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Accreditation standards being reshaped for 2019: Refined missions, integrated systems, tech standards and MAT among issues addressed by Joint Commission, CARF and COA.

The opioid epidemic, increasing suicides, integration of behavioral health into large systems, the needs of children in foster care, and more are driving accreditation organizations to significant changes in the year ahead. For this article, Behavioral Healthcare Executive spoke with Michael W. Johnson, managing director, behavioral health, Commission on Accreditation of Rehabilitation Facilities (CARF); Richard Klarberg, CEO, Council on Accreditation; and Julia S. Finkens, executive director for behavioral healthcare of the Joint Commission.

"Accreditation is a driver for quality," Johnson of CARF says. "We do change and update standards. That forces organizations to move forward." Licensing, on the other hand, is often called "taking the same test over and over again, because the rules don't change, and the test doesn't change."

Below are highlights of some of the changes ahead.


At the Council on Accreditation (COA), the emphasis this year has been a new strategic plan which is "rethinking the how and why of accreditation," says Klarberg. The "logic model" of COA accreditation has always been that a "strong board and management give rise to strong programs," he says. "So, if you have strong management, this will result in stronger services and better outcomes."

Instead of looking at the board as an isolated component of an organization, COA is going to consider what it contributes to the outcomes and how it helps the consumers of the programs. Ultimately, this will increase the value of accreditation itself. "The message to boards is that they have a responsibility, not only for the financial stability of an organization, not only to ensure that employees are treated well and not discriminated against, but also to review and ensure that the mission of the organization is being met," says Klarberg. "That mission is not just to provide a service, but to provide a service so that a specific outcome is being obtained."

In addition, the focus on standards is more on the impact on the consumer than on the process. "We are streamlining the standards and the process so that they focus much more dramatically on the impact that the service has on the consumer," says Klarberg. "This means that we are looking at reducing not only the number of standards, but eliminating redundancies and taking a hard look at what standards really don't need to be there." For example, the no-smoking standard has been made redundant by laws and ordinances.

At the same time, COA will be emphasizing benchmarking, so that organizations of like size and services can view themselves in the context of other COA-accredited organizations.


The Joint Commission is improving its survey process to accommodate integrated behavioral healthcare systems, says Finkens. These multi-site, multi-program systems have centralized functions, such as human resources, information management, performance improvement, emergency management, and more. The survey process needs to look across many locations and programs to identify more than location-specific areas for improvement, says Finkens. For example, systemic issues need to be identified and brought back to central leadership.

"Specifically, our goal is to help them improve the major systemic issues that are moderate to high risk and are moderate or widespread to close those quality and safety gaps they may not be seeing when they view location-specific data," Finkens says.

In fact, the Joint Commission will continue to educate providers "about the efficacy of integrating physical healthcare services with mental health and even substance use disorder services," says Finkens. The Joint Commission has some primary physical healthcare standards incorporated into the behavioral health standards to assist organizations with integration. "Given our strong background in physical health care, we also encourage organizations to pursue our Behavioral Health Home certification which is an add-on recognition to their accreditation," she says. "The BHH certification standards provide a strong framework for behavioral health organizations to develop an integrated delivery model that is effective and efficient in delivering high-quality and safe care to individuals who have a prevailing mental health or substance use disorder along with acute or chronic medical needs." The BHH certification is based on the Certified Community Behavioral Health Clinic (CCBHC) model of care, and helps organizations prepare for that model, says Finkens.


CARF will be introducing new standards for the use and management of technology--including email with patients, electronic health records and "apps," explained Johnson. "Everyone uses technology to some degree," he says. CARF is not prescriptive about any of its standards, but it gives providers a structure to determine how it applies in their environment. For example, "we wouldn't say that you have to have an electronic health record, but if you have one, you need to pay attention to security and privacy," he says.


The Joint Commission is overhauling its standards for child welfare and other human services agencies settings.

"These organizations are being stretched right now because of a rise in the influx of children in their care, many of whom come from parents affected by drug or alcohol addiction," says Finkens. "Our improvements to our standards in this area will help them standardize processes, reduce risk, and improve the overall quality and safety of their programs."

The Family First Prevention and Services Act (FFPSA) is a mandate for children's residential treatment centers in states which want to qualify for federal funding. Some states are delaying compliance for up to two years, but at least 10 are moving toward the Oct. 1, 2019 deadline for accreditation. The Joint Commission will be focusing on working with children's qualified residential treatment programs (QRTPs) to understand and complywith the accreditation requirement of this legislation, says Finkens.

"We also will work with them to understand the value and benefits of accreditation above and beyond meeting this legislative requirement," she says. "They are also required to put in place some measures beyond the accreditation, such as a trauma-informed care model, family involvement and aftercare, and Joint Commission standards will provide a framework to help them do that," she says.

The Joint Commission has nearly doubled its surveyor capacity over the past two years to handle the increased capacity this mandate will generate, she says.

The law, signed in February 2018, allows federal reimbursement for mental health services, substance use treatment and in-home parenting training, as a way to prevent children from entering foster care. It also tries to improve the lives of children already in foster care by reducing their placement in institutions via incentives to states.


CARF has a new accreditation program for office-based opioid treatment programs--those programs that specialize in the prescribing of buprenorphine. An organization like Cleanslate--a chain of outpatient providers of buprenorphine--would be an example of a good fit for this new accreditation program because of its scale, says Johnson. But many other organizations, including substance use disorder treatment providers which CARF already accredits but have started adding buprenorphine treatment--are candidates for this accreditation. The residential treatment programs - which CARF also accredits--would most likely not be, as they do not provide services long enough to include all three phases of buprenorphine treatment, says Johnson. These phases include induction, maintenance, and--for patients who want to stop taking the medication or who must be administratively discontinued from it--detoxification.

CARF is also introducing a new certification--not accreditation, which applies to residential addiction treatment facilities, and their use of the ASAM levels of care.

"Medication-assisted treatment is a trend we expect to see continuing as it has demonstrated effectiveness for some populations," says the Joint Commission's Finkens. "As the opioid crisis has shown no signs of abating, we need to provide effective long-term treatment for those affected so that they can return to productive lives," she says.

The Joint Commission is currently reviewing the literature and evidence related to medication-assisted treatment in order to inform its strengthened addiction treatment standards mentioned earlier, Finkens says. This review will include the pre-admission assessment of care, treatment and services, and the discharge planning process, for example, in order to enhance existing requirements or develop new requirements for those providing addiction treatment services.

Another problem is that most of the people who need treatment don't receive it. Interventions can help, and the Joint Commission has just started accrediting "interventionist groups that use case management and other behavioral health processes relevant to their services," says Finkens. This will expand the "quality and safety model of Joint Commission accreditation earlier in the addiction treatment process."


Alison Knopf is a freelance writer based in New York.
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Title Annotation:POLICY; medication-assisted treatment, Commission on Accreditation of Rehabilitation Facilities, Council on Accreditation
Author:Knopf, Alison
Publication:Behavioral Healthcare Executive
Geographic Code:1USA
Date:Sep 22, 2018
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