Caring for the Whole Person

Michael,* a 43-year-old man living with schizoaffective disorder, was successfully managing his mental illness through regular outpatient treatment. But he hadn’t told his mental health clinicians that he had heart disease—or that he did not have a primary care clinician. His care team did know that he lacked permanent housing and was moving in and out of different living situations in the Portland area, which could only make matters worse. Without access to regular physical healthcare, he soon began visiting the emergency department (ED) for each heart-related incident.

Each time he went to the ED, he left with a referral to a cardiologist. But—largely due to his housing situation and lack of primary care—he was never connected to the specialty services that could have changed the course of his disease. The situation kept worsening, until soon he was visiting the ED twice a month. Hospital workers gave him the best possible care while he was with them, only to see him readmitted again … and again … and again.

In a typical scenario, Michael might never have gotten access to the heart care he needed. All too often, patients like Michael fall through the cracks of our fragmented, overburdened healthcare system, continually utilizing EDs or hospitals for health crises that could be avoided with timely access to specialty outpatient services and chronic disease management. In the worst-case scenario, his untreated heart disease might have ultimately killed him; he would be one of millions of Americans living with serious mental illness whose lives are cut short due to untreated physical health conditions.

But Michael had the benefit of being a client at LifeWorks NW, a mental health clinic piloting a new model of care delivery under the Certified Community Behavioral Health Clinic (CCBHC) demonstration.^† As a newly minted CCBHC—with enhanced funding designed to transform service delivery—LifeWorks NW had the strategies and know-how to help. The LifeWorks NW Rapid Response Team flagged Michael’s frequent ED visits and stepped in to intervene.

LifeWorks NW’s Rapid Response Team is just one of many innovations supported by the CCBHC model. It’s a mobile team of three master’s level clinicians whose sole purpose is to connect with clients who have been hospitalized or seen in the ED and keep them from being readmitted. With access to an electronic system that tracks hospital and ED usage in real time, the team can flag clients in need, coordinate with hospital staff, touch base directly with clients to help them navigate their time in the hospital or ED, and get them access to the right outpatient health services upon discharge—including community mental health services, primary care, and specialty services like cardiology. The team can also help clients address unmet social drivers of health, like lack of food or cold exposure, that all too often push them to EDs when there is nowhere else to go.

After the Rapid Response Team connected with Michael, they helped him set and attend his referral appointment with the cardiologist. With support from the Lifeworks NW care coordinators and outreach specialists, he was able to move into supported housing with primary care available onsite. Through LifeWorks NW’s onsite pharmacy, Michael had convenient access to the medications he needed. His heart disease began to come under control. The result: Michael went from two ED visits per month to two total visits in the following six months—an 83 percent reduction. In all likelihood, the LifeWorks NW team had helped save Michael’s life.

What Is a CCBHC?

CCBHCs are clinics that meet defined federal criteria for comprehensive, evidence-based mental health and substance use care that is coordinated and integrated with primary care, hospitals, and other partners. The CCBHC model recognizes that true well-being goes beyond addressing behavioral health or physical health needs to attend to the whole person. Using staff with appropriate training, CCBHCs must provide nine core services: crisis services; treatment planning; screening, assessment, diagnosis, and risk assessment; outpatient mental health and substance use services; targeted case management; outpatient primary care screening and monitoring; community-based mental health care for veterans; peer, family support, and counselor services; and psychiatric rehabilitation services. They must offer access to care at times and places convenient to those served, including by delivering services outside the four walls of the clinic, while still meeting standards for timely access to care. CCBHCs are also required to conduct client- and family-centered support activities—for example, the coordination of transportation and housing assistance that Michael received—that are not billable under typical payment systems but are critical to addressing each client’s whole spectrum of needs. They must reach out into communities to engage with vulnerable or high-risk individuals and bring them into care. Other criteria relate to organizational structure, including the requirements that members of the community served be part of the CCBHC’s board, and specify the state and national quality reporting standards to which CCBHCs will be held accountable.¹ Importantly, given the high prevalence of co-occurring physical and mental health conditions, CCBHCs are expected to monitor clients’ basic physical health indicators, screen them for any needs or barriers related to accessing primary care, and help connect them to physical health services as needed to address any acute or chronic conditions.

