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Joint Commission Behavioral Health Update

October 2014     
In This Issue
New Client Welcome!
Congratulations Corner
Changes to Behavioral Health Human Resources Chapter
TJC Behavioral Health Home Certification
Barrins & Associates
Barrins & Associates
Greetings to Our Colleagues in Anne Final for Newletter
Behavioral Healthcare! 

It was a pleasure to catch up with so many of you at the TJC Annual Behavioral Health Care Conference in Chicago last week! Once again, the conference had two tracks: one for organizations accredited under the Behavioral Health standards and one for organizations accredited under the Hospital standards. Both tracks were full of the latest information on best practices and TJC initiatives.


One of the key presentations at the conference was on the revised standards in the Human Resources chapter of the Behavioral Health manual that go into effect on January 1, 2015. Our first article this month covers that topic and how the revisions may impact your organization. Our second article covers the requirements for the new Behavioral Health Home Certification available from TJC.


We value your feedback on the newsletter. Please email us your comments and tell us what topics you would like to see in future issues.  We look forward to hearing from you!  Also, feel free to forward this newsletter to your colleagues. 


Best regards and enjoy the fall season in your part of the country!   


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Welcome - Left  New Client Welcome!      


Barrins & Associates is pleased to welcome our new client Grafton Integrated Health Network with headquarters in Winchester, Virginia Grafton provides a broad continuum of services including residential treatment, education, clinical services, early intervention, day treatment, and specialized applied behavior analysis treatment. Grafton is preparing for initial Joint Commission accreditation and we are pleased to be working with them to achieve that goal!

 Congratulations Corner    


Congratulations to Haven Behavioral Hospital of Southern Colorado in Pueblo, Colorado who recently achieved Joint Commission accreditation and CMS deemed status! The hospital provides specialized inpatient psychiatric services to military personnel and veterans. Also included in their TJC accreditation for the first time was the Family Support Center of Colorado Springs. The Center operates a PHP and outpatient service for military personnel and their families as well as the Colorado Autism Center which offers assessment, diagnosis and treatment of autism.  Haven Behavioral Hospital of Southern Colorado is part of Haven Behavioral Healthcare which provides specialty psychiatry services such as geriatric psychiatry as well as specialized services for military personnel at various locations throughout the United States.

Changes to Behavioral Health Human Resources Chapter      


At the TJC Annual Behavioral Health Conference in Chicago last week, a key presentation focused on the revisions to the Human Resources chapter in the Behavioral Health Manual that go into effect on January 1, 2015. So, what are the changes and what do you need to do to ensure compliance with the revised standards?


Here are the highlights:


  • The name of the chapter has been changed to the Human Resources Management chapter.
  • The standards have been reduced from 17 to 12 and have been re-numbered.
  • The previous standard HR.02.01.03 that dealt with the credentialing and assigning of clinical responsibilities for licensed independent practitioners (LIPs) has been eliminated. The requirements for verifying credentials and assigning job duties/responsibilities for these practitioners have now been folded into the other standards. In addition, the process has been simplified.
  • The terminology "staff" that is used throughout the chapter includes staff, LIPs, and contractors.
  • There are essentially only two new requirements in the revised standards:
    • Written job descriptions (HRM.01.01.01): Each position must have a written job description. This was not explicitly required in the previous standards. The job description must contain the following three elements:
      • Minimum qualifications
      • Minimum competencies
      • Duties and responsibilities
      • Note: For contractors, a written contract may replace a job description.
    • Verification of identity (HRM.01.02.01): The identity of all job applicants must be verified by viewing a valid picture ID issued by a state of federal agency (e.g. driver's license or passport.) Previously, this was required only for LIPs. 
So, a bit more about simplifying the process for LIPs: The terms "LIPs" and "assigning clinical responsibilities" are not used in the revised standards. As noted above, LIPs are now included under the term "staff." The requirements for verifying credentials and assigning job duties/responsibilities for all types of practitioners are now included under one standard (HRM.01.02.01.) In addition, there is no longer a requirement for the governing body to grant clinical responsibilities nor a requirement to assign clinical responsibilities every two years. Once again, these clinical responsibilities can be defined in the job description (or contract.)


