Is Your Accrediting Body Still the Right Fit?

Your organization is not the same one it was 10 or 20 years ago (or likely even 3 years ago!). New programs/services may have been opened and staff changes have taken place. There are new requirements from payors, licensing bodies, the federal government, etc. Perhaps there has been a merger or acquisition, or new partnerships developed with other entities to ensure the continuum of care. Or, you may have directly integrated physical health care into your service delivery or begun to offer telehealth services as a result of the pandemic.

Likewise, the accrediting bodies may have changed over time:

  1. Standards are updated annually – do they still fit with your current program/services?
  2. Has there been a shift by the accrediting body to be more closely aligned with your line of business – toward behavioral health or toward child welfare, for example?
  3. Perhaps there has been a new approach to sales and marketing that could have affected customer service?

When you initially selected your accreditor, you likely considered such things as cost, reputation in the marketplace, and may have had a recommendation from another organization. (See our blog article on 10 Things to Consider When Selecting an Accrediting Body for more information.)

I’m sure that the intent was to do your research and find the best fit for a long-term relationship. However, relationships can change.

So, when do you know if it is time to look around? And, if you do, what questions should you ask?

If you are asking yourself these questions, might I suggest that you consider the following:

  1. Standards – your programs and services’ fit with the current accreditation standards
  2. Reputation – current feedback from other accredited organizations
  3. Mandates – is there a current mandate for accreditation or one on the horizon, and if so, does it specify a particular accrediting body or bodies?
  4. Effort – how much work will it take to switch vs. remain with your existing accreditor*
  5. Costs – fees always matter, but what is the true value of the accreditation process and experience and what is the cost to maintain your accreditation?
  6. Timing – how long have you been with your existing accreditor?

Note, I do not recommend making a change simply for the sake of change. However, it never hurts to look around and ask a few questions to make sure that your accrediting body is still the right fit for today and for the future of your organization.

 

*If already accredited and deciding to make a switch, it is important to focus on the similarities and differences between the two accrediting bodies’ standards and processes for the most effective use of time and resources. It is also critical to understand the different approaches and philosophies from one accrediting body to another.

To further discuss any of the above items, or if you are interested in assistance with switching from one accrediting body to another, please contact us at Info@AccreditationGuru.com / 212.209.0240. This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.

Five Reasons for Substance Use Treatment Providers to Become Accredited

Substance use disorder treatment providers have many reasons to seek national accreditation and to benefit from this process. Whether seeking accreditation from The Joint Commission, CARF International, Council on Accreditation (a division of Social Current), Accreditation Commission for Health Care (ACHC), or other, here are 5 top reasons to become accredited:

Reason #1 – Promotes Quality Treatment in a Safe and Healthy Environment

An external survey of quality and safety conducted by well-trained professional accrediting body surveyors provides reassurance and builds trust for the individual, family, or referral source seeking a treatment resource. The accreditation hallmark distinguishes a treatment resource as going beyond minimum state licensing standards. Accrediting bodies promote accredited organizations on their websites so that parents, individuals, and healthcare professionals can easily identify treatment resources with the accreditation hallmark of distinction.

Reason #2 – Strengthens Business Practices

Accreditation standards address ethical marketing practices, require transparency in plans and policies, look for actions taken based on staff and consumer feedback, and promotes equity in treatment based on the person’s needs.

Reason #3 – Standardizes Administrative and Clinical Processes

Accreditation supports consistent delivery of good care to every consumer. It requires a multi-dimensional assessment (best practice) so that each consumer is receiving exactly the care and treatment needed by competent and qualified staff. The standardization of processes provides a framework for increasing service capacity, allowing for expansion of levels of care, new programs and services, and treatment at additional locations.

Reason #4 – Expands Reimbursement Options

Accreditation is increasingly being used as an indicator of quality by third-party payers as a condition of substance use treatment payment approval. Private, commercial insurance companies, and managed care entities require accreditation to become an “approved” provider. The accreditation hallmark of quality and safety may also result in more diversified referral sources as healthcare professionals recognize the organization’s commitment to quality and safety.

Reason #5 – Supports Efficient and Effective Billing

Being reimbursed in a timely manner is a critical business practice component for any substance use treatment provider. The clinical documentation required by accrediting bodies supports and justifies admissions (medical necessity of services), level of care, treatment interventions, continued stay/treatment, and transfer or discharge. This type of clinical documentation reduces denials of reimbursement or provides the documentation needed for appeals of denials.

