Characterizing crisis services offered by certified community behavioral health clinics: Results from a national survey

Abstract

Objective.

This study examines how certified community behavioral health clinics (CCBHCs) fulfill crisis service requirements and whether clinics added crisis services after becoming a CCBHC.

Methods.

2022 national survey data on CCBHC crisis services was paired with data on clinic features and the demographic and socioeconomic characteristics of the county(ies) within a CCBHC service area. The dependent variables were whether CCBHCs provided the three categories of CCBHC crisis services (i.e., crisis call lines, mobile crisis response, crisis stabilization) directly or through another organization; and whether these services were added after becoming a CCBHC. Descriptive statistics and multivariable logistic regression analyses are presented using data about clinics and the county(ies) they serve. The universe of CCBHCs (449 clinics) was surveyed in the summer of 2022 with a response rate of 55.46%. The final sample size was 247 clinics.

Results.

The number of CCBHC employees per 1,000 people within a CCBHC service area was positively associated with whether clinics provided some crisis services directly (mobile crisis response: AOR=1.46, 95% CI=1.08–1.98; crisis stabilization services: AOR=1.60, 95% CI=1.17–2.19). Compared to clinics that did not receive a CCBHC Medicaid bundled payment, clinics that received this payment had 2.52 (95% CI=1.28–4.97) and 3.19 (95% CI= 1.51–6.72) higher odds of adding mobile crisis response and crisis stabilization services, respectively, after becoming a CCBHC.

Conclusions.

CCBHC initiatives, particularly CCBHC Medicaid bundled payments, may provide opportunities to increase the availability of behavioral health crisis services, though the sufficiency of this increase for meeting crisis care needs remains unknown.

Introduction

Rising rates of suicide and drug overdose deaths,^1,2 as well as growing visibility in the prevalence of behavioral health problems among populations who are unhoused, incarcerated, and interacting with law enforcement,^3–6 have turned attention to failures within existing behavioral health crisis systems. Particularly, many have focused on inadequacies and inconsistencies in crisis continuums. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines three core components of crisis care: 24/7 call centers, mobile crisis response teams, and crisis stabilization facilities.^7–9 However, empirical research characterizing the behavioral health crisis system remains limited.^10–13

Recently, the federal government made several substantive investments in behavioral health crisis care,¹⁴ including initiatives involving community behavioral health centers. Certified community behavioral health clinics (CCBHC) fulfill SAMHSA criteria related to the delivery of nine categories of mental health and substance use disorder care to patients regardless of ability to pay. Organizations may become designated as a CCBHC through two mechanisms. First, the Centers for Medicare and Medicaid Services has authorized programs in 12 states under the federal Section 223 Medicaid Demonstration or Medicaid state plan amendments that primarily pay participating clinics using a per diem or monthly encounter-based, bundled rate for all CCBHC services. Second, SAMHSA awards CCBHC Expansion grants to organizations in any state that meet or will meet federal CCBHC criteria. While organizations in the 38 states without a CCBHC Medicaid bundled payment may only become designated as a CCBHC through the Expansion Grant program, clinics in the 12 states with an authorized CCBHC Medicaid bundled payment may become a CCBHC through the state Medicaid demonstration, the Expansion Grant program, or both. As of January 2024, 192 organizations received a CCBHC Medicaid bundled payment, and 375 clinics had active Expansion grants (https://www.thenationalcouncil.org/program/ccbhc-success-center/ccbhc-locator/).

A primary difference between the Medicaid initiatives and Expansion Grant program is that the former alters Medicaid reimbursement for clinics, theoretically addressing historic shortfalls in Medicaid payments for community mental health services and offering more sustained support for the intensive CCBHC requirements.^15–17 The payment achieves this through its design: the CCBHC Medicaid bundled payment model is structured to reflect clinics’ real costs of expanding services. Specifically, in the first year, clinics’ payment rates are inclusive of their anticipated costs of fulfilling all CCBHC criteria; states then determine a schedule upon which rates will be rebased to reflect historic actual cost data. In contrast, the SAMHSA CCBHC Expansion grants provide a fixed amount of money (up to $4 million) for a set period of time (2 years for the grantees in this analysis).

