CCBHC Reporting & Quality Measures

CCBHC Reporting Overview

CCBHCs face a multi-layered reporting landscape that includes quality measure reporting, Government Performance and Results Act (GPRA) data collection, National Outcome Measures (NOMS), annual progress reports, and quarterly financial reports. Each reporting stream serves a different purpose and has its own timeline, data requirements, and submission process.

The reporting burden is significant — but it is also one of the CCBHC model's greatest strengths. Standardized quality measurement enables cross-clinic comparison, evidence-based program improvement, and a national data set that demonstrates the value of the CCBHC model to policymakers and funders. The clinics that manage reporting effectively use it as a management tool, not just a compliance exercise.

The 21 CCBHC Quality Measures

SAMHSA has defined 21 quality measures specifically for CCBHCs. These measures are grouped into several domains and track both clinical outcomes and process performance. The specific measures may be updated across NOFO cycles, but the following represents the current core set.

Clinical Outcome Measures

Process and Screening Measures

Additional Quality Domains

Beyond the measures listed above, the 21-measure set includes additional indicators covering:

• Metabolic monitoring: Screening and monitoring for metabolic side effects of psychiatric medications, including diabetes screening, lipid panels, and glucose monitoring for clients on antipsychotics
• Suicide risk assessment: Percentage of clients who receive a standardized suicide risk assessment at intake and periodically throughout treatment
• Child and adolescent measures: Measures specific to youth populations, including ADHD follow-up, well-child visit coordination, and age-appropriate screening
• Housing status: Tracking changes in housing status for clients, reflecting the CCBHC model's attention to social determinants of health
• Time to initial evaluation: Average number of days from first contact to initial evaluation, with a target of 10 business days or fewer

GPRA Reporting for SAMHSA Grantees

The Government Performance and Results Act (GPRA) requires all SAMHSA grantees to collect and report standardized outcome data. For CCBHC expansion grantees, GPRA data collection is mandatory and involves administering structured interviews with clients at intake, 6-month follow-up, and discharge.

GPRA Data Collection Points

GPRA follow-up rates are a critical performance metric. SAMHSA expects grantees to achieve a follow-up rate of 80% or higher. Clinics that consistently fall below this threshold face increased oversight and potential conditions on their awards. Building GPRA follow-up into your clinical workflow — rather than treating it as a separate administrative task — is essential for achieving high follow-up rates.

National Outcome Measures (NOMS)

National Outcome Measures (NOMS) are SAMHSA's standardized outcome indicators that track changes in key life domains for individuals receiving behavioral health services. NOMS data is derived primarily from GPRA interviews and supplemented by clinical data. The core NOMS domains include:

• Abstinence from substance use: Reduction in drug and alcohol use between intake and follow-up
• Employment/education: Increase in employment or enrollment in education/training programs
• Stable housing: Maintenance of or improvement in housing stability
• Criminal justice involvement: Reduction in arrests and criminal justice contacts
• Social connectedness: Improvement in social support and interpersonal functioning
• Mental health functioning: Reduction in psychological distress and improvement in functioning

Financial Reporting: SF-425

CCBHC expansion grantees must submit SF-425 (Federal Financial Report) forms quarterly to SAMHSA's Payment Management System. The SF-425 reports cumulative federal expenditures, unliquidated obligations, and the unobligated balance of federal funds. Key requirements:

• Quarterly submission: SF-425 reports are due within 30 days of the end of each federal quarter (January 30, April 30, July 30, October 30). Late submissions trigger compliance flags.
• Expenditure tracking: All expenditures reported on the SF-425 must be supported by underlying accounting records that comply with 2 CFR 200 cost principles. Maintain clear audit trails from SF-425 line items to general ledger entries to source documents.
• Expenditure rate monitoring: SAMHSA monitors expenditure rates across the project period. Significantly under-spending in early quarters may indicate implementation delays and trigger program officer follow-up. Rapid spending in final quarters raises concerns about end-of-period spending surges.

Annual Progress Reports

SAMHSA requires annual progress reports from CCBHC expansion grantees. These reports provide a comprehensive assessment of project implementation, service delivery outcomes, and financial status over the preceding grant year. The progress report typically includes:

• Service delivery data: Number of clients served, service encounters delivered, by service category. This data demonstrates that the CCBHC is meeting its service delivery targets across all 9 required categories.
• Quality measure results: Performance on all 21 CCBHC quality measures, with year-over-year trends and analysis of measures that are below target.
• Implementation narrative: Discussion of successes, challenges, and adjustments made during the reporting period. SAMHSA expects honest reporting about implementation difficulties, not just positive narratives.
• Staffing status: Current staffing against the staffing plan, including vacancies, recruitment efforts, and any staffing model changes.
• Sustainability planning: Updates on the clinic's plan for sustaining CCBHC operations after the grant period ends, including progress toward Medicaid PPS reimbursement where applicable.

Client-Level Data Requirements

Beyond aggregate reporting, SAMHSA requires client-level data submission for GPRA and selected quality measures. This means your data systems must capture individual client records with sufficient detail to support both clinical care and federal reporting requirements.

• Client demographics: Age, gender, race, ethnicity, primary language, veteran status, housing status, and insurance status at intake
• Diagnosis data: Primary and secondary diagnoses using current ICD-10-CM codes, with documentation of co-occurring conditions
• Service encounter data: Date, type, duration, and provider for each service encounter, mapped to the 9 CCBHC service categories
• Screening results: PHQ-9 scores, substance use screening results, BMI, tobacco use status, and other screening data required for quality measure calculation
• Outcome data: Treatment outcomes, functioning assessments, and discharge status for each client

EHR Requirements for Quality Measure Extraction

The CCBHC certification criteria require electronic health record systems that can extract quality measure data. This is not an aspirational goal — it is a certification requirement. Clinics that cannot extract quality measures from their EHR face significant compliance challenges and must develop a realistic plan for achieving EHR-based reporting.

EHR Capability Requirements

• Structured data capture: Clinical data elements needed for quality measure calculation must be captured in structured fields, not free-text notes. PHQ-9 scores, screening results, diagnosis codes, and encounter types must be extractable through queries or reports.
• Denominator identification: The EHR must be able to identify the population denominator for each quality measure. For example, the depression screening measure requires identifying all clients aged 12+ who had a qualifying encounter during the measurement period.
• Numerator calculation: The system must calculate the numerator for each measure based on clinical data. This requires mapping clinical events (screenings completed, follow-ups documented) to measure specifications.
• Reporting dashboards: Real-time or near-real-time dashboards that display quality measure performance enable clinical teams to identify gaps and intervene before measurement periods close.
• DCO data integration: When services are delivered by DCOs, the DCO service data must flow into the CCBHC's quality measure calculations. This requires data exchange interfaces, shared EHR access, or structured data import processes.

Reporting Calendar

Managing the CCBHC reporting calendar requires advance planning. These are the primary reporting deadlines for SAMHSA expansion grantees:

For guidance on how quality measure reporting intersects with your EHR infrastructure, see the Common Mistakes page, which covers EHR readiness gaps in detail.