KBH's CCBHC Treatment Plan Transition Process
Effective: July 1, 2025

Maine CCBHC Treatment Plan Requirements

ADULT:
The Individual Treatment Plan builds from the initial and comprehensive assessments and is completed no later than 60 calendar days following the initial assessment and reviewed and updated at least every 180 calendar days.

CHILD:
The Individual Treatment Plan must be started within ten business days of the first point of contact, fully completed within 60 calendar days, and reviewed every 90 calendar days for any necessary updates.

1. KBH Treatment Plan process for New Access Center clients entering CCBHC effective July 1, 2025:
 

• At Initial Assessment
  Clients receive a CCBHC Preliminary Treatment Plan with a verbal overview and documented verbal consent.
   
• At Comprehensive Assessment:
  Clients receive a CCBHC Initial Treatment Plan, signed in person or via the client portal. This plan is valid for 180 days for adults and 90 days for children. Once a Service-Specific Treatment Plan is implemented, the Initial CCBHC Plan does not require renewal.

2. KBH Treatment Plan process for clients who completed a Comprehensive Assessment prior to July 1, 2025 
    and are awaiting services:

These clients will not receive a CCBHC Initial Treatment Plan. A Service-Specific Treatment Plan will be developed within 30 days of starting services, consistent with current procedures. 

3. KBH Treatment Plan process for clients who were already receiving services that fall under our CCBHC  
    umbrella prior to July 1, 2025:

These clients will transition to the standard CCBHC treatment plan review cycle of 180 days for Adults and 90 days for children at their next treatment plan review date. All treatment plans must align with this cycle by July 1, 2026. A report will be generated and shared with the KBH Senior Management Team identifying any outstanding clients still needing transition by June 30, 2026.

Preliminary & