coordination of services and treatment planning.*

*Certifying*The CCBHC is responsible for peer specialist and recovery coaches, peer counseling, and family/caregiver supports. States should specify the scope of peer and family services they will require based upon the needs of the population served. Peer services that might be considered include: peer‐run drop‐in centers, peer crisis support services, peer bridge services to assist individuals transitioning between residential or inpatient settings to the community, peer trauma support, peer support for older adults or youth, and other peer recovery services. Potential family/caregiver support services that might be considered include: family/caregiver psycho-education, parent training, and family-to-family/caregiver support services.

**Note:** See program requirement 3 regarding coordination of services and treatment planning.

### Criteria 4.K: Intensive, Community-Based Mental Health Care for Members of the Armed Forces and Veterans

4.k.1 The CCBHC is responsible for providing directly, or through a DCO, intensive, community-based behavioral health care for certain members of the U.S. Armed Forces and veterans, particularly those Armed Forces members located 50 miles or more (or one hour’s drive time) from a Military Treatment Facility (MTF) and veterans living 40 miles or more (driving distance) from a VA medical facility, or as otherwise required by federal law. Care provided to veterans is required to be consistent with minimum clinical mental health guidelines promulgated by the Veterans Health Administration (VHA), including clinical guidelines contained in the Uniform Mental Health Services Handbook of such Administration. The provisions of these criteria in general and, specifically, in criteria 4.K, are designed to assist the CCBHCCCBHCs in providing quality clinical behavioral health services consistent with the Uniform Mental Health Services Handbook.

**Note:** See program requirement 3 regarding coordination of services and treatment planning.

4.k.2 All individuals inquiring about services are asked whether they have ever served in the U.S. military.

Current Military Personnel: Persons affirming current military service will be offered assistance in the following manner:

1. Active Duty Service Members (ADSM) must use their servicing MTF, and their MTF Primary Care Managers (PCMs) are contacted by the CCBHC regarding referrals outside the MTF.

2. ADSMs and activated Reserve Component (Guard/Reserve) members who reside more than 50 miles (or one hour’s drive time) from a military hospital or military clinic enroll in TRICARE PRIME Remote and use the network PCM, or select any other authorized TRICARE provider as the PCM. The PCM refers the member to specialists for care he or she cannot provide; and works with the regional managed care support contractor for referrals/authorizations.

3. Members of the Selected Reserves, not on Active Duty (AD) orders, are eligible for TRICARE Reserve Select and can schedule an appointment with any TRICARE-authorized provider, network or non- network.

Veterans: Persons affirming former military service (veterans) are offered assistance to enroll in VHA for the delivery of health and behavioral health services. Veterans who decline or are ineligible for VHA services will be served by the CCBHC consistent with minimum clinical mental health guidelines promulgated by the VHA. These include, including clinical guidelines contained in the Uniform Mental Health Services Handbook as excerpted below (from VHA Handbook 1160.01, Principles of Care found in the Uniform Mental Health Services in VA Centers and Clinics).

**Note:** See also program requirement 3 requiring coordination of care across settings and providers, including facilities of the Department of Veterans Affairs.

4.k.3 The CCBHC ensuresIn keeping with the general criteria governing CCBHCs, CCBHCs ensure there is integration or coordination between the care of substance use disorders and other mental health conditions for those veterans who experience both, and for integration or coordination between care for behavioral health conditions and other components of health care for all veterans.

4.k.4 Every veteran seen for behavioral health services is assigned a Principal Behavioral Health Provider. When veterans are seeing more than one behavioral health provider and when they are involved in more than one program, the identity of the Principal Behavioral Health Provider is made clear to the veteran and identified in the healthmedical record. The Principal Behavioral Health Provider is identified on a consumer tracking database for those veterans who need case management. The Principal Behavioral Health Provider ensures the following requirements are fulfilled:

1. Regular contact is maintained with the veteran as clinically indicated ifas long as ongoing care is required.

2. A psychiatrist, or such other independent prescriber as satisfies the current requirements of the VHA Uniform Mental Health Services Handbook, reviews and reconciles each veteran’s psychiatric medications on a regular basis.

3. Coordination and development of the veteran’s treatment plan incorporates input from the veteran (and, when appropriate, the family with the veteran’s consent when the veteran possesses adequate decision-making capacity or with the veteran’s surrogate decision- maker’s consent when the veteran does not have adequate decision- making capacity).

4. Implementation of the treatment plan is monitored and documented. This must include tracking progress in the care delivered, the outcomes achieved, and the goals attained.

5. The treatment plan is revised, when necessary.[footnoteRef:27] [27:  These services must still meet the basic CCBHC requirements to review and update every 6 months in criterion 2.b.2 ] 

6. The principal therapist or Principal Behavioral Health Provider communicates with the veteran (and the veteran's authorized surrogate or family or friends when appropriate and when veterans with adequate decision-making capacity consent) about the treatment plan, and for addressing any of the veteran’s problems or concerns about their care. For veterans who are at high risk of losing decision- making capacity, such as those with a diagnosis of schizophrenia or schizoaffective disorder, such communications need to include discussions regarding future behavioral health care treatment (see information regarding Advance Care Planning Documents in VHA Handbook 1004.2).

7. The treatment plan reflects the veteran’s goals and preferences for care and that the veteran verbally consents to the treatment plan in accordance with VHA Handbook 1004.1, Informed Consent for Clinical Treatments and Procedures. If the Principal Behavioral Health Provider suspects the veteran lacks the capacity to make a decision about the mental health treatment plan, the provider must ensure the veteran’s decision-making capacity is formally assessed and documented. For veterans who are determined to lack capacity, the provider must identify the authorized surrogate and document the surrogate’s verbal consent to the treatment plan.

4.k.5 In keeping with the general criteria governing CCBHCs, behavioral health services are recovery-oriented. The VHA adopted the National Consensus Statement on Mental Health Recovery in its Uniform Mental Health Services Handbook. SAMHSA has since developed a working definition and set of principles for recovery updating the Consensus Statement. Recovery is defined as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” The following are the 10 guiding principles of recovery:

· Hope

· Person-driven

· Many pathways

· Holistic

· Peer support

· Relational

· Culture

· Addresses trauma

· Strengths/responsibility

· Respect[footnoteRef:28]  [28:  See SAMHSA’s Working Definition of Recovery.] 