LifeWorks NW is one of 12 clinics in Oregon that went through a lengthy process to become CCBHC-certified when the model first launched in 2017 as a Medicaid pilot in eight states. LifeWorks NW provides quality, culturally responsive mental health and addiction services and integrated physical healthcare across the lifespan throughout Washington, Clackamas, and Multnomah counties. Its status as a CCBHC and the funding that comes with it have enabled it to greatly expand services like the Rapid Response Team that would not otherwise be reimbursable under standard payment models.

For clients like Michael, those services can make all the difference.

Today, LifeWorks NW is one of nearly 150 state-certified CCBHCs in 12 states. There are also more than 350 clinics in 37 states and territories that have received temporary, time-limited federal grants to initiate CCBHC activities. Interest in the model is growing, and the recent authorization of up to 10 new states in the demonstration every two years means CCBHCs could be nationwide within the next 10 years.²

Why the CCBHC Model?

To understand the CCBHC model’s origin, it is helpful to take a short trip back in time. The nation’s community mental health centers, or CMHCs, were established in 1963 under the last bill President John F. Kennedy signed into law. Envisioned as “a wholly new emphasis and approach to care for the mentally ill,” these community-based providers were designed as an alternative to psychiatric hospitals that had become known for confining people with serious mental illness within “antiquated,” “overcrowded” settings while providing suboptimal—and often actively harmful—treatment. In contrast, proponents reasoned, the newly created CMHCs would provide treatment and supportive services to individuals living within their own communities, with care based on the latest medical advances. Ultimately, this would enable the closure of costly, ineffective psychiatric hospitals and offer people living with mental illness the opportunity to thrive in their communities.³

Unfortunately, while the following decades brought a surge in psychiatric hospital closures, an accompanying surge in resources for community-based care never materialized.⁴ Many people with the most severe conditions struggled to access care,⁵ while homelessness, unemployment, and poverty grew.⁶ Some former state hospital patients “began to cycle in and out of acute care settings or migrate to jails, prisons, homeless shelters, and similar settings, a trend that has come to be known as ‘trans-institutionalization.’ ”⁷

Congress’s 1980 passage of the Mental Health Systems Act attempted to “right the ship”⁸ with an infusion of funding for CMHCs, augmented with community support services. Yet, this landmark law was nearly entirely repealed by the subsequent Congress through the Omnibus Budget Reconciliation Act of 1981, signed into law by President Reagan. The following year, federal funds for CMHCs were shifted to a Mental Health Block Grant program, which was capped each year and routed through state mental health departments.⁹

Since that time, federal funding for the Mental Health Block Grant and its parallel program, the Substance Abuse Prevention and Treatment Block Grant, has not kept pace with the rising need for care.¹⁰  Though Medicaid has emerged as the single largest payer for mental health and substance use treatment,¹¹ Medicaid reimbursement for behavioral health services falls far short of payment for comparable medical/surgical services,¹² leaving community providers severely underfunded and frequently unable to meet the full need for care in their communities.

Inaccessibility and unaffordability of treatment are consistently cited among the top reasons that people do not receive care.¹³ The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that only 47.2 percent of American adults with any mental illness received mental health treatment in 2021. Among adults with a serious mental illness, 65.4 percent received treatment—better, but still reflecting that more than 3 in 10 Americans who truly need care did not access it. The situation is even worse for those living with a substance use disorder: just 4.1 million of the 43.7 million Americans over 12 years old who needed substance use treatment received it in 2021.¹⁴

People whose mental health or substance use conditions go untreated all too often wind up in hospitals and EDs for conditions or complications that could have been more effectively addressed earlier in the course of illness. Lack of community-based care capacity has contributed to “boarding,” in which patients remain longer than medically required in a hospital or ED because there is no appropriate care setting to which they can be discharged. This limits bed availability for other individuals in need and places additional burden on hospital and ED clinicians and staff. According to the American College of Emergency Physicians, “the stresses created by psychiatric patient boarding can lead to longer-term problems for physicians, including increasing levels of frustration and burnout”¹⁵—but the problem isn’t limited to physicians. Nurses and other hospital and ED staff experience comparable challenges and are just as likely to experience moral distress and moral injury under these conditions.¹⁶