The results of a recent study of Joint Commission accredited organizations by ROI Institute supports National Accreditation and identifies returns on accreditation investment.

If you are ready to reap the benefits of accreditation for your organization, or if you have questions about the process, please contact us.

 

For more information or questions about the contents of this article, please write or call Peggy Lavin @ Peggy@AccreditationGuru.com / 847.219.1296.

This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.

What happens when a mandate for accreditation is on the horizon or comes through?

If your organization is impacted by either a Federal, State or Association mandate, it is important to get in front of it early so you don’t get caught in the crunch-which can happen when hundreds of organizations try to get accredited at the same time

How Accreditation Supports Recovery Principles

The national accrediting bodies have been among the moving forces in the integration of the recovery model into the care, treatment and services for people with mental health and/or substance use disorders. Recovery principles can now be seen throughout behavioral health standards of accrediting bodies as well as the outlined expectations that an organization will demonstrate conformance/compliance to these standards. And, the integration makes sense – this model not only complements the more traditional model of medication and “talk” therapies, but also expands the focus to include the person’s own goals and strengths and empowers them to be actively involved in the process.

The US Substance Abuse and Mental Health Administration (SAMHSA) has also integrated the recovery model in their publications, requirements for certified community-based behavioral health clinics, training materials, and grants. To that end – they’ve developed the Working Definition of Recovery. Several of the guiding principles shown here are addressed in the accrediting bodies’ standards.

Accrediting bodies’ implementation of such a model involves workforce training so that staff can fully understand and embody the organization’s philosophy, thus permeating service delivery to positively impact the recovery of the people served.  In addition, the accreditation survey process itself supports the recovery principles. Surveyor(s) not only review written documents, but also observe interactions amongst staff at all levels and persons served and share their observations with the organization. This external survey can confirm, enhance, and strengthen the organization’s intent and commitment to recovery principles

While accreditation as a whole supports the recovery model, below are specific examples of ways in which accreditation and the recovery model intersect:

Person-Driven – An individualized plan of care, treatment, and services based on the needs, strengths and abilities, preferences/expectations and goals of each person being provided care, treatment or services is a core accreditation requirement. “Boiler plate” plans that repeat over and over the same information for each person served will result in survey findings (unsatisfactory conformance/noncompliance with standards) and the need for correction to achieve full accreditation. Furthermore, it’s an expectation that an accredited organization actively involve the person served in identifying their needs and preferences for aftercare and, as much as possible, making choices about where, type, and by whom.

Holistic – The needs of the person in relation to various life domains, such as physical health and housing, are addressed in case management/care coordination standards (assessment of the person’s needs and assistance in meeting these identified life domain needs). Since access to routine and needed physical health care can be a challenge for those who need it, the accrediting bodies offer options for the integration/coordination of physical health care. Health Home standards have been established to facilitate successful integration of physical health care with an organization’s traditional behavioral health programs.

Culture and Respect – Accreditation standards emphasize that the person served encounters respect in all aspects of their care, treatment, or service experience and this is reflected in the organization’s policies, procedures, rules, and expectations as well as the rights and responsibilities of the person served. Standards clearly emphasize that service delivery is provided by staff in an atmosphere of respect and understanding and sensitivity to cultural values, beliefs, and preferences.

Trauma – The approach of the accrediting bodies to trauma centers around their screening and assessment, planning and delivery of services, and workforce training standards. Standards require a screening and assessment process to identify people whose lived experiences either currently and/or in the past may have included trauma(s). Also, organizations need to demonstrate that the impact of trauma on the person served is considered in the planning and delivery of care, treatment, or services.

Peer Support – Peer support services are an important component of the recovery model. These services are part of the plan of care, treatment, or services, and are provided by trained individuals who share similar lived experiences with mental health and substance use challenges. Accrediting bodies not only recognize the utilization of this type of service by mental health and substance use treatment providers, but also have developed standards addressing the integration of these services into the planning of care with the active involvement of the person served.

The accrediting bodies require written plans, policies, or procedures promoting these recovery principles to form a framework for implementation and a communication to staff and people served of the philosophy, beliefs, and values of an organization.

For more information on the recovery model and/or how accreditation can benefit your organization, visit AccreditationGuru.com.

 

For more information or questions about the contents of this article, please write or call Jennifer Flowers @ Jennifer@AccreditationGuru.com / 212.209.0240.   This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.

What is Accreditation?