(Substance Abuse and Mental Health Services Administration [2012]). As implemented in VHA recovery, the recovery principles also include the following:

· Privacy

· Security

· Honor

Care for veterans must conform to that definition and to those principles in order to satisfy the statutory requirement that care for veterans adheres to guidelines promulgated by the VHA.

4.k.6 In keeping with the general criteria governing CCBHCs, all behavioral health care is provided with cultural competence.

1. Any staff who is not a veteran has training about military and veterans’ culture in order to be able to understand the unique experiences and contributions of those who have served their country.

2. All staff receivereceives cultural competency training on issues of race, ethnicity, age, sexual orientation, and gender identity.

4.k.7 In keeping with the general criteria governing CCBHCs, there is a behavioral health treatment plan for all veterans receiving behavioral health services.

1. The treatment plan[footnoteRef:29] includes the veteran’s diagnosis or diagnoses and documents consideration of each type of evidence-based intervention for each diagnosis. [29:  If the treatment plan section of the electronic health record does not include fields for capturing diagnosis, it shall be captured in other areas of the electronic health record.] 

2. The treatment plan includes approaches to monitoring the outcomes (therapeutic benefits and adverse effects) of care, and milestones for reevaluation of interventions and of the plan itself.

3. As appropriate, the plan considers interventions intended to reduce/manage symptoms, improve functioning, and prevent relapses or recurrences of episodes of illness.

4. The plan is recovery oriented, attentive to the veteran’s values and preferences, and evidence-based regarding what constitutes effective and safe treatments.

5. The treatment plan is developed with input from the veteran, and, when the veteran consents, appropriate family members. The veteran’s verbal consent to the treatment plan is required pursuant to VHA Handbook 1004.1.

## Program Requirement 5: Quality and Other Reporting

### Criteria 5.A: Data Collection, Reporting, and Tracking

5.a.1 The CCBHC has the capacity to collect, report, and track encounter, outcome, and quality data, including, but not limited to, data capturing: (1) consumer characteristics of people receiving services; (2) staffing; (3) access to services; (4) use of services; (5) screening, prevention, and treatment; (6) care coordination; (7) other processes of care; (8) costs; and (9) consumer outcomes of people receiving services.. Data collection and reporting requirements are elaborated below and in Appendix B. Where feasible, information about people receiving services and care delivery should be captured electronically, using widely available standardsA.

***Note:****See criteria 3.b for requirements regarding health information systems.*

5.a.2 Both Section 223 Demonstration CCBHCs, and CCBHC-Es awarded SAMHSA discretionary CCBHC-Expansion grants beginning in 2022, must collect and report the Clinic-Collected quality measures identified as required in Appendix B. Reporting is annual and, for Clinic-Collected quality measures, reporting is required for all people receiving CCBHC services. CCBHCs are to report quality measures nine (9) months after the end of the measurement year as that term is defined in the technical specifications. Section 223 Demonstration CCBHCs report the data to their states and CCBHC-Es that are required to report quality measure data report it directly to SAMHSA.

	States participating in the Section 223 Demonstration must report State-Collected quality measures identified as required in Appendix B. The State-Collected measures are to be reported for all Medicaid enrollees in the CCBHCs, as further defined in the technical specifications. Certifying states also may require certified CCBHCs to collect and report any of the optional Clinic-Collected measures identified in Appendix B. Section 223 Demonstration program states must advise SAMHSA and its CCBHCs which, if any, of the listed optional measures it will require (either State-Collected or Clinic-Collected). Whether the measures are State- or Clinic-Collected, all must be reported to SAMHSA annually via a single submission from the state twelve (12) months after the end of the measurement year, as that term is defined in the technical specifications. 

States participating in the Section 223 Demonstration program are expected to share the results from the State-Collected measures with their Section 223 Demonstration program CCBHCs in a timely fashion. For this reason, Section 223 Demonstration program states may elect to calculate their State-Collected measures more frequently to share with their Section 223 Demonstration program CCBHCs, to facilitate quality improvement at the clinic level.

Quality measures to be reported for the Section 223 Demonstration program may relate to services individuals receive through DCOs.Reporting is annual and data are required to be reported for all CCBHC consumers, or where data constraints exist (for example, the measure is calculated from claims), for all Medicaid enrollees in the CCBHCs.

To the extent possible, these criteria assign to the state responsibility for data collection and reporting where access to data outside the CCBHC is required. Data to be collected and reported and quality measures to be reported, however, may relate to services CCBHC consumers receive through DCOs. Collection of some of the data and quality measures that are the responsibility of the CCBHC may require access to data from DCOs and it is the responsibility of the CCBHC to arrange for access to such data as legally permissible upon creation of the relationship with DCOs. CCBHCs should  and to ensure thatadequate consent is obtained and documented as appropriate, and that releases of information are obtained for each affected person. CCBHCs that are not part of the Section 223 Demonstration are not required to include data from DCOs into the quality measure data that they reportconsumer.

**Note:**CCBHCs may be required to report on quality measures through DCOs as a resultAs specified in Appendix A, some aspects of participating in a state CCBHC program separate from data reporting will be the Section 223 Demonstration, such as a program to support the CCBHC model throughresponsibility of the state, using Medicaid plan. 

5.a.3 	In addition to the State-claims and Clinic-Collected quality measures described above, Section 223 Demonstration program states may be requested to encounter data. States must provide CCBHC-identifiableCCHBC-level Medicaid claims or encounter data to the evaluators of the Section 223 this demonstration program annually for evaluation purposes. These data also must be submitted to CMS through T-MSIS in order to support the state’s claim for enhanced federal matching funds made available through the Section 223 Demonstration program.. At a minimum, Medicaid claimsconsumer and encounter data provided by the state to the national evaluation team, and to CMS through T-MSIS, service-level data should include a unique consumer identifier for each person receiving services, unique clinic identifier, date of service, CCBHC-covered service provided, units of service provided and diagnosis. Clinic site identifiers are very strongly preferred.

