Attachment E. CCBHC Demo Eval Clinic Survey_OMB 3 19 25

CCBHC Demonstration Evaluation Clinic Survey - DRAFT

Section 223 Demonstration Program for Certified Community Behavioral Health Clinics - Evaluation Clinic Survey

Q1A. Our records indicate that the name of your CCBHC is [Autofill CCBHC Name]. Is this correct?

• Yes (1)

• No (0)

Q1B. Please provide the correct CCBHC name here:

Section A. Certified Community Behavioral Health Clinic (CCBHC) structure

A1. In this section, we would like to learn about how your CCBHC is organized.

Please enter the main street address of your Section 223 Medicaid Demonstration CCBHC here:

STREET 1: (STREET1)	______________________________
STREET 2: (STREET2)	______________________________
CITY: (CITY)	______________________________
STATE: (STATE)	______________________________
ZIPCODE: (ZIP)	______________________________

A2A. How many service locations does your organization have? [NUMERICAL RESPONSE, RANGE 1-100]

[ASK A2B IF A2A ≥ 1]

A2B. How many of your organization's service locations offer CCBHC services? [NUMERICAL RESPONSE, RANGE 1-100]

A2C. How many of these locations participate in the Section 223 CCBHC Medicaid Demonstration? [NUMERICAL RESPONSE, RANGE 1-100]

A2D. Please enter the physical address of each location that offers CCBHC services funded by the Section 223 CCBHC Medicaid Demonstration and indicate if the location is urban, suburban, or rural:

	STREET 1	STREET 2	CITY	STATE	ZIPCODE	LOCATION CLASSIFICATION
1 -100	______	______	______	DROPDOWN	______	DROPDOWN

A3. What is the name and job title of the primary person completing this survey?

First Name: (Autofill FNAME)	______________________________
Last Name: (Autofill LNAME)	______________________________
Job title: (Autofill TITLE)	______________________________

A4A. Which of the following best describes the type of treatment provided by your clinic prior to CCBHC certification?

Select one.

• Primarily substance use disorder services (1)

• Primarily mental health services (2)

• Mix of mental health and substance use disorder services (3)

• Primarily physical health services (4)

• Other (please describe): (5)____________

A4B. Which of the following best describes the type of treatment provided by your CCBHC currently?

Select one.

• Primarily substance use disorder services (1)

• Primarily mental health services (2)

• Mix of mental health and substance use disorder services (3)

• Primarily physical health services (4)

• Other (please describe): (5)____________

A5. Is your Is your CCBHC accredited by any of the following organizations :

Check all that apply.

• Commission on Accreditation of Rehabilitation Facilities (CARF) (1)

• National Committee for Quality Assurance (2)

• Healthcare Facilities Accreditation Program (3)

• The Joint Commission CCBHC accreditation (4)

• Other Joint Commission accreditation (5)

• Council on Accreditation (COA) (now a part of Social Current) (6)

• Other (please describe): (7)____________

• None of the above

A6. Is your CCBHC any of the following?

• Community mental health center (1)

• Federally Qualified Health Center (2)

• Health Center Program look-alike (3)

• CMS-certified Rural Health Clinic (4)

• National Committee for Quality Assurance-recognized Patient-Centered Medical Home (5)

• Medicaid health home or Medicare medical home (6)

• Medicaid or Medicare accountable care organization (7)

• SAMHSA-certified Opioid Treatment Program (8)

• Indian Health Service facility, tribal clinic, tribal FQHC, or Urban Indian Organization (9)

• None of the above

A7A. Has your CCBHC also received a CCBHC Expansion (CCBHC-E) grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) in the past or have a CCBHC-E grant currently?

• Yes (1)

• No (0)

[ASK A6B IF A6A=1 (YES)]

A7B.What year did your CCBHC FIRST receive a CCBHC Expansion grant? (select)

• 2018

• 2019

• 2020

• 2021

• 2022

• 2023

• 2024

• 2025

• 2026

A7C. Do all of your CCBHC’s locations that are funded by the Section 223 Medicaid Demonstration also use CCBHC Expansion grant funding?

• Yes (1)

• No (0)

A7D. Which of your CCBHC’s locations that are funded by the Section 223 Medicaid Demonstration DO NOT also use CCBHC Expansion grant funding?

Table prepopulated from A2D

	STREET 1	STREET 2	CITY	STATE	ZIPCODE
1 -100	______	______	______	DROPDOWN	______

A7E. Does your CCBHC have satellite facilities that are NOT funded by the Section 223 Medicaid Demonstration (see LINK for a definition of satellite facilities)?

• Yes (1)

• No (0)

Section B. Certified Community Behavioral Health Clinic (CCBHC) staffing

In this section, we would like to learn about how your CCBHC is staffed.