Meanwhile, community-based providers struggle with a fractured financing system that fails to fully support and incentivize timely comprehensive services, care coordination, and population health management. Community-based mental health and substance use providers work tirelessly to cobble together funding from multiple private and public sources to deliver the latest evidence-based care. Yet, the scope and quality of services vary from community to community, creating inequities and leaving clients and health system partners unsure of what to expect from referral partners. Severe workforce shortages¹⁷ have contributed to long wait times for care, stretching to 48 days on average within community-based mental health centers.¹⁸ With Medicaid reimbursement rates too low to support competitive wages, clinics report losing staff to other employers that offer better pay, such as grocery stores, fast food restaurants, banks, and the hospitality industry.¹⁹ And without a defined status in federal law, initiatives to support the rest of the healthcare system with technology adoption and other modernization efforts too often bypass behavioral health providers,²⁰ leaving them struggling to share electronic data and participate in value-based payment systems.²¹

Amid these problems, the CCBHC model emerged in 2014. The Protecting Access to Medicare Act²² established a new Medicaid demonstration program that articulated, for the first time since 1963, a federal definition for community-based mental health and substance use providers offering comprehensive outpatient care. This definition, which was further detailed in guidance from SAMHSA (updated in 2023),²³ established substantial new requirements for clinics in order to

• expand the scope of services they offer;
• engage proactively with unserved and underserved populations to reduce unmet need for care;
• ensure individuals receive high-quality, evidence-based services; and
• improve coordination and connectivity across health sectors.

CCBHCs must serve anyone in need of care, regardless of their diagnosis, ability to pay, or place of residence. They must meet standards related to timeliness of access, including 24/7 access to crisis services delivered by mobile teams. They are subject to quality reporting requirements aimed at ensuring accountability for services and outcomes.

In return, qualifying clinics receive a bundled daily or monthly Medicaid payment rate calculated to support their costs of expanding services and reaching new populations. This payment rate, known as the Medicaid prospective payment system or PPS, gives CCBHCs flexibility to devote resources to a wide variety of activities not traditionally billable under the medical model of insurance, but which are known to improve clients’ engagement in care and their health outcomes. For the first time, participating clinics have an ongoing, sustainable source of federal funding for supporting clients through care transitions, identifying and reaching out to individuals at risk in their communities, leveraging technology to expand their reach, and engaging in active collaboration with health sector partners.

The original eight-state demonstration program was expanded to two additional states in 2020 via the CARES Act.²⁴ Two additional states have implemented the model independently in Medicaid outside of the demonstration, and 15 states are currently going through a yearlong process to plan their CCBHC programs and apply for the demonstration. Meanwhile, a SAMHSA-run grant program offers temporary funding supporting hundreds of individual clinics around the nation in building out CCBHC services and activities. Most recently, Congress opened participation in the demonstration to all states over the coming years.²⁵ Today, there are nearly 150 certified CCBHCs, along with more than 350 CCBHC-like grantees. Together, they operate in 49 states and territories, serving an estimated 2.1 million individuals.²⁶

The results have been transformative, with clinics expanding staffing, increasing the types of services they offer, shifting expanding care delivery in communities outside the walls of brick-and-mortar clinics, and engaging with partners in innovative ways—ultimately, contributing to vastly improved care on behalf of the clients they serve.²⁷ The effects extend beyond mental well-being, with CCBHCs better positioned to help clients address their full spectrum of health needs. As our team regularly hears from clinic staff participating in the model, its financial flexibility gives them the ability to support clients in ways that were previously impossible. Put another way, as the New York Times noted in a recent editorial on the development of CCBHCs, “The solution to America’s mental health crisis already exists.”²⁸

CCBHCs Serve Patients and Communities

The CCBHC model has allowed demonstration participants to transform the ways they deliver care, improving patient health and well-being, but that isn’t the only area where its results are measurable. CCBHCs also return significant benefits to the communities they serve, especially by helping to reduce strain on overwhelmed healthcare systems and health professionals—and they work because they allow each clinic to devote resources to the needs of their specific communities.

