Mo. Code Regs. tit. 9 § 30-6.010

Current through Register Vol. 49, No.12, June 17, 2024

Section 9 CSR 30-6.010 - Certified Community Behavioral Health Organization

PURPOSE: This amendment updates terminiology and eligibility criteria for certification as a Certified Community Behavioral Health Organization (CCBHO), adds current or former members of the U.S. Armed Forces as a population of focus, and clarifies requirements for substance use disorder treatment services, national accreditation and certification, evidence-based practices, and the fee schedule.

PUBLISHER'S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

(1) Definitions. The following definitions apply to terms used in this rule:

(A) Certified Community Behavioral Health Organization (CCBHO)-an entity certified by the department to provide CCBHO services within their designated service area(s). The entity must be a nonprofit organization and an administrative agent or affiliate provider in Missouri;

(B) Department - the Department of Mental Health; and

(C) Designated Collaborating Organization (DCO)-an entity that is not under the direct supervision of a Certified Community Behavioral Health Organization (CCBHO) but is engaged in a contractual arrangement with a CCBHO to provide CCBHO services under the same requirements as the CCBHO.

(2) Regulations. All CCBHOs shall comply with 9 CSR 10-7, 9 CSR 303, and 9 CSR 30-4, as applicable.

(3) Designated Service Areas. Organizations must be certified by the department to provide CCBHO services in one (1) or more service areas as established by the department under 9 CSR 30-4.005. The required CCBHO services, as specified in this rule, must be provided in each designated service area.

(A) Each CCBHO shall develop and maintain services and supports designed to meet the needs of the populations of focus. Populations of focus shall include-

1. Adults with serious mental illness as defined in 9 CSR 30-4.005(6);

2. Children and youth with serious emotional disturbances as defined in 9 CSR 30-4.005(7);

3. Children, adolescents, and adults with moderate to severe substance use disorders;

4. Children with behavioral health disorders who are in state custody;

5. Individuals involved with law enforcement, the courts, and hospital emergency rooms who have been identified as in need of community behavioral health services; and

6. Current or former members of the U.S. Armed Forces.

(B) Each CCBHO shall regularly assess the unique socio-demographic factors of their service area(s) and implement strategies to improve access, quality of care, and reduce health disparities experienced by relevant cultural and linguistic minorities.

(4) Availability and Accessibility of Services. Services shall not be denied or limited based on an individual's ability to pay, place of residence, homelessness, or lack of a permanent address.

(A) CCBHOs shall provide, at a minimum, crisis response, evaluation, and stabilization, as needed, for individuals who present for services but do not reside within the CCBHO's designated service area(s). Policies and procedures shall specify the CCBHO's process for managing the ongoing treatment needs of such individuals, such as linkage to a CCBHO in the service area where the individual currently lives.

(B) CCBHOs shall provide outpatient services at times and locations that ensure accessibility and meet the needs of individuals in the service area, including some evening hours, and when appropriate and practicable, weekend hours.

(C) CCBHOs shall ensure-

1. No individual in the populations of focus is denied services including, but not limited to, crisis management because of an inability to pay for such services; and

2. Any fees or payments required by the CCBHO for such services shall be reduced as provided by the sliding fee schedule described in section (13) of this rule in order to enable the CCBHO to fulfill the assurance described in paragraph (4)(C)1. of this rule.

(D) CCBHOs shall ensure individuals determined to need specialized behavioral health services beyond the scope of its program are referred to a qualified provider(s) for necessary services.

(5) Certification and National Accreditation. CCBHOs shall maintain national accreditation and/or department certification as specified below.

(A) Certification/deemed certification from the department in accordance with 9 CSR 30-3 and 9 CSR 30-4 to provide-

1. American Society of Addiction Medicine (ASAM) Level 1 Outpatient and Level 1- WM Ambulatory Withdrawal Management without Extended On-Site Monitoring for adolescents and adults. The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, 3rd edition (2013), hereby incorporated by reference and made a part of this rule, is developed by and available from the American Society of Addiction Medicine, Inc., 11400 Rockville Pike, Suite 200, Rockville, MD 20852, (301) 656-3920. This rule does not incorporate any subsequent amendments or additions to this publication; and

2. Community Psychiatric Rehabilitation (CPR) for children, youth, and adults;

(B) Appropriate accreditation from CARF International (CARF), The Joint Commission (TJC), Council on Accreditation (COA), or other accrediting body approved by the department for the following services:

