Care Plus New Jersey’s CCBHC journey

Success story for behavioral health, social services, primary care and substance use rehabilitation services

About Care Plus New Jersey

Care Plus NJ is a full-service community behavioral health center founded in 1978. The organization provides the entire continuum of care as its services span from residential, conventional outpatient care, individual and group therapy, medication monitoring and more. Care Plus NJ also operates the 24/7 psycho-emergency program in the county as well as a rapid access program for adults in order to divert hospitalization.

---

As Certified Community Behavioral Health Centers (CCBHCs) continue to populate the country, care coordination, data analytics and evidence-based practices are becoming the new norm for human services organizations. CCHBCs empower organizations to provide more effective care at a lower cost. In order to succeed and serve in a value-based care model, Care Plus New Jersey (Care Plus NJ) sought guidance took the proper steps and facilitated new workflows in order to excel as a CCBHC.

Like many community-based organizations, Care Plus NJ saw the need to integrate traditional behavioral health services with primary care. Having already implemented integrated primary care services in their Paramus, New Jersey facility, Care Plus NJ was the first organization in New Jersey to receive a four-year Integrated Primary Care and Behavioral Healthcare Services grant in 2010. The organization’s commitment to integrated care continued when it was certified as New Jersey’s first Behavioral Health Home in 2014 and was one of seven CCBHCs in New Jersey in 2017.

We’ve now become like a well-oiled machine. Change can always be challenging at first, but through staff training, shifted workflows and the technology, we’ve been able to find success with it.

Michelle Alkhalaileh, CIO, Care Plus NJ

---

Implementation

Thanks to years of implementing various types of integrated primary care projects, the philosophical commitment to CCBHC status was not difficult for the Care Plus NJ staff. The culture was very open to the CCBHC goals supporting integration. However, high-level commitment and understanding is not the same as hands-on operations, and it was here that Care Plus NJ faced its biggest hurdles implementing CCBHC requirements.

New procedures and assessments had to be developed and implemented, and old workflows had to be redesigned. New and old data had to be integrated, aggregated and analyzed. Clinicians were now accountable for completing tasks that were foreign, and some existing processes had to be reworked to comply with the new CCBHC standards.

For example, assessment tools like the PHQ9 and the AUDIT were now required for all CCBHC clients. If the assessments were not completed, clinicians needed to know as soon as possible to remedy this deficit, but such feedback loops did not exist. Not only did Care Plus NJ have to train staff on how to use the instruments themselves, monitoring and reporting infrastructures had to be created to track and inform managers and clinicians as well. Despite these challenges, Care Plus NJ succeeded in getting not one CCBHC grant, but two.

We’ve now become like a well-oiled machine,” Care Plus NJ CIO, Michelle Alkhalaileh, said. “Change can always be challenging at first, but through staff training, shifted workflows and the technology, we’ve been able to find success with it.”

How they did it

Care Plus NJ had a strategic plan in order to both qualify and achieve these grants.

“Right away, we created a core CCBHC clinical team,” Alkhalaileh said. “This team included clinical leadership, finance, quality assurance and others. We wanted to hear the voices of the people who were directly affected by the care delivery process.”

This strategy, modeled after the Learning Communities promoted by the National Council, was extremely helpful in working out the kinks in proposed workflows, identifying new tools and processes that needed to be developed, and removing obsolete or irrelevant procedures. Once these processes were agreed upon, clinician training and orientation began. Some key implementation factors for Care Plus NJ included:

• Orienting clinical staff to the whole picture. Rather than simply training staff on just the specifics of their job or workflow, Care Plus NJ expanded their training to include the new workflows. This resulted in new perspectives and input from the clinical staff that otherwise would have been missed and Increased ownership of the new processes by the clinicians. One example was streamlined electronic health record (EHR) forms based on clinician’s day-to-day experience.
• Utilizing data to inform care. Building on a culture that appreciated and used data regularly, Care Plus NJ added clinical and operational measures and reports to assist clinicians. For example, monthly deficiency reports let clinicians know what data elements were missing so they could remedy the deficiency.
• Clinical decision support. As part of the effort to use data to inform care, Care Plus NJ built alerts into the system using existing measures and tools. One example used item nine of the PHQ9, which asks about suicidal ideation. If that question had a positive response, the system displays it to the clinical staff in a way that subtly but effectively conveys

The agency also developed a unique and creative way to use telehealth. In the event a client calls to cancel their clinical session, Care Plus NJ staff offers the client a telehealth appointment as an alternative. They used the Netsmart Care Pathways platform to manage and report required state and federal measures and to review the data in real time.

Right away, we created a core CCBHC clinical team. This team included clinical leadership, finance, quality assurance and others. We wanted to hear the voices of the people who were directly affected by the care delivery process.

Michelle Alkhalaileh, CIO, Care Plus NJ

---

Challenges

Despite their success, there were challenges with Care Plus NJ’s CCBHC implementation, some of which were internal and some externally imposed.

As an early adopter to CCBHC, Care Plus NJ didn’t have the luxury of modeling their implementation on some other successful organization. Much had to be discovered or invented on the fly. Alkhalaileh credits Care Plus NJ’s culture of primary care integration and openness to solving new problems as the reasons for success.

Externally imposed requirements continue to pose challenges today. Care Plus NJ has found that requirements for fidelity to the CCBHC model are sometimes at odds with other external requirements. For example, the requirement to assess for the initiation of alcohol or drugs. Many of Care Plus NJ substance use disorder (SUD) clients are served in intensive outpatient programs (IOP) where they are seen several times per week for several hours each time, usually in groups. The IOP CPT codes Care Plus NJ uses are not an eligible treatment encounter. Individual therapy is an eligible treatment encounter, however many clients will attend IOP and cancel their individual therapy session, thus resulting in the less then desired measure outcomes reporting. A similar problem exists with the Depression Screening and Follow-up measure. Family therapy is another ineligible service on the same day that the PHQA is administered.

There is also the question of what will happen when the CCBHC funding ends. Will the reimbursement for the services be picked up by other payers? Will the move to value-based care finally occur? So far, interactions with other payers has not been encouraging in spite of the positive outcomes Care Plus NJ has demonstrated. Despite these concerns, Care Plus NJ is optimistic that the work done to move the organization to CCBHC status will yield positive benefits. The hard part of the transition is behind them, and Care Plus NJ is now positioned to do value-based care whenever the payer community reciprocates.

Moving forward

The organization has more enhancements in the works. They will be implementing the telehealth consumer app. They are moving their myEvolv EHR from on premise to cloud hosted, which will open up more efficiencies and opportunities. They are implementing a front desk kiosk that will allow easier data collection data and measures for analysis and reporting. Finally, they are implementing a data analytics tool, KPI Dashboards, to deliver the data they need for timely analysis and monitoring. Currently, feedback to providers and managers is provided approximately one month after services are delivered, which is not timely enough.

“This tool will help us become even more real-time,” Alkhalaileh said. “Right now, I’m not running measures until the next month. We want to leverage CarePathways to create a timely dashboard, showing our staff automatic, real-time updates.”

When asked what advice Alkhalaileh would give to other CCBHC aspirants, she is quick to suggest they call Care Plus NJ or some other CCBHCs for advice. She encourages providers to attend the Netsmart CONNECTIONS conference both for the learning opportunities and the interaction with other attendees who are grappling with the same challenges. Because there are more resources available now than when Care Plus NJ started this journey in 2017, Alkhalaileh strongly encourages others to take advantage of those resources.

When asked if it was all worth it, Alkhalaileh response was an immediate, “Absolutely.”