Care coordination is an activity rather than a service. The CCBHC is responsible for all care coordination, whether it involves coordination within the CCBHC, with a designated collaborating organization (DCO), or with another entity identified in the statutory language related to care coordination. More information is provided under Program Requirement 3: Care Coordination in the CCHBC certification criteria – 2016 (PDF | 789 KB).

The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing consumer care activities and sharing information among all of the participants concerned with a consumer’s care to achieve safer and more effective care. This means the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.”

Who is Involved in Care Coordination?

Care coordination may include the following facilities and services:

• Federally qualified health centers and rural health clinics may provide services that are not provided directly through the CCBHC
• Inpatient psychiatric facilities, substance use detoxification services, post-detoxification step-down services, and residential programs
• Schools, child welfare agencies, juvenile and criminal justice agencies and facilities, Indian Health Service (IHS) youth regional treatment centers, state-licensed and nationally accredited child placing agencies for therapeutic foster care service, and other social and human services
• Department of Veterans Affairs (VA) medical centers, independent outpatient clinics, drop-in centers, and other VA facilities
• Inpatient acute care hospitals and hospital outpatient clinics

Determining Which Services to Include

The states have flexibility to determine the standard outpatient mental health and substance use disorder services that will be required for their CCBHCs. Frequent outpatient treatment services include group and individual therapy, medication evaluation and management, and addiction technologies.

Specifically, criteria 4.f.2 states that, based on the needs assessment, “states must establish a minimum set of evidence-based practices required of the CCBHCs.” In addition, states have the flexibility to determine whether any services beyond the “minimum set” should be offered to meet the needs of the consumers served. These additional evidence-based practices can either be provided directly by the CCBHC or through a DCO arrangement.

Intellectual and developmental disabilities (IDD) Services

Although clinics can provide services to the IDD population, these services are not part of the CCBHC certified services and are not to be included in the prospective payment system (PPS). CCBHCs are to provide behavioral health, not IDD, services. Individuals who have co-morbid behavioral health/IDD conditions would be eligible for the behavioral health services that are provided if they meet the eligibility criteria.

How to Coordinate Care

Access more information on establishing and supporting care coordination:

• Care Coordination Agreements and Care Transitions
• Working With a Designated Collaborating Organization (DCO)
• Substance Use Providers and CCBHCs
• CCBHCs Using Telehealth or Telemedicine
• Screening, Evaluation, and Timely Services for New Consumers
• Person- and Family-Centered Care and Peer Support