What does high-quality, evidence-based mental health and substance use disorder care look like? Mental health and substance disorder experts believe that even though services may differ depending on the specific person and situation, high-quality, evidence-based care rests on a few core principles. It is free from stigma, not coercive or punitive, and is trauma-informed. Ideally, it is accessible to anyone, any time — day or night, seven days a week — and includes services such as crisis management, peer counseling, support groups, medications, and therapy.

Studies show that approximately 23% of the U.S. population has a mental health condition, 6% have a severe mental health condition, and 8% have a co-occurring mental health and substance use disorder (SUD). However, the U.S. has a severe shortage of behavioral health providers, especially in rural areas. Recent data has shown that approximately one-third of adults with symptoms of depression and anxiety disorder reported receiving no care for these symptoms, and over 90% of people with SUD received no treatment. Rates of behavioral health conditions are also higher in low-income, rural, and indigenous communities and communities of color, and there are significant racial disparities in access to services. In places where mental health providers do accept Medicaid or care for the uninsured, months-long wait times are frequently the norm.

The Certified Community Behavioral Health Clinic (CCBHC) model was designed to address these access issues and promote more integrated care for people with serious behavioral health conditions. This blog post provides a broad overview of CCBHC implementation opportunities and explores the experiences and impact of two programs:  VIP Community Services in the Bronx, New York, and GRAND Mental Health in Oklahoma.

Background

CCBHCs are a behavioral health care model established initially under section 223 of the Protecting Access to Medicare Act of 2014. Today, over 500 CCBHCs and CCBHC grantees operate in 46 states and deliver coordinated, community-based behavioral health care. CCBHCs must meet federal standards and criteria for the range of services they provide and are required to get people into care quickly. Central to the CCBHC model is that care is available in a timely manner to anyone, regardless of ability to pay — and CCBHCs accept Medicaid, Medicare, and private insurance and deliver care for the uninsured.

Either directly or through formal partnerships, CCBHCs must provide nine core services, including:

• Crisis services
• Screening, diagnosis, and risk assessment
• Psychiatric rehabilitation services
• Outpatient primary care screening and monitoring
• Targeted case management
• Outpatient mental health and substance use services
• Person- and family-centered treatment planning
• Community-based mental health care for veterans
• Peer, family support, and counselor services

There are different types of CCBHCs established by different programs:

• Section 223 Medicaid CCBHC Demonstration Programs: Ten states began participating in the CCBHC demonstration in 2017. Clinics that want to become CCBHCs under the demonstration have to meet certification criteria and prospective payment system (PPS) guidance. Under the 2022 Bipartisan Safer Communities Act, additional states can be added to the demonstration, and ten new demonstration states were announced in June 2024.
• SAMHSA CCBHC Grantees: SAMHSA has administered grants to individual clinics nationwide to deliver core CCBHC services. These CCBHCs use federal grant money to deliver these services, and do not receive the PPS rate.
• Independent State Programs: Some states have used Medicaid authorities outside of the Section 223 demonstration to define the CCBHC array of services and payments for CCBHC services.

The National Council for Mental Wellbeing tracks all CCBHCs.

Implementation

The PPS payment model under the section 223 Medicaid demonstration program gives CCBHCs the flexibility to design their care delivery model in ways that traditional fee-for-service payments do not support. The PPS is designed to support interdisciplinary teams and care delivery models tailored to meet patients' comprehensive behavioral health needs whenever they seek care. States in the CCBHC demonstration program can also tie payments to quality performance, choosing either a daily (PPS-1) or monthly (PPS-2) prospective payment rate with potential quality bonus payments. CCBHCs funded only by SAMHSA grants, while not eligible for the PPS, can use grant funds to invest in critical infrastructure or activities that would not otherwise be reimbursable. 