For those interested in a bit of TJC standards "history": The existing BH standard for credentialing and assigning clinical responsibilities for LIPs (HR.02.01.03) was modeled after the credentialing and privileging standards in the Medical Staff chapter of the Hospital manual. Thus, the requirements in the BH manual have been very similar to those in the Hospital manual. However, in the BH manual the term "privileging" (which has a medical model connotation) was replaced with the term "assigning clinical responsibilities." The simplified process in the 2015 revised standards is a better fit for many BH organizations in terms of how they hire and use LIPs within their organizations.


A few additional clarifications emphasized at the conference:


  • Education needs to be verified from the primary source for college degree and above. For high school diploma, a copy is sufficient.
  • If you confirm that your state licensing authority already does verification of education in order to issue the license, you do not need to re-verify the education.
  • Remember that if you are using contractors to provide care, treatment or services, the evaluation of those contracted services must also comply with the Leadership standard LD.04.03.09. (Take note: This standard is being closely scrutinized during surveys.)
  • If your BH program is part of a hospital that is surveyed under the Hospital standards, you would continue to conduct credentialing and privileging according to the requirements of the Medical Staff chapter in the Hospital manual.

So, a few tips to ensure full compliance with the revised standards:


  • Make a decision as to whether you will move to the simplified process for LIPs or retain your current process for credentialing and assigning clinical responsibilities.
  • Make sure your job descriptions are current and include all three elements required by standard HRM.01.01.01.
  • Put in place a process to verify identity for all newly hired staff.
  • If you sare using contractors to provide clinical services, make sure you are complying with all of the requirements of LD.04.03.09 regarding how you evaluate those contracted services. See our BH Checklist for Contract Services to assist you with this.

TJC Behavioral Health Home Certification 


Another highlight of the Annual Behavioral Health Care Conference in Chicago last week was the presentation on TJC's new Behavioral Health Home Certification. Several BH organizations have achieved this exciting new certification option! So, here's some information to help you decide if BHH Home Certification would be a good fit for you!


What exactly is a Behavioral Health Home? 

A Behavioral Health Home is not a physical location but rather a service delivery model for the integration of primary physical health care and behavioral health care. The creation of Health Homes became an option for states under the Affordable Care Act. The target population is Medicaid enrollees with multiple chronic health conditions including mental health and substance abuse disorders.


There are three models of Behavioral Health Homes that are recognized by SAMHSA: 

  1. In-house Model: The BH organization provides the behavioral health services and some of the primary physical health services in-house.
  2. Co-located Partnership Model: The BH organization arranges for health care providers to offer some basic primary physical health care services on-site at the BH organization.
  3. Facilitated Referral Model: The BH organization has processes in place to ensure the coordination of primary physical heath care provided off-site.

What is TJC's Behavioral Health Home Certification? 

It is an optional certification for organizations accredited under the Behavioral Health standards that provide integrated primary physical health care and behavioral health care.


What are the requirements for Behavioral Health Home Certification?  

The specific requirements for Behavioral Health Home Certification are included in the Behavioral Health Care Standards Manual. The standards are identified as "For organizations that elect The Joint Commission Behavioral Health Home option."


Highlights of key requirements in the various chapters are as follows:


Care, Treatment Services Chapter


Physical Exams (CTS.02.01.05 EP 2)

  • If the health screening indicates need for a history and physical exam, the BHH arranges for that H&P.

Assessments (CTS.02.02.01 EP 6, 7, 8)

The assessment includes:

  • The individual's long and short term physical health care goals
  • Screening for metabolic syndrome, diabetes, hypertension, heart disease, asthma, COPD, hepatitis C, HIV/AIDS, obesity
  • Assessment of the individual's ability to self manage chronic behavioral and physical health conditions

Plan of Care, Treatment or Services (CTS.03.01.03 EP 17)

The plan includes:

  • The individual's physical health care need and goals
  • How the organization will help the individual achieve those goals
  • The individual's self management goals

Coordinated Care (CTS.04.01.01)

  • There is an Integrated Care Team assigned to provide services for a designated panel of individuals.
  • The team has a Team Coordinator.

