Delivery of ACT within Certified Community Behavioral Health Clinics

Background: The Certified Community Behavioral Health Clinics (CCBHCs) program is a federal initiative to provide enhanced funding to community mental health centers, which offer comprehensive services through crisis care, evidence-based practices, and care coordination. With nearly a billion dollars in federal investment, this represents the most significant reform of community mental health since its inception, leading to more than 500 CCBHCs in 46 states. A primary goal has been to increase access to services for people with severe mental illnesses (SMI). Assertive Community Treatment (ACT) has traditionally been a core program providing services and coordinating care for people with SMI, but the enhanced service delivery of CCBHCs may provide alternative ways to meet the needs of this population. We examined the effect of CCBHC implementation on ACT service delivery compared to community care program (CCP) services, which provide less intense outpatient services to people with SMI.

Methods: This study utilized administrative data that included all outpatient services delivered by a single clinic in the year before and after CCBHC certification in 2018. Overall, the agency served 10,385 adults in 2017 with 183,977 visits and 10,710 adults with 187,538 visits in 2019. The dataset included CCP visits (such as individual and group therapy, psychiatry, psychiatric rehabilitation) and ACT visits by client, visit type, and location. Descriptive data analysis and chi-square analysis were conducted to examine the number of ACT and CCP clients served, average visits per year and location of visits per year pre-and post-CCBHC implementation.

Results: The number of CCP clients increased from 686 to 1,076 (p<0.001) but the number of ACT clients did not change following CCBHC implementation. ACT visits decreased from 7,665 to 4,876 (p<0.001), whereas CCP visits increased from 61,435 to 66,899 (p<0.001) following CCBHC implementation. ACT clients had no change in average visits per year and average number of CCP visits decreased from 72.2 to 55.2 (p<0.001) after CCBHC implementation. In terms of location, office-based ACT visits decreased from 36.8% of all visits to 33.1% (p<0.001), home visits decreased from 47.8% to 44.8% (p<0.001) but visits in the community increased from 15.4% to 22.5% (p<0.001) following CCBHC implementation. Office-based CCP visits decreased from 63.8% of all visits to 55.6% (p<0.001), home visits increased from 20% to 26% (p<0.001) and visits in the community increased from 16.3% to 18.4% (p<0.001) following CCBHC implementation.

Conclusion: After CCBHC implementation, access to services for SMI significantly increased within the CCP program as compared with the ACT program. But within CCP, clients received fewer visits per year, indicating broader service reach but less intensity, either due to less capacity or improved fit between services offered and client needs within CCBHCs. In addition, CCP significantly increased home visits and community visits, suggesting CCP may be fulfilling more of the functions of ACT services, although ACT visits also increased in the community. Overall, the expansion and increased provision of community-based services within CCP may indicate that less intensive services are replacing ACT services within CCBHCs.