1. Healthcare home for children, youth, and adults;

2. Outpatient mental health and substance use disorder treatment services for children, youth, and adults;

3. Crisis and information call center for the provision of a twenty-four- (24-) hour crisis line for children, youth, and adults with mental health and/or substance use disorders;

4. Crisis intervention services for the provision of a twenty-four- (24-) hour mobile crisis team for children, youth, and adults with mental health and substance use disorders-

A. If the CCBHO contracts with a DCO to provide crisis intervention services, the DCO must be accredited as specified above; and

B. The twenty-four- (24-) hour crisis line and twenty-four- (24-) hour mobile response team shall also comply with 9 CSR 30-4.195, Access Crisis Intervention (ACI) program; and

(C) Provisional certification from the department to provide outpatient mental health treatment and substance use disorder treatment for children, youth, and adults is acceptable until accreditation is obtained as specified.

(6) Required Services. CCBHOs shall provide a comprehensive array of services to create and enhance access, stabilize people in crisis, and provide the necessary treatment for individuals with the most serious, complex mental illnesses and substance use disorders.

(A) The following core CCBHO services must be directly provided by the CCBHO in each designated service area:

1. Crisis mental health services, including a twenty-four- (24-) hour crisis line and twenty-four- (24-) hour mobile crisis response team. Crisis mental health services must be available at the CCBHO during regular business hours and be provided by a Qualified Mental Health Professional (QMHP). The crisis line and mobile crisis response team services may be directly provided by the CCBHO or by contract with a department- approved DCO.

A. If CCBHO staff determine an in-person intervention is required based on the presentation of an individual, the intervention must occur within three (3) hours.

B. CCBHO staff shall monitor and have the capacity to report the length of time from each individual's initial crisis contact to the in-person intervention and take steps to improve performance, as necessary;

2. Screening, assessment, and diagnosis, including risk assessment;

3. Individualized treatment, including risk assessment and crisis prevention planning;

4. Outpatient mental health services;

5. Substance use disorder treatment services including -

A. Individual and group counseling;

B. Group rehabilitative support;

C. Community support;

D. Peer support;

E. Family therapy;

F. Medication services to support medication assisted treatment; and

G. American Society of Addiction Medicine (ASAM) Level 1 Outpatient and Level 1-WM Ambulatory Withdrawal Management without Extended On-Site Monitoring as referenced in paragraph (5)(A)1. of this rule;

6. Outpatient clinic primary care screening and monitoring of key health indicators and health risks;

7. Community support;

8. Psychiatric rehabilitation services;

9. Peer support, counseling, and family support services, including peer and family support services for individuals receiving CPR and/or Comprehensive Substance Treatment and Rehabilitation (CSTAR) services, consistent with the array of services and supports specified in the job descriptions of Certified Family Support Providers and Certified Peer Specialists; and

10. Outpatient mental health services for active members of the U.S. Armed Forces and veterans.

(B) In addition to the core services, CCBHOs shall directly provide, contract with a DCO, or have a referral agreement with an organization that is certified/deemed certified by the department to provide the following services:

1. General adult, adolescent, and women and children's CSTAR services;

2. Recovery support services, if services are available in the CCBHO's designated service area(s);

3. Outreach services to reduce unnecessary utilization of emergency rooms by the populations of focus, including case managers to respond to and engage individuals who present at collaborating emergency rooms, access necessary resources to meet the individual's basic needs on an emergency basis, and assist individuals in accessing CCBHO services on an emergency, urgent, and/or routine basis, as needed.

(7) Required Staff. CCBHOs must maintain adequate staffing to meet the needs of the populations of focus. Staff may be full- or part-time employees of the CCBHO or contracted by the CCBHO to provide services.

(A) Required staff shall include-

1. Medical Director who is a licensed psychiatrist;

2. Licensed mental health professionals with expertise and specialized training in the treatment of trauma-related disorders;

3. Community Behavioral Health Liaison (a cooperative agreement with a CCBHO that employs a Community Behavioral Health Liaison is acceptable);

4. Clinical staff to complete comprehensive assessments, annual assessments, and treatment plans;

5. Licensed mental health professionals who have completed training on evidence-based, best, and promising practices as required by the department;

6. Qualified practitioner(s) to treat opioid use disorders with narcotic medications approved by the Food and Drug Administration (FDA). Methadone must be provided by a certified opioid treatment program;

7. Community Support Specialists who have completed department-approved wellness training;

8. Individuals who have completed department-approved smoking cessation training;

9. Certified Family Support Providers who are credentialed by the Missouri Credentialing Board; and

10. Certified Peer Specialists who are credentialed by the Missouri Credentialing Board.

(8) Screening, Assessment, and Treatment Planning. Unless a specific tool is required by the department, CCBHO staff shall use standardized and validated screening and assessment tools, including age-appropriate functional assessments and screening tools, and, when appropriate, brief motivational interviewing techniques.

