New Quality-Control Standards Coming to CMHCs

Community mental health centers (CMHCs) would have to adhere to new quality-control standards under a proposed rule issued by the Centers for Medicare and Medicaid Services (CMS) on June 16. Currently, there are no conditions of participation (CoPs) governing treatment of the more than 25,000 Medicare beneficiaries who receive mental health care at CMHCs each year.

The proposed rule is designed to ensure that CMHCs participating in the Medicare program meet certain health and safety benchmarks in their treatment, with the goal of achieving a more "client-centered, outcome-oriented" degree of care. The introduction of these first-ever standards for CMHCs would help CMS establish a process for evaluating the quality of patient treatment and holding accountable those clinics providing substandard care.

Julie Clements, deputy director for regulatory affairs in APA's Department of Government Relations, said APA is encouraged by the development of a patient-centered approach to CMHC standards that specifies the role of psychiatrists as part of an interdisciplinary treatment team. She said she is in the process of drafting APA's comments on the proposed rule, which are due to CMS by August 16.

Among the CoPs described in the proposed rule are standards related to the qualifications of CMHC personnel, patient rights, continuity of care, the establishment of a coordinated treatment plan and services, creation of a quality-assessment and performance-improvement program, and the administration and governance of CMHCs.

Personnel Qualifications

The proposed rule outlines the specific requirements for all types of potential CMHC staff members, including administrators, psychiatrists, clinical psychologists and social workers, mental health counselors, occupational therapists, non-psychiatric physicians, and psychiatric registered nurses.

CMS would require that all psychiatrists working in a CMHC be certified by the American Board of Psychiatry and Neurology (or have documented equivalent education, training, or experience) and be fully licensed to practice medicine in the state in which the clinic is located.

Patient Rights

All CMHC patients would be entitled to both verbal and written explanations of their rights under the proposed rule, as well as have the opportunity to play an active role in development of a treatment plan, exercise consent for their treatment and the exchange of information about that treatment, and be safe from discrimination and mistreatment.

The proposal lays out specific standards regarding patient restraint and seclusion. While "strongly" discouraged for use in outpatient treatment, CMS acknowledges that such measures may be required in cases in which the patient, staff, or other individuals face a physical threat.

Continuity of Care

The proposed rule also outlines preferred practices for each step of a patient's experience at a CMHC—from admission to initial evaluation to comprehensive assessment to discharge or transfer. According to CMS, these proposed requirements are essential to the establishment of a "client-centered, interdisciplinary, and systematic" approach to patient care.

Under the proposed standards for CMHC intake and care, an on-staff psychiatric registered nurse or clinical psychologist would be charged with completing an initial patient evaluation within 24 hours of admission. This would be followed by a more comprehensive assessment conducted by a physician-led interdisciplinary treatment team, with the goal of establishing a baseline against which to track patient progress.

At the conclusion of a patient's stay at a CMHC, the treatment team would determine if the individual should be discharged or transferred, and accordingly provide referrals or identify an external support system.

Treatment and Services

An interdisciplinary, physician-led team would be responsible for developing a "client-centered" treatment plan under the proposed rule. The treatment team would comprise a psychiatric registered nurse, clinical psychologist, or social worker, as well as an occupational therapist and other licensed mental health professionals, as necessary.

Within three working days of a patient's admission, CMHCs would be required to provide a written plan including diagnoses, treatment goals, interventions, and a description of necessary services (for example, psychotherapy and medication). The treatment team would also be required to update the patient plan with new information gathered from a comprehensive assessment conducted following intake.

Quality Assessment and Performance Improvement

CMS would also require under the proposed rule that CMHC executives develop, implement, and maintain a quality-assessment and performance-improvement (QAPI) program to ensure ongoing evaluation and operational effectiveness. CMS would not require the use of specific evaluation tools or markers; the goal of the QAPI program is to create a self-monitoring system that tracks progress and institutes corrective measures as needed.

Organization, Governance, and Administration

In regard to the day-to-day operations of CMHCs, the proposed rule seeks to ensure an "organized and accountable" management structure. This would involve maintaining a "safe and comfortable environment" for patients, as well as training all in-house staff and supervising any external service providers.