CCBHCs Help Alleviate Burdens on Hospitals and Emergency Departments

Utilization of inpatient and ED services frequently occurs when individuals experience a mental health or substance use crisis—yet research indicates that the vast majority of these individuals do not require inpatient treatment and could be effectively helped at lower levels of care. For example, a decade of data from Georgia found that just 14 percent of individuals who were cared for by a mobile crisis team, ED, or crisis facility had clinical needs that aligned with inpatient treatment.²⁹

The CCBHC model offers improved opportunities to engage clients in early, effective, community-based treatment that reduces their need for inpatient and emergency care. It expands the continuum of crisis response by requiring CCBHCs to ensure all community members have access to 24/7/365 crisis care, including mobile crisis response, crisis stabilization, and other types of emergency intervention. In addition, all CCBHCs are required to establish care coordination partnerships with local hospitals and emergency departments. These partnerships are designed to reduce psychiatric boarding in emergency and inpatient units, improve care transitions, and reduce hospital readmissions by ensuring individuals don’t fall through the cracks upon discharge, whether they were admitted for mental health or substance use issues or for physical health issues, as Michael was. With their hospital partners, CCBHCs have taken a variety of approaches. Among them: 50 percent report they have implemented a notification system in which CCBHCs are informed when a client is admitted for any reason or discharged and can follow up accordingly; 42 percent have established telehealth models in which CCBHC staff provide consultations, assessments, or other support to hospital and ED patients; and 20 percent report they have co-located CCBHC staff in an emergency department to conduct risk assessments, provide referrals and/or linkages to care, or offer peer support to assist patients with navigating the hospital/ED experience and discharge process.³⁰ Taken together, these interventions not only improve patients’ access to treatment but also alleviate the burden on overworked hospital staff.

To measure and ensure the efficacy of their collaborations, clinics and states in the federal CCBHC demonstration must report on timeliness of post-hospital/ED follow-up for psych-related visits, and clinics in the CCBHC grant program must track changes in clients’ utilization of hospital and ED services.³¹ SAMHSA reports that among CCBHC grantees, as of July 2022, clients had experienced a 72 percent reduction in hospitalization and a 69 percent reduction in ED visits over the period from individual intake to most recent reassessment (at least six months).³² Similarly, in a 2021 research effort, four CCBHC demonstration states provided data showing a reduction in utilization of higher levels of care, including ED visits and hospital inpatient admissions, through the CCBHC program. Remarkably, states reported the reductions even as they substantially increased the number of people served, many of whom had prior unmet needs and often had more complex mental health, substance use, and/or physical health needs.³³

The results have been even more impressive at some CCBHCs. As part of its CCBHC implementation in 2015–2017, GRAND Mental Health in Oklahoma put in place a new crisis response model designed to divert individuals in crisis from law enforcement involvement and psychiatric hospitalization. GRAND Mental Health opened several new crisis stabilization units across its 12-county service area in rural northeastern Oklahoma. Every individual who left the crisis stabilization unit went home with a tablet exclusively equipped to offer free access to behavioral health support at all hours of the day or night. Tablets were also provided to law enforcement officers so they could connect with mental health professionals as needed during calls. By connecting individuals in crisis to immediate behavioral health telehealth support, offering them a 24/7 facility for in-person observation and care, and delivering clinical support to individuals during encounters with law enforcement, GRAND was able to reduce psychiatric hospitalizations by 93.1 percent and eliminate inpatient hospital utilization in 2021.³⁴

Expanding access to care has proven particularly important in rural communities, which frequently lack a comprehensive continuum of care. A recent study of Oregon’s CCBHC program found that access to community-based services increased 30.6 percent at rural and remote CCBHCs during the study period, in contrast to a 4.2 percent decrease in access among a comparison group of clinics that were not certified as CCBHCs.³⁵ These access expansions are coming at the same time rural hospitals are under increasing strain.³⁶ By reducing psychiatric patients’ avoidable hospital use, the CCBHC model has the potential to remove a source of stress on our nation’s hardest-hit hospitals.