These data must be reported through MMIS/T-MSIS in order to support the state’s claim for enhanced federal matching funds made available through this demonstration program. For each consumer, the state must obtain and link the consumer level administrative Uniform Reporting System (URS) information to the claim (or be able to link by unique consumer identifier). CCBHC consumer claim or encounter data must be linkable to the consumer’s pharmacy claims or utilization information, inpatient and outpatient claims, and any other claims or encounter data necessary to report the measures identified in Appendix A. These linked claims or encounter data must also be made available to the evaluator. In addition to data specified in this program requirement and in Appendix BA that the Section 223 Demonstration state is to provide, the state will provide such other data, including Treatment Episode Data Set (TEDS) data and data from comparison settings, as may be required for the evaluation to HHS and the national evaluation contractor annually. To the extent CCBHCs participating in the Section 223 Demonstration program are responsible for the provision of data, the data will be provided to the state and, as may be required elsewhere, to HHS and the evaluator. CCBHC states are required to submit cost reports to CMS annually including years where the state’s rates are trended only and not rebased. CCBHCs participating in the Section 223 Demonstration program If requested, CCBHCs will participate in discussions with the national evaluation team and participate in other evaluation-related data collection activities as requested.

5.a.4 	CCBHCs participating in the Section 223 Demonstration programCCBHCs annually submit a cost report with supporting data within six months after the end of each Section 223 demonstration year to the state. The Section 223 Demonstration state will review the submission for completeness and submit the report and any additional clarifying information within nine months after the end of each Section 223 demonstration year to CMS.

**Note:** In order for a clinic *participating in the Section 223 Demonstration Program*to receive payment using the CCBHC PPS, it must be certified *by a Section 223 Demonstration state*as a CCBHC.

### Criteria 5.B: Continuous Quality Improvement (CQI) Plan

5.b.1 In order to maintain a continuous focus on quality improvement, The CCBHC develops, implements, and maintains an effective, CCBHC- wide data-driven continuous quality improvement (CQI) plan for theclinical services provided. The CCBHC establishes a critical review process to review CQI outcomes and implement changes to staffing, servicesclinical management. The CQI projects are clearly defined, implemented, and availability that will improve the qualityevaluated annually. The number and timelinessscope of services.distinct CQI projects conducted annually are based on the needs of the CCBHC’s population and reflect the scope, complexity and past performance of the CCBHC’s services and operations. The CCBHC-wide CQI plan addresses priorities for improved quality of care and client safety, and requires all improvement activities be evaluated for effectiveness. The CQI plan focuses on indicators related to improved behavioral and physical health outcomes, and takes actions to demonstrate improvement in CCBHC performance. The CQI plan should also focus on improved patterns of care delivery, such as reductions in emergency department use, rehospitalization, and repeated crisis episodes. The Medical Director is involved in the aspects of the CQI plan that apply toThe CCBHC documents each CQI project implemented, the reasons for the quality of projects, and the medical components of care, including coordination and integration with primary caremeasurable progress achieved by the projects. One or more individuals are designated as responsible for operating the CQI program.

5.b.2 Although the CQI plan is to be developed by the CCBHC and addresses how the CCBHC will review known significantreviewed and approved by the state during certification, specific events are expected to be addressed as part of the CQI plan, including, at a minimum: (1) deaths byCCBHC consumer suicide deaths or suicide attempts of people receiving services; (2) fatal and non-fatal overdoses; (3) all-cause mortality among people receiving CCBHC services; (4)CCBHC consumer 30 day hospital readmissions for psychiatric or substance use reasons; and (53) such other events the state or applicable accreditation bodies may deem appropriate for examination and remediation as part of a CQI plan.

5.b.3 The CQI plan is data-driven and the CCBHC considers use of quantitative and qualitative data in their CQI activities. At a minimum, the plan addresses the data resulting from the CCBHC-collected and, as applicable for the Section 223 Demonstration, State-Collected, quality measures that may be required as part of the Demonstration. The CQI plan includes an explicit focus on populations experiencing health disparities (including racial and ethnic groups and sexual and gender minorities) and addresses how the CCBHC will use disaggregated data from the quality measures and, as available, other data to track and improve outcomes for populations facing health disparities. 

## Program Requirement 6: Organizational Authority, Governance, and Accreditation

### Criteria 6.A: General Requirements of Organizational Authority and Finances

6.a.1 The CCBHC maintains documentation establishing the CCBHC conforms to at least one of the following statutorily established criteria:

· Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United States Internal Revenue Code;

· Is part of a local government behavioral health authority;

· Is operated under the authority of the Indian Health Service, an Indian tribe, or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 et seq.).);

· Is an urban Indian organization pursuant to a grant or contract with the Indian Health Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.).).

**Note:** A CCBHC is considered part of a local government behavioral health authority when a locality, county, region or state maintains authority to oversee behavioral health services at the local level and utilizes the clinic to provide those services.

6.a.2 To the extent CCBHCs are not operated under the authority of the Indian Health Service, an Indian tribe, or tribal or urban Indian organization, CCBHCs shallstates, based upon the population the prospective CCBHC may serve, should require CCBHCs to reach out to such entities within their geographic service area and enter into arrangements with those entities to assist in the provision of services to tribal membersAI/AN consumers and to inform the provision of services to tribal membersthose consumers. To the extent the CCBHC and such entities jointly provide services, the CCBHC and those collaborating entities shall, as a whole, satisfy the requirements of these criteria.

6.a.3 An independent financial audit is performed annually for the duration that the clinic is designated as a CCBHCof the demonstration in accordance with federal audit requirements, and, where indicated, a corrective action plan is submitted addressing all findings, questioned costs, reportable conditions, and material weakness cited in the Audit Report.