(A) At first contact, individuals seeking CCBHO services shall receive a preliminary screening to determine acuity of need. Emergency, urgent, or routine service needs shall be identified and addressed as follows:

1. Individuals who present with emergency needs shall receive services immediately, including arrangements for any necessary outpatient follow-up services;

2. Individuals who present with an urgent need shall receive clinical services and an eligibility determination within one (1) business day of the time the request was made; and

3. Individuals who present with routine needs shall receive clinical services and an eligibility determination within ten (10) days of first contact.

(B) Following the preliminary screening, qualified staff shall conduct a comprehensive assessment or eligibility determination. Eligibility determination may be completed to expedite the admission process. A risk assessment shall be included as part of the eligibility determination or comprehensive assessment, whichever occurs first, and shall include-

1. Depression screening for all adolescents age thirteen (13) to eighteen (18) years of age;

2. Depression screening for all adults age nineteen (19) and older;

3. Suicide risk assessment for all adolescents and adults diagnosed with major depression;

4. Brief health screen, as specified by the department;

5. Alcohol use disorder screening; and

6. Substance use disorder screening, including opioid use disorder.

(C) The comprehensive assessment must be completed within the first three (3) outpatient visits or within specific treatment program timelines.

(D) Results of the comprehensive assessment shall be utilized to develop an initial treatment plan within sixty (60) days of the individual's first contact with the CCBHO, unless a shorter time frame is required by a specific treatment program. The treatment plan shall be developed collaboratively with the individual served and/or parents/guardian, family members, and other natural supports, as appropriate.

(E) Treatment plans shall be reviewed and updated in accordance with specific program timelines, not to exceed ninety (90) days, to assess the continued need for services, changes in health status, responses to treatment, and progress achieved during the past ninety (90) days. A functional assessment may be utilized as the quarterly treatment plan review/update. The occurrence of a crisis or significant clinical event may require a further review and modification of the treatment plan.

1. The updated treatment plan shall reflect the individual's current strengths, needs, abilities, and preferences in the goals and objectives that have been established or continued based on the review. Updates must be documented in the individual record by one (1) of the following:

A. A progress note which specifies updates made to the treatment plan; or

B. A treatment plan review conducted quarterly; or

C. An updated functional assessment score with a brief narrative.

(F) The initial treatment plan and treatment plan updates must include the dated signature(s), title(s), and credential(s) of staff completing the plan. The individual served shall also sign the plan unless there is a current signed consent to treatment included in the individual record.

1. CCBHOs shall promote collaborative treatment planning by providing the individual's primary care provider (PCP) with relevant assessment, evaluation, and treatment plan information, seeking all relevant treatment and test results from the PCP, and inviting the PCP to participate in treatment planning.

(G) The following information shall be collected and be available for reporting to the department or other entities, upon request:

1. The number and percentage of new and established individuals served who were determined to need emergency, urgent, and routine care;

2. The number and percentage of new and established individuals with urgent needs who began receiving needed clinical services within one (1) business day;

3. The number and percentage of new and established individuals with routine needs who began receiving needed clinical services within ten (10) business days; and

4. The mean number of days from first contact to completion of the comprehensive assessment/ eligibility determination and initial treatment plan for individuals served.

(9) Consent to Treatment. Each individual served or a parent/guardian must provide informed, written consent to treatment.

(A) A copy of the consent form, which must include the date of consent and signature of the individual served or a parent/guardian, shall be retained in the individual record.

(B) Consent to treat shall be updated annually, including the date of consent and signature of the individual served or a parent/guardian, and be maintained in the individual record.

(10) Services for Members of the U.S. Armed Forces and Veterans. CCBHOs must determine whether all individuals seeking service are current or former members of the U.S Armed Forces.