CCBHCs Help Alleviate the Workforce Shortage

Expanded access and reduced hospitalization have been driven in no small part by CCBHCs’ ability to improve staff recruitment and retention after implementation. The National Council for Mental Wellbeing found in a recent survey that CCBHCs hired an average of 27 new staff per clinic—a 13 percent expansion over prior staffing levels.³⁷

Peer support specialists—people with lived experience who are trained to provide nonclinical support services—are CCBHCs’ most common type of newly hired staff. They are essential to the model because they provide critical outreach and support to help keep clients engaged in care and in control of their health. Peer support specialists contribute to transforming the practice culture at CCBHCs with their focus on reaching clients by connecting through lived experience, often with individuals who otherwise might not have sought care. One clinic administrator in Oregon called this a “transformative” development in behavioral health because it enabled a culture shift: instead of focusing on treating “compliant” clients who show up at the clinic, peer support specialists are able to focus on reaching the clients who don’t show up but who may be the most in need of assistance.³⁸

CCBHCs have also sharply increased their hiring of primary care providers, with 68 percent of CCBHCs reporting they have hired nurses, medical assistants, and in some cases primary care physicians.³⁹ These staff are responsible for screening and monitoring clients’ physical health needs to ensure they receive care for chronic physical health conditions that all too often go untreated when care is not integrated.

The driver of this hiring is CCBHCs’ financing model. Both grant-funded and Medicaid-funded CCBHCs have reported using their increased financial resources to support workforce expansion, but the results have been most significant among those that receive funds through the Medicaid prospective payment system.⁴⁰ Clinics have used their daily or monthly bundled PPS rates to introduce competitive pay, higher staffing levels with lower caseloads, revised job roles that allow clinicians to practice at the top of their licenses, and other workforce benefits into their practice model. The costs associated with these changes are included in the formula states use to calculate each clinic’s PPS rate. That formula incorporates both the total cost of delivering care aligned with the CCBHC model and the number of daily or monthly encounters to arrive at an average per-encounter rate designed to support CCBHCs’ true costs of serving their population. This means that for the first time, CCBHCs’ payment is set at a level that allows them to better recruit, support, and retain their workforce. As an administrator at the Central Kansas Mental Health Center reported,

We have several positions to fill, but once filled, we are retaining employees for longer periods of time. We are finally more competitive with other area behavioral health agencies/positions/schools. We’ve had an increased interest in practicums, so much so that we don’t have room for all of the interested students!⁴¹

Many CCBHCs report that these changes have had a profound effect on their workforce. At the National Council, our team hears regularly from CCBHC staff who report enjoying the practice climate of the CCBHC more than other community-based behavioral health settings, leading to improved retention. Without the time constraints and financial pressures of billing for units of service, they are freed up to practice in new ways and have increased flexibility to meet clients’ needs.

This flexible practice environment also allows CCBHCs to be a better resource to health colleagues in their service area. With reduced wait times, referrals can get in the door more quickly. Because they have staff devoted to community partnerships and care coordination—along with financing for technology that supports electronic health information exchange—CCBHCs are better positioned to collaborate with their primary care and hospital partners on shared clients.⁴²

CCBHCs Tailor Care to Each Community

Part of what helps CCBHCs be effective is the way the model positions client needs—rather than financial imperatives or constraints—as the driver of clinical care. At the beginning of their implementation effort, states participating in the demonstration and clinics participating in the grant program must complete a community needs assessment to understand local demographics, service needs, co-occurring conditions, social determinants of health, and more.⁴³ Many of states’ and CCBHC grantees’ implementation decisions are driven by the results of this needs assessment—from the types of language translation services CCBHCs must make available to the types of partnerships CCBHCs must form with other local social service providers (such as homeless shelters or food banks), and more.

