Certified community behavioral health clinics (CCBHCs) were federally enacted in 2014 to address unmet needs for substance use and mental health care in community-based settings. Currently, over 500 CCBHCs operate across the country in 49 states and territories through a federal demonstration, grants from the Substance Abuse and Mental Health Services Administration (SAMHSA), and independent state implementations. CCBHCs can be strong partners for federally qualified health centers (FQHCs) and play a crucial role in the delivery of medications for opioid use disorder (MOUD), due to their expertise in mental health and substance use disorder (SUD) treatment.
This case study explores implementation of MOUD through a partnership between a Missouri-based FQHC and CCBHC. The Center for Health Care Strategies (CHCS) developed the case study drawing from a series of interviews with FQHC and CCBHC staff.
ACCESS Family Care Medical & Dental Clinics (Access) is an FQHC founded in the mid-1990s as a small medical clinic in Pineville, Missouri. Since then, Access has grown into a multi-site health center with more than 200 employees serving residents in seven southwest Missouri counties, which are predominantly rural except for the city of Joplin, where Access’ largest clinic is located. Access serves patients across the lifespan, including a large percentage of individuals who are uninsured or enrolled in Medicaid. Patients have access to medical, dental, pharmacy, pediatrics, OB/GYN and midwifery services, as well as behavioral health services and counseling.
Clark Community Mental Health Center (Clark) is a CCBHC located in three rural southwest Missouri counties. It is certified with Missouri’s Department of Mental Health (DMH) as a clinical outpatient provider and is the Administrative Agent responsible for residents in Barry, Dade, and Lawrence counties with mental health and/or SUDs. This means that Clark is the primary treatment provider for both adults and children in DMH’s comprehensive psychiatric service division. Clark provides a range of behavioral health services, including crisis services. The center was part of the initial eight-state pilot demonstration led by the SAMHSA for CCBHCs starting in July 2017 and has grown substantially, increasing from 80 to more than 180 employees and from 1,700 to 5,300 patients served per year. Clark has 10 prescribers of MOUD. It has offered extended-release injectable naltrexone since it became available in 2010 and buprenorphine/naloxone sublingual films (e.g., Suboxone) since becoming a CCBHC, as required by SAMHSA. During interviews with CHCS, staff reflected that this requirement enabled providers to see the successes of buprenorphine treatment, which has led more providers at Clark to begin prescribing.
Access sought to offer MOUD in response to the opioid epidemic’s impact on the community. Access staff felt they needed assistance in learning how to provide MOUD. Primary care providers were overwhelmed, and many were not waivered to prescribe buprenorphine, which was required at the time. While Access had therapy staff prior to the partnership with Clark, MOUD implementation was difficult because no one at Access had sufficient SUD expertise. Simultaneously, Clark was providing services in several counties and had many patients who could not pay for their MOUD medications. These challenges were resolved upon the formation of the partnership between Access and Clark.
The CEOs of both organizations had been working together for more than 10 years before Access began offering MOUD. Clark began providing psychiatry consults to better address the behavioral health needs of Access patients. This led to a collaboration around MOUD for Access patients, which began in October 2021 when a psychiatric mental health nurse practitioner (PMHNP) at Clark began working part-time at Access. The PMHNP serves as Clark’s Integrated Outpatient Services Director and as Access’ Behavioral Health Director. She is referred to as the “key connection” behind the Access and Clark partnership. She meets weekly with the CEOs of both organizations and is responsible for hiring new employees to staff the MOUD program under the partnership.
The MOUD partnership is made possible through a grant from the Missouri Department of Mental Health for integrating behavioral health into primary care and a grant through the Missouri Primary Care Association focused on encouraging FQHCs to treat individuals with SUD, including opioid use disorder (OUD). Access and Clark have a Business Associate Agreement in place in which Access entrusts Clark with managing and staffing Access’ MOUD program. The partnership allows community members to receive MOUD at Access, Clark, or via telehealth.
How We Built This
When Access first started offering MOUD, the organization adopted Clark’s SUD policies and procedures related to OUD, including significantly changing some processes. For example, previously Access required a one-hour slot for new behavioral health patient appointments, often resulting in month-long delays for a first appointment. Access made a significant change by adjusting to 30-minute intake appointments for new patients and enabling same- or next‑day treatment initiation for MOUD to provide immediate access to treatment.
Today, MOUD is provided at eight different Access clinics, and patients can receive MOUD treatment with providers via telehealth at all Access and Clark facilities. Patients who receive primary care at Access and behavioral health services at Clark can have in-person visits at Clark locations as well. Patients typically pick up their medications at a local pharmacy; however, there is a pharmacy at Access’ Joplin location where patients can pick up buprenorphine products.
To effectively coordinate care for patients across providers at both Access and Clark, the two organizations have patients sign a release of information that fulfills requirements under 42 CFR Part 2 when they start MOUD treatment. This allows Access and Clark staff to share information via secure email and coordinate care. Staff can also work in both organizations’ electronic health records (EHR) — eClinicalWorks for Access and Insync for Clark. Employees not involved in the MOUD program cannot see both EHRs.