### Criteria 6.B: Governance

6.b.1 CCBHC governance must be informed by representativesAs a group, the CCBHC’s board members are representative of the individuals being served by the CCBHC in terms of demographic factors such as geographic area, race, ethnicity, sex, gender identity, disability, age, and sexual orientation, and in terms of health and behavioral health needs.types of disorders. The CCBHC will incorporate meaningful participation from individualsby adult consumers with lived experience of mental and/or illness, adults recovering from substance use disorders and their families, including youth. This participation is designed to assure that the perspectives of people receiving services, families, and people with lived experience of mental health and substance use conditions are integrated in leadership and decision-making. Meaningful participation means involving a substantial number of people with lived experience and family members of people receiving services or individuals with lived experience in developing initiatives; identifying community needs, goals, and objectives; providing input on service development and CQI processes; and budget development and fiscal decision making.[footnoteRef:30] CCBHCs reflect substantial participation by one of two options: [30:  For more information regarding meaningful participation, see Participation Guidelines for Individuals with Lived Experience and Family | SAMHSA] 

**Option 1:** At least fifty-one percent of the CCBHC governing board is comprised of individuals with lived experience of mental and/or substance use disorders and families.

**Option 2:** Other means are established to demonstrate meaningful participation in board governance involving people with lived experience (such as creating an advisory committee that reports to the board). The CCBHC provides staff support to the individuals involved in any alternate approach that are equivalent to the support given to the governing board.

Under option 2, individuals with lived experience of mental and/or substance use disorders, and family members of people receiving services must have representation in governance that assures input into:

1. Identifying community needs and goals and objectives of the CCBHC

2. Service development, quality improvement, and the activities of the CCBHC

3. Fiscal and budgetary decisions

4. Governance (human resource planning, leadership recruitment and selection, etc.) 

Under option 2, the governing board must establish protocols for incorporating inputCCBHC consumers, either through 51 percent of the board being families, consumers or people in recovery from individuals with lived experience and family behavioral health conditions, or through a substantial portion of the governing board members. Board meeting summaries are shared with those participating in the alternate arrangement and recommendations from the alternate arrangement shall be entered into the formal board record; a member or members of the arrangement established under option 2 must be invited to board meetings; and representatives of the alternate arrangement must have the opportunity to regularly address the board directly, share recommendations directly with the board, and have their comments and recommendations recorded in the board minutes. The CCBHC shall this criteria and other specifically described methods for consumers, people in recovery and family members to provide staff support for posting an annual summary of the recommendations from the alternate arrangement under option 2 on the CCBHC website. meaningful input to the board about the CCBHC’s policies, processes, and services.

6.b.2 If option 1 is chosen, The CCBHC mustwill describe how it meets this requirement, or providedevelop a transition plan with a timeline that indicates how it will do so.

If option 2 is chosen, for CCBHCs not certified by the state, the federal grant funding agency will determine if this approach is acceptable, and, if not, require additional mechanisms that are acceptable. The CCBHC must make available the results of timelines appropriate to its efforts in terms of outcomes and resulting changes.

	For certifying states, if option 2 is chosen then states will determine ifgoverning board size and target population to meet this approach is acceptable, and, if not, require additional mechanisms that are acceptable. The CCBHC must make available the results of its efforts in terms of outcomes and resulting changesrequirement.

6.b.3 To the extent the CCBHC is comprised of a governmental or tribal organization, entity or a subsidiary, or part of a larger corporate organization that cannot meet these requirements for board membership, the CCBHCstate will specify the reasons why itthe CCBHC cannot meet these requirements. and the CCBHC will have or develop an advisory structure and describe other specifically described methods for individuals with lived experience and familiesconsumers, persons in recovery, and family members to provide meaningful participation as defined in 6.b.1. input to the board about the CCBHC's policies, processes, and services.

6.b.4 As an alternative to the board membership requirement, any organization selected for this demonstration project may establish and implement other means of enhancing its governing body’s ability to insure that the CCBHC is responsive to the needs of its consumers, families, and communities. Efforts to insure responsiveness will focus on the full range of consumers, services provided, geographic areas covered, types of disorders, and levels of care provided. The state will determine if this alternative approach is acceptable and, if it is not, will require that additional or different mechanisms be established to assure that the board is responsive to the needs of CCBHC consumers and families. Each organization will make available the results of their efforts in terms of outcomes and resulting changes.Members of the governing or advisory boards will be representative of the communities in which the CCBHC's service area is located and will be selected for their expertise in health services, community affairs, local government, finance and accountingbanking, legal affairs, trade unions, faith communities, commercial and industrial concerns, or social service agencies within the communities served. No more than one half (50 percent) of the governing board members may derive more than 10 percent of their annual income from the health care industry.

6.b.5 States will determine what processes will be used to verify that these governance criteria are being met.

### Criteria 6.C: Accreditation

6.c.1 CCBHCs will adhere to any applicable state accreditation, certification, and/or licensing requirements.

6.c.2 The CCBHC enrolled as a Medicaid provider and licensed, certified, or accredited provider of both mental health and substance use disorder services including developmentally appropriate services to children, youth, and their families, unless there is a state or federal administrative, statutory, or regulatory framework that substantially prevents the CCBHC organization provider type from obtaining the necessary licensure, certification, or accreditation to provide these services. The CCBHC will adhere to any applicable state accreditation, certification, and/or licensing requirements. Further, the CCBHC is required to participate in SAMHSA Behavioral Health Treatment Locator.

6.c.3 CCBHCs must be certified by their state as a CCBHC or have submitted an attestation to SAMHSA as a part of participation in the SAMHSA CCBHC Expansion grant program. Clinics that have submitted an attestation to SAMHSA as a part of participation in the SAMHSA CCBHC Expansion grant program are designated as CCBHCs only during the period for which they are authorized to receive federal funding to provide CCBHC services. CCBHC expansion grant recipients are encouraged to seek state certification if they are in a state that certifies CCBHCs. 

	State-certified clinics are designated as CCBHCs for a period of time determined by the state but not longer than three years before recertification. States may decertify CCBHCs if they fail to meet the criteria, if there are changes in the state CCBHC program, or for other reasons identified by the state. Certifying states may use an independent accrediting body as a part of their certification process as long as it meets state standards for the certification process and assures adherence to the CCBHC Certification Criteria.