Accreditation is a review process to determine if human service, healthcare or educational programs demonstrate their ability to meet defined standards of quality. Once achieved, accreditation is not permanent—it is renewed periodically to ensure that quality is maintained.

Requirements differ per accrediting body, but the intent remains the same: to validate an organization’s commitment to meeting accreditation standards that result in a higher level of performance. Accreditation standards have been researched, vetted and field-tested and are updated regularly, as necessary.

Earning accreditation specifies that the organization (or specific program) is appropriately managing its resources and is continually providing the highest levels of service to its clients and stakeholders. Being accredited provides credibility and helps validate and improve the safety and quality of care an organization provides.

Organizations need to demonstrate conformance with the accrediting body’s requirements by implementing the accreditation standards and undergoing an onsite survey or, more recently due to the COVID-19 pandemic, virtual review.

For human service and healthcare organizations, the broad purposes of accreditation are to establish quality measurement criteria and to raise the level of services and professionalism within a given profession or industry (QUALITY) and to ensure services are delivered in a safe manner and in a safe environment (SAFETY).

Becoming accredited offers organizations professional recognition for meeting the highest standards in quality service delivery while providing clients with an appropriate tool for effectively evaluating service providers. Organizations that achieve accreditation have reached beyond the minimum licensing standards and made a long-term commitment to strong management, program consistency, outcome measurements and continuous improvement throughout their agencies.

Accreditation standards address such areas as:

  • Leadership and governance
  • Financial controls
  • Facilities security and safety
  • Workforce development – recruiting, hiring practices, background checks, performance appraisals, training and supervision
  • Performance measurement and improvement
  • Client rights and confidentiality
  • Program administration and service delivery

With all of the needed information in-hand during a survey, the accrediting body will determine whether accreditation has been earned and, if so, will accredit the organization accordingly.

The entire process may take anywhere from 12 to 18 months to complete. For behavioral health and social service organizations, accreditation is valid for 3 or 4 years and there is another full survey at the end of each accreditation cycle.

While accreditation is generally a private (non-governmental), voluntary process, it is often a significant decision-making consideration by potential clients, individual donors, foundations, governmental funding agencies, and billing and private insurance companies.

Here are just a few of the businesses and nonprofits that value the benefits of maintaining accreditation within their respective industries:

  • Mental healthcare and substance use treatment facilities
  • Service providers for people with intellectual or developmental disabilities
  • Foster care and adoption agencies
  • Group homes/residential treatment for children and youth
  • Early childhood education centers and day care providers
  • Hospitals
  • Nursing homes and assisted living facilities
  • Medical laboratories and blood banks
  • Credit counseling agencies
  • Colleges and universities – must be accredited by one of the federally-recognized accreditors for students to be eligible for U.S. federal student aid
  • Continuing education providers
  • Museums
  • Aquariums and zoos – Accreditation from angelfish to zebras!

More often than not, many people don’t realize how often accreditation actually touches their lives. Accreditation is everywhere!

If you are ready to explore how accreditation could be a benefit to your organization or if you have questions about the process, please contact us.

For more information or questions about the contents of this article, please write or call Jennifer Flowers @ Jennifer@AccreditationGuru.com / 212.209.0240.   This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.

Organizational Benefits to Becoming Accredited

Achieving accreditation offers human service organizations professional recognition for meeting quality standards in service delivery. It also provides clients and other key stakeholders with an appropriate tool for effectively evaluating service providers. Organizations that earn accreditation have reached beyond the minimum licensing standards and made a long-term commitment to strong governance, program consistency, outcome measurements and continuous improvement throughout their agencies.

Accreditation requires an organization to undergo an objective review by an independent accrediting body. Becoming accredited signifies that an organization is effectively managing its resources and enhancing the quality of life of persons served.

Accreditation – A Solid Foundation for a CCBHC

The Certified Community Behavioral Health Clinic (CCBHC) model has seen rapid uptake in the last decade because it improves the quality of life for individuals with behavioral health needs. It does this by improving community-based access to behavioral healthcare, regardless of an individual’s ability to pay, which is important. Studies have shown that, in the U.S., one in five adults have a mental illness, but fewer than half received treatment in the past year. In addition, individuals with behavioral health needs often have poor physical health outcomes due to a lack of physical health care access, so the CCBHC model integrates and coordinates physical health services for this population. In order to meet this mission, CCBHCs receive enhanced Medicaid funding that allows them to provide more services as well as services that are not always reimbursed, like community outreach and partnerships.