Crisis behavioral health services is one of the nine required CCBHC service categories. Current SAMHSA criteria require CCBHCs offer all three core components of the crisis continuum: telephonic, text, and chat crisis intervention call centers that meet 988 Suicide & Crisis Lifeline standards; 24/7 behavioral health mobile crisis response that arrives within one hour (two hours for rural and frontier communities) from dispatch; and crisis receiving and stabilization services that de-escalate the crisis and connect individuals to a safe and the least-restrictive setting for ongoing care. These services may be offered directly or through designated collaborating organizations (DCO) that are certified, licensed, or state-sanctioned providers of behavioral health crisis services.¹⁸ The original SAMHSA CCBHC criteria mandated clinics offer mobile crisis response and crisis stabilization but not crisis call line services;¹⁹ crisis call lines were added as a required service in the 2023 CCBHC criteria update.¹⁸

Despite the investment in CCBHCs to improve crisis services across the county,^20–23 minimal research exists on how CCBHCs offer crisis care, and whether crisis services were added to fulfill CCBHC requirements. Research on the mechanism of delivering crisis services (i.e., direct or through another organization) informs about the characteristics of local crisis continuums;^15,24 providing crisis services through partnerships is suggestive but not indicative that the clinic relies on existing crisis resources to meet CCBHC criteria. In contrast, direct delivery suggests that no crisis provider in the community delivers crisis care in line with the CCBHC requirements, or the CCBHC is fulfilling capacity issues within its service area’s crisis infrastructure. Further, while research suggests that CCBHCs that receive per diem or monthly Medicaid reimbursement added crisis services after becoming a CCBHC,¹⁵ it is not clear whether this finding persists for organizations that exclusively participate in the CCBHC Expansion Grant program. Building on other research surveying CCBHCs,²⁵ we used data from a national survey of all CCBHCs to determine the prevalence and correlates of whether CCBHCs offered the three types of crisis services directly and whether services were added after becoming a CCBHC.

Methods

Between July 14^th-August 26^th, 2022, the Harris Poll, on behalf of the National Council for Mental Wellbeing, surveyed the 449 organizations designated as CCBHCs by federal and/or state authorities.²⁴ To date, this is the only survey of the universe of CCBHCs. The survey completion rate was 55.5%, which is better or comparable to other recent surveys of safety net providers of health services.^26,27 Two organizations were dropped from the analysis because of incomplete survey data, yielding a final sample size of 247 clinics.

If an organization does not meet all CCBHC requirements at the time of designation, SAMHSA and state authorities grant provisional certification: a set period in which clinics must fulfill CCBHC criteria. We excluded CCBHCs that reported that they were still working towards fulfilling the crisis service requirement, resulting in a sample of 240 and 231 clinics for analyses related to mobile crisis response and crisis stabilization services, respectively. 100% of CCBHCs provided crisis call lines.

The dependent variables were organized into two questions. First, we assessed whether CCBHCs provided the three types of crisis services – crisis call lines, mobile crisis response, and crisis stabilization – directly or through an agreement with a DCO.¹⁸ We grouped the small proportion of organizations that reported that they offered mobile crisis response (4.7%) and crisis stabilization (5.0%) both directly and through a DCO into the direct service category. The second dependent variable assessed whether CCBHCs added the three crisis services before or after becoming a CCBHC.

Independent variables included a combination of demographic, socioeconomic, and organizational measures gathered from additional sources and survey responses. Several variables characterized the counties within the area served by a CCBHC, which we note is distinct from the population actually served by the clinic. Appendix 1 describes the process for collecting county-level CCBHC service areas. While 44.9% of CCBHCs serve a single county, the majority serve multiple. Thus, measures are calculated based on the characteristics of all of the counties within a CCBHC service area.

From the United States Department of Agriculture Economic Research Service, we included the average rural-urban continuum code (RUCC) among all counties served by a CCBHC (Rural). RUCCs values range from 1 (counties in metro areas of 1 million population or more) to 9 (completely rural or less than 2,500 urban population, not adjacent to a metro are). Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research provided the 2020 size of the population served by a CCBHC (Population) measured as the sum of all county populations within a CCBHC service area. We included covariates for the proportion of the 2021 population within a CCBHC service area racialized as Black (Black) and Hispanic (Hispanic) from the Census Demographic and Housing Characteristics File. We used the Census Small Area Income and Poverty Estimates to include the 2021 number of persons with incomes below 100 percent of the federal poverty line per 1,000 persons within the CCBHC service area (Poverty). The 2020 number of uninsured persons per 1,000 people within a CCBHC service area (Uninsured) was gathered from the Small Area Health Insurance Estimates using the American Community Survey (ACS). In addition, we used the ACS to add a covariate for the 2021 5-year estimate for the number of people enrolled in Medicaid per 1,000 persons within a CCBHC service area (Medicaid Enrolled).

