What are CCBHCs

Certified Community Behavioral Health Clinics (CCBHCs) are government funded facilities to provider mental health care to vulnerable populations including those requiring care on an immediate basis and individuals who are unable to pay for medical care. Federal funding on them focuses on acute crises such as Substance Used Disorder, while state level funding such as Medicaid may use them as a primary source of care for mental health emergencies for those who otherwise couldn’t cover mental health care costs.

CCBHCs take a larger role than community mental health centers in the medical aspect of behavioral health care and have the availability to access significantly more federal funding. As a result, they’re subject to more federal oversight and have a greater focus on services; for example, they are required to provide veterans with services, not just on an emergency basis.

CCBHCs were created with four primary goals in mind:

1. Creating affordable mental health care centers to meet demand: prior to the development of CCBHCs there were not always state funded facilities that could provide mental healthcare for those who were experiencing behavioral health issues. By federalizing the Community Mental Health Center model, the funding availability became more stable (federal budgets as opposed to state budgets) and the resources available increased.
2. Reduce ED visits: as mental health awareness has grown, so too has the recognition of mental health problems as actual health issues. Unfortunately, without immediate recognition, the problems can become acute. With previous shortages of initial outpatient care, and a general shortage of psychiatrists and other behavioral health providers such as nurse practitioners and physicians assistants, there was nowhere for those seeking immediate care to go except an Emergency Department. Unfortunately, Emergency Room doctors were not specialists in mental health care, and the inability to provide immediate treatment led to a situation where boarding (admitting the patient pending further treatment) became a liability, as resources were finite.
3. View behavioral health as part of regular healthcare: by adding these as “mental health emergency rooms”, care provided by primary care providers or other doctors treating traditional illnesses can be combined with behavioral health care. If a patient is lower income they can see the same group who are using the same electronic health record, ensuring continuity of care. If it’s a patient seeing different medical groups, the integrated behavioral health aspect can be an electronic exchange of notes. Additionally, recent advances in treatment such as the Collaborative Care Model take this a step further by including care coordinators.
4. Make sure treatment is standardized and evidence based: often treatment outcomes and steps taken have become siloed between various clinics and states. Advancements often come out of an academic setting, and the efficacy of actual treatment can be unknown. By administering standardized tests, treatments, and monitoring patient progress the field of mental health can be better measured to make sure investments are better spent.

The idea behind CCBHCs is very useful for mental health, but misses one big question – where are the providers going to be hired from?

What Are the Barriers to Behavioral Health at CCBHCs

Mental health faces a shortage of providers, with it being the oldest average age per practitioner leading to an expectation of a retirement crisis, and a flat number of residencies in the field. In order to increase mental health care, many states have added more autonomy to psychiatric nurse practitioners, physicians’ assistants, and even psychologists in some cases to make or recommend medication prescriptions. Care models have integrated more administrative staff to ensure that patients are able to find doctors and show up to appointments in an attempt to increase utilization.

Despite these steps, an aging population and an increase in mental health awareness has created a demand for mental health care that outweighs resources. Even with the CCBHC model, the care can’t be provided if no behavioral health care providers are available.

While a staffing increase may be possible in some areas, it’s important to remember that there are multiple issues with hiring at CCBHCs:

1. A Diverse and Acute Set of Mental Health Issues: Functioning as both an emergency mental health facility and one funded by Medicaid, the payor of last resort, the facilities are open to anyone in a mental health crisis. While most mental health providers have specialty populations they work with, such as adolescent psychiatrists or addiction psychiatrists, a mental health professional at a CCBHC will need to deal with clients that may be outside their normal field of comfort.
2. Expensive Onboarding and Low Overhead: Hiring for CCBHCs and other community mental health facilities can be expensive, as it’s often more difficult to fill these positions than private practices, which can often pay more and exist in a less stressful environment. High recruiting costs combine with significant costs for turnover: if a provider finds it’s not a good fit, there are still onboarding costs, benefits, recruitment costs, and tail costs that the facility may be responsible for paying.
3. Difficulty in Matching Salaries: With the shortage in mental health providers and increasing demand, many providers can form their own clinics or telemedicine services and take cash only payments directly from patients. While regulations for telemedicine can change and still reflect pandemic era waivers, there has been an over 90% adoption rate by psychiatrist and psychiatric nurse practitioners for appointments with patients. Additionally temporary staffing, referred to as locum tenens, can find themselves to be both high paying and providing lodging for medical providers.
4. Difficulty in Utilization: Many CCBHC groups have multiple locations and serve populations in multiple locations that may not be convenient for travel for a provider. However, having a different provider for each location can lead to low utilization, resulting in unbillable time while the doctor or nurse practitioner still must be paid. CCBHC locations do not operate with high income overhead, so paying a provider to not work doesn’t make sense, but at the same time there needs to be provider availability for walk ins.