B1. How many full time equivalent (FTE) of the following types of staff did your CCBHC hire as a result of CCBHC certification? [NUMERICAL RESPONSE, RANGE 1-100]

Adult psychiatrist(s) (1)	______________________________
Child/adolescent psychiatrists (2)	______________________________
Nurses (3)	______________________________
Licensed staff including psychologists, clinical social workers, counselors, and marriage and family therapists (4)	______________________________
Substance use disorder or addiction medicine specialists (5)	______________________________
Certified/trained peer specialist(s)/recovery coaches (6)	______________________________

B2A. Have any of the following staff positions gone completely unfilled for two months or longer during the past 12 months?

Check all that apply.

• Adult psychiatrist(s) (1)

• Child/adolescent psychiatrists (2)

• Nurses (3)

• Licensed staff including psychologists, clinical social workers, counselors, and marriage and family therapists (4) Please note which position has gone unfilled: _______________________

• Licensed or certified substance use treatment counselors or specialists (5)

• Peer specialist(s)/recovery coaches (6)

• Family support staff (7)

• Care managers/coordinators (8) [ASK B2B IF B2A=1(YES)]

B2B. If so, please describe why (for example, has a position been difficult to fill?):

B3A. Has your clinic been trying to add more of the following types of staff during the past 12 months?

Check all that apply.

• Adult psychiatrist(s) (1)

• Child/adolescent psychiatrists (2)

• Nurses (3)

• Licensed staff including psychologists, clinical social workers, counselors, and marriage and family therapists (4)

• Licensed or certified substance use treatment counselors or specialists (5)

• Peer specialist(s)/recovery coaches (6)

• Family support staff (7)

• Care managers/coordinators (8)

[ASK B3B IF B3A=1(YES)]

B3B. Please describe why your clinic has been trying to add more of the following types of staff (for example, was a need for more staff identified through the CCBHC’s community needs assessment, or has the clinic added new or expanded availability of services?):

Section C. Certified Community Behavioral Health Clinic Certified Community Behavioral Health Clinic (CCBHC) accessibility

Questions in this section will help us understand how clients access services at your clinic.

C1. How are clients referred to CCBHC services?

Check all that apply.

• Self-referral (1)

• Referred by physical health care providers (2)

• Referred by other behavioral health providers (3)

• Referred by courts/involuntary or assisted outpatient treatment order (4)

• Referred by schools or other child service providers (5)

• Referred by family (6)

• Referred by crisis service providers (7)

• Referred by hospitals (8)

• Referred by emergency departments (9)

• Other (please describe): (10)____________

C2A. Does your CCBHC physically provide services in locations outside of the clinic (excluding services provided via telehealth)? Where are services provided if so?

Check all that apply.

• Clients' homes (1)

• Hospitals (2)

• Emergency departments (3)

• Restaurants, coffee shops (4)

• Shelters (5)

• Permanent supportive housing placements (6)

• Social service organizations (e.g., Medicaid, housing agencies) (7)

• Schools (8)

• Parole offices (9)

• Courts, jails, police stations or law enforcement offices (10)

• Libraries (11)

• Other community locations (please describe): (12)____________

• Does not provide services in locations outside of the clinic

[ASK C2B IF C2A=1(YES)]

C2B. In which 3 locations does your CCBHC see the fewest clients outside of the clinic (excluding services provided via telehealth)?

Select the 3 locations that apply.

[Locations prepopulated from C2B:]

• Clients' homes (1)

• Hospitals (2)

• Emergency departments (3)

• Restaurants, coffee shops (4)

• Shelters (5)

• Social service organizations (e.g., Medicaid, housing agencies) (6)

• Schools (7)

• Parole offices (8)

• Courts, jails, police stations or law enforcement offices (9)

• Libraries (10)

• Other community locations (please describe): (11)____________

• Other community locations (please describe): (12)____________

• Other community locations (please describe): (13)____________

C3. For each service below, please indicate:

a. If your CCBHC provides the service type via telehealth. (C3B_0)
b. What telehealth method, if any, your CCBHC uses to provide the service to CCBHC clients. (C3B_1-4)
c. Whether the service offered by telehealth is available to all clients or only specific populations. (C3B_5-6)

	C3A_0 -		C3A_1 - Video conference	C3A_2 - Mobile applications	C3A_3 - Telephone	C3A_4 - Other	C3A_5 - All clients	C3A_6 - Specific populations only (please describe)
	Yes (1)	No (0)
Crisis services (1)						______		______
Screening, assessment, and diagnosis (2)						______		______
Outpatient mental health (3)						______		______
Outpatient SUD services (4)						______		______
Targeted Case Management (5)						______		______
Primary Care Screening and Monitoring (6)						______		______
Person- and Family-Centered Treatment Planning Services (7)						______		______
Psychiatric Rehabilitation Services (8)						______		______
Peer Support Services (9)						______		______
Intensive Community-Based Mental Health Services for Armed Forces and Veterans (10)						______		______
Other (please describe): (11)____________						______		______

C4A.Does your clinic provide services in languages other than English?

• Yes (1)

• No (0)

C4B. Does your CCBHC offer translation services to clients?

