Starting the accreditation process can be overwhelming: from determining which accrediting body to work with, to obtaining buy in from the board of directors and staff, to creating your team. In this video Jennifer highlights initial items to consider when beginning the road to national accreditation.
For assistance with any aspect of accreditation preparation or maintenance of accreditation, please contact us or schedule a free 30-minute consultation meeting.
Since 2018, there has been significant merger and acquisition activity in the behavioral healthcare field, but why? Individuals are becoming more aware of healthcare issues; there is less stigma about seeking help for mental health struggles; and more effective treatments are now available. This has created increased demand for and use of mental health and addiction treatment services, as well as channeling more funding towards meeting the demand and growing need. Not only this, but as individuals, including professionals, gain understanding of the link between mental and physical wellbeing, more integration of physical and behavioral health care is occurring. So, where does accreditation come in?
There are a number of accrediting bodies that work to ensure providers of substance use disorder treatment and mental health services meet specific, nationally accepted standards, including The Joint Commission, CARF International, Council on Accreditation (a service of Social Current) and others.
Accreditation requirements (standards of safety and quality of care) center around three main areas: documentation, facilities, and people. Documentation standards focus on written plans; polices and procedures; clinical records; and personnel files. For people, standards address not only the care of the persons served, but also those that provide it. Facility standards ensure that the physical environment where care is being provided is safe, healthy, and therapeutic for everyone within. All these standards create stability within an organization, which is a favorable factor in M&A activity.
Achieving accreditation also gives a behavioral health organization a framework for growth and management of their internal resources. It helps to standardize clinical processes and documentation and provides an external validation of the quality of services provided. Accredited organizations will often see increased efficiencies from improved practice consistency, tightened administrative practices, and an increased emphasis on risk management. Because of accreditation requirements, organizations will inevitably have a broader view and a more detailed approach to risk mitigation and risk management than they’re doing on their own.
For an investor looking to acquire a service provider, seeing that a facility is accredited can provide peace of mind. Accreditation indicates that an organization has gone through the work to create a strategic plan, comply with legal and regulatory requirements, and has implemented quality monitoring practices. All of which assist with due diligence, both on the administrative and clinical sides. Investors can also be assured that the facility’s finances are well managed, as accreditation speaks to sound financial management practices. There are even a number of reports that say accreditation reduces staff turnover, which can save an organization money and maintain a high-quality workforce.
Another part of due diligence is examination of litigation and claims history of an organization. Have there been any lawsuits filed or any pending? What is the frequency and severity of claims? Are there identifiable patterns and trends? What steps were taken to reduce the chance of reoccurrence? Accreditation supports this type of investigation by helping to maintain a positive history by proactive identification of risk and finding ways to mitigate or eliminate it where possible. Secondly, it encourages a performance improvement process that requires collection and analysis of key data and then taking action for improvement. Additionally, accreditation promotes a safe and healthy physical environment with requirements for emergency and disaster planning.
If your organization is going through a merger or considering accreditation, you are not alone! Accreditation Guru operates nationwide and provides a number of services to guide you through the process, such as:
If you would like to have a conversation, please feel free to contact us via our website or schedule a free Zoom consultation with one of our experts.
For more information or questions about the contents of this article, please write Peggy Lavin @ peggy@accreditationguru.com. 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.
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.
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:
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:
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.
Achieving accreditation is recognition that your organization adheres to a higher level of standards; that you are producing high quality services; and are operating at an effective level as recognized by an expert outside agency.
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.
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:
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:
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.
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:
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.
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.
In this video, we explain some of the challenges organizations typically face trying to obtain national accreditation. When agencies understand some of these fundamental issues, it can equip them to both anticipate, and mitigate, these challenges-making the road to accreditation much smoother.
