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.

How to determine which accrediting body is the right fit for your organization

Selecting a national accrediting body to work with is a significant undertaking. The commitment goes beyond the initial accreditation cycle and, in most cases, it continues for many more years, sometimes even decades. Because of the investment in time, money and effort involved, the selection process should not be taken lightly. Watch our video for tips on determining which accrediting body is the right fit for your organization.

 

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.

Accreditation’s Significance in Time of Crisis

Since late February 2020, child welfare agencies and behavioral health care organizations have been forced to focus on two critical functions – infection control and emergency management. Depending on the services provided and location of the organization, providers have been forced to change their operations in ways that include having all employees work remotely, provide telehealth services or even “closing the gates” and delivering residential services without people going on or off the property.

In these trying times, the framework provided by implementing national accreditation standards certainly helps service providers better manage the necessary pivot in operations and service delivery in this time of crisis.

Accreditation Standards – Detailed Plans and Strategic Safety Net

Accreditation standards that address risk prevention and management, infection prevention and control, performance and quality improvement, technology and information management and staff training are all being put to the test these days.

Effective risk management controls include, but are not limited to, emergency response preparedness. An accredited agency is required to have a written disaster plan for evacuation and relocation of staff and clients, parent-child reunification following a disaster, as well as specific plans to meet the needs of individuals with disabilities and other special needs during emergencies. The organization must also address coordination with governmental authorities and emergency responders. Further, staff needs to be trained on how to respond to medical threats and emergencies and how to handle potential safety risks they may encounter on the job.

Accreditation (maintenance and preparation) guides an organization through a thoughtful, structured and planned process to create an infrastructure for risk management and performance improvement that can be seamlessly implemented during times of crisis like this one.

The accreditation process also helps organizations review and strengthen their policies and practices through compliance with national standards of care. This includes creating processes for gathering and using data for continuous improvement of the quality of the services provided. It is not enough to collect and analyze data related to outputs such as the number of clinical sessions provided or the total number of clients served, but they also must identify, observe and measure the effects of a program’s services on clients.

“Plan and procedures for disaster readiness are a lived concept for CARF-accredited organizations. The readiness mindset of our programs has helped organizations and their staff to transition services to better support children and families during this pandemic.” – Leslie Ellis-Lang, MMFT, Managing Director, CARF Child and Youth Services *

Technology-Based Service Delivery – AKA Telehealth

Due to the pandemic and resulting COVID-19 funding legislation that now expands coverage for telehealth services for Medicaid and Medicare beneficiaries, a vast number of service providers were given the opportunity to make a seemingly overnight shift to employees working remotely and providing telehealth services.

The existing accreditation standards in place that address the management of technology-based service delivery allow companies to reference their strategic plan and immediately embrace the full-time use of this technology.

Any accredited organization that engages or plans to engage service recipients in technology-based service delivery needs to develop policies and procedures to guide telehealth service delivery to address privacy and security measures. They must also assess the appropriateness of technology-based service delivery for each individual and monitor effectiveness of using this model.

Accreditation standards further address competency-based training for personnel on the use of equipment and software, privacy and confidentiality issues, and recognizing and responding to emergency or crisis situations from a remote location.

While many organizations may not have developed a detailed pandemic response plan, wouldn’t it have been helpful to have already addressed and planned for the use of telehealth services and having employees work remotely under the framework of accreditation standards?

Accreditation Drivers

“Accreditation is not just a box to tick and this is even more apparent during times of crisis,” says Jody Levison-Johnson, President and CEO, Council on Accreditation (COA). “COA has standards that address key preparedness and response issues. These fall under the broad standards categories of human resources management, safety and security, and emergency preparedness – all of which are critical during times of crisis.” *

The three major accrediting bodies for human service organizations (CARF International Council on Accreditation and The Joint Commission) research and develop their unique set of accreditation standards that address a commitment to helping child welfare and behavior health care organizations provide safe and high-quality care, treatment or service. Applying the standards often leads to an increase in consumer confidence in service delivery. Read “Increasing Consumer Confidence Through Accreditation“.