• Yes (1)

• No (0)

C5A. Does your CCBHC offer open access or same-day scheduling?

• Yes (1)

• No (0)

C5B. For which service types is open access, walk in, or same-day scheduling available?

Check all that apply.

• Crisis behavioral health services (1)

• Screening, assessment, and diagnosis (2)

• Outpatient mental health (3)

• Outpatient SUD services (4)

• Targeted Case Management (5)

• Primary Care Screening and Monitoring (6)

• Person- and Family-Centered Treatment Planning Services (7)

• Psychiatric Rehabilitation Services (8)

• Peer Supports, Peer Counseling, and Family/Caregiver Supports (9)

• Intensive Community-Based Mental Health Services for Armed Forces and Veterans (10)

C6. Does your CCBHC offer childcare to clients during appointments?

• Yes (1)

• No (0)

C7. In the past 12 months, what has your CCBHC done to increase access to care?

C8. What specific activities has your CCBHC implemented to increase access to care for children/youth and their families as a result of the demonstration?

C9. What challenges has your CCBHC faced related to increasing access to care under the demonstration in the last 12 months?

C10. How many NEW clients (i.e., individuals who have not received services from your CCBHC in the past six months) has your CCBHC served in the past 12 months?

C11. Has your CCBHC experienced challenges meeting any of the following requirements when people request services?

a. Please select “Yes” or “No” for each response.

b. If you select “Yes” for any response, please describe what challenges your CCBHC has encountered.

	C11B_0		C11B_1 Describe why for “Yes” responses
	Yes (1)	No (0)
Providing preliminary triage, including screening and risk assessment, to determine acuity of needs at the time of first contact by people new to CCBHC services (1)		
Providing services for urgent needs within 1 business day of first contact by people new to CCBHC services (2)		
Providing services and completing the initial evaluation within 10 business days of first contact for those new to CCBHC services with routine needs (3)		
Providing comprehensive evaluation within 60 days of first contact by people new to CCBHC services (4)		
Providing people already receiving services from your CCBHC with an appointment within 10 business days of contact (5)		

C12. Beyond general improvements to increase access to care for all populations, indicate if your clinic has implemented activities to specifically increase access to care for the following in the last 12 months?

Check all that apply.

• People experiencing homelessness or housing insecurity (1)

• People with co-occurring mental and substance use disorders (2)

• People with intellectual or developmental disabilities (3)

• People with physical health disabilities (4)

• People with limited English proficiency (5)

• Other [Please describe:____________________] (6)

• Other [Please describe:____________________] (7)

• Other [Please describe:____________________] (8)

Section D. Certified Community Behavioral Health Clinic (CCBHC) care coordination

The following questions will help us understand how client care is coordinated at your clinic.

D1. Are any of the following steps or processes involved in person- and family-centered treatment planning at your CCBHC?

Check all that apply.

• Documentation of the needs, strengths, abilities, preferences, and goals of people receiving services using their own words (1)

• Documentation of wishes of people receiving services regarding involvement of family member and others in treatment (2)

• Use of shared decision-making tools to identify treatment goals and develop treatment plans (3)

• Identification of wellness and recovery goals (4)

• Input to plan provided by interdisciplinary care team (5)

• Consultations obtained as needed to develop plan (e.g. for addressing intellectual and developmental disability) (6)

• Written endorsement of the plan provided by people receiving services or their parents/caregivers (7)

• Documentation of plans for monitoring progress of people receiving services toward goals (8)

• Documentation of plans to ensure care is provided in the least restrictive setting (9)

• None of the above

D2. How specifically are preferences for care of people receiving services elicited and documented?

Please describe:

D3A. Does your CCBHC provide on-site primary care services (in addition to primary care screening and monitoring)?

• Yes (1)

• No (0)

[ASK D3B IF D3A=1(YES)]

D3B. Does your CCBHC have a primary care clinician on staff or under contract?

• Yes (1)

• No (0)

D3C. Does your CCBHC routinely document the name of clients’ external primary care provider(s) in client health records?

• Yes (1)

• No (0)

D3D. What physical health conditions does your CCBHC routinely screen for and monitor?

D4A. What electronic health record (EHR) system does your CCBHC use?

D4B. Does your CCBHC’s EHR include, generate, or document the following?

	D4D_0
	Yes (1)	No (0)
Physical health records (1)		
Electronic care plan (2)		
Crisis plan (3)		
Psychiatric advance directives (4)		

D4C. Does your CCBHC's EHR calculate performance on the quality measures required for the demonstration?

• Yes (1)

• No (0)

[ASK D4D-F IF D4C =1(YES)]

D4D. Are the required demonstration quality measures calculated by your CCBHC’s EHR able to be accessed by your CCBHC?

• Yes (1)

• No (0)

D4E. Who in your clinic can access the quality measures generated by your EHR?

Check all that apply.

• CCBHC leadership (e.g., executive director, medical director) (1)

• Frontline clinical staff (2)

• Quality officers/managers (3)

• Staff access varies by measure (4)

• Other (please describe): (5)____________

D5. Indicate if your clinic uses the following types of health information technology (HIT).