Impact

The CCBHC model has been showing promising results so far. An evaluation of the first two years of the CCBHC demonstration noted that some quality of care measures improved substantially, while the impact of the model on service use varied across states. A study of two CCBHC demonstration states reported that the CCBHC model led to reduced behavioral health emergency department visits and all-cause hospitalizations. The 2024 CCBHC Impact Report published by the National Council for Mental Wellbeing collected data from both Medicaid demonstration CCBHCs and SAMHSA grantees and noted some examples of how the prospective payment system may contribute to a greater ability to increase access to care and address behavioral health workforce shortages. While both types of CCBHCs reported increases in patients served after becoming a CCBHC, demonstration CCBHCs reported substantially higher average increases. Demonstration CCBHCs also hired more new positions than SAMHSA CCBHCs, and the most common positions hired included licensed clinicians, peer support specialists, care coordinators, and nurses.

The following descriptions of two CCBHCs in New York City and Oklahoma, both providing mental health services since the 1970s, offer two different variations of how this unique model can be implemented and sustained to improve coordinated care delivery for people with mental health conditions and/or SUD.

VIP Community Services in the Bronx, New York

VIP Community Services (VIP) is a Medicaid demonstration CCBHC and federally qualified health center (FQHC) based in the Bronx, New York. It delivers a full continuum of behavioral health, physical health, and social service care and serves approximately 7,000 individuals.

Debbian Fletcher-Blake, VIP’s CEO since 2018 and a family nurse practitioner, explains that the CCBHC model allows VIP to provide high-quality behavioral health care services beyond what can be provided by their FQHC partner. VIP receives a PPS-1 or daily rate to provide care management, case management, peer services, substance use counseling, crisis management services, and visits with social workers and psychiatrists. “Because of the payment model, a CCBHC can provide the community-based, in-depth, team-based care needed for people with SUD and more serious mental health conditions,” said Fletcher-Blake. “The CCBHC model allows us to bill regardless of who provides care, and care doesn’t revolve around the physician's services. This means everyone is accountable for taking care of the client. Any team member can pick up the mantle and care for that client anytime. It's based on client needs, not organizational needs.”

In CCBHCs, unlicensed staff, such as peers with lived experience of mental health or prior substance use, play a critical role in client care. Empowered to step in at any moment or to meet clients in the community, they are often the people who can engage individuals who may be fearful of seeking care and who can convey respect for patients by meeting them where they are. They can also help clinical staff better understand what a patient is going through and improve care delivery. Fletcher-Blake explains that “when you have peers providing services, the way patients are treated is different than when you have someone who's not a peer. Peers can relate, and they teach everyone else what the patient needs.” Everyone who works with patients at the VIP CCBHC receives training in trauma-informed care, implicit bias, and motivational interviewing, skillsets foundational to VIP’s approach. Unlicensed staff receive support to discuss cases with a licensed social worker every week.

The culture at VIP’s CCBHC is also unlike what one might find in a more traditional health care environment. Fletcher-Blake says, “It absolutely feels different because the whole team feels empowered and critical to patient care.” The turnover rate for staff at VIP’s CCBHC is also low. Since VIP receives a PPS for each client, regardless of when they are seen for a visit, and because anyone on the team can provide care depending on what the individual needs, team-based care thrives, and staff feel more valued and empowered.

VIP also has deep roots in the community at large and can use its flexible funding to support community partnerships. It also works closely with the local criminal justice system, providing training on mental health and SUD, and with the court system, providing reports and evaluations for individuals who have been mandated to attend SUD treatment programs instead of being incarcerated.

Fletcher-Blake notes that 95% of VIP's clients who need mental health or substance use care are seen within 1- to 2-days and that our CCBHC has led to 40% reduction in their clients using the emergency department."

When asked if she has any advice for others who might want to start their own CCBHC, Fletcher-Blake says, “Do the organizational readiness assessment and don’t just jump into it. Make sure that your staff understands the CCBHC model and how different it is from traditional care. And advocacy with the state is crucial. Make sure you have someone who can advocate for coverage of the services you are providing.”

GRAND Mental Health in Northeast Oklahoma

GRAND Mental Health (GRAND) became a Medicaid demonstration CCBHC in 2016. GRAND provides mental health and substance use services integrated with primary health care and operates 27 clinics and centers in 13 Oklahoma counties. It employs more than 1,700 staff and provides services to approximately 18,000 individuals, including youth and adults, annually.