(A) CCBHOs shall refer Active Duty and activated Reserve Component service members to their Military Treatment Facility or TRICARE PRIME Remote Primary Care Manager for referral to services.

(B) Selective Reserve service members not on active duty, who are enrolled in TRICARE Reserve Select, shall be referred to a TRICARE Reserve Select provider.

(C) If an individual is a veteran not currently enrolled in the Veterans Health Administration (VHA), CCBHO staff must offer to assist them in enrolling in the VHA.

(11) Withdrawal Management. CCBHOs must ensure individuals have access to appropriate withdrawal management services twenty-four (24) hours per day, seven (7) days per week as follows:

(A) Each CCBHO shall directly provide ASAM Level 1-Withdrawal Management (WM) services as referenced in paragraph (5) (A)1. of this rule;

(B) Each CCBHO that is certified/deemed certified by the department shall directly provide the following services or have a documented referral relationship with an organization that is certified/deemed certified by the department to provide-

1. ASAM Level 2-WM with and without Extended On-Site Monitoring;

2. ASAM Level-3.2 Clinically Managed Residential Withdrawal Management, commonly referred to as social setting detoxification services; and

3. ASAM Level 3.7 Medically Monitored Inpatient Withdrawal Management, commonly referred to as modified medical detoxification services.

(12) Care Coordination. CCBHOs shall actively pursue and promote collaborative working relationships with the broad array of community organizations and providers that deliver services and supports for individuals receiving services from the CCBHO.

(A) Consistent with requirements of privacy, confidentiality, and individual preference and need, CCBHO staff shall assist individuals and families of children and youth who are referred to external providers or resources in obtaining an appointment and confirming the appointment was kept.

(B) Nothing about a CCBHO's agreements for care coordination shall limit an individual's freedom of choice of provider(s) with the CCBHO or its DCOs.

(C) CCBHO policies and procedures shall promote and describe its care coordination roles and responsibilities, and whenever possible, the development of formal agreements with community organizations and providers that document mutual care coordination roles and responsibilities, with particular attention to emergency room, hospital, and residential treatment admissions and discharges. CCBHO policies and procedures shall ensure reasonable attempts are made and documented to-

1. Track admissions and discharges of non-Medicaid eligible individuals to and from a variety of settings, and to provide transitions to safe community settings; and

2. Follow up with individuals served within twenty-four (24) hours following hospital discharge.

(D) CCBHOs shall utilize Missouri Behavioral Health Connect (MOConnect), the designated platform to identify, unify, and track behavioral health treatment resources.

(E) For all individuals in the populations of focus, CCBHO staff shall inquire whether they have a PCP, assist individuals who do not have a PCP to acquire one, and establish policies and procedures that promote and describe the coordination of care with each individual's PCP.

(F) For all individuals in the populations of focus, CCBHO staff shall document in the individual record the name of each individual's PCP, indicate they are assisting them in acquiring a PCP, or the individual refuses to provide the name of their PCP or accept assistance in acquiring a PCP.

(13) Evidence-Based Practices. CCBHOs shall incorporate evidence-based, best, and promising practices into its service array.

(A) CCBHOs shall have adopted, or be participating in a department-approved initiative, to promote trauma-informed care and suicide prevention.

(B) CCBHOs shall have adopted with fidelity, a model for providing integrated treatment for co-occurring disorders approved by the department.

(C) CCBHOs shall demonstrate a continued commitment to adopting or continuing evidence-based, best, and promising practices to fidelity, such as-

1. Assertive Community Treatment (ACT);

2. Supported employment;

3. Supported housing;

4. Parent-Child Interaction Therapy;

5. Dialectical Behavior Therapy;

6. Multi-systemic Therapy;

7. First Episode Psychosis; and

8. Eye Movement Desensitization and Reprocessing (EMDR).

(14) Fee Schedule. CCBHOs shall establish a sliding fee discount program for all available services that conforms to state statutory or administrative requirements or to federal statutory or administrative requirements that may be applicable to existing clinics. Absent applicable state or federal requirements, the sliding fee discount program shall be based on locally prevailing rates or charges and include reasonable costs of operation.

(A) Written policies and procedures shall be maintained by the CCBHO describing eligibilty for services and implementation of the sliding fee discount program which must ensure-

1. Equitable use of the sliding fee schedule for all individuals seeking services;

2. The provision of services regardless of ability to pay; and

3. Waiver or reduction of fees for those unable to pay.

(B) The CCBHO shall screen each individual seeking services to determine eligiblity for a sliding fee discount.

