CCBHC State Official Interview Protocol Year 4

State Officials Interview Protocol – Evaluation Year Four

EVALUATION YEAR FOUR TELEPHONE INTERVIEW QUESTIONS – STATE OFFICIALS

In each evaluation year, we will conduct semi-structured telephone interviews with state Medicaid and behavioral health officials in each demonstration state to gather information on demonstration progress at different stages of implementation. The focus of interviews will be adapted based on which evaluation questions will be answered during that evaluation year, and questions will vary between new and original demonstration states. We will tailor the interview protocol in advance of each interview to reflect information about the demonstration in that state. We have identified by name and color-coded questions or parts of questions below that are specific to new states (blue text). The interviewer will transfer the information gathered from the interviews into an Excel template that organizes data by PAMA topic and corresponding research questions. The general protocol for telephone interviews with state officials is presented below.

1. Introduction

   1. Interviewer introduction

      1. Obtain verbal consent to record

   2. Please describe your current role(s)/position(s) and responsibilities.

2. Demonstration Oversight

1. Could you please briefly share how implementation has been going for your state and CCBHCs since we last spoke in the spring (2024)?

1. Does the state still have [number] CCBHCs participating in the demonstration? [If no] Why has the number changed?

2. What have been the key challenges and successes for the state in the last year? What about for the CCBHCs?

2. Has the state’s role in demonstration implementation evolved since we last spoke with you? Please describe if so.

3. How have consumers (including adults with serious mental illness [SMI] and those with substance use disorders), family members (including of adults with SMI and children with serious emotional disturbances), providers, and other stakeholders (including American Indian/Native Alaskans, and other local and state agencies) been involved in demonstration administration over the last three years?

1. What critical issues have they raised?

2. How has their input influenced the demonstration in your state?

4. Could you please update us on how your state has monitored CCBHCs’ adherence to the certification criteria? Any updates on CCBHCs’ efforts to self-monitor?

1. How has the state worked with CCBHCs to ensure they have continued to meet the certification criteria?

3. Access to Care:

   1. Could you please update us on state activities to increase access to care since we last spoke with you in the spring of last year?

   2. Has the state changed any requirements related to access since we last spoke?

   3. Have CCBHCs been able to maintain their activities to increase access during this last year?

   4. How have CCBHC efforts to increase access to care evolved over the course of the demonstration in your state?

      1. What kinds of refinements did CCBHCs make to their strategies or approach to increasing access to care in later years of the demonstration?

   5. What activities to increase access have been most successful over the last few years for CCBHCs? Least successful? Why?

      1. Has this varied by geographic setting?

      2. Have CCBHCs had difficulties reaching any particular populations? Please describe.

      3. What have been some of the lessons learned?

      4. What have been some of the “bright spots”? For example, are you aware of any particularly innovative strategies that CCBHCs have tried that have increased access?

   6. What specific elements of the CCBHC model and its requirements have most helped or hindered efforts to improve access to care under the demonstration? (E.g., the PPS, quality measures or bonus payments?)

   7. How do CCBHCs’ activities to increase or maintain gains in access at this point in the demonstration compare with those of non-CCBHC behavioral health clinics in the state?

   8. Do you have a sense for whether the introduction of the CCBHC model impacted hospitalization rates, ED visits, or ambulatory care visits for CCBHC clients relative to non-CCBHC clients?

      1. If yes, is your perception anecdotal, or have you collected any data on such impacts?

4. Scope of Services:

   1. Has the state established any new requirements or changed any existing requirements related to scope of services since we last spoke? Why?

   2. Have there been any major changes in the scope of services provided by CCBHCs? Please describe.

   3. Has the state provided any new guidance or support or made any new investments to help CCBHCs provide the required services since we last spoke?

      1. [If yes]: What prompted those actions?

   4. Did CCBHCs maintain the required scope of services over time?

      1. [If yes]: What has allowed CCBHCs to maintain the required scope of services over time?

      2. What have been some of the key successes in terms of maintaining the required services? Key challenges?

   5. Have certain services been more or less difficult to maintain?

      1. What challenges did CCBHCs encounter in providing particular types of services?

   6. What challenges did CCBHCs encounter in providing services to particular target populations?

      1. Did CCBHCs overcome these challenges?

      2. Did the state help CCBHCs address these challenges?

   7. [Kentucky and Michigan] What type of primary care screening and monitoring activities did CCBHCs implement?