“(The Joint Commission) recognizes the challenges behavioral healthcare organizations are facing during this difficult time and we want to hear from all behavioral health care providers what else we can do to help.” – Julia Finken, Executive Director, Behavioral Health Care Accreditation *

This Too Shall Pass

“This too shall pass” is comforting and indeed it will (or be better controlled). But, as the pandemic stretches on and businesses start to develop a “new normal” for addressing the various health and economic needs of the public at large, a pre-laid foundation of strategic plans and detailed response initiatives can provide a more effective pivot for a company.

Is your organization one of them? By scheduling time to focus on accreditation, you can address key initiatives now and stay ahead of the game in the future. Don’t delay your preparation for achieving accreditation. Develop a work schedule that includes accreditation preparation whether you are applying for the first time or maintaining your status.

Keep Your Momentum Going!

*For additional information from the accrediting bodies:

CARF International

COA “Preparing for Response to COVID-19”

The Joint Commission

Why are behavioral health (and other) organizations flocking to accreditation?

The interest in national accreditation is on the rise. More and more behavioral health and human services organizations making an investment in their future by becoming nationally accredited. Why? Here are five reasons service providers should consider accreditation this year.

  • Accreditation provides an external validation of the quality of your programs and services. This can increase credibility and boost your reputation to help expand your referral base, attract individuals looking for services, and recruit and retain quality staff.
  • As health insurance coverage for mental health and addiction treatment rises, accreditation is increasingly being used as an indicator of quality by private payers, Medicaid and managed care programs such as TRICARE. Becoming accredited can help you diversify your funding streams, qualify for more contracts and receive payment approvals.
  • Going through the accreditation process helps standardize policies and procedures across programs/services and throughout multiple locations. This helps build staffing efficiencies and expands best practices across your organization. The result is a consistent framework that can be easily replicated to facilitate future growth.
  • Accreditation is also an exercise in reducing your risk profile. In addition to helping your organization reduce and/or better manage difficult situations and emergencies (helping your legal team sleep better at night!), it may also give you a chance to renegotiate your liability insurance, sometimes significantly.
  • The accreditation process helps organizations review and strengthen their policies and practices through compliance with national standards of care. This includes creating processes for gathering and using data for continuous improvement of the quality of the services you provide.

For questions and assistance with your accreditation and/or post accreditation, please contact us at 212.209.0240 or email Rocio@AccreditationGuru.com.

Increasing Consumer Confidence through Accreditation

When a consumer has made the life changing decision to seek treatment for a mental health or substance usage issue or a parent/spouse/friend is struggling with where their loved one will receive safe and quality care, treatment or services, national accreditation of an organization can be re-assuring.   Increasing the confidence of the consumer or significant other is a significant benefit of accreditation.  Accreditation signals to the consumer/significant other that the organization’s physical environment has been surveyed for safety and its service delivery, surveyed for quality.  After this rigorous survey, the organization has been awarded accreditation based on its compliance with standards for safety and quality of care, treatment or services. For this reason, an accredited organization may post its accreditation status on its website and proudly display its accreditation award certificate in its main entrance(s).  A brief overview of the meaning of accreditation and the accreditation process is often provided to consumers/significant others verbally or in an admissions brochure. Each accrediting body’s logo includes a symbol of approval which an accredited organization may add on its social media and marketing materials.  Accrediting bodies post on their websites a list of accredited organizations so that key stakeholders including consumers/significant others can locate safe and quality care, treatment or services.

Accreditation tells the consumer/significant other that your organization has gone beyond basic state licensing requirements to achieve a higher level of safety and quality of care, treatment or services based on industry standards.

To read more on the advantages of accreditation, click here.

For questions and assistance with your accreditation and/or post accreditation, please contact us at 212.209.0240 or email Rocio@AccreditationGuru.com

Wisdom and Value in Strategic Planning

By Dave Branding, PhD

One of my absolute favorite days of the work year calendar is strategic planning. I look forward to this special opportunity when key leaders come together and focus. We scan the environment, assess our positions, incorporate input, determine goals and set priorities for how we intend to perform the important work together in alignment.