Access to Care (CTS.04.01.07)

  • 24/7 access to contact the BHH to request:
    • Appointments
    • Prescription renewals
    • Clinical advice for urgent health care needs
  • 24/7 response to urgent care needs
  • Facilitating the individual's online access to their health information (e.g. lab results) within 4 business days
  • Use of certified electronic health record to provide appointment reminders

Prevention, Screening and Primary Physical Health Care (CTS.04.02.23)

  • Integrated Care Team has information needed to facilitate delivery of integrated physical and behavioral health care.
  • BHH staff has access to primary physical health care clinician for consultation.
  • BHH staff has access to behavioral health care clinician for consultation.

Facilitating Provision of Integrated Care (CTS.04.02.25)

Manage transitions in care and facilitate access to integrated care including:

  • Acute care
  • Management of chronic care
  • Prevention services
  • Behavioral health services
  • Oral health care
  • Vision care
  • Urgent and emergency care

Case Management/Care Coordination (CTS.06.01.05)

  • The individual served partners with the Integrated Care Team to identify needs, preferences, and goals in various life domains.
  • Integrated Care Team assists with achieving goals of independent living.
  • All services provided are evaluated.  

Human Resources Chapter


Staff Orientation and Education (HR.01.04.01, HR.01.05.03)

  • Staff are oriented and trained on the most common behavioral health conditions and chronic physical health conditions in the population served.  

Information Management Chapter


Information Management (IM.01.01.01)

Organization uses health information technology to:

  • Support continuity of care
  • Document and track care, treatment, services
  • Support disease management
  • Support preventive care
  • Create reports
  • Facilitate electronic exchange of information
  • Support performance improvement  

Leadership Chapter


Leadership (LD.04.04.09)

  • Organization identifies clinical practice guidelines and/or evidence based practices for both physical and behavioral health care.  

Performance Improvement Chapter


Performance Improvement (PI.01.01.01, PI.02.01.01, PI.03.01.01)

Data collected on

  • Disease management outcomes
  • Access to care
  • Consumer satisfaction
  • Data used to improve performance 

Rights Chapter


Right to Information about the Behavioral Health Home (RI.01.04.03)

  • Individual is provided information about the functions and services of the BHH.
  • Individual has right to:
    • Choose clinicians
    • Obtain a second opinion
    • Seek specialty care 

How will organizations be surveyed for Behavioral Health Home Certification?

For most organizations, the length of the survey for BHH Certification is one day. This can be conducted either as part of the organization's triennial survey or scheduled as a separate survey. The BHH Certification will be awarded for a period of three years.


If we become certified as a Behavioral Health Home, does that mean that BHH services must be provided to all of our clients?

No, your organization determines the population that will be served by the Behavioral Health Home. This can be a defined subset of the population such as consumers living in a particular geographic area, consumers who are Medicaid enrollees, consumers with a particular diagnosis, etc.


What is the advantage to obtaining Behavioral Health Home Certification?

TJC is currently working with state authorities to acquire each state's recognition for the new Behavioral Health Home Certification. This state recognition will help behavioral health care organizations meet Medicaid requirements and, as a result, may improve an organization's reimbursement structure.


How can we prepare for Behavioral Health Home Certification?

The first step is to study the BHH Certification requirements in the BH manual as well as some of the background material listed in the Resources section of this article. Based on that research, determine if you organization is well positioned to pursue this certification. If so, contact us to arrange for training and technical assistance on achieving Behavioral Health Home Certification. We are currently working with several clients who are considering this new certification.


Resources on Behavioral Health Homes and TJC's BHH Certification: 

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Barrins & Associates provides Joint Commission and CMS consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry.  Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years.