In 2002, eight community mental health clinics formed the first CCBHC pilot. The number of CCBHCs has now grown to over 400 operating in 40 states. More states are considering adopting this model now that the program has gone nationwide. “Certified Community Behavioral Health Clinics help connect Americans to easy-to-access, comprehensive mental health and substance use disorder treatment and supports in their own communities,” said Miriam E. Delphin-Rittmon, Ph.D., the U.S. Health and Human Services Assistant Secretary for Mental Health and Substance Use and the leader of SMAHSA.

But becoming a CCBHC can be complex. Agencies may need to expand services and hours, hire staff, and determine how and where to integrate physical health care into their operations so they have the capabilities they need to meet the qualifications. CCBHCs are nonprofit organizations or units of a local government behavioral health authority, including tribal government. They must directly provide (or contract with partner organizations to provide) nine types of services, with an emphasis on the provision of 24-hour crisis care and substance use disorder treatment, use of evidence-based practices, care coordination with local primary care and hospital partners, and integration with physical health care.

Some of the key expectations for certified community behavioral health clinics are closely aligned with the accreditation requirements of the national accrediting bodies. These include:

  • Advancing integration of behavioral and physical health care
  • Coordination of care, treatment and services through care coordination/case management
  • Delivering services based on individualized plan of care/treatment by well-trained, competent staff who match culturally/linguistically to the population(s) served
  • Providing patient-centered, trauma-informed, recovery-oriented best practices in their care, treatment and services
  • Enhancing quality to improve outcomes for individuals served
  • Collecting, reporting, and tracking data
  • Continuous quality improvement.

Because national accreditation requirements contain standards of care for addressing these same CCBHC criteria, achieving and maintaining accreditation with Accreditation Association for Ambulatory Health Care (AAAHC) CARF International (CARF), Council on Accreditation (COA), or the The Joint Commission can provide a solid foundation for a  behavioral health care clinic’s journey as a CCBHC. Through compliance with accreditation requirements, organizations will have a roadmap to follow for addressing many key CCBHC components. These areas are then assessed by surveyors/reviewers during on-site or virtual site visits, providing validation of good practices and potential feedback that can generate further enhancements.

Recognizing this solid foundation, SAMHSA encourages accreditation for a CCBHC by an appropriate, nationally recognized organization such as AAHC, CARF, COA, or The Joint Commission. SAMHSA’s intent for a CCBHC is to improve access to and quality of mental health and addiction care, treatment and services for all persons in need. This intent is reflected in the mission of each of the national accrediting bodies: AAAHC, CARF, COA, and The Joint Commission.

Accreditation Guru has experts who can provide consulting to assist organizations throughout the CCBHC accreditation/reaccreditation process. Recently, AG was proud to partner with BestSelf Behavioral Health, a CCBHC, in their achievement of accreditation through COA. BestSelf provides outpatient, integrated behavioral and physical health care using evidence-based practices. Its programs and services include education and vocational supports, mobile mental health and substance use disorder services, homeless outreach and housing, community and school-based programs, and coordination with law enforcement and medical, mental health and child protection professionals. “COA accreditation has allowed BestSelf to focus on quality and maintain best practices as well as operate our Opioid Treatment Program,” says Rebecca S. Steffen LCSW-R, Vice President of Quality Improvement & Accreditation.

We would love to discuss your clinic’s accreditation needs, click here to contact us.

  1. The National Council for Mental Wellbeing, CCBHC Success Center, 2021 Impact Report, https://www.thenationalcouncil.org/wp-content/uploads/2021/08/2021-CCBHC-Impact-Report.pdf?daf=375ateTbd56 (October, 2021)
  2. National Alliance on Mental Illness, Certified Community Behavioral Health Clinics, https://www.nami.org/Advocacy/Policy-Priorities/Improving-Health/Certified-Community-Behavioral-Health-Clinics (October, 2021)
  3. The National Council for Mental Wellbeing, CCBHC Success Center CCBHC Overview, Success Center, CCBHC Overview, https://www.thenationalcouncil.org/ccbhc-success-center/ccbhcta-overview (October, 2021)
  4. Substance Abuse and Mental Health Services Administration, Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish Certified Community Behavioral Health Clinics https://www.samhsa.gov/sites/default/files/programs_campaigns/ccbhc-criteria.pdf (October, 2021)

For more information or questions about the contents of this article, please write or call Jennifer Flowers @ Jennifer@AccreditationGuru.com / 212.209.0240.   This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.