6.c.4 States are encouraged to require accreditation of the CCBHCs by an appropriate independent accrediting bodynationally-recognized organization (e.g., the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities [CARF], the Council on Accreditation [COA], the Accreditation Association for Ambulatory Health Care [AAAHC]). Accreditation does not mean “deemed” status.

## Appendix A. Terms and Definitions

Terms and Important terms used in these criteria are defined below. SAMHSA recognizes states may have existing definitions of the terms included in this appendix are meant to guide states, territories, tribes, and existing/potential CCBHCs to understand the intent of the CCBHC certification criteria. The terms andhere and these definitions are not intended to replacesupplant state definitions that areto the extent a state definition is more specific or areencompasses more broadly defined.  than the definition used here.

**Agreement:**As used in the context of care coordination, an agreement is an arrangement between the CCBHC and external entities with which care is coordinated. Such an agreement is evidenced by a contract, Memorandum of Agreement (MOA), or Memorandum of Understanding (MOU) with the other entity, or by a letter of support, letter of agreement, or letter of commitment from the other entity. The agreement describes the parties’ mutual expectations and responsibilities related to care coordination.

**Behavioral health:**Behavioral health is a general term that encompasses the promotion of emotional health; the prevention of mental illnesses and substance use disorders; and treatments and services for mental and/or substance use disorders.[footnoteRef:31]“used to refer to both mental health and substance use” (SAMHSA-HRSA [2015]). [31:  Available at Glossary of Terms and Acronyms for SAMHSA Grants | SAMHSA.] 

**Care coordination:**CCBHCs establish activities within their organizationThe Agency for Healthcare Research and with Quality (2014) defines care coordination partners that promote clear and timely communication, deliberate coordination, and seamless transition. This may include (but is not limited to): 

· Establishing accountability and agreeing on responsibilities betweenas “deliberately organizing consumer care coordination partners.

· Engaging and supporting people receiving services in and, subject to appropriate consent, their family and caregivers, to participate in care planning and delivery and ensuring that the supports and services that the person receiving services and family receive are provided in the most seamless manner that is practical.

· Communicating activities and sharing knowledge and information, including the transfer among all of health records and prescriptions, withinthe participants concerned with a consumer’s care to achieve safer and more effective care teams and other care coordination partners, as allowable and agreed upon with the individual being served.  

· Coordinating and supporting transitions of care that include tracking of admission and discharge and coordination of specific services if the person receiving services presents as a potential suicide or overdose risk.   

· Assessment of the person receiving services needs and goals to create a proactive treatment plan and linkage to community resources. 

· Monitoring and follow-up, including adapting supports and treatment plans as needed to respond to changes in the. This means the patient’s needs and preferences are known ahead of individuals being served.

· Coordinating directly with external providers for appointment schedulingtime and follow up after appointment for any prescription changes or care needs, ‘closingcommunicated at the loop.’

· Communicatingright time to the right people, and sharing knowledge andthat this information to the full extent permissible under HIPAA, 42 CFR part 2, and ONC and CMS interoperability regulations on information blocking without additional requirements unless based on state law. 

is used to provide safe, appropriate, and effective care to the patient.” As used here, care coordinationthe term applies to activities by CCBHCs that have the purpose of coordinating and managing the care and services furnished to each person receiving servicesconsumer as required by PAMA (including both behavioral and physical health care), regardless of whether the care and services are provided directly by the CCBHC or through referral or other affiliation with care providers and facilities outside the CCBHC. Care coordination is regarded as an activity rather than a service.

**Case management:**Case management may be defined in many ways and can encompass services ranging from basic to intensive. The National Association of State Mental Health Program Directors (NASMHPD) defines case management as “a range of services provided to assist and support individuals in developing their skills to gain access to needed medical, behavioral health, housing, employment, social, educational and other services essential to meeting basic human services; linkages and training for patient served in the use of basic community resources; and monitoring of overall service delivery”.[footnoteRef:32]” (NASMHPD [2014]). See also the definition of “targeted case management.” [32:  NASMHPD. The Role of Supportive Housing, Case Management, and Employment Services in Reducing the Risk of Behavioral Health Crisis. 2022. Accessible at The Role of Supportive Housing, Case Management, and Employment Services in Reducing the Risk of Behavioral Health Crisis (nasmhpd.org).] 

**Certified Community Behavioral Health Clinic****(CCBHC) or Clinic:**A CCBHC is a qualifying clinic that is responsible for providing all nine services in a manner that meets or exceeds CCBHC criteria described herein. The qualifying clinic may deliver the nine required services directly or through formal agreements with DCOs. The CCBHC must have the capacity to directly provide mental health and substance use services to people with serious mental illness and serious emotional disorders as well as developmentally appropriate mental health and substance use care for children and youth separate from any DCO relationship, unless substantially prohibited by their state because of their provider type.  

A qualifying clinic must be one of the following: a nonprofit organization; part of a local government behavioral health authority; an entity operated under authority of the IHS, an Indian tribe, or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the IHS pursuant to the Indian Self-Determination Act; or an entity that is an urban Indian organization pursuant to a grant or contract with the IHS under Title V of the Indian Health Care Improvement Act (PL 94-437). CCBHC and Clinic are used interchangeably to refer to Certified Community Behavioral Health Clinics.

CCBHCs must be  as certified by their state as a CCBHC or have submitted an attestation to SAMHSA as a part of participation in the SAMHSA CCBHC Expansion grant program. State-certified clinics are designated as CCBHCs for a period of time determined by the state but not longer than three years. CCBHCs must be recertified or submit a new attestation every three years. States may decertify CCBHCs if they fail to meet the criteria, if there are changes in the state CCBHC program, or for other reasons identified by the statestates in accordance with these criteria and with the requirements of PAMA. A CCBHC may offer services in different locations. For multi-site organizations, however, only clinics eligible pursuant to these criteria and PAMA may be certified as CCBHCs.