Training and Capacity Building
During the Access onboarding process, staff are made aware of the MOUD program, and how patients can access it. New behavioral health staff are required to participate in MOUD program training led by embedded Clark providers. In addition, new Access providers complete an online training and receive additional training directly from existing Clark providers to increase their comfort level with prescribing MOUD. Bias and unconscious bias are addressed during ongoing staff trainings, which in combination with the integration of the two organizations, has helped to combat stigma around behavioral health, including OUD. Clark also has guidelines for prescribing buprenorphine/naloxone sublingual films that providers can reference at any time to assist with prescribing decisions. Providers receive $3,000 and one week off each year for continuing education. Providers can choose which area of continuing education they would like to participate in. For example, several providers attended a national SUD conference with these funds.
Ongoing support and open lines of communication between Access and Clark staff enable them to easily get questions answered via email, phone, or by flagging other staff down in the hallway for a conversation about a patient. With Clark staff physically present at Access locations, Access’ primary care providers learn more about behavioral health and MOUD through ongoing open dialogue. While there are no formalized case conferences, the frequent communication between staff at both organizations enable Access providers to feel more confident about the care decisions they make with the behavioral health expertise they receive from Clark. Access staff acknowledge that behavioral health is a big part of primary care, and the partnership increases their confidence in providing their patients with the best care possible.
Staffing and Services
All MOUD prescribers at Access clinics are Clark employees doing business as Access. Employee badges are two-sided with Clark on one side and Access on the other, made possible through the Business Associate Agreement. Another agreement allows Access patients in two counties to be referred to Clark for mental health treatment. Access therapists provide mental health treatment to patients in four other counties.
The MOUD care team includes:
- Psychiatrist and three psychiatric mental health nurse practitioners, who are responsible for prescribing MOUD to patients and overseeing patient care. Primary care providers at Access can also start patients on MOUD to ensure timely treatment initiation.
- Behavioral health consultants (BHCs) are Access employees serving as therapists under the primary care health home program. Access providers can refer patients to a BHC when they identify a mental health or substance use concern. Providers make a warm handoff to the BHC, whom the patient can meet with briefly while the provider is still in the room. Staff have found that this brief meeting often leads patients to become more agreeable to therapy and other behavioral health services. If indicated, the BHC then refers patients to prescribing providers. In the absence of a BHC, many patients are not initially open to see a therapist, which staff believe is related to stigma associated with accessing behavioral health services.
- Mental health counselors provide traditional mental health therapy, and they often work with patients whose needs exceed those typically addressed by a BHC. Access patients who present with counseling needs in Barry and Lawrence counties receive services at Clark from their staff.
- Outreach staff go into the community to locate patients and help connect them to services. These include community liaisons who may work with law enforcement officials or help connect people to housing. Outreach staff also connect Access patients being referred to Clark in Barry and Lawrence counties to case management services.
- Nursing staff (licensed practical nurses and medical assistants) are responsible for checking patients into appointments, calling-in medications, administering injectable medications, and assisting patients in getting registered in a tracking system for grant reporting purposes.
Access bills insurance providers for MOUD, with Medicaid representing 55 percent of their payer mix, 18 percent commercial insurance, and seven percent Medicare. The remaining 20 percent of patients are uninsured. Clark’s payer mix is about 75 percent Medicaid, 14 percent commercial insurance, two percent Medicare, and nine percent uninsured.
The services provided to uninsured patients as well as medications and staffing are covered by several grants that Access receives. These grants include an Integrated SUD grant through Missouri’s Department of Mental Health, a grant through the Missouri Primary Care Association, and a 330 grant through Health Resources & Services Administration (HRSA). Interviewed staff noted that Medicaid expansion has enabled their grant dollars to go further and serve more uninsured patients. This funding also played a role in covering upfront costs when Access started their MOUD program.
FINANCING THE PARTNERSHIP
Access supports its MOUD program through insurance reimbursement, as well as grant funding. Clark covers their employees’ paid time off and only bills Access for the time the contracted employee works.
Staff Time: Clark invoices Access each month for the time their staff are doing business as Access. The rate for each provider differs based on the provider’s salary. Clark providers (doing business as Access) bill in the Access system, which enables Access to recoup the payment. These providers receive their paychecks directly from Clark despite working part of the time at Access.
Intake: Neither Access nor Clark bills for the initial screening that is administered to patients. After the initial screening, Clark oversees a second part of the intake process that is considered an “initial evaluation” and then the agencies collaboratively conduct a comprehensive evaluation by psychiatry or therapy staff. Both Clark and Access bill this intake process for psychiatric medication appointments as a 99202-99205 code. However, a new visit can only be billed by the location where it is provided, so if the patient is seen for the first time at Access, they will bill the intake and vice versa. These visits are scheduled as hour-long evaluations. If the comprehensive assessment is done by therapy staff, this is conducted as an hour-long evaluation often in three different visits billed as a 90834.
