Knowledge base: Community mental health and the CCBHC model in Oklahoma
The community mental health system provides services to the vast majority of Oklahomans with serious mental health issues. These services are delivered locally in the community, rather than restrictive inpatient settings like psychiatric hospitals. In Oklahoma, the community mental health system is made up of 13 Certified Community Behavioral Health Clinics, or CCBHCs, that offer coordinated, comprehensive mental health and substance use care to anyone who asks for it, regardless of their ability to pay, whether they have insurance, their age, or where they live.
CCBHCs serve Oklahomans in all 77 counties with a no-wrong-door approach, never turning away people in need of behavioral health services. While CCBHCs are open to anyone, these clinics often function as a mental health safety net in Oklahoma and across the country, serving people who don’t have the means to access care elsewhere. Many people who receive services from CCBHCs have health coverage through Medicaid rather than through an employer-sponsored or commercial health plan.
As the first state to fully transition to the CCBHC model, Oklahoma has been at the forefront of embracing change to better deliver community mental health care to its residents.
CCBHCs in Oklahoma
Background: community mental health in the U.S.
The concept of community mental health originates in the deinstitutionalization movement, which advanced the idea that people with mental illness could — and should — be treated in the least restrictive setting possible. The movement emerged in the 1950s and 60s alongside the civil rights movement and the discovery of the first effective antipsychotic medication, chlorpromazine, more commonly known as Thorazine. As part of the deinstitutionalization movement, states began closing their larger inpatient psychiatric hospitals and bringing individuals back into their communities to receive psychiatric treatment, no matter the severity of their mental illness.
These efforts gained more traction when President John F. Kennedy signed his final bill, the Community Mental Health Act, in 1963. Through the act, individuals once treated in state hospitals were reintegrated into their communities, receiving outpatient treatment in newly established Community Mental Health Centers, or CMHCs. The act also allocated federal funding to build new CMHCs and facilities to further mental health research through state grants.
In Oklahoma, these funds led to the establishment of a first-of-its-kind community mental health center anywhere in the country: the Central Oklahoma Community Mental Health Center in Norman.
While states took advantage of the grants, which provided funding for three years, only about half of the intended community mental health centers were built across the county.
The CMHCs that were built lacked strict guidelines or regulations. Many centers prioritized treating people with less severe mental illnesses, as it was less expensive and time-consuming to do so. Furthermore, federal funding for CMHCs faced cuts starting in the 1970s. As a result, many people previously treated in state psychiatric hospitals struggled to access mental health care.
Despite the intentions of the Community Mental Health Act, inadequate funding consistently hampered the full realization of the CMHC model. While these centers still exist across the country, an updated model for community mental health — Certified Community Behavioral Health Clinics — addresses many of the shortcomings in CMHCs’ financial sustainability and array of services.
CCBHCs in the U.S. and Oklahoma
According to the federal Substance Abuse and Mental Health Services (SAMHSA), “CCBHCs were created to transform mental health and substance use treatment across the country and provide sustainable funding for robust community outpatient mental health treatment. These clinics are required to meet federal standards for the range of services that they provide.”
To be designated as a CCBHC, an organization must provide nine core services, including 24-hour mobile crisis response and stabilization, care coordination, outpatient mental health and substance use treatment, psychiatric rehabilitation, peer support, and integration with primary health care services.
CCBHCs use what is called a “prospective payment system,” in which clinics are paid a set dollar amount for each person served, rather than a standard fee-for-service model of providers billing for each service provided.
Using the prospective payment system, clinics can tailor services to an individual’s unique treatment needs, which could include services like transportation reimbursement, grocery shopping with a client, and other unique methods to integrate treatment into one’s daily life.
To provide coordinated and comprehensive care, CCBHCs employ many types of health providers from different backgrounds, including nurses, psychiatrists, social workers, and peers. By offering several points of entry, such as an outpatient appointment or crisis intervention, CCBHCs offer community members access to an array of mental health services and specialists at any point throughout their lives.
Oklahoma’s history with CCBHCs
In 2015, Oklahoma was among 24 other states that received a one-year planning grant from SAMHSA and the Centers for Medicare and Medicaid Services (CMS) to help states prepare and design CCBHC programs within their states.
In December 2016, SAMHSA announced that eight states would participate in the CCBHC demonstration program: Oklahoma, Minnesota, Missouri, New Jersey, New York, Nevada, Oregon, and Pennsylvania. Less than five months later, Oklahoma was one of two U.S. states to launch CCBHC services — about three months ahead of other states selected for the demonstration. Oklahoma’s three centers designated as CCBHCs for the demonstration were NorthCare, GRAND Mental Health, and Red Rock Behavioral Health.
Seeing the success of the CCBHC model at these demonstration sites, Oklahoma received approval from CMS for a Medicaid state plan amendment to continue CCBHC services in the state beyond the demonstration period. Each state has a Medicaid state plan agreed on by the state and the federal government, outlining how the state will administer its Medicaid program. States need permission from CMS to make changes to this plan.
Through the state plan amendment, Oklahoma became the first state to replace all its former CMHCs with CCBHCs. Today, 13 CCBHCs serve all of Oklahoma’s 77 counties. Most of these clinics are independent nonprofits, and a few are run by the state under the guidance of the Oklahoma Department of Mental Health and Substance Abuse Services.
Roughly 200,000 Oklahomans — about 5% of the population — receive care overseen by the Oklahoma Department of Mental Health and Substance Abuse Services via CCBHCs. More could likely be served by CCBHCs, as a significant number of Oklahomans live with unmet needs for mental health treatment. Nearly 20% of current Medicaid enrollees nationally have a behavioral health diagnosis, making Medicaid the highest payer for CCBHCs. As of July 2023, more than 1.2 million Oklahomans were enrolled in SoonerCare, the state’s Medicaid program.
What’s next for CCBHCs
Because CCBHCs provide services across the behavioral health continuum — from prevention to intensive outpatient and crisis services — they are often at the center of behavioral health innovations and advancements, such as integrating behavioral health in primary care and team-based approaches to service delivery.
Nationally, SAMHSA continues to invest in CCBHCs: nearly every state has at least one CCBHC, and SAMHSA’s goal is for the model to be adopted in all 50 states. Earlier this year, SAMHSA released updated certification criteria for states and clinics, which take into account new developments in crisis care and 988, responding to the opioid epidemic and increasing rates of overdose death, and improving health equity.
In Oklahoma, CCBHCs are key partners in improving both the accessibility of care, as well as the health outcomes of Oklahomans with significant behavioral health needs. As the U.S. continues to invest in CCBHCs, Oklahoma can be an example of the model’s successful implementation, innovation, and growth.
CCBHC Impact Report from the National Council for Mental Wellbeing