Check all that apply.

• Electronic clinical decision support tools (1)

• Data dashboard(s) (2)

• Electronic prescribing (3)

• Electronic exchange of clinical information with external providers (4)

• Clinical registry (5)

• State operated health information exchange (6)

• Privately operated health information exchange (7)

• Patient portals (8)

• Other health information technology (please describe): (9)____________

D6A. Has your clinic changed or enhanced its HIT systems or EHR in the past 12 months as a result of the demonstration?

• Yes (1)

• No (0)

D6B. Please describe the HIT or EHR alterations made in the last 12 months:

D7. Does your CCBHC have relationships with any of the following types of external facilities or providers? For each, indicate the type of relationship or that there is no relationship. Some partners might not be applicable to your CCBHC; please indicate if so.

	D7_1 - Designated collaborating organization (DCO)	D7_2 – Formal, signed care coordination agreement or unsigned written joint protocol	D7_3 - Informal relationship	D7_4 - No relationship	D7_5 – Not applicable to CCBHC
Federally qualified health centers (1_1)					
Rural health clinics (1_2)					
Primary care providers (1_3)					
Urgent care centers (1_4)					
Emergency departments (1_5)					
988 Suicide & Crisis Lifeline call center (1_6)					
Inpatient psychiatric facilities (2_1)					
Psychiatric residential treatment facilities (2_2)					
Substance use disorder residential treatment facilities (2_3)					
Coordinated Specialty Care programs for first episode psychosis (2_4)					
Medical detoxification facilities (3_1)					
Ambulatory detoxification facilities (3_2)					
Post-detoxification step-down facilities (3_3)					
Hospital outpatient clinics (3_4)					
Providers of medication for substance use disorder treatment (3_5)					
Opioid treatment program (3_6)					
Substance use prevention and harm reduction programs (3_7)					
SUD Recovery/ Transitional housing (3_8)					
Schools (4_1)					
School-based health centers (4_2)					
Child welfare agencies (4_3)					
Therapeutic foster care service agencies (4_4)					
Juvenile justice agencies (5_1)					
Adult criminal justice agencies/courts (5_2)					
Mental health/drug courts (5_3)					
Law enforcement (5_4)					
Legal aid (5_5)					
Indian Health Service or other tribal programs (6_1)					
Indian Health Service youth regional treatment centers (6_2)					
Immigrant and refugee services (6_3)					
Department of Veterans Affairs treatment facilities (6_4)					
Homeless shelters (7_1)					
Housing agencies (7_2)					
Suicide/crisis hotlines and warmlines (7_3)					
State-sanctioned crisis systems (7_4)					
Residential (non-hospital) crisis settings (7_4)					
Employment services and/or supported employment (8_1)					
Older adult services (8_2)					
Home visiting programs (8_3)
Early Head Start/Head Start programs (8_4)
Infant and Early Childhood Mental Health Consultation programs (8_5)
Other programs and services for families with young children (8_6)					
Other social and human service providers (8_4)					
Peer- operated/peer service provider organizations (8_4)					
Ryan White Program providers (8_6)					
Other (please describe): (9_1)____________					

D8A. Has your CCBHC experienced challenges establishing written care coordination agreements or unsigned written joint protocols with any type of external organizations?

• Yes (1)

• No (0)

D8B. Please describe the challenge.

D9. [Prepopulated from responses to D7 – for each category for which D7_4 = 1 and D7_5 = 0] Is your working on written agreements or joint protocols with this type of entity?

	Yes, we are working on formal, signed agreements or joint protocols	No, we are not working on formal, signed agreements or joint protocols but we plan to	No, we are not working on formal, signed agreements or joint protocols and we do not plan to
Prepopulated category 1			
Prepopulated category 2…			

D10. To what extent do the following external providers notify your CCBHC if they provide services to a person receiving services from your CCBHC?

	Never	Sometimes	Frequently
Inpatient psychiatric facilities	1 m	2 m	3 m
Acute care hospitals	1 m	2 m	3 m
Emergency departments	1 m	2 m	3 m
Crisis services delivered by another provider	1 m	2 m	3 m
Residential treatment	1 m	2 m	3 m
Primary care providers	1 m	2 m	3 m
Outpatient mental health	1 m	2 m	3 m
Outpatient substance use	1 m	2 m	3 m
School-based services	1 m	2 m	3 m

D11A. Does your CCBHC provide support or services for the 988 crisis hotline?

• Yes (1)

• No (0)

[ASK D11B IF D11A=1(YES)]

D11B. What type of support or services for the 988 crisis hotline does your CCBHC provide?

Check all that apply.

• Serves as a 988 call center (1)

• Receives referrals from 988 crisis line (2)

• Provides mobile crisis response for 988 calls (3)

• Operates a behavioral health crisis center (4)

• Other (specify): (5) _____________________

• None of the above

D12. Does your CCBHC do any of the following to help people receiving services manage their medications?