      1. How did CCBHCs change their practices and workflows to integrate primary care screening and monitoring?

      2. What kind of support did the state provide, if any?

      3. What were the main challenges and successes with this work?

   8. How have on-site primary care arrangements worked out in your state? Did most pre-date the demonstration or did the CCBHC demonstration prompt the integration of on-site primary care services? Did the state help to facilitate any of these arrangements?

9. Could you reflect on the strength of relationships between CCBHCs and primary care providers in your state?

   1. Do they share data?

   2. Do they have formal partnering agreements?

   3. Are they located in close proximity to each other?

   4. What is the relationship between FQHCs and CCBHCs?

10. [If applicable] How have health home initiatives or other relevant policy initiatives affected CCBHC clients’ access to primary care?

11. Do you think that the CCBHC model helped to improve primary care access? Why or why not?

5. Quality of Care

   1. Have there been any changes to the way the state or CCBHCs have collected or reported the required quality measures since we last spoke?

1. Have there been any technological improvements implemented by the state or CCBHCs that have facilitated reporting since we last spoke?

1. Has quality measure reporting gotten easier over time? Why or why not?

   1. Do you feel like these were the right measures to monitor for the demonstration? Why or why not?

2. How has the state used performance on quality measures to help clinics improve quality since we last spoke?

3. How is the state supporting CCBHCs’ continuous QI activities?

   1. Have the state or other groups offered any technical assistance related to quality?

   2. What have been the key challenges and successes for continuous quality improvement at CCBHCs?

   3. Are there any “bright spots” you’d like to share? For example, are you aware of any particularly innovative and successful CQI activities that you’d like to highlight?

4. Has the state used quality measure performance to change any policies since we last spoke? Please describe if so.

5. [Except Oregon] Do you think quality bonus payments incentivized higher quality care in your state? Why or why not?

1. What specific mechanisms of the quality bonus payment systems changed provider behaviors?

   1. If applicable, what specifically is it about the quality bonus payment system that incentivizes higher quality? For example, is it the amount of the payment? The measures the state is using? The ability to benchmark a clinic to others in the state?

2. Were there any surprises in how the quality bonus payment system played out in your state over these last few years or did it work as expected? Any other reflections you’d like to share?

1. Impacts on Costs and Sustainability

   1. Did the state rebase its PPS rates or adjust them for inflation in the last year?

      1. [If yes]: What led to the decision to do so? How did you use cost reports for rebasing?

1. Did you need to make new appropriations to fund the demonstration since we last spoke? How much is currently allocated for the demonstration?

2. [Managed care states] Did the state fully incorporate PPS rates into capitation payments or elect to make wraparound payments to CCBHCs?

1. [States that incorporated] Did the state make any adjustments to the portion of the state’s capitation rate associated with the CCBHC demonstration?

2. [Wraparound payment states] Did the state make wraparound payments to CCBHCs in the past year?

3. Have there been any changes in the state that would affect the way CCBHCs are submitting Medicaid claims for clients in CCBHCs?

4. How did the PPS system support your state’s efforts to improve access, quality of care, and scope of services, if at all? What about for clinics?

1. Has the PPS facilitated any specific innovations? For example, innovative ways of service provision, use of technology?

5. How did the introduction of the CCBHC model impact state Medicaid costs? What were the main drivers of demonstration impacts on costs?

   1. Do you have a sense for what could explain variation in costs across CCBHCs? For example, was it primarily due to CCBHC location (urban vs. rural clinics), challenges hiring staff in some areas, or other reasons?

6. If state Medicaid costs increased as a result of the demonstration, were those increases fully covered by the enhanced demonstration FMAP?

7. Have you been able to determine whether the state has seen any savings as a result of the demonstration?

1. Were these savings experienced in the Medicaid program? Or other service systems (behavioral health, criminal justice, etc.)?

8. Are you planning to sustain the model after the demonstration? Why or why not?

   1. [If yes] How are you planning to sustain the model?

   2. [If yes] Are you planning to make any changes to the requirements of the CCBHC model? Will you retain all the required services and types of staff? Why?

   3. [If yes] What specific funding mechanisms do you plan to use? Are you planning to make any changes to the payment system? Please describe.

9. Would you like to share any updates on how your state integrated CCBHCs with other policy initiatives over the course of the demonstration?

7. Interviewee Feedback/Open Discussion

   1. Any final reflections you would like to share? For example, reflections on greatest benefits of model? Biggest drawbacks?

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

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