Larry Smith, chief executive officer, and Josh Cantwell, a licensed clinical social worker and chief operating officer, have each worked at GRAND for over 20 years. Both leaders speak of how becoming a CCBHC helped GRAND make a significant paradigm shift to getting paid for outcomes and not for the volume of services they provided. Cantwell says, “We sat around in rooms for so long before we became a CCBHC, and the conversation was never about what worked for our patients because we could see what worked. It was always about figuring out how to get paid for it or sustain delivering it. Becoming a CCBHC finally allowed the cost reimbursement to match up with what our clients needed.”

GRAND’s approach to crisis management care offers one example of successfully aligning a nontraditional care model with a payment strategy. Before becoming a CCBHC, GRAND developed a promising model to assist people experiencing a behavioral health crisis but lacked a reimbursement strategy to support it. Oklahoma is one of the few states that chose the monthly PPS reimbursement rate or PPS-2. Oklahoma’s Medicaid agency gave each CCBHC a list of individuals in their area who were considered high-risk, who were visiting the emergency room frequently, and who had high costs. CCBHCs in Oklahoma are rewarded for engaging these individuals in care, and the monthly PPS rate reflects an assumed benchmark for how many people each CCBHC will connect with. If the CCBHCs don’t engage individuals at the benchmark level, they can lose money or experience downside risk. This has incentivized places like GRAND to conduct ongoing outreach in the community to ensure that those who need care are getting it.

Recognizing a gap in the community for a lower level of care for individuals who were in crisis but didn’t necessarily need hospitalization and were too frequently being taken to jail, GRAND had previously developed a three-pronged strategy that included urgent recovery centers providing 24/7 crisis stabilization services; an integrated support access app available on iPads distributed to GRAND patients, first responders, hospitals, and other community partners to provide immediate access to a GRAND therapist; and trained clinicians who answer iPad and crisis calls 24/7. Becoming a CCBHC meant they could finally pay for, sustain, and expand this program.

An evaluation of GRAND’s program by the National Association of State Mental Health Program Directors Research Institute shows positive results from their crisis management model. The evaluation was conducted through interviews, document review, analysis, and verification of data provided by GRAND and Oklahoma Medicaid. From 2016–2021, inpatient hospitalizations among GRAND adult clients were reduced by 93%, and these decreases saved more than $62 million. The evaluation also reported that law enforcement saved 576 days in time and over $718,000 because of the reduction in the number of clients transported who were instead engaged by GRAND staff.

“We didn’t start out by focusing on reducing cost,” said Smith. “We started by always asking, ‘Is this person in the least restrictive environment they can be in?’ Living at home and having a job but having that iPad might be the least restrictive environment that works for them. If that person needs more care, it might look like GRAND providing services to them at home or in the community. Turns out that having someone in the least restrictive environment is also the least expensive environment.”

Like VIP, GRAND has also seen the CCBHC model help address staff burnout and decrease turnover. “It used to be that wages here in Oklahoma were much lower than other places. We decided we would not do that anymore, and with the CCBHC model, we don’t have to,” said Cantwell.

Insights

Following are insights for standing up and sustaining a CCBHC model drawing from the experiences of VIP and GRAND:

• The CCBHC payment model supports team-based care. It addresses workforce challenges, empowering all levels, especially staff such as peers and counselors, to play a larger role in the care of all clients. Because all staff feel more empowered to care for patients, this can reduce turnover and burnout rates. Higher salaries and lower staff turnover rates can positively impact care — with a higher chance of maintaining relationships and engagement with individuals with mental health and substance use conditions.
• Peers with lived experience and 24/7 crisis management services are critical. Peers and 24/7 access to care provided by CCBHCs lead to improved outcomes and reduced cost. These benefits can go beyond the health care system, helping those in crisis in the community to have a safe place to get care.
• Success for a CCBHC can also bring challenges. GRAND’s CCBHC model has been so successful that they are expanding rapidly, but Smith and Cantwell worry about staying financially stable. “We do a cost report every year, but the state looks at it every two years, and then they’re supposed to set our rate based upon our past costs,” said Smith. “At some point, if you’re expanding, your costs from two years ago will not be what your costs are now. But there is so much need out there, and we want to try and meet it.”