Induction: Access and Clark both do inductions, managed by the patient in their home environment. During the initial assessment, which is billed through an Evaluation & Management (E&M) code, the provider discusses at-home inductions and develops a plan with the patient. Services for patients who are enrolled in the MOUD grant are billed to Access and then Access bills those services to the grant.
Mental Health Services: Access bills E&M codes for psychiatric mental health services. For established patients, the health center bills the appropriate code, which is often a 99214-99215 code for the evaluation visit. For new patients, Access bills the appropriate code, which is often a 99204 or 99205 code. The health center can bill for a medical E&M code and a behavioral health (therapy) code on the same day but cannot bill for two medical E&M codes on the same day. The time BHCs spend with patients is covered through Access’ Patient Centered Medical Home.
Case Management: Case management is provided by Clark staff in select counties — Barry, Lawrence, and Dade — and reimbursed through Medicaid. These services are primarily for adults with severe mental illness and/or SUD, as well as for children with severe emotional disturbances. Where Clark and Access share service areas, Clark has staff co-located in Access’ Barry and Lawrence County offices who can take direct referrals to Clark for all services including case management. Private insurance does not pay for case management, but when someone presents with a qualifying diagnosis for case management, Clark will serve these individuals, regardless of pay source and ability to pay.
Successes and Challenges
The partnership between Access and Clark has been advantageous for both entities and their patients. For patients, the major benefits include access to coordinated medical care, mental health and SUD treatment, and care coordination. For Access, the major benefit is the ability to use the behavioral health expertise and staffing from Clark that they were unable to obtain on their own. This has been helpful for both the clinical and operational aspects of the MOUD program. Clark has been able to learn from Access’ strong grant writing abilities to augment its own programming.
Staff shared that between 25 and 30 percent of the behavioral health program’s patient population is composed of individuals with OUD. When comparing billed services, psychiatry visits increased by 66 percent and therapy visits increased by 55 percent between October 2021 to January 2022 and October 2022 to January 2023 respectively, reflecting the successes of the partnership.
Several challenges emerged during the initial stages of the partnership between Access and Clark that were subsequently resolved. One early challenge involved the two organizations agreeing on how to share grant funding — the strong relationship between the CEOs helped address this relatively easily.
Clark’s CEO had some initial concerns about serving Access patients outside of the three counties that Clark was designated to work within, due to the administrative agent system in Missouri where specific organizations are tasked with meeting the behavioral needs of residents in each county. This was resolved through conversations between the CEOs.
Technology integration continues to be a challenge between Access and Clark as the organizations use different EHRs. The organizations are currently using a common email platform to help streamline communication, and their leadership and IT staff meet weekly to better understand opportunities to facilitate communication.
Another challenge experienced by Clark management staff who work part time at Access is that they often feel like they are working two full-time jobs with part-time availability. The needs of the patient population are so great that these staff could easily work full-time at either organization.
Access and Clark staff shared several recommendations based on their experience that would be useful to other organizations seeking to form a similar FQHC-CCBHC partnership, including:
- Foster organizational and leadership buy-in since starting a partnership requires a top‑down approach. Clinical champions are beneficial, but leadership also needs to be on board for an MOUD program to be successful. This is best facilitated through the development of positive, trusting relationships between staff and leadership at both organizations. The Access and Clark CEOs built trust with each other through conversations that revealed their similar values about serving their patient populations. In addition, Access welcomed a Clark leadership representative into their executive management team to ensure integration. This allowed barriers and issues to be resolved quickly.
- Seek alignment between organizations that govern FQHCs and CCBHCs. In Missouri, strong relationships extend beyond Access and Clark leadership to support an effective partnership. The CEO of the Missouri Primary Care Association, which includes Access as a member, and the CEO of the Missouri Behavioral Health Council, which includes Clark as a member, have a strong relationship with each other. This helped with higher-level coordination of the partnership at the state level. For example, the strong emphasis of the Missouri Primary Care Association and Behavioral Health Council to create alliances between FQHCs and CCBHCs was a significant factor in helping to alleviate the concerns of Clark’s CEO regarding doing business as Access.
- Seek partners who are open and honest about the challenges they face. Access and Clark have communicated openly with each other, which has been helpful in working through any challenges that came up. If an organization is not upfront about the challenges they are facing, it could be difficult to work together effectively.
Additional recommendations shared by staff pertaining to MOUD implementation include:
- Be creative with problem solving, particularly when the health center does not have the in-house expertise to build out an MOUD program. This can be accomplished by finding creative ways to consult with experts and bringing experts into the health center to get the program off the ground. At Access, that was accomplished mainly by bringing in Clark staff, who had the necessary behavioral health expertise to launch the MOUD program.
- Avoid making stigmatizing assumptions that only certain subsets of the population experience OUD. Access and Clark see patients from all facets of life. It can take time to achieve buy-in for MOUD, but firsthand experience reveals the positive impact that MOUD has on people’s lives. Once staff learn more and witness the transformation MOUD creates for patients, stigmatizing assumptions such as viewing MOUD as “trading one substance for another” are eliminated.