CCBHC care managers-site interview

ATTACHMENT D

Site Interview Protocol
Ccbhc CARE MANAGERS

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site visit Interview questions- ccbhc CARE MANAGERS

On-site interviews will be conducted with program leadership, providers, and administrative staff from CCBHC demonstration sites in 4 states. The interviews will address specific factors that shape CCBHC policies, and will be tailored based on the information already gathered through applications and other sources—or gaps in that information—regarding participating sites’ program characteristics. The interviewer will transfer the information gathered from the interviews into a Debrief Template that organizes data by criteria domain and corresponding research questions. The general protocol for site visit interviews with CCBHC care managers is presented below.

A. Introduction

1. Please describe your current role/position.

a. For how long have you held this position?

b. [For CCBHC staff] What are your key responsibilities in the CCBHC?

c. [For CCBHC staff] If you were at this agency prior to CCBHC certification, how has your role changed with CCBHC certification?

2. What are the most important ways that your work in the CCBHC differs from your prior work in this site before certification or in other places you've worked with this population?

B. Care coordination

1. How is client care coordinated (i.e., designated care manager, case manager, care coordinator; direct communication between providers)?

a. Describe the process for care planning?

• Who is responsible for updating the treatment plan and when?

2. What types of staff are involved in care management for CCBHC clients (i.e., the interdisciplinary treatment team for directing, coordinating, and managing care)?

3. How many clients do you typically manage at any given time?

a. What is the average caseload of CCBHC clients for full-time care managers, or the CCBHC staff who manage care coordination?

4. Please describe the process for linking patients to external healthcare services.

a. Describe the process for referring clients to services at a designated collaborating organization (DCO), if applicable?

• For each DCO, probe on whether the relationship with DCO is new since CCBHC certification or pre-existing, and if a pre-existing relationship, how has the process for referring changed since certification.

b. How are referrals to external services (e.g., specialists) managed?

c. How are referrals tracked, with follow-up? [e.g., paper or electronically, sharing clinical information, tracking status of referrals, following up to obtain specialist reports] How often?

d. Which staff are responsible for follow-up with referrals?

e. Describe the process for exchange of information regarding discharges from external healthcare entities?

• Are there discharge planning procedures?

• If yes, please describe discharge planning procedures and reasons for them.

f. What is the process for exchange of information regarding crisis services provided via a DCO, outside entity, or state-sanctioned crisis service system?

5. Please describe the process for linking patients to other community/social services.

a. How are client’s non-healthcare needs (e.g., housing authority, transportation, child care, legal, peer support, etc.) managed, and by whom?

b. How often are clients linked to community resources? Are these referrals tracked?

c. Is the referral process new or was it in place prior to CCBHC certification?

• How has the processed changed since CCBHC certification, if at all?

d. What kinds of partnerships do you have with community organizations? How does the CCBHC interdisciplinary treatment team interface with other organizations in the community?

6. Which providers do you work with most closely within the CCBHC? 

a. How do you share information with those providers? 

b. Do you have regularly scheduled meetings with those providers?

7. Which providers do you work with most closely in the community? 

a. DCOs?

b. Primary care providers?

c. Social services providers?

d. Other community providers?

e. If any, what are the differences between working with DCOs and working with other providers?

8. Has becoming a CCBHC affected how you interact with those providers?

9. Are electronic health records used by your CCBHC?

a. Do you have full access to EHR information on your patients in the CCBHC? 

b. Are EHR information and/or services available to CCBHC clients through a secure electronic system? (e.g., health information, clinical visit summaries, 2-way communication with the practice, emails to notify clients about needs.)

c. Do you have an interactive website to support CCBHC client access?

d. Does the EHR have a clinical registry function or tool to track patients with certain conditions?

C. Accessibility

1. Has the range of services that you can provide your clients changed under the CCBHC model? 

2. What hours/days are care coordination services available to clients?

a. Over the phone?

b. In person?

c. Electronically?

3. What hours/days are various services available for clients at your CCBHC, in person? Let’s talk about them one-by-one.

• Outpatient MH services

• Outpatient SUD services

• Assisted Outpatient Treatment

• Management of psychoactive drugs

• Medication assisted treatment

• Crisis planning services

• Screening/assessment/diagnostic services

• Crisis services/Urgent care

• Treatment planning services

• Psychiatric rehabilitation services

• Peer support services for patients

• Support services for families

• Targeted case management

• Primary health screening and monitoring

• Armed forces and veteran’s services

• Other (specify)

4. Can appointments for MH and PC visits be made during the same call, or scheduled for the same day?

5. Are services available on a walk-in basis? If yes, what types of services?

6. Are there waiting lists for services or visits?

a. If yes, approximately how many people are on waiting lists?

b. What is the duration of time on waiting list until service is received?

7. How are appointments made and coordinated with DCOs?

8. What services (e.g., MH / PC advice, community or social supports) are available to clients by phone or electronically? During what hours?

• Outpatient MH services

• Outpatient SUD services

• Assisted Outpatient Treatment

• Management of psychoactive drugs

• Medication assisted treatment

• Crisis planning services

• Screening/assessment/diagnostic services

• Crisis services/Urgent care

• Treatment planning services

• Psychiatric rehabilitation services

• Peer support services for patients

• Support services for families

• Targeted case management

• Primary health screening and monitoring

• Armed forces and veteran’s services

• Other (specify)

a. If clinical advice is provided by phone or electronically, does the program have relevant written policies, defined standards, and performance monitoring about the timeliness of this advice?

9. What is the process for talking to clients directly about the range of services available to them under the CCBHC model?

a. Are you carrying out any outreach activities to reach clients who are not engaged in CCBHC services?

b. What kinds of outreach (e.g., developing relationships with community organizations, advertising, etc.)?

c. Specific types of clients/target population(s)?

D. CCBHC benefits and challenges

1. What do you think have been the best part or benefits of working in a CCBHC? 

2. What do you think have been the most challenging parts of working in a CCBHC? 

a. Is there anything you would like to change/anything that could be improved? How?

E. Interviewee feedback/open discussion

1. What have we missed? What else do we need to know that we haven’t asked you?

2. Is there anyone else who works in care management/coordination who should be included in these interviews?

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