Check all that apply.

• Make a person’s full list of current prescriptions, over the counter medications, herbal remedies, and dietary supplements available to all relevant clinic providers (1)

• Review and reconcile any new medications prescribed by external providers (2)

• Consult the state Prescription Drug Monitoring Program before prescribing new medications (3)

• Educate people on the side effects and benefits of medications when they are prescribed (4)

• Routinely assess peoples’ adherence to prescribed medications (5)

• Routinely assess medication side effects and if medications are helping (6)

• None of the above (7)

Section E. Certified Community Behavioral Health Clinic (CCBHC) scope of services

In this section, we would like to learn about the services your clinic provides, the extent of their availability, and whether your clinic was providing them prior to certification.

E1. Which of the following services does your CCBHC or its DCO(s) provide?

For each service, please indicate the following: If the service is provided by your CCBHC or a DCO. The time of day/week the service is available. If the service was added in the past 12 months.

E1A. Crisis Behavioral Health Services

	E1A_1 - CCBHC	E1A_2 - DCO	E1A_3 - During business hours	E1A_4 - Outside business hours	E1A_5 - Added in the past 12 months	E1A_6 - Does not provide
Crisis Behavioral Health Services (1)						
Please answer the same questions for each individual crisis service your CCBHC offers below. Otherwise, select "does not provide". (0)
24-hour mobile crisis teams (2)						
Emergency crisis intervention (3)						
Crisis stabilization (4)						
Suicide prevention and intervention (5)						
Services capable of addressing crises related to substance use, including overdose prevention (6)						

E1B. Screening, Assessment, and Diagnosis

	E1B_1 - CCBHC	E1B_2 - DCO	E1B_3 - During business hours	E1B_4 - Outside business hours	E1B_5 - Added in the past 12 months	E1B_6 - Does not provide
Screening, Assessment, and Diagnosis (1)						
Please answer the same questions for each individual screening, assessment, or diagnosis service your CCBHC offers below. Otherwise, select "does not provide". (0)
Mental health screening, assessment, diagnostic services (2)						
Substance use disorder screening, assessment, diagnostic services (3)						

E1C. Person- and Family-Centered Treatment Planning Services

	E1C_1 - CCBHC	E1C_2 - DCO	E1C_3 - During business hours	E1C_4 - Outside business hours	E1C_5 - Added in the past 12 months	E1C_6 - Does not provide
Person- and Family-Centered Treatment Planning Services (1)						

E1D. Outpatient Mental Health and/or Substance Use Disorder (SUD) Services

	E1D_1 - CCBHC	E1D_2 - DCO	E1D_3 - During business hours	E1D_4 - Outside business hours	E1D_5 - Added in the past 12 months	E1D_6 - Does not provide
Outpatient Mental Health and/or Substance Use Disorder (SUD) Services (1)						
Please answer the same questions for each individual service your CCBHC offers below. Otherwise, select "does not provide". (0)
Outpatient mental health counseling (2)						
Outpatient SUD treatment (3)						
Motivational interviewing (4)						
Individual cognitive behavioral therapy (CBT) (5)						
Group CBT (6)						
Online CBT (7)						
Trauma-focused CBT (8)						
Dialectical behavioral therapy (9)						
Coordinated Specialty Care for First Episode Psychosis (10)						
Multi-systemic therapy (11)						
Assertive community treatment (ACT) (12)						
Forensic ACT (13)						
Evidence-based medication evaluation and management (14)						
Methadone (15)						
Buprenorphine (16)						
Other FDA-approved medications for opioid, alcohol, and tobacco use disorders (17)						
Therapeutic foster care (18)						
Community wraparound services for youth/children (19)						
Specialty mental health/SUD services for children and youth (20)						
Seeking Safety (21)						

E1E. Psychiatric Rehabilitation Services

	E1E_1 - CCBHC	E1E_2 - DCO	E1E_3 - During business hours	E1E_4 - Outside business hours	E1E_5 - Added in the past 12 months	E1E_6 - Does not provide
Psychiatric Rehabilitation Services (1)						
Please answer the same questions for each individual service your CCBHC offers below. Otherwise, select "does not provide". (0)
Medication education (2)						
Self-management (3)						
Skills training (4)						
Psychoeducation (5)						
Community integration services (6)						
Illness management and recovery (7)						
Financial management (8)						
Wellness education services (diet, nutrition, exercise, tobacco cessation, etc.) (9)						
Help for clients to find and maintain safe and stable housing (10)						
Supported employment (11)						
Individual Placement and Support (12)						
Support for clients to participate in education (13)						
Support for clients to achieve social inclusion and community connectedness (14)						