From the Harris Poll/National Council for Mental Wellbeing survey, we included whether the organization received a CCBHC Medicaid bundled payment (CCBHC Medicaid Bundled Payment), coded as 0 if the CCBHC exclusively participated in the CCBHC Expansion Grant program, and 1 if the CCBHC received a bundled payment for all CCBHC services. To clarify, organizations that do not receive a CCBHC Medicaid bundled payment may still bill Medicaid; it just does not receive the CCBHC bundled rate. Also, from the Harris Poll/National Council for Mental Wellbeing survey, we included a proxy for organizational size: the number of CCBHC employees per 1,000 people within a CCBHC service area (Employees).

All analyses were conducted using Stata, version 18.0 and weighted with survey-specific weights to produce estimates that were representative of the proportion of CCBHCs in each state that received and did not receive a CCBHC Medicaid bundled payment in summer 2022. Appendix 2 contains information on the weighting scheme. We present descriptive statistics and multivariable logistic regression analyses examining how CCBHCs offered crisis care (i.e., directly or through a DCO) and when they began offering crisis services.

Results

Among organizations that offered crisis services, the vast majority provided crisis call lines (83.6%), mobile crisis response (79.3%), and crisis stabilization (81.6%) directly (see Table 1). Each crisis service was already being offered by the majority of clinics before it received CCBHC designation (crisis call lines: 74.7%; mobile crisis response: 59.3%; crisis stabilization: 73.3%), though differences exist by CCBHC Medicaid Bundled Payment status. Among clinics that received a CCBHC Medicaid bundled payment, the proportions of clinics that added mobile crisis response and crisis stabilization after becoming a CCBHC and the proportion that offered these services before were similar (mobile crisis response: after designation=56.1%, before designation=43.9%; crisis stabilization: after designation=45.7%, before designation=54.3%). In contrast, for clinics that did not receive the CCBHC Medicaid bundled payment, the proportions of clinics that added these services after becoming a CCBHC were substantially lower than the proportions of clinics that added the crisis service before receiving the CCBHC designation (mobile crisis response: after designation=34.7%, before designation=65.3%; crisis stabilization: after designation=19.2%; before designation=80.9%).

Table 1:

Number and Percent of CCBHCs Providing Crisis Services by CCBHC Medicaid Bundled Payment Status

	N	Weighted %	95% CI	N	Weighted %	95% CI	Pearson χ2 (DF)
	Offered Crisis Service Directly			Offered Crisis Service Through a DCO
Crisis Line (N: 247)
All	207	83.64	78.27–87.88	40	16.36	12.12–21.73	-
CCBHC Medicaid Bundled Payment	65	90.21	80.37–95.40	7	9.79	4.60–19.63	2.94 (246)
No CCBHC Medicaid Bundled Payment	142	81.16	74.44–86.16	33	18.84	13.57–25.56
Mobile Crisis Response (N: 240)
All	192	79.29	73.42–84.14	48	20.71	15.86–26.58	-
CCBHC Medicaid Bundled Payment	61	83.58	72.44–90.79	11	16.42	9.21–27.56	1.08 (239)
No CCBHC Medicaid Bundled Payment	131	77.61	70.40–83.48	37	22.39	16.52–29.60
Crisis Stabilization (N: 231)
All	189	81.56	75.79–86.21	42	18.44	13.79–24.21	-
CCBHC Medicaid Bundled Payment	58	81.66	69.99–89.48	12	18.34	10.52–30.01	0.00 (230)
No CCBHC Medicaid Bundled Payment	131	81.52	74.55–86.91	30	18.48	74.55–86.91
	Added Crisis Services After Becoming a CCBHC			Added Crisis Services Before Becoming a CCBHC
Crisis Line (N: 198)
All	49	25.32	19.49–32.19	149	74.68	67.81–80.51	-
CCBHC Medicaid Bundled Payment	18	32.08	21.03–45.58	42	67.92	54.42–78.97	1.90 (197)
No CCBHC Medicaid Bundled Payment	31	22.64	16.17–30.75	107	77.36	69.25–83.83
Mobile Crisis Response (N: 240)
All	96	40.70	34.31–47.42	144	59.30	52.58–65.69	-
CCBHC Medicaid Bundled Payment	41	56.11	43.90–67.63	31	43.89	32.37–56.10	9.52** (239)
No CCBHC Medicaid Bundled Payment	55	34.67	27.35–42.78	113	65.33	57.22–72.65
Crisis Stabilization (N: 231)
All	60	26.67	21.12–33.08	171	73.33	66.92–78.88	-
CCBHC Medicaid Bundled Payment	30	45.74	33.95–58.02	40	54.26	41.98–66.05	16.95*** (230)
No CCBHC Medicaid Bundled Payment	30	19.15	13.56–26.33	131	80.85	73.67–86.44