Critically, the community needs assessment must address the needs of not only individuals who are already in treatment but also community members who are unserved or underserved, with an emphasis on reaching populations who have historically experienced health disparities. These findings help clinics planning to become CCBHCs determine the appropriate levels and types of staffing for their client population, along with cultural or population-specific competencies staff must have. The costs associated with hiring and training these staff are then built into clinics’ payment rates. Thus, reimbursement is set at a level specifically designed to secure the right number and type of staff to meet community needs.

This differs dramatically from a traditional fee-for-service system, where the availability of services and staff is driven by financial incentives and constraints within the Medicaid fee schedule rather than client needs. Under that traditional system, there is typically limited to no financial support for nonbillable activities that are critical to achieving client health outcomes, such as outreach, engagement, and efforts to leverage data to identify high-risk clients and manage health across subpopulations.

This client-centered staffing model—along with the flexibility afforded by a bundled payment model—allows CCBHC clinicians and staff to prioritize client needs even when services or activities fall outside what behavioral health clinics are typically able to provide. At the same time, the CCBHC model supports and emphasizes the delivery of services outside the clinic, at times and places convenient to those served. Together, these changes have upended traditional service delivery by putting clients’ needs at the forefront.

What’s Next for CCBHCs?

Through the Bipartisan Safer Communities Act signed into law by President Biden in June 2022, every state will have the opportunity to apply to join the CCBHC demonstration by 2030. While that is a historic success and expansion of the program, without establishing a definition for CCBHCs in federal law, it could remain just that—a demonstration program with an end date. Securing a definition for CCBHCs in Medicaid and Medicare—much as hospitals and other healthcare facilities currently have—will also help ensure consistency and longer-term sustainability for CCBHCs across states. Right now, there’s an opportunity to urge our elected officials to cement CCBHCs’ status across the nation. Learn more and register to join our day of CCBHC advocacy on October 18 by going to our advocacy center (go.aft.org/9ut). Together, we can call on lawmakers to ensure there are more CCBHCs in every community nationwide.

The results are clear: CCBHCs are a game changer for improving access to mental health and substance use services coordinated and integrated with physical health and social services, helping reduce the burden on hospitals to provide care to people struggling with a mental health or substance use challenge. They expand access to comprehensive services and provide the person-centric care approach needed to make mental well-being, including recovery from substance use challenges, a reality for everyone.

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Rebecca Farley David, MPH, is a senior advisor on policy and special initiatives with the National Council for Mental Wellbeing, where she oversees the Certified Community Behavioral Health Clinic Success Center. Connor McKay is a director of communications and public relations for the National Council for Mental Wellbeing.

*The client’s name, age, and mental health diagnosis have been changed to protect his privacy. (return to article)

^†Demonstrations are projects conducted and sponsored by the Centers for Medicare and Medicaid Services (CMS) that test new ways to deliver and pay for healthcare; the CCBHC demonstration is overseen by the Substance Abuse and Mental Health Services Administration in partnership with CMS. (return to article)

Endnotes

1. Substance Abuse and Mental Health Services Administration, Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish Certified Community Behavioral Health Clinics (Rockville, MD: US Department of Health and Human Services, 2022), samhsa.gov/sites/default/files/programs_campaigns/ccbhc-criteria.pdf.

2. Bipartisan Safer Communities Act, S.2938, June 25, 2022, congress.gov/bill/117th-congress/senate-bill/2938.

3. J. Kennedy, “Special Message to the Congress on Mental Illness and Mental Retardation, February 5, 1963,” American Presidency Project, presidency.ucsb.edu/documents/special-message-the-congress-mental-illness-and-mental-retardation.

4. R. Frank and S. Glied, Better But Not Well: Mental Health Policy in the United States Since 1950 (Baltimore: Johns Hopkins University Press, 2006).

5. Frank and Glied, Better But Not Well.

6. T. Insel, Healing: Our Path from Mental Illness to Mental Health (New York: Penguin Press, 2022).

7. D. Pinals and D. Fuller, Beyond Beds: The Vital Role of a Full Continuum of Psychiatric Care (Alexandria, VA, and Arlington, VA: National Association of State Mental Health Program Directors and the Treatment Advocacy Center), 9, treatmentadvocacycenter.org/storage/documents/beyond-beds.pdf.