How can Telepsychiatry Work with CCBHC Facilities

Given their missions and the issues faced by CCBHCs, it becomes important for administrators to attempt to “think outside of the box” and find new ways to provide service. Telepsychiatry, or providing psychiatry over two-way video conference between a mental health professional and a patient, is a technology that first came into use in the mid-2000s for specific projects such as ACT teams, but as videoconferencing technology and medical regulations moved forward the service became more common.

The COVID pandemic put telemedicine into the mainstream for all specialties. While many specialties used telemedicine during the pandemic, many fields found that it wasn’t as good as in person treatment. Surveys for psychiatry have found them to have similar results and patient satisfaction, and doctors and nurse practitioners are still working under pandemic era regulations, resulting in 90% of mental health providers still using telemedicine.

Telemedicine is often looked at as only a direct-to-consumer product, but CCBHC telepsychiatry is a treatment modality that overcomes most issues while still providing high quality care. Telepsychiatry can be used to contract specialist psychiatrists without needing them to work full time at one location or even just use them as contractors in either hourly blocks or a fee for service model. Psychiatrists and psychiatric nurse practitioners can be on call 24×7 to reach patients for triage and begin working for treatment. This can either be used for the full treatment including virtual rounding or it can be integrated into a hybrid telemedicine environment.

Telepsychiatry is much more open to contract models, especially through outsource providers. While CCBHC telepsychiatry can include a technical setup and continuing to hire providers, the use of an outside staffing model can move to assisted setup, ongoing support, and bring in providers on a contract basis. This contract prevents the need for benefit and recruiting costs, and the use of a provider over telemedicine means they can cover multiple locations just by switching calls. An outside contracted staffing agency can cover every issue with employment and even run a telepsychiatry on demand service, but it’s important to do research into the service being used.

How Outsourcing Works for CCBHC

With the difficulty in creating a new telepsychiatry program from scratch internally, there are many instances of CCBHC telepsychiatry being outsourced to groups that specialize in the needs of these facilities, such as FasPsych. An external group can bill either in hourly blocks, a fee for service model with a normal schedule, or an on-demand service model that only works when on call. Once a vendor is picked, they will typically meet with site administration and medical leadership to see how to integrate outsourced telemedicine service with existing processes. Often the outside providers will use existing electronic health records and have email addresses on the CCBHC network, ensuring a patient and provider experience that is white glove to everyone involved.

One thing to make sure of is that the goals of a telepsychiatry staffing vendor meet what the goals of the CCBHC are, whether it’s seeing as many patients as possible or meet state mandated standards; additionally, telepsychiatry can support unique treatment plans such as a Collaborative Care Model for individuals being treated or Medication-assisted treatment for substance use disorders. Telepsychiatry allows a clinic to use multiple specialists, so a different nurse practitioner can see one specialty while a psychiatrist sees another. Since there’s no one physically coming on site, the only limitation is what your vendor has available.

Next Steps for CCBHC Decision Makers

Once a CCBHC has decided to go with telepsychiatry, the first decision to make is whether they will handle it in-house or outsource the project. The use of in-house resources still has many of the downsides of on-site staffing and creates an additional headache of having to create an infrastructure and policies from scratch. If an outsourced model is used, leadership needs to make sure that all onsite staff are on board and make sure that they’re ready to bring in offsite staff to the team.

CCBHC telepsychiatry is the future of providing coverage as the resource limitations continue to hamper the availability of mental health care while the clinics have to provide care; if a clinic doesn’t start organizing now, it’s going to get left behind in the provider shortage.

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