Notes:

^***p < 0.001,

^**p<0.01,

^*p<0.05. CCBHC = certified community behavioral health clinic. DCO = designated collaborating organization. DF = degrees of freedom for Pearson χ². There were 49 missing responses to the question asking whether an organization added a crisis call line after becoming a CCBHC. Presented proportions are weighted using survey-specific weights. See Appendix 2 for details on the weighting scheme. Appendix 3 contains the unweighted proportions.

Table 2 presents the means of the continuous independent variables for CCBHCs that offered crises services directly or through a DCO. CCBHCs that offered mobile crisis response (direct=3.3, DCO=1.7) and crisis stabilization (direct=3.1, DCO=2.2) directly were significantly more rural than clinics that provided these services through a DCO. Additionally, the mean number of CCBHC employees per 1,000 persons within a CCBHC service area was greater for clinics that provided direct services for mobile crisis response (direct=0.9, DCO=0.2) and crisis stabilization (direct=0.8, DCO=0.3). Except for crisis call lines, the mean size of the population within a CCBHC service area (mobile crisis response: direct=902,852, DCO=1,571,659; crisis stabilization: direct=1,088,159, DCO=1,177,049) and proportion of CCBHC service area population racialized as Black (mobile crisis response: direct=0.1, DCO=0.2; crisis stabilization: direct=0.1, DCO=0.2) were lower for CCBHCs that offered these services directly.

Table 2:

Characteristics of CCBHCs that Offered Services Directly Compared to Through Another Organization

Characteristic of CCBHC	Among CCBHCs that Provided Service Directly		Among CCBHCs that Provided Service Through A DCO		T-Statistic
	Mean	95% CI	Mean	95% CI
Offered Crisis Call Line (N: 247, DF: 246)
Rural (average RUCC among counties within CCBHC service area)	3.02	2.30–3.34	2.47	1.78–3.16	1.43
Population Size (CCBHC service area)	1,023,387	776,244–1,270,531	1,391,765	749,517–2,034,014	−1.05
Black (rate per population within CCBHC service area)	0.10	0.09–0.12	0.14	0.10–0.18	−1.77
Hispanic (rate per population within CCBHC service area)	0.16	0.14–0.18	0.15	0.11–0.18	0.53
Poverty (rate per 1,000 persons within CCBHC service area)	131.15	124.74–137.55	132.91	118.30–147.52	−0.22
Uninsurance (rate per 1,000 persons within CCBHC service area)	79.69	73.78–85.60	69.00	57.19–80.81	1.59
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	147.44	144.08–150.79	147.74	141.68–153.80	−0.09
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	0.80	0.62–0.93	0.48	0.11–0.86	1.44
Offered Mobile Crisis Response (N: 240, DF: 239)
Rural (average RUCC among counties within CCBHC service area)	3.27	2.93–3.62	1.71	1.33–2.10	5.95***
Population Size (CCBHC service area)	902,852	662,973– 1,142,733	1,571,659	1,053,247– 2,090,071	−2.31*
Black (rate per population within CCBHC service area)	0.09	0.08–0.11	0.16	0.13–0.20	−3.7***
Hispanic (rate per population within CCBHC service area)	0.15	0.13–0.17	0.18	0.14–0.22	−1.45
Poverty (rate per 1,000 persons within CCBHC service area)	130.80	123.90–137.71	134.36	122.49–146.24	−0.51
Uninsurance (rate per 1,000 persons within CCBHC service area)	81.28	75.03–87.53	66.69	56.59–76.80	2.42*
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	146.11	142.70–149.51	152.12	145.65–158.60	−1.62
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	0.90	0.72–1.08	0.15	0.07–0.22	7.7***
Offered Crisis Stabilization (N: 231, DF: 230)
Rural (average RUCC among counties within CCBHC service area)	3.11	2.76–3.45	2.19	1.56–2.81	2.54*
Population Size (CCBHC service area)	1,088,159	795,752–1,380,567	1,177,049	853,159–1,500,939	−0.40
Black (rate per population within CCBHC service area)	0.09	0.08–0.11	0.16	0.12–0.20	−3.1**
Hispanic (rate per population within CCBHC service area)	0.16	0.14–0.18	0.16	0.12–0.20	0.10
Poverty (rate per 1,000 persons within CCBHC service area)	130.67	123.87–137.47	137.76	123.95–151.56	−0.91
Uninsurance (rate per 1,000 persons within CCBHC service area)	80.68	74.46–86.89	70.95	58.69–83.21	1.39
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	146.66	143.29–150.02	151.57	144.51–158.64	−1.24
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	0.84	0.67–1.02	0.28	0.10–0.45	4.53***

