CCBHC Quality Measures Track, score, report.
What is a Certified Community Behavioral Health Clinic?
A Certified Community Behavioral Health Clinic (CCBHC) is a clinic designation established under Section 223 of the Protecting Access to Medicare Act of 2014 and administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). CCBHCs provide comprehensive behavioral health services to adults with mental illness or substance use disorders and children with serious emotional disturbance, funded through a prospective payment system rather than fee-for-service.
Certification requires meeting six criteria: staffing, accessibility, care delivery, scope of services, quality and other reporting, and organizational authority. The "quality and other reporting" area is where patient-reported measurement enters every CCBHC's operating reality. SAMHSA publishes a technical specifications manual listing the quality measures every CCBHC must collect and report annually.
As of 2026, CCBHCs operate in all 50 states and the District of Columbia, with ongoing federal demonstration expansion. The model continues to evolve, the 2024 guidance added measures for social determinants of health (SDOH) and refined the Suicide Risk Assessment (SRA) requirement.
The required quality measures
The SAMHSA CCBHC quality measure set splits into two collection types: clinic-collected measures (things the clinic captures directly at the point of care) and state-reported administrative measures (things the state Medicaid agency pulls from claims on the clinic's behalf). Both must be submitted; the clinic is responsible only for the first bucket.
| Domain | Measure | Collection |
|---|---|---|
| Depression | Depression screening (PHQ-9 or equivalent) and remission at 6 months | Clinic |
| Suicide | Suicide risk assessment for adults and youth | Clinic |
| Substance use | Alcohol use screening; initiation and engagement of SUD treatment (I-SERV); MOUD use | Clinic + claims |
| Physical health | BMI screening and follow-up; tobacco use screening and cessation; diabetes screening for people with SMI | Clinic |
| Care transitions | Follow-up after hospitalization for mental illness (FUH); follow-up after ED for substance use (FUA) | State |
| Social | Social determinants of health (SDOH) screening; health-related social needs | Clinic |
Note: the exact required set is versioned by SAMHSA and may differ by state demonstration. Always refer to the current SAMHSA technical specifications manual for the version applicable to your reporting period.
How HiBoop maps each clinic-collected measure
The clinic-collected measures that require a validated patient-reported scale are where HiBoop does the work. State-reported measures (follow-up after hospitalization, readmission rates, MOUD engagement) are computed from claims data by your state Medicaid agency and do not require action from the clinic's measurement system.
| CCBHC measure | Validated scale | In HiBoop |
|---|---|---|
| Depression screening and remission | PHQ-9 (adult); PHQ-A (adolescent) | ✓ Included |
| Anxiety (linked co-measure) | GAD-7 | ✓ Included |
| Suicide risk assessment | C-SSRS | ✓ Included |
| Alcohol use screening | AUDIT | ✓ Included |
| Substance use (non-alcohol) | DAST-10 | ✓ Included |
| Trauma symptoms (linked) | PCL-5; PC-PTSD-5 | ✓ Included |
| BMI screening and follow-up | Height / weight capture | EHR / claims |
| Tobacco use screening | Yes / no item + cessation offer | EHR / claims |
| Follow-up after hospitalization (FUH) | Claims-derived | EHR / claims |
| MOUD initiation | Claims-derived | EHR / claims |
Physical-health measures (BMI, tobacco use screening) and claims-driven care-transition measures (FUH, FUA, MOUD initiation) are satisfied through your EHR and state claims pipeline, HiBoop works alongside those systems rather than replacing them. The patient-reported outcome layer is what we own.
Reporting cadence and data format
Each CCBHC submits quality measure data annually as part of the federal demonstration reporting cycle, with the exact window set by SAMHSA and the state agency. Clinics also submit state-specific reports on cadences defined by their Medicaid contract, often quarterly.
For the patient-reported measures, HiBoop exports a CSV with one row per completed assessment. Each row includes:
- Patient identifier (de-identified or clinic-assigned, per your export setting)
- Scale name (PHQ-9, GAD-7, C-SSRS, AUDIT, etc.)
- Completion date and time
- Total score
- Severity band (e.g., Minimal, Mild, Moderate, Moderately Severe, Severe for PHQ-9)
- Assigned clinician
This field layout matches the row-level structure most state CCBHC data templates expect. For depression remission tracking specifically, the 6-month PHQ-9 follow-up is the score against which remission is calculated, HiBoop's longitudinal view makes that computation trivial.
For Philadelphia providers
Pennsylvania is a CCBHC demonstration state and most Philadelphia community providers hold both CCBHC certification and a provider contract with Community Behavioral Health (CBH), the nonprofit Medicaid managed care organization for Philadelphia residents. The two sets of requirements overlap substantially:
- PHQ-9 satisfies both CCBHC depression screening and CBH's evidence-based depression monitoring expectation
- C-SSRS satisfies both CCBHC suicide risk assessment and CBH's clinical practice guideline for suicide screening
- AUDIT and DAST-10 satisfy the CCBHC alcohol and substance use screening measures and are among the CPG-aligned tools CBH accepts
See the CBH provider requirements guide for the Philadelphia-specific P4P metrics (7-day and 30-day follow-up, readmission, MOUD initiation) and treatment plan documentation expectations.