**CCBHC directly provides:**When the term, “CCBHC directly provides” is used within these criteria, it means employees or contract employees within the management structure and, under the direct supervision of the CCBHC, deliver the service.

**Consumer:**Within this document, the term “consumer” refers to clients, persons being treated for or in recovery from mental and/or substance use disorders, persons with lived experience, service recipients and patients, all used interchangeably to refer to persons of all ages (i.e., children, adolescents, transition aged youth, adults, and geriatric populations) for whom health care services, including behavioral health services, are provided by CCBHCs. Use of the term “patient” is restricted to areas where the statutory or other language is being quoted. 

**Community Needs Assessment:**A systematic approach to identifying community needs and determining program capacity to address the needs of the population being served. CCBHCs will conduct or collaborate with other community stakeholders to conduct a community needs assessment. The assessment should identify current conditions and desired services or outcomes in the community, based on data and input from key community stakeholders. Specific CCBHC criteria are tied to the community needs assessment including staffing, language and culture, services, locations, service hours and evidence- based practices. Therefore, the community needs assessment must be thorough and reflect the treatment and recovery needs of those who reside in the service area across the lifespan including children, youth, and families. If a separate community needs assessment has been completed in the past year, the CCBHC may decide to augment, or build upon the information to ensure that the required components of the community needs assessment are collected. 

The community needs assessment is comprised of the following elements: 	

1. A description of the physical boundaries and size of the service area, including identification of sites where services are delivered by the CCBHC, including through DCOs.

2. Information about the prevalence of mental health and substance use conditions and related needs in the service area, such as rates of suicide and overdose.

3. Economic factors and social determinants of health affecting the population's access to health services, such as percentage of the population with incomes below the poverty level, access to transportation, nutrition, and stable housing. 

4. Cultures and languages of the populations residing in the service area.

5. The identification of the underserved population(s) within the service area.

6. A description of how the staffing plan does and/or will address findings.

7. Plans to update the community needs assessment every 3 years.

8. Input with regard to:

· cultural, linguistic, physical health, and behavioral health treatment needs; 

· evidence-based practices and behavioral health crisis services; 

· access and availability of CCBHC services including days, times, and locations, and telehealth options; and 

· potential barriers to care such as geographic barriers, transportation challenges, economic hardship, lack of culturally responsive services, and workforce shortages.  

Input should come from the following entities if they are in the CCBHC service area: 

· People with lived experience of mental and substance use conditions and individuals who have received/are receiving services from the clinic conducting the needs assessment; 

· Health centers (including FQHCs in the service area); 

· Local health departments (Note: these departments also develop community needs assessments that may be helpful); 

· Inpatient psychiatric facilities, inpatient acute care hospitals and hospital outpatient clinics; 

· One or more Department of Veterans Affairs facilities; and

· Representatives from local K-12 school systems.

CCBHCs must engage also with other community partners, especially those who also work with people receiving services from the CCBHC and populations that historically are not engaging with health services, such as: 

· Organizations operated by people with lived experience of mental health and substance use conditions; 

· Residential programs; 

· Juvenile justice agencies and facilities; 

· Criminal justice agencies and facilities; 

· Indian Health Service or other tribal programs such as Indian Health Service youth regional treatment centers as applicable; 

· Child welfare agencies and state licensed and nationally accredited child placing agencies for therapeutic foster care service; and 

· Crisis response partners such as hospital emergency departments, crisis stabilization settings, crisis call centers and warmlines.

· Specialty providers of medications for treatment of opioid and alcohol use disorders;

· Peer-run and operated service providers; 

· Homeless shelters and  housing agencies; 

· Employment services systems; 

· Services for older adults, such as Area Agencies on Aging;

· Aging and Disability Resource Centers; and 

· Other social and human services (e.g., domestic violence centers, pastoral services, grief counseling, Affordable Care Act navigators, food and transportation programs).

**Cultural and linguistic competence:** Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.Elsewhere, the word “consumer” is used.

**Cultural and linguistic competence:**Culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse consumers.[footnoteRef:33] (Office of Minority Health [2014]). [33:  Office of Minority Health. Cultural and Linguistic Competency. Rockville, MD: U.S. Department of Health and Human Services, December 12, 2014. Available at: Cultural Competency - The Office of Minority Health (hhs.gov).] 

**Designated Collaborating Organization (DCO):**A DCO is an entity that is not under the direct supervision of the CCBHC but is engaged in a formal relationship with the CCBHC to deliver one or more (or elements of) of the required services as described in criteria 4. CCBHC services provided through a DCO must conform to the relevant applicable CCBHC criteria. The formal relationship is evidenced by a contract, Memorandum of Agreement (MOA), Memorandum of Understanding (MOU), or such other formal, legal arrangements describing the parties’ mutual expectations and establishing accountability for services to be provided and funding to be sought and utilized. The formal relationship between CCBHCs and DCOs creates the platform for seamlessly integrated services delivered across providers under the umbrella of a CCBHC. DCO agreements shall include provisions that assure that the required CCBHC services that DCOs provide under the CCBHC umbrella are delivered in a manner that meets the standards set in the CCBHC certification criteria. To this end, DCOs are more than care coordination or referral partners, and there is an expectation that relationships with DCOs will include more regular, intensive collaboration across organizations than would take place with other types of care coordination partners. 

From the perspective of the person receiving services and their family members, services received through a DCO should be part of a coordinated package with other CCBHC services and not simply accessing services through another provider organization. To this end, the DCO agreement shall take active steps to reduce administrative burden on people receiving services and their family members when accessing DCOs services through measures such as coordinating intake process, coordinated treatment planning, information sharing, and direct communication between the CCBHC and DCO to prevent the person receiving services or their family from having to relay information between the CCBHC and DCO. CCBHCs and their DCOs are further directed to work towards inclusion of additional integrated care elements (e.g., including DCO providers on CCBHC treatment teams, collocating services). Regardless of DCO relationships entered into, the CCBHC maintains responsibility for assuring that people receiving services from the CCBHC receive all nine services as needed in a manner that meets the requirements of the CCBHC certification criteria. 