Notes:

^***p < 0.001,

^**p<0.01,

^*p<0.05. CCBHC = certified community behavioral health clinic. RUCC = rural urban continuum code. DF = degrees of freedom for t-test. Presented percentages and means are weighted using survey-specific weights. See Appendix 2 for details on the weighting scheme. While in Table 4’s regression analyses we use logged forms of Population, Black, Hispanic, and Employee to address their skewed nature, here, we present the unlogged forms.

Table 3 compares CCBHCs that added crisis care after becoming a CCBHC compared to those that already offered these services before. The number of uninsured persons per 1,000 people within a CCBHC service area was lower for CCBHCs that added mobile crisis response (after=71.88, before=82.65) and crisis stabilization (after=68.79, before=82.55) after receiving CCBHC designation. Further, the Medicaid enrolled rate was higher for CCBHCs that added mobile crisis response after CCBHC designation (after=151.13, before=144.76), and the poverty rate was lower for CCBHCs that added crisis stabilization services (after=121.66, before=135.73).

Table 3:

Characteristics of CCBHCs that Added Crisis Services After Becoming a CCBHC Compared to CCBHCs that Offered Crisis Services Before Becoming a CCBHC

Characteristics of CCBHCs	Among CCBHCs that Added Service After Becoming a CCBHC		Among CCBHCs that Offered Service Before Becoming a CCBHC		T-Statistic
	Mean	95% CI	Mean	95% CI
Offered Crisis Call Line (N: 198, DF: 197)
Rural (average RUCC among counties within CCBHC service area)	2.71	2.13–3.26	3.19	2.79–3.58	−1.40
Population Size (CCBHC service area)	1,058,697	754,488–1,362,906	999,640	672,534–1,326,747	0.26
Black (rate per population within CCBHC service area)	0.11	0.08–0.15	0.09	0.08–0.11	1.20
Hispanic (rate per population within CCBHC service area)	0.16	0.12–0.20	0.15	0.13–0.18	0.33
Poverty (rate per 1,000 persons within CCBHC service area)	128.85	118.45–139.24	131.82	123.83–139.81	−0.45
Uninsurance (rate per 1,000 persons within CCBHC service area)	79.32	66.66–91.97	80.58	73.69–87.46	−0.17
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	152.98	146.13–159.82	145.80	141.83–149.79	1.79
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	0.60	0.38–0.83	0.86	0.66–1.06	−1.68
Offered Mobile Crisis Response (N: 240, DF: 239)
Rural (average RUCC among counties within CCBHC service area)	2.79	2.32–3.26	3.06	2.67–3.45	−0.88
Population Size (CCBHC service area)	1,262,192	873,300–1,651,084	889,762	630,373–1,149,152	1.57
Black (rate per population within CCBHC service area)	0.11	0.09–0.13	0.11	0.09–0.12	0.20
Hispanic (rate per population within CCBHC service area)	0.15	0.12–0.18	0.16	0.14–0.18	−0.71
Poverty (rate per 1,000 persons within CCBHC service area)	133.31	122.20–144.41	130.33	123.73–136.92	0.45
Uninsurance (rate per 1,000 persons within CCBHC service area)	71.88	63.95–79.80	82.65	75.39–89.90	−1.97*
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	151.13	146.07–156.18	144.76	141.05–148.48	2.00*
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	0.69	0.49–0.89	0.79	0.58–0.99	−0.68
Offered Crisis Stabilization (N: 231, DF: 230)
Rural (average RUCC among counties within CCBHC service area)	2.68	2.11–3.25	3.03	2.67–3.39	−1.02
Population Size (CCBHC service area)	1,213,935	751,079–1,676,792	1,064,760	774,944–1,354,575	0.54
Black (rate per population within CCBHC service area)	0.11	0.08–0.13	0.11	0.09–0.12	0.14
Hispanic (rate per population within CCBHC service area)	0.15	0.11–0.18	0.16	0.14–0.19	−0.83
Poverty (rate per 1,000 persons within CCBHC service area)	121.66	111.46–131.87	135.73	128.43–143.02	−2.21*
Uninsurance (rate per 1,000 persons within CCBHC service area)	68.79	59.49–78.08	82.55	75.83–89.28	−2.36*
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	150.46	143.91–157.00	146.51	143.11–149.91	1.05
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	0.68	0.45–0.90	0.77	0.57–0.95	−0.55