8. Insel, Healing, 35.

9. Insel, Healing.

10. National Association of State Alcohol and Drug Abuse Directors, “Substance Abuse Prevention and Treatment (SAPT) Block Grant,” February 2021, nasadad.org/wp-content/uploads/2019/03/SAPT-Block-Grant-Fact-Sheet-Feb.-2021-FINAL.pdf; and J. Miller, Too Significant to Fail: The Importance of State Behavioral Health Agencies in the Daily Lives of Americans with Mental Illness, for Their Families, and for Their Communities (Alexandria, VA: National Association of State Mental Health Program Directors, 2012), nasmhpd.org/sites/default/files/Too%20Significant%20To%20Fail_0.pdf.

11. Medicaid, “Behavioral Health Services,” Centers for Medicare and Medicaid Services, medicaid.gov/medicaid/benefits/behavioral-health-services/index.html.

12. S. Melek, S. Davenport, and T. Gray, Addiction and Mental Health vs. Physical Health: Widening Disparities in Network Use and Provider Reimbursement (Hockessin, DE: Mental Health Treatment and Research Institute, November 19, 2019), milliman.com/-/media/milliman/importedfiles/ektron/addictionandmentalhealthvsphysicalhealthwideningdisparitiesinnetworkuseandproviderreimbursement.ashx.

13. National Council for Mental Wellbeing, “More Than 4 in 10 U.S. Adults Who Needed Substance Use and Mental Health Care Did Not Get Treatment,” thenationalcouncil.org/news/more-than-4-in-10-us-adults-who-needed-substance-use-and-mental-health-care-did-not-get-treatment.

14. Substance Abuse and Mental Health Services Administration, 2021 National Survey on Drug Use and Health Annual National Report (Rockville, MD: US Department of Health and Human Services, January 4, 2023), samhsa.gov/data/report/2021-nsduh-annual-national-report.

15. J. Simon et al., “The Impact of Boarding Psychiatric Patients on the Emergency Department: Scope, Impact and Proposed Solutions; An Information Paper,” American College of Emergency Physicians, October 2019, acep.org/globalassets/new-pdfs/information-and-resource-papers/the-impact-of-psychiatric-boarders-on-the-emergency-department.pdf.

16. Letter from American College of Emergency Physicians et al. to President Biden, November 7, 2022, acep.org/globalassets/new-pdfs/advocacy/emergency-department-boarding-crisis-sign-on-letter-11.07.22.pdf.

17. Health Resources and Services Administration, “Health Workforce Shortage Areas,” National Summary: Mental Health, US Department of Health and Human Services, February 21, 2023, data.hrsa.gov/topics/health-workforce/shortage-areas.

18. Joy Fruth, lead process change consultant, MTM Services, interview by Rebecca Farley David and Connor McKay, May 2021. Data extracted from MTM Services analysis of 10,000 care access protocol flowcharts collected from 1,000 community mental health centers engaged in initiatives to measure and reduce wait times for care in 47 US states.

19. National Council for Mental Wellbeing, 2022 CCBHC Impact Report: Expanding Access to Comprehensive, Integrated Mental Health & Substance Use Care (Washington, DC: 2022), thenationalcouncil.org/wp-content/uploads/2022/10/2022-CCBHC-Impact-Report.pdf.

20. National Association of State Mental Health Program Directors, “Health Information Technology (HIT) and the Public Mental Health System,” December 2010, nasmhpd.org/sites/default/files/HIT_Policy_Brief.pdf.

21. M. Bailey, R. Matulis, and K. Brykman, Behavioral Health Provider Participation in Medicaid Value-Based Payment Models: An Environmental Scan and Policy Considerations (Hamilton, NJ, and Washington, DC: Center for Health Care Strategies and the National Council for Behavioral Health), chcs.org/media/behavioral-health-provider-participation-in-medicaid-value-based-payment-models-an-environmental-scan-and-policy-considerations.pdf.

22. Protecting Access to Medicare Act of 2014, Pub. L. No. 113-93, April 1, 2014, congress.gov/113/plaws/publ93/PLAW-113publ93.pdf.