In the Section 223 CCBHC Demonstration,and delivers services under the same requirements as the CCBHC. Payment for DCO services is included within the scope of the CCBHC PPS, and DCO encounters will be treated as CCBHC encounters for purposes of the PPS. The CCBHC maintains clinical responsibility for the services provided for CCBHC consumers by the DCO. To the extent that services are needed by a person receiving services or their familyrequired that cannot be provided by either the CCBHC directly or by a DCO, referrals may be made to other providers or entities. The CCBHC retains responsibility for care coordination including services to which it refers consumers. Payment for those referred services is not through the PPS but is made through traditional mechanisms within Medicaid or other funding sources.

**Engagement:**Engagement includes a set of activities connecting people receiving servicesconsumers with needed services and supporting their retention services.. This involves the process of making sure people receiving services consumers and families are informed about and are able toinitiate access needed serviceswith available services and, once services are offered or received, individuals and families make active decisions to continue receipt of the services provided. Activities such as outreach and education can serve the objective of engagement. Conditions such as accessibility, provider responsiveness, availability of culturally and linguistically competent care, and the provision of quality care, also promote consumer person receiving services engagement.

**Family:**Involvement of Families of both adultsadult and children receiving services ischild consumers are important to components of treatment planning, treatment, and recovery. Families come in different forms and, to the extent possible, the CCBHC should respect the individual consumer’s view of what constitutes their family. Families can be organized in a wide variety of configurations regardless of social or economic status. Families can include biological parents and their partners, adoptive parents and their partners, foster parents and their partners, grandparents and their partners, siblings and their partners, extended family members, care givers, friends, and others as defined by the family. The CCBHC respects the view of what constitutes the family of the individual person receiving services.

**Family-centered:**The Health Resources and Services Administration defines family- centered care, sometimes referred to as “family-focused care,” as “an approach to the planning, delivery, and evaluation of health care whose cornerstone is active participation between families and professionals. Family-centered care recognizes families are the ultimate decision-makers for their children, with children gradually taking on more and more of this decision-making themselves as developmentally appropriate.. When care is family-centered, services not only meet the physical, emotional, developmental, and social needs of children, but also support the family’s relationship with the child’s health care providers and recognize the family’s customs and values”.[footnoteRef:34]” (Health Resources and Services Administration [2004]). More recently, this concept was broadened to explicitly recognize that family-centered services should beare both developmentally appropriate and youth guided.[footnoteRef:35] (American Academy of Child & Adolescent Psychiatry [2009]). Family-centered care is *family-driven*and *youth-driven*. [34:  Health Resources and Services Administration, Maternal and Child Health Bureau. The National Survey of Children with Special Health Care Needs Chartbook 2001. Rockville, Maryland: U.S. Department of Health and Human Services, 2004. Available at Chartbooks | MCHB (hrsa.gov). ]  [35:  American Academy of Child & Adolescent Psychiatry. Family and Youth Participation in Clinical Decision-Making. Washington, D.C., October 2009. Available at Family and Youth Participation in Clinical Decision-Making (aacap.org).] 

**Formal relationships:**As used in the context of scope of services and the relationships between the CCBHC and DCOs, a formal relationship is evidenced by a contract, Memorandum of Agreement (MOA), Memorandum of Understanding (MOU), or such other formal arrangements describing the parties’ mutual expectations and establishing accountability for services to be provided and funding to be sought and utilized. This formal relationship does not extend to referrals for services outside either the CCBHC or DCO, which are not encompassed within the reimbursement provided by the PPS.

**Limited English Proficiency (LEP):**LEP describes a characteristic ofincludes individuals who do not speak English as their primary language or who have a limited ability to read, write, speak, or understand English and who may be eligible to receive language assistance with respect to the particular service, benefit, or encounter.

**Lived Experience:** People with lived experience are individuals directly impacted by a social issue or combination of issues who share similar experiences or backgrounds and can bring the insights of their experience to inform and enhance systems, research, policies, practices, and programs that aim to address the issue(s). Because CCBHCs are designed to serve people with mental disorders, adults with serious mental illness, children with serious emotional disturbance and their families, and individuals with substance use disorders, individuals with lived experiences provide valuable insight to improving the delivery of CCBHC services. 

**Measurement-Based Care:**For purposes of these criteria, measurement-based care (MBC) is the use of patient-reported information to inform clinical care and shared decision-making among clinicians and patients and to individualize ongoing treatment plans.

**Peer/Family/Caregiver SupportPeer Support Services:**Peer support services are services designed and delivered by individuals who have experienced a mental or substance use disorder and are in recovery. This also includes services designed and delivered by family members of those in recovery.

**Peer Support Specialist:**A peer support provider (e.g., peer support specialist, recovery coach) is a person who uses their lived experience of recovery from mental or substance use disorders or as a family member/caregiver of such a person, plus skills learned in formal training, to deliver services in behavioral health settings to promote recovery and resiliency. Peer providers may have titles that may differ from state to state, e.g., certified peer specialist, peer support specialist, recovery coach, family partner, parent partner specialist. In states where Peer Support Services are covered through the state Medicaid Plans, the title of “certified peer specialist” often is used. SAMHSA recognizes states use different terminology for these providers. Peer support may be provided in behavioral health, health, and community settings, e.g., mobile crisis outreach, psychiatric rehabilitation, outpatient mental health/substance use treatment, emergency rooms, wellness programs, peer-operated programs.

**Person or People Receiving Services:** Within this document, person or people receiving services refers to people of all ages (i.e., children, adolescents, transition age youth, adults, and older adults) who are receiving one of the nine required services from the CCBHC (including through any DCO arrangements). Use of the term “patient” is restricted to areas where the statutory or other language is being quoted. In many places in the Certification Criteria, the person receiving services has a role in directing, expressing preferences, planning, and coordinating services. In these situations, when there is a legal guardian for the person receiving services, these roles shall also be filled by the legal guardian.