Of course, strategic planning is less a day and more an ongoing, evolving process that often includes an identifiable day when teams actively plan together. From my position as a CEO, the value is having key leaders and governing bodies hear the same information and build consensus regarding the way forward.

Imagine YOUR key stakeholders forecasting, projecting and designing elements of a future together. It’s a joy to have teams listen intently, brainstorm and contribute insights in a safe, positive setting. The goal is to find a collective, coherent way forward despite operating in risk-bearing, fiscally challenging and often ambiguous environments. How empowering!

The strategic plan, when thoughtfully developed, might be the single greatest gift that boards and leadership teams can give each other and ultimately to the community served.

Providing a concise framework for strategic planning, accreditation standards emphasize what should be considered in the ongoing planning process, how the plan itself is to be developed, what it must include and how it is maintained and shared with others.

In my experience as a CARF surveyor, one frequently missed standard is ensuring that the plan reflects financial positioning at the time it’s drafted and at projected points in the future.

Organizations achieve substantial conformance by paying attention to detail in documentation and using the actual standards as an outline for the content generated by the process, which informs the resulting written plan.

The Planning Process

In our organization, planning practices have evolved over many years and are constantly being refined.  Rough outlines guiding the planning process, collected formally and informally, are written on large paper pages displayed around the room for reference by everyone.

For our first step, the leadership team and governing board meet together and we facilitate the meeting ourselves. Other organizations find it helpful to use an external facilitator.

We update everyone on the status of the existing plan, acknowledging those items that are completed , note others that are still in process and jettison the ones that will not be pursued.  We use a large electronic screen to update a simple SWOT (strengths, weaknesses, opportunities, threats) analysis and spend most of the time brainstorming priority areas for our efforts, which are recorded on large sheets of paper.

Further discussion, reorganization and prioritization helps us solidify the plan’s rough content. In the following days, we draft a brief, concise document that is shared with the leadership team and governance board for input and revisions.

Successful Implementation

Last year, we then shared our draft goals and objectives with all 60 staff members throughout our organization and used a nominal voting process to solicit everyone’s input and document priorities.

We listed strategic opportunities on large post-it sheets around the room and everyone voted by placing stickers next to the issues they thought to be most important.  This input also factored strongly into the development of our final written plan.

Ultimately, the governing board approves the strategic plan’s final draft, which is implemented with at least twice-annual updates that are submitted to the board. This year, we are trying a Gantt chart format to more clearly specify when each element of the plan initiates and concludes.

We also seek input and feedback to strengthen our planning process for the coming year by sharing elements of the plan at key community stakeholders meetings, distributing reports to all staff members and holding regular meetings with the people we serve – tailoring content to each audience, as appropriate. Other organizations use their website to share strategic directions with a broader audience.

There is strong wisdom and incredible value in the alignment of people, ideas, resources and purposeful work that’s specified in a well-developed strategic plan, which helps us implement continuous, organization-wide quality improvement and sustainability more than any other initiative or directive.

Accreditation Guru can help you and your colleagues achieve a strategic planning process that meets your needs while conforming to accreditation standards that help your organization Prepare for Greatness

Dave is CEO at JAMHI Health & Wellness in Juneau, Alaska, a CARF surveyor and a consultant with Accreditation Guru.

For assistance with your strategic planning, please contact us at 212.209.0240 or email Rocio@AccreditationGuru.com.

 

What does it mean to “live” accreditation?

Achieving national accreditation is more than passing a test. Navigating the road to accreditation requires a service provider to commit to quality improvement, focus on the unique needs of each person the provider serves and monitor the results of services. It announces to the world that your organization strives to be the best it can be. That’s hard work, but the process sets you on the course for long-term greatness.

Organizations are best served to approach accreditation as investment in their future. It helps to raise the bar internally and not only creates a more stable entity, but one that can more effectively manage growth in the future. Once achieved, if a human service provider truly “lives” accreditation (embraces and applies enhanced operational and program practices) it will strengthen their ability to improve the lives of the people they serve.

To read more on the advantages of accreditation, click here.

For questions and assistance with your accreditation and/or post accreditation, please contact us at 212.209.0240 or email Jennifer Flowers.