E1F. Peer Support Services

	E1F_1 - CCBHC	E1F_2 - DCO	E1F_3 - During business hours	E1F_4 - Outside business hours	E1F_5 - Added in the past 12 months	E1F_6 - Does not provide
Peer Support Services (1)						
Please answer the same questions for each individual service your CCBHC offers below. Otherwise, select "does not provide". (0)
Peer specialists (2)						
Peer counseling (3)						
Family/caregiver supports (4)						
Peer‐run wellness and recovery centers (5)						
Youth/young adult peer support (6)						
Recovery coaching (7)						
Peer-run crisis respites (8)						
Peer-led crisis planning (9)						
Peer navigators to assist with care transitions (10)						
Mutual support and self-help groups (11)						
Family-to-family caregiver support (12)						

E1G. Targeted Case Management

	E1G_1 - CCBHC	E1G_2 - DCO	E1G_3 - During business hours	E1G_4 - Outside business hours	E1G_5 - Added in the past 12 months	E1G_6 - Does not provide
Targeted Case Management (1)						

E1H. Primary Care Screening and Monitoring

	E1H_1 - CCBHC	E1H_2 - DCO	E1H_3 - During business hours	E1H_4 - Outside business hours	E1H_5 - Added in the past 12 months	E1H_6 - Does not provide
Primary Care Screening and Monitoring (1)						
Please answer the same questions for each individual service your CCBHC offers below. Otherwise, select "does not provide". (12)
Testing for hepatitis (2)						
Tuberculosis screening (3)						
HIV screening (4)						
Tobacco use screening (5)						
Cholesterol screening (6)						
Triglyceride testing (7)						
Waist circumference screening (8)						
Weight (9)						
Blood pressure screening (10)						
Blood sugar testing (11)						
Other: (12)____________						
Other: (13)____________						

E1I. Intensive Community-Based Mental Health Services for Armed Forces and Veterans

	E1I_1 - CCBHC	E1I_2 - DCO	E1I_3 - During business hours	E1I_4 - Outside business hours	E1I_5 - Added in the past 12 months	E1I_6 - Does not provide
Intensive Community-Based Mental Health Services for Armed Forces and Veterans (1)						

(E1I_ACTIVITIES) Please describe any specific activities or services that are targeted to members of the Armed Forces or Veterans:

E1J. Other required CCBHC services (please list):

	E1J_1 - CCBHC	E1J_2 - DCO	E1J_3 - During business hours	E1J_4 - Outside business hours	E1J_5 - Added in the past 12 months	E1J_6 - Does not provide
Enter 1st additional service here: (1)____________						
Enter 2nd additional service here: (2)____________						
Enter 3rd additional service here: (3)____________						

E2. If your CCBHC has made any changes to the scope of services provided in the past 12 months, please briefly explain why you made them.

E3. Has your CCBHC experienced challenges meeting any of the following requirements for crisis services?

a. Please select “Yes” or “No” for each response.

b. If you select “Yes” for any response, please describe what challenges your CCBHC has encountered.

	E3A_0		E3A_1 Describe why for “Yes” responses
	Yes (1)	No (0)
Provide mobile crisis services within 3 hours (1)		
Provide services for urgent needs within 1 business day (2)		
Follow up with people presenting suicide risk within 24 hours until linked to services and assessed as no longer at risk (3)		
Provide urgent care/walk-in mental health and substance use disorder services
Attempt to contact clients within 24 hours of discharge from inpatient, emergency, residential, substance use, or criminal or juvenile justice facilities (4)		

Section F. Certified Community Behavioral Health Clinic (CCBHC) quality and other reporting

Questions in this section will help us understand your clinic’s efforts to monitor and improve care.

F1A. Does your CCBHC have a process in place to monitor its ongoing compliance with the CCBHC certification criteria?

• Yes (1)

• No (0)

F1B. Please describe how your CCBHC monitors its compliance with the certification criteria:

F1C. Has your CCBHC been unable to fulfill any of the following component(s) of the certification criteria at any point during the demonstration?

a. Please select “Yes” or “No” for each response.

b. If you select “Yes” for any response, please describe what challenges your CCBHC has encountered.

	F1C_0		F1C_1 Describe why for “Yes” responses
	Yes (1)	No (0)
Staffing (1)		
Availability and accessibility of services (2)		
Care coordination (3)		
Scope of services (4)		
Quality and other reporting (5)		
Organizational authority, governance, and accreditation (6)		

F2A. Does your state conduct ongoing monitoring of CCBHCs’ compliance with the certification criteria?

• Yes (1)

• No (0)

[ASK F2B IF F2A=1(YES)]

F2B. How does your state conduct ongoing monitoring of CCBHCs' compliance with the certification criteria?

F3. Which of these quality improvement practices are part of your CCBHC’s standard operating procedures?

Check all that apply.

• Regularly scheduled case review with a supervisor (1)

• Regularly scheduled case review by an appointed quality review committee (2)

• Clinical provider peer review (3)

• Root cause analysis (4)

• Other (please describe): (5) __________________________

F4A. How many current Continuous Quality Improvement projects are underway as a result of the demonstration?