Notes:

^***p < 0.001,

^**p<0.01,

^*p<0.05. CCBHC = certified community behavioral health clinic. RUCC = rural urban continuum code. DF = degrees of freedom for t-test. Presented percentages and means are weighted using survey-specific weights. See Appendix 2 for details on the weighting scheme. There were 49 missing responses to the question asking whether an organization added a crisis call line after becoming a CCBHC. While in Table 4’s regression analyses we use logged forms of Population, Black, Hispanic, and Employee to address their skewed nature, here, we present the unlogged forms.

In adjusted analyses (Table 4), the number of employees per 1,000 people within a CCBHC service area was positively associated with whether a CCBHC provided mobile crisis response (AOR=1.5) and crisis stabilization services (AOR=1.6) directly compared to through a DCO. Turning toward Panel B of Table 4, clinics that received the CCBHC Medicaid bundled payment had 2.5 and 3.2 higher odds of adding mobile crisis response and crisis stabilization services, respectively, after becoming a CCBHC compared to clinics that did not receive this payment.

Table 4:

Multivariable Logistic Regression Examining Factors Associated with Whether a CCBHC Offered Crisis Services Directly and Added Crisis Service After Becoming a CCBHC

Characteristics of CCBHCs	Panel A: Provided Service Directly (Relative to Through a DCO)		Panel B: Added Service After Becoming a CCBHC (Relative to Before)
	AOR	95% CI	AOR	95% CI
Offered Crisis Line
Rural (average RUCC among counties within CCBHC service area)	0.83	0.57–1.21	0.99	0.72–1.35
Population Size (CCBHC service area)	0.73	0.46–1.16	1.45	0.88–2.39
Black (rate per population within CCBHC service area)	0.58	0.33–1.03	1.16	0.66–2.03
Hispanic (rate per population within CCBHC service area)	1.53	0.77–3.03	0.67	0.35–1.29
Poverty (rate per 1,000 persons within CCBHC service area)	1.00	0.99–1.01	1.00	0.99–1.01
Uninsurance (rate per 1,000 persons within CCBHC service area)	0.99	0.98–1.01	1.01	1.00–1.03
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	1.01	0.99–1.04	1.01	0.99–1.02
CCBHC Medicaid Bundled Payment (Ref. No.)	2.53*	1.02–6.28	1.56	0.63–3.87
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	1.00	0.77–1.30	1.21	0.89–1.66
Offered Mobile Crisis Response
Rural (average RUCC among counties within CCBHC service area)	1.10	0.75–1.63	0.92	0.75–1.15
Population Size (CCBHC service area)	1.20	0.69–2.08	1.43	0.94–2.18
Black (rate per population within CCBHC service area)	0.50	0.25–1.01	0.74	0.48–1.13
Hispanic (rate per population within CCBHC service area)	1.05	0.55–2.03	0.78	0.49–1.23
Poverty (rate per 1,000 persons within CCBHC service area)	1.00	0.99–1.01	1.01	1.00–1.02
Uninsurance (rate per 1,000 persons within CCBHC service area)	1.00	0.98–1.02	1.00	0.99–1.01
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	1.01	0.99–1.03	1.01	1.00–1.03
CCBHC Medicaid Bundled Payment (Ref. No.)	0.78	0.30–2.05	2.52**	1.28–4.97
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	1.46*	1.08–1.98	1.03	0.80–1.32
Offered Crisis Stabilization
Rural (average RUCC among counties within CCBHC service area)	1.06	0.78–1.45	1.04	0.79–1.36
Population Size (CCBHC service area)	1.42	0.82–2.48	1.40	0.84–2.33
Black (rate per population within CCBHC service area)	0.82	0.45–1.50	1.22	0.67–2.19
Hispanic (rate per population within CCBHC service area)	0.94	0.50–1.78	1.01	0.58–1.74