(C) If a CCBHO service is provided through a DCO, the DCO shall provide such services in accordance with the CCBHO fee schedule and corresponding policies and procedures.

1. The CCBHO shall provide the DCO with a copy of its policies and procedures related to the sliding fee discount program.

2. Prior to the provision of a CCBHO service, the CCBHO shall inform the DCO if an individual has been determined eligible for a fee discount. The DCO is not required to conduct its own discount eligibility screening.

(D) CCBHOs (and their DCOs, as applicable) shall provide individuals and their family members/natural supports with information regarding the sliding fee discount program.

1. The fee discount schedule shall be communicated in languages and formats appropriate for individuals seeking services who have limited English proficiency or disabilities.

2. The fee discount schedule shall be posted on the CCBHO/DCO website and in the waiting/reception area.

(15) Information Systems. CCBHOs shall maintain a health information technology (HIT) system that includes, but is not limited to, electronic health records of all individuals served. Electronic health record systems must comply with state and federal regulations.

(A) The HIT system must have the capability to capture structured information in individual records, including demographic information, diagnoses, and medication lists, provide clinical decision support, and electronically transmit prescriptions to the pharmacy.

(16) DCO Contracts. If the CCBHO enters into a contractual agreement(s) with a DCO, the contract shall include the following provisions:

(A) DCO staff having contact with individuals served, and/or their families, are subject to the same training requirements as staff of the CCBHO;

(B) The CCBHO coordinates care and services provided by the DCO in accordance with the individual's current treatment plan;

(C) The CCBHO is ultimately clinically responsible for all care provided;

(D) The individual's freedom to choose service providers is maintained;

(E) All individuals have access to the CCBHO's grievance procedures; and

(F) Services provided by the DCO shall meet the same quality standards as those provided by the CCBHO.

(17) Governing Body Representation. CCBHOs shall ensure individuals served and their parents/guardians, family members, and other natural supports have meaningful participation in the development and ongoing review of the organization's policies and procedures, service delivery practices, and service array.

(A) Meaningful participation shall be demonstrated by one (1) of the following:

1. At least fifty-one percent (51%) of the governing body consists of individuals who are receiving or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/ guardian, family members/natural supports of individuals served;

2. A substantial portion of the governing body consists of individuals who are receiving services or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/guardian, family members/natural supports of individuals served; or

3. A transition plan is developed, with timelines appropriate to the size of the governing body and target population, to establish a governing body with at least fifty-one percent (51%) or a substantial portion of the governing body consisting of individuals who are receiving services or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/guardian, family members and other natural supports of individuals served.

(B) If the CCBHO is a subsidiary or part of a larger corporate organization and cannot meet the requirements identified in paragraphs (16)(A)1.-3. of this rule, the CCBHO shall have or develop an advisory structure or other specifically described process to ensure individuals who are receiving services or have received services for a serious mental illness, serious emotional disturbance, or substance use disorder, or the parents/guardian, family members and other natural supports of individuals served, have meaningful input to the governing body related to its policies and procedures, service delivery practices, and service array.

(C) CCBHOs may develop and implement an alternative process, which must be approved by the department, to ensure the governing body is responsive to the needs of individuals served and their parents/guardians, family members, natural supports, and the communities it serves.

(D) CCBHOs must be able to document input from individuals served and their parents/guardian, family members, natural supports, and communities served, including the impact on its policies, processes, and services.

(E) To the extent practicable, each CCBHO's governing body and/or advisory board shall be representative of the populations served in terms of demographic factors such as geographic area, race, ethnicity, sex, gender identity, disability, age, and sexual orientation.

(F) Each CCBHO's governing body members or advisory board members shall be selected for their expertise in health services, community affairs, local government, finance and banking, legal affairs, trade unions, faith communities, commercial and industrial concerns, and social services within the communities served.

(G) No more than fifty percent (50%) of the governing body members may derive more than ten percent (10%) of their annual income from the health care industry.

9 CSR 30-6.010

Adopted by Missouri Register May 1, 2019/Volume 44, Number 9, effective 7/1/2019

Amended by Missouri Register September 2, 2019/Volume 44, Number 17, effective 10/31/2019

Amended by Missouri Register December 1, 2023/volume 48, Number 23, effective 1/30/2024.