• None (0)

• 1 (1)

• 2 (2)

• 3 (3)

• 4 (4)

• 5 (5)

• 6 (6)

• 7 (7)

• 8 (8)

• 9 (9)

• 10 or more (10)

F4B. Please list the current Continuous Quality Improvement projects and note the length of time they have been implemented (in months):

	F4B_P - Project	F4B_T - Length of time implemented
1 (1)	______	______
2 (2)	______	______
3 (3)	______	______
4 (4)	______	______
5 (5)	______	______
6 (6)	______	______
7 (7)	______	______
8 (8)	______	______
9 (9)	______	______
10 (10)	______	______

F5A. In the past 12 months, has your CCBHC used any of the quality measure data collected as part of the demonstration to change clinical practice?

• Yes (1)

• No (0)

[ASK F4B IF F4A=1(YES)]

F5B. Please indicate which quality measure(s) your clinic used to change clinical practice and the nature of those changes:

	F5B_M – Measure name	F5B_C – Describe changes to clinical practice
Quality measure 1 (1)	______	______
Quality measure 2 (2)	______	______
Quality measure 3 (3)	______	______
Any other (4)	______	______

F5C. Did your CCBHC find all of the quality measures required for the demonstration relevant and useful for monitoring the quality of CCBHC services?

• Yes (1)

• No (0)

[ASK F5D IF F5C=1(YES)]

F5D. Which measure(s) did your CCBHC not find relevant or useful and why?

	F5B_M – Measure name	F5B_C – Describe why
Quality measure 1 (1)	______	______
Quality measure 2 (2)	______	______
Quality measure 3 (3)	______	______
Any other (4)	______	______

F6A. Has your clinic found reporting quality measures challenging?

• Yes (1)

• No (0)

[ASK F6B IF F6A = YES]

F6B. What has your CCBHC found challenging about reporting the measures?

Check all that apply.

• Incorporating data collection into clinical workflows (1)

• Conducting the required screenings (2)

• Accessing data from electronic sources, including electronic health records (3)

• Missing data (4)

• Tracking/contacting clients in the community to conduct follow-up assessments (5)

• Other (specify): (6) _____________________

F7A. Does your CCBHC use tools such as data dashboards and, report cards, to monitor and/or improve quality of care?

• Yes (1)

• No (0)

[ASK F7B-D IF F7A=1(YES)]

F7B.What tools does your CCBHC use?

Check all that apply.

• Data dashboards (1)

• Report cards (2)

• Other (please describe): (3)____________

F8C. Do your CCBHC’s data dashboard(s) or report card(s) report the following

a. Please select “Yes” or “No” for each response.

b. If you select “Yes” for any response, please describe how the information is used.

	F8C_0		F8C_1 Describe how the information is used for “Yes” responses
	Yes (1)	No (0)
Appointment statistics (appointments kept, no-shows) (1)		
Quality measures required for the demonstration (2)		
Other quality measures (not required for the demonstration) (3)		
Staff productivity and performance indicators (4)		
Client risk stratification/risk indicators (5)		
Other (please describe _____________) (6)		

F8D. Can all staff view your CCBHC’s data dashboards and/or report cards?

• Yes (1)

• No (0)

F9A. Is your CCBHC eligible to receive Quality Bonus Payments from the state for achieving certain quality measure benchmarks or improvements under the demonstration?

• Yes (1)

• No (0)

[ASK F9B-F IF F9A=1(YES)]

F9B. Was the bonus payment amount your CCBHC was eligible to receive sufficient to motivate any changes (such as to changes clinical practice, staffing, or other processes) at your CCBHC?

• Yes (1)

• No (0)

F9C. Did your CCBHC make any of the following changes as a result of the opportunity to receive Quality Bonus Payments?

Check all that apply.

• Implemented new screening tools or processes for depression (1)

• Implemented new screening tools or processes for alcohol use (2)

• Implemented new screening tools or processes for suicide risk (3)

• Implemented new screening tools or processes for physical health conditions (4)

• Added new services (5)

• Expanded service hours (6)

• Implemented same day scheduling (7)

• Hired staff (8)

• Provided staff training (9)

• Changed staff roles (10)

• Changed documentation or data collection processes (11)

• Changed client outreach or follow-up practices (12)

• Changed processes to improve medication adherence (13)

• Other (please describe): (14)____________

F9D. Which aspect of the Quality Bonus Payments motivated changes at your CCBHC?

Check all that apply.

• Bonus payment amounts (1)

• The quality measures used to award payments (2)

• The quality measure performance threshold used to award payments (3)

• Comparing performance to other CCBHCs in your state (4)

• Other (please describe): (5)____________

F9E. Has your CCBHC received a Quality Bonus Payment since the beginning of the demonstration?

• Yes (1)

• No (0)

[ASK F9F-G IF F9E= 1(YES)]

F9F. Has there been a demonstration year in which your CCBHC was not awarded a Quality Bonus Payment (excluding years that have not yet been awarded)?

• Yes (1)

• No (0)

F9G. How has your CCBHC used the Quality Bonus Payment funds it received?