**Person-centered care:**Person-centered care is aligned with the requirements of Section 2402(a) of the Patient Protection and Affordable Care Act, as implemented by the Department of Health & Human Services Guidance to HHS Agencies for Implementing Principles of Section 2403(a) of the Affordable Care Act: Standards for Person-Centered Planning and Self-Direction in Home and Community-Based Services Programs.[footnoteRef:36] (Department of Health & Human Services [June 6, 2014]). That guidance defines “person-centered planning” as a process directed by the person with service needs which identifies recovery goals, objectives and strategies. If the person receiving servicesconsumer wishes, this process may include a representative whom the person has freely chosen, or who is otherwise authorized to make personal or health decisions for the person. Person-centered planning also includes family members, legal guardians, friends, caregivers, and others whom the person wishes to include. Person-centered planning involves the person receiving servicesconsumer to the maximum extent possible. Person-centered planning also involves self- direction, which means the person receiving servicesconsumer has control over selecting and using services and supports, including control over the amount, duration, and scope of services and supports, as well as choice of providers.[footnoteRef:37] (Department of Health & Human Services [June 6, 2014]). [36:  Department of Health & Human Services. Guidance to HHS Agencies for Implementing Principles of Section 2403(a) of the Affordable Care Act: Standards for Person Centered Planning and Self-Direction in Home and Community-Based Services Programs (June 6, 2014). Available at: Implementing Standards for Person-Centered Planning and Self-Direction in Home and Community-Based Services Programs | Guidance Portal (hhs.gov).]  [37:  Ibid.] 

**Practitioner or Provider:**Any individual (practitioner) or entity (provider) engaged in the delivery of health care services and who is legally authorized to do so by the state in which the individual or entity delivers the services (42 CFR § 400.203).

**Recovery:**Recovery is defined as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” The 10 guiding principles of recovery are: hope; person- driven; many pathways; holistic; peer support; relational; culture; addresses trauma; strengths/responsibility; and respect. Recovery includes: Health (“(abstinence, ”making informed healthy choices that support physical and emotional wellbeing”); Home (safe, stable housing); Purpose (“meaningful daily activities ... and the independence, income and resources to participate in society”); and Community (“relationships and social networks that provide support, friendship, love, and hope”).[footnoteRef:38]”) (Substance Abuse and Mental Health Services Administration [2012]). [38:  Substance Abuse and Mental Health Services Administration. SAMHSA’s Working Definition of Recovery. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Available at: SAMHSA's Working Definition of Recovery | SAMHSA Publications and Digital Products.] 

**Recovery-oriented care:**Recovery-oriented care is oriented toward promoting and sustaining a person's recovery from a behavioral health condition. Care providers identify and build upon each individual’s assets, strengths, and areas of health and competence to support the person in managing their condition while regaining a meaningful, constructive sense of membership in the broader community. (Substance Abuse and Mental Health Services Administration [2015]).

**Required services:**The nine service areas identified in PAMA, which CCBHCs must provide to people receiving services based on their needs (described in Program Requirement 4: Scope of Services), 1. Crisis Services; 2. Screening, Assessment, and Diagnosis; 3. Person-Centered and Family-Centered Treatment Planning; 4. Outpatient Mental Health and Substance Use Services; 5. Primary Care Screening and Monitoring; 6. Targeted Case Management Services; 7. Psychiatric Rehabilitation Services; 8. Peer Supports and Family/Caregiver Supports; and 9. Community Care for Uniformed Service Members and Veterans.

**Satellite Facility:** A satellite facility of a CCBHC is a facility that was established by the CCBHC, operated under the governance and financial control of that CCBHC, and provides the following services: crisis services; screening, diagnosis, and risk assessment; person and family centered treatment planning; and outpatient mental health and substance use services as specified in CCBHC certification criteria Program Requirement 4. For CCBHCs participating in the Section 223 Demonstration only, the Protecting Access to Medicare Act of 2014 stipulates that “no payment shall be made to a satellite facility of a CCBHC established after April 1, 2014, under this Demonstration.” This definition does not limit the provision of services in non-clinic settings such as shelters and schools or at other locations managed by the CCBHC that do not meet the definition of a satellite facility.  

**Shared Decision-Making (SDM):** Shared decision-making is a best practice in behavioral and physical health that aims to help people in treatment and recovery have informed, meaningful, and collaborative discussions with providers about their health care services. It involves tools and resources that offer objective information upon which people in treatment and recovery incorporate their personal preferences and values. Shared decision-making tools empower people who are seeking treatment or in recovery to work together with their service providers and be active in their own treatment.[footnoteRef:39] [39:  Substance Abuse and Mental Health Services Administration. Shared Decision-Making Tools. Available at: Shared Decision-Making Tools | SAMHSA.] 

**Shared Decision-Making (SDM):**SDM is an approach to care through which providers and consumers of health care come together as collaborators in determining the course of care. Key characteristics include having the health care provider, consumer, and sometimes family members and friends acting together, including taking steps in sharing a treatment decision, sharing, information about treatment options, and arriving at consensus regarding preferred treatment options (Schauer, Everett, delVecchio, & Anderson [2007]).

**Targeted case management:**Targeted case management is case management, as defined above, directed at specific groups, which may vary by state. CMS defines targeted case management as case management furnished without regard to requirements of statewide provision of service or comparability that typically apply for Medicaid reimbursement. 42 CFR § 440.169(b). Examples of groups that might be targeted for case management are children with serious emotional disturbance, adults with serious mental and/or substance use disorders, pregnant women who meet risk criteria, individuals with HIV, and such other groups as a state might identify as in need of targeted case management. See also the definition of “case management.”

**Trauma-informed:**A trauma-informed approach to care “*realizes*the widespread impact of trauma and understands potential paths for recovery; *recognizes*the signs and symptoms of trauma in people receiving services, theirclients, families, staff, and others involved in the system; and *responds*by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively *resist re- traumatization*.*.*” The six key principles of a trauma-informed approach include: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice; and cultural, historical and gender issues.[footnoteRef:40] (Substance Abuse and Mental Health Services Administration [2014]). [40:  Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Available at: SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach | SAMHSA Publications and Digital Products.] 

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