23. Substance Abuse and Mental Health Services Administration, Certified Community Behavioral Health Clinic (CCBHC) Certification Criteria (Rockville, MD: US Department of Health and Human Services, March 2023), samhsa.gov/sites/default/files/ccbhc-criteria-2023.pdf.

24. Coronavirus Aid, Relief, and Economic Security Act, Pub. L. No. 116-136, March 27, 2020, congress.gov/116/plaws/publ136/PLAW-116publ136.pdf.

25. Bipartisan Safer Communities Act, Pub. L. No. 117-159, June 25, 2022, congress.gov/117/plaws/publ159/PLAW-117publ159.pdf.

26. National Council for Mental Wellbeing, 2022 CCBHC Impact Report, 4 and 6.

27. National Council for Mental Wellbeing, 2022 CCBHC Impact Report; and National Council for Mental Wellbeing, Transforming State Behavioral Health Systems (Washington, DC: February 2022), thenationalcouncil.org/wp-content/uploads/2022/02/Transforming-State-Behavioral-Health-Systems.pdf.

28. X. Opiyo, “The Solution to America’s Mental Health Crisis Already Exists,” New York Times, October 4, 2022, nytimes.com/2022/10/04/opinion/us-mental-health-community-centers.html.

29. E. Broadway and D. Covington, A Comprehensive Crisis System: Ending Unnecessary Emergency Room Admissions and Jail Bookings Associated with Mental Illness, Assessment #5 (Alexandria, VA: National Association State Mental Health Program Directors, August 2018), dls.virginia.gov/groups/mhs/NASMHPD.pdf.

30. National Council for Mental Wellbeing, 2022 CCBHC Impact Report.

31. Substance Abuse and Mental Health Services Administration, Certified Community Behavioral Health Clinic (CCBHC) Certification Criteria; and Substance Abuse and Mental Health Services Administration, “SAMHSA’s Performance Accountability and Reporting System (SPARS): Services Tool,” OMB No. 0930-0285, Center for Mental Health Services, August 2022, spars.samhsa.gov/sites/default/files/2022-09/CMHSNOMSToolEnglish.pdf.

32. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration: Justification of Estimates for Appropriations Committees, Fiscal Year 2024 (Rockville, MD: 2022), samhsa.gov/sites/default/files/samhsa-fy-2024-cj.pdf, 141.

33. National Council for Mental Wellbeing, Transforming State Behavioral Health Systems.

34. J. Bronson and L. Washington, An Evaluation of the Grand Response Access Network on Demand Model (GRAND Model): Evidence of Effective Outcomes (Nowata, OK: GRAND Mental Health, June 2022), nri-inc.org/media/qa2k0wdf/grand-model-evaluation_june2022_v2.pdf.

35. N. Wallace et al., Evaluation of the Oregon Certified Community Behavioral Health Clinic (CCBHC) Program (Salem, OR: Oregon Health Authority, Oregon Health & Science University, Portland State University School of Public Health, January 26, 2023), oregon.gov/oha/HSD/BHP/Documents/CCBHC-Evaluation-Final-Report.pdf.

36. American Hospital Association, Rural Hospital Closures Threaten Access: Solutions to Preserve Care in Local Communities (Washington, DC: September 2022), aha.org/system/files/media/file/2022/09/rural-hospital-closures-threaten-access-report.pdf.

37. National Council for Mental Wellbeing, 2022 CCBHC Impact Report.

38. Wallace et al., Evaluation of the Oregon Certified Community Behavioral Health Clinic (CCBHC) Program.

39. National Council for Mental Wellbeing, 2022 CCBHC Impact Report.

40. National Council for Mental Wellbeing, 2022 CCBHC Impact Report.

41. National Council for Mental Wellbeing, 2022 CCBHC Impact Report, 12.

42. National Council for Mental Wellbeing, 2022 CCBHC Impact Report.

43. Substance Abuse and Mental Health Services Administration, Certified Community Behavioral Health Clinic (CCBHC) Certification Criteria.

[illustrations: Kim Salt]