F10A. Would your CCBHC find additional support and technical assistance helpful to improve quality reporting?

• Yes (1)

• No (0)

[ASK F10B IF F10A=1(YES)]

F10B. What types of support would your CCBHC find helpful and from whom (e.g., state officials, others)?

Section G. Certified Community Behavioral Health Clinic (CCBHC Costs)

In this section we would like to know more about your CCBHC’s experience with the prospective payment system (PPS).

G1. Please indicate if the PPS allowed your CCBHC to cover the costs of any of the following:

Check all that apply.

• Services not reimbursed under your Medicaid state plan prior to the demonstration (please indicate which services): (1)____________

• Staff or staff types not supported by traditional Medicaid or other reimbursement mechanisms prior to the demonstration (please indicate which staff types): (2)____________

• Providing services to more people than before (3)

• Open access or same day scheduling (4)

• Transportation vouchers or assistance (5)

• Other access improvements. Please list these improvements: (6)____________

• Care coordination improvements (e.g., care coordination partnerships). Please list these improvements : (7)______________

• Data dashboards or report cards (8)

• Other data collection or quality improvement activities (e.g., data dashboards). Please list these efforts: (9)____________

• Staff training (10)

• Other activities to support the CCBHC model (e.g. staff meetings) (please list): (11)____________

• Other activities not previously supported by traditional Medicaid or other reimbursement mechanisms (please list): (12)____________

G2A. We would like to understand if the PPS rate for your CCBHC has been adequate to cover the costs of the CCBHC model. Please indicate if the PPS does not fully cover the costs of providing the CCBHC services for clients enrolled in Medicaid.?

• Yes (1)

• No (0)

G2B. Does your CCBHC rely on federal block grants, non-Medicaid state or local funds, donations, or other sources of funding to cover the costs of services and supports for Medicaid beneficiaries? Please indicate what the funds are used to pay for if so. why if so.

	G2B_0		G2B_1 Describe what the funds are used to cover for Medicaid beneficiaries
	Yes (1)	No (0)
Federal block grants (1)		
Non-Medicaid state or local funds (2)		
Donations (3)		
Other (please list):______________ (4)		
Other (please list):______________ (5)		
Other (please list):______________ (6)		

G3. To what extent did the actual number of visits during the year deviate from the projected number of visits used to set the PPS rate for the previous demonstration year?

The actual number of visits in the previous demonstration year was:

Select one response.

• Very close to the projected number of visits (1)

• Somewhat close to the projected number of visits (2)

• Not at all close to the projected number of visits (3)

• Unsure (4)

G4. Are there any services your CCBHC delivers to Medicaid beneficiaries that your CCBHC bills Medicaid for separately (that is, that are not covered by the PPS)?

• Yes. Please list the services:______ (1)

• No (0)

G5. What challenges has your clinic experienced with the PPS, if any?

Section H. Sustainability

In this section, we would like to learn about your clinic’s plans for sustaining the CCBHC model.

H1A. Is your clinic planning to sustain the CCBHC model after demonstration funding ends?

• Yes (1)

• No (0)

[ASK H1B-D IF H1A=1(YES)]

H1B. Does your CCBHC currently have a formal, written sustainability plan in place?

• Yes (1)

• No (0)

H1C. How does your clinic plan to sustain the model after demonstration funding ends (for example, seeking a CCBHC Expansion grant or using other Medicaid funding)?

Please describe:

H1D. How confident are you that your organization clinic will be able to fully sustain the following components of the CCBHC certification criteria after the grant funding ends?

	Very confident we will NOT	Fairly confident we will NOT	I don’t know if we will or not	Fairly confident we WILL	Very confident we WILL
Staffing	1m	2m	3m	4m	5m
Mental health services	1m	2m	3m	4m	5m
Substance use disorder services	1m	2m	3m	4m	5m
Psychiatric rehabilitation services	1m	2m	3m	4m	5m
Crisis services	1m	2m	3m	4m	5m
Primary care screening or monitoring	1m	2m	3m	4m	5m
Services for children or adolescents	1m	2m	3m	4m	5m
Open access or same-day scheduling	1m	2m	3m	4m	5m
Services on weekends or after business hours	1m	2m	3m	4m	5m
Providing care for anyone regardless of ability to pay	1m	2m	3m	4m	5m
Partnerships with external providers	1m	2m	3m	4m	5m
Collecting data for CCBHC-required quality measures	1m	2m	3m	4m	5m
Continuous quality improvement activities	1m	2m	3m	4m	5m
Including consumers, family members, and people with lived experience in clinic governance	1m	2m	3m	4m	5m

Section I. Wrap-up

I1. Please use the space below to provide any additional information that you think would help us understand your clinic’s experience implementing the CCBHC model. If you do not have additional information to add, please click next to complete the survey.

THANK_YOU. Thank you for your responses to this survey! To change any of your answers, please navigate to the appropriate section using the provided buttons. To complete the survey, click "Next" to submit.

DRAFT 05/19/25 Mathematica^® Inc. 43