Frequently asked questions
What is a CCBHC and how does a clinic become one?
A Certified Community Behavioral Health Clinic (CCBHC) is a clinic designation established under Section 223 of the Protecting Access to Medicare Act of 2014 and administered by SAMHSA. CCBHCs deliver comprehensive behavioral health services funded through a prospective payment system rather than fee-for-service. Certification runs through the state Medicaid agency: the clinic demonstrates it meets the six SAMHSA criteria (staffing, accessibility, care delivery, scope, quality reporting, organizational authority), commits to quality measure reporting, and completes a multi-month readiness assessment.
What are the CCBHC quality measures?
The SAMHSA CCBHC measure set covers five domains: depression (screening + 6-month remission), suicide (risk assessment for adults and youth), substance use (alcohol/drug screening, I-SERV initiation and engagement, MOUD use), physical health integration (BMI, tobacco, diabetes screening for people with serious mental illness), and care transitions (follow-up after hospitalization or ED visit). The 2024 guidance added SDOH screening and refined adult suicide risk assessment.
How often do CCBHCs report outcomes?
CCBHCs submit quality measure data annually as part of the federal demonstration cycle. States typically require additional quarterly submissions in the CCBHC contract. Clinic-collected measures (like PHQ-9 scores) are captured continuously at the point of care; state-reported measures (like readmission rates) are computed from claims data on an annual cycle.
What scales satisfy depression screening + system-wide remission?
The PHQ-9 is the most common scale for both the CCBHC depression screening and remission measures. PHQ-A is used for adolescents (ages 12-17). For remission specifically, the 6-month follow-up PHQ-9 score is compared to baseline. Remission is typically defined as a score under 5. HiBoop schedules the 6-month follow-up automatically and stores both scores against the same patient record so the remission computation is straightforward at reporting time.
What scales do CCBHCs use for suicide risk assessment for entire populations?
The Columbia Suicide Severity Rating Scale (C-SSRS) is the most widely used scale for the CCBHC adult and youth suicide risk requirement. C-SSRS produces structured ideation and behavior data, supports the SAMHSA risk stratification, and is in the public domain. Clinics that already use the Patient Safety Screener (PSS-3) or Ask Suicide-Screening Questions (ASQ) for ED triage often use C-SSRS for the more detailed clinic-collected measure.
What format does CCBHC data submission require?
Submissions follow state-specific data templates, typically a row-per-event CSV or similar structured format. Each row needs the patient identifier, scale name, completion date, total score, severity band, and assigned clinician. HiBoop exports this format directly. No manual reformatting required.
Does HiBoop replace our EHR for CCBHC reporting?
No. HiBoop works alongside your existing EHR. HiBoop owns the patient-reported outcome layer: the scales and scores required for measures like depression screening, suicide risk, and substance use. Physical health measures (BMI, tobacco) and claims-derived measures (FUH, FUA, MOUD engagement, I-SERV) are satisfied through your EHR and claims pipeline, not changed by adding HiBoop.
How does CCBHC funding work?
CCBHCs are reimbursed through a Prospective Payment System (PPS) rather than fee-for-service. Each visit by a Medicaid-eligible patient generates a daily or monthly bundled payment calculated from the clinic's actual costs of delivering the full CCBHC scope. The PPS rate is established at certification and rebased periodically. This payment model is what allows CCBHCs to deliver crisis services, structured patient handoffs, and evidence-based interventions that fee-for-service rates would not sustain.
Sources & Citations
Federal guidance & certification criteria
- G1.SAMHSA. CCBHC Quality Measures Technical Specifications Manual.samhsa.gov/ccbhc/guidance-and-webinars
- G2.SAMHSA. CCBHC Certification Criteria (2023 update).PDF
Peer-reviewed literature
- P1.Breslau J, Ashwood JS, Kase CA, Pincus HA, Lovejoy SL. Evaluation Design Recommendations for the Certified Community Behavioral Health Clinic Demonstration Program. RAND Health Quarterly 2017;6(3):7.PMID 28845359
- P2.Frank RG, Paris J. Investing in Certified Community Behavioral Health Centers to Fulfill Their Promise. Psychiatric Services 2024;75(3):268-274.doi:10.1176/appi.ps.20230037
- P3.Petrovsky M, Damodaran S, Lim CT. Addressing community mental health needs in the United States: a comparison of the federal CCBHC and Massachusetts CBHC models. Frontiers in Health Services 2025;5:1681093.doi:10.3389/frhs.2025.1681093
- P4.Olgac T, McCann E, Riske-Morris M, Hussey DL. A Critical Examination of the Certified Community Behavioral Health Clinic Model: Provider Perceptions and Themes. Health Services Research 2026;61(1):e70041.doi:10.1111/1475-6773.70041