Poverty (rate per 1,000 persons within CCBHC service area)	1.00	0.99–1.01	0.99	0.98–1.00
Uninsurance (rate per 1,000 persons within CCBHC service area)	0.99	0.97–1.01	1.00	0.99–1.01
Medicaid Enrolled (rate per 1,000 persons within CCBHC service area)	0.99	0.97–1.01	1.00	0.99–1.02
CCBHC Medicaid Bundled Payment (Ref. No.)	0.62	0.23–1.71	3.19**	1.51–6.72
CCBHC Employees (rate per 1,000 persons within CCBHC service area)	1.60**	1.17–2.19	1.24	0.92–1.66

Notes:

^***p < 0.001,

^**p<0.01,

^*p<0.05. CCBHC = certified community behavioral health clinic. DCO = designated collaborating organization. Logistic regression models are weighted using survey-specific weights. See Appendix 2 for details on the weighting scheme. There were 49 missing responses to the question asking whether an organization added a crisis call line after becoming a CCBHC. All models contain region fixed effects (i.e., Northwest, Midwest, South, West) to account for potential regional patterns in crisis service systems. We use logged forms of Population, Black, Hispanic, and Employee to address their right-skewed nature. Appendix 4 reports the regression results using the original forms of the four logged-transformed independent variables, and Appendix 5 reports the regression results without the region fixed effects. Both Appendices are consistent with the results shown here.

Discussion

This study used the only national survey of the universe of CCBHCs to expand upon minimal research into the CCBHC requirement that clinics provide crisis services,^15,24 adding to the growing literature characterizing federal, state, and local crisis systems.^10–13

We find that the factors associated with the delivery and addition of crisis call lines differed from those correlated with the other crisis services. Clinics with more employees per 1,000 people within a CCBHC service area were more likely to provide mobile crisis response and crisis stabilization services, but not crisis call line services, directly. Because these services are more costly and sensitive to capacity issues than crisis call lines, this difference may reflect resource intensity.^28–31 Moreover, in alignment with other research,¹⁵ clinics that received a CCBHC Medicaid bundled payment were more likely to have added mobile crisis response and crisis stabilization, but not crisis call lines, after CCBHC designation than CCBHCs that did not receive this payment. This finding may reflect billing differences: health insurers are more likely to reimburse for mobile crisis response and crisis stabilization than crisis call line services.^32,33 Consequently, organizations may be more likely to add these services in response to a billing change, like the CCBHC Medicaid bundled payment, than crisis call lines.

The finding that the number of employees per 1,000 persons within a CCBHC service area is positively correlated with offering some crisis services directly is suggestive, but by no means indicative, of characteristics of the local crisis service environment. A partnership suggests that CCBHCs may be tapping into existing resources rather than building duplicative service capacity. Direct delivery, on the other hand, may indicate that there is no other crisis provider in the community that delivers crisis services in line with CCBHC requirements, and/or that existing crisis providers do not have sufficient capacity to meet the full demand for crisis services, leading the CCBHC to supplement the existing crisis infrastructure.

Differences in the structure of CCBHC Medicaid initiatives and the CCBHC Expansion grant program shed light on the finding that clinics that received a CCBHC Medicaid bundled payment were more likely to have added mobile crisis response and crisis stabilization after CCBHC designation. Because the CCBHC Medicaid bundled payment model is designed to provide a sustainable financial foundation for service line expansions necessary to fulfill CCBHC criteria, particularly resource-intensive ones like crisis, clinics participating in their state’s Medicaid demonstration may be more financially secure to launch and sustain new mobile crisis and crisis stabilization capacity. In contrast, the CCBHC Expansion grants may primarily attract applicants that already offer these services because the lump sum awards do not provide sufficient financial resources to support the costs of launching and sustaining new crisis services.

If this explanation is valid, planned expansions of CCBHC Medicaid bundled payments may increase the availability of crisis care nationally, though our study does not shed light on the sufficiency of this increase for meeting crisis care needs. While the site-specific CCBHC bundled rate reflects the projected need for crisis care (and other needs) according to the CCBHC community needs assessment – completed before the clinic receives CCBHC designation – our data do not measure if the addition of crisis services led to a small or substantial change in crisis care access for the population served by the CCBHC. Previous and future expansions of CCBHC Medicaid Bundled payments, such as the Bipartisan Safer Communities Act (Pub. Law. 117–45) expanding the current 10 state Section 223 Demonstration program by 10 states every two years beginning in 2024,³⁴ or the 2024 addition of crisis per diem or monthly rates for mobile crisis response and/or crisis stabilization to the Section 223 prospective payment system,^23,35 provide opportunities for researchers to evaluate if these payments alone or in combination with other policies sufficiently increase crisis care access.

Recently, the federal government has invested other Medicaid resources in behavioral health crisis care. For context, federal law does not require Medicaid programs cover crisis care, but states use a variety of “building blocks” – like state options, waivers, and federal administrative matching funds – to add these services as a Medicaid benefit.^32,36 As of 2022, Medicaid directors from 22 states and DC reported that their Medicaid programs for adult beneficiaries covered crisis hotlines and 33 and 28 reported coverage of mobile crisis response and crisis stabilization, respectively.³³ State actors should explore if and how recent federal investments in Medicaid crisis services, including the 5-year 85% enhanced Medicaid match for mobile crisis response, can work in partnership with CCBHC Medicaid bundled payments to support the expansion of crisis care.^20,21,37

Limitations

First, our data answer whether the CCBHC provides any amount of crisis services but does not inform whether this amount is sufficient to meet the access needs of the populations it serves. Second, our analysis informs about associations between the delivery and addition of crisis services and data on characteristics of the clinics and the county(ies) they serve that by no means imply any causal relationship. Third, the years for most of our independent variables precede our dependent variables by one or two years, indicating that our analysis examined relationships between lagged versions of many of the exposure variables and our outcomes of interest. Fourth, the landscape of CCBHCs has evolved since this survey was administered in 2022, including 128 new CCBHC Expansion grants in 2023. Consequently, data may not be generalizable to the landscape today; however, these findings serve as a useful benchmark for comparison with data capturing CCBHCs operating under different policy contexts, including recent and planned federal and state investments impacting CCBHCs and crisis services.^20,23,35

Conclusion

Actors across levels of governments have proposed CCBHCs as an integral component of establishing robust crisis systems,^20–23 particularly given the growing crisis service needs resulting from 988 implementation.¹⁴ Our findings suggest that CCBHC initiatives, particularly CCBHC Medicaid bundled payments, might be an effective tool for increasing the availability of mobile crisis response and crisis stabilization services, though the sufficiency of this increase for meeting crisis care needs remains unknown. As the program expands, future research will provide additional insights into how CCBHC initiatives increase access to and quality of behavioral health crisis services.

Highlights.

• The authors analyzed the only national survey of the universe of certified community behavioral health clinics (CCBHCs) to assess whether CCBHCs offered behavioral health crisis care directly or through another organization, and whether clinics added these services before or after becoming a CCBHC.

• The number of employees per population within a CCBHC service area was positively associated with offering mobile crisis response and crisis stabilization services directly compared to through another organization, and clinics that received a CCBHC Medicaid bundled payment had higher odds of adding these two crisis services after becoming a CCBHC than clinics that did not receive this payment.

• CCBHC initiatives, particularly CCBHC Medicaid bundled payments, may provide opportunities to increase the availability of behavioral health crisis services, though the sufficiency of this increase for meeting crisis care needs remains unknown.