CCBHC RFI Webinar 5/20/2016 - Part 2

Care Coordination for Certified Community Behavioral Health Clinics (CCBHCs)

Lee Ann Reinert, LCSW

Clinical Policy Specialist

Division of Mental Health

Case Management vs. Care Coordination

  • Case management is a service
    • Helping an individual gain access to needed supports and services
    • Rule 132 service/DASA contracts
  • Care coordination is an activity
    • Involves agreements with other providers
    • Entails tracking and follow-up

The case for needing Care Coordination:

  • High rates of medical errors.
  • Serious unmet needs.
  • Poor satisfaction with care.
  • High rates of preventable readmissions.

This has resulted in significant cost burden, but more importantly, there is a human cost involved.

CCBHCs are responsible for Care Coordination

  • Organize care activities among different services and providers, and across various facilities.
  • This deliberate organization of care also requires sharing information among all of the participants concerned with a consumer's care to achieve safer and more effective care.

In order to effectively coordinate care

  • The individual's needs and preferences must be known ahead of time.
  • These must be communicated at the right time to the right people.
  • This information can then be used to provide safe, appropriate and effective care to the individual.

Who is Involved?

  • FQHCs and rural health clinics
    • Inpatient Services
    • psychiatric hospitals
    • detoxification services
    • post-detoxification step-down services
    • residential programs
    • acute care hospitals
    • hospital outpatient clinics
  • Schools
  • DCFS contracted providers
  •  Juvenile justice
  • Criminal justice
  • Department of Veterans Affairs
    • (VA) medical centers
    • independent outpatient clinics
    • drop-in centers
    • other VA facilities.
  • Other social and human services

Care Coordination Agreements and Care Transitions

  • Ensure quality care.
  • Establish protocols for supporting effective care transitions.
  • Agreements:
    • Orderly
    • Promote the highest quality of care possible.

Redesign of a health care system…

  • Current systems are often disjointed and processes vary among and between primary care and specialty care sites.
  • Individuals are often unclear about why they are being referred from primary care to a specialist, how to make appointments and what to do after seeing a specialist.
  • Specialists do not consistently receive clear reasons for the referral or adequate information on tests that have already been done.
  • Primary care physicians do not often receive information about what happened in a referral visit.
  • Referral staff deal with many different processes and lost information, which means that care is less efficient.

Effective Care Coordination Requires Systems To:

  • Transfer medical records of services received from those providers, including prescriptions.
  • Track admission and discharge.
  • Actively follow-up after discharge.
  • Coordinate specific services determined by specific risks (e.g. a potential suicide risk).

Specific Care Coordination Activities…

  • Establish accountability and agreement on who maintains responsibility.
  • Engage each person you're working with (and their family, when appropriate) in the development of a care plan that reflects their own health care needs and priorities.
  • Ensure that the person and his/her team understands their role in the plan and feels equipped to fulfill responsibilities.
  • Identify barriers that affect the person's ability to adhere to treatment.
  • Assemble the appropriate team of health care professionals and team members.
  • Assist the individual in navigating the network of providers.
  • Ensure the individual's electronic health record reflects up-to-date information and is accessible to all care team members.
  • Facilitate appropriate and timely communication between care team members.
  • Follow-up with the individual periodically to ensure their needs (and goals) are being met and that circumstances and priorities have not changed.
  • Communicate and share knowledge related to care.
  • Work to align resources with consumer needs.

Care Coordination …

  • Has the potential to improve the effectiveness, safety and efficiency of the community health care system.
  • When well-designed and well-delivered, Care Coordination improves outcomes for everyone: consumers, providers and payers.

First 24 hours post discharge

  • Make and document reasonable attempts to contact consumers who are discharged from higher levels of care.
  • For all who pose potential risks for suicide:
    • plan for suicide prevention and safety
    • coordinate consent and follow up services
    • Contact attempts continue until the individual is linked to services or assessed to no longer be at-risk.
  • Involvement of individuals with lived experience is encouraged in this process.


  • CCBHC must make and document reasonable attempts to determine medications prescribed by providers for CCBHC consumers.
  • With proper consent, the CCBHC should also provide such information to other providers to ensure safe, quality care.

Cornerstones of care:

  • Timely sharing of information that supports multiple providers being able to access information and document care plan progress.
  • CCBHCs should have a plan that addresses how to improve care coordination with all designated collaborating organizations (DCOs) using health information technology.
    • Must maintain HIPAA compliance!

A High Quality Referral is:

  • Safe - planned and managed to prevent harm
  • Effective - based on scientific knowledge and executed well to maximize benefit
  • Timely - individuals receive needed services without unnecessary delays
  • Person-centered - responsive to individual and family needs & preferences
  • Efficient - limited to necessary referral and avoids duplication of services
  • Equitable - availability and quality do not vary

Individual Support

  • The team is organized to optimally provide support to individuals and families during referrals and transitions.
  • Referral Coordinator:
    • Tracks all referrals and transitions
    • Provides individuals (and families) with information about referral
    • Addresses barriers to referrals
    • Follows up on missed appointments

Strong Relationships & Agreements

  • Relationships with key specialist groups, hospitals and community agencies.
  • Formal agreements with these key groups and agencies.
  • Opportunities to Document Lessons Learned:
    • Talk through the process for a "typical" person's experience in the system
    • Work on a global (versus an individual) basis encourages you to focus on the system and not individual people.

Where to Start

  • Tracking & following up on lab/imaging results
  • Identification & tracking of linkages to community resources
  • Guidelines for referral, prior tests, and information;
  • Expectations about future care and specialist-to-specialist referral;
  • Expectations for information back to CCBHC
  • Notification of visit/admission and discharge;
  • Medication reconciliation after transition;
  • Involvement of CCBHC in post-discharge care.

Care Coordination…

  • Complements and improves health care.
  • Ensures continuity for improved health.
  • Avoids preventable poor outcomes. spending.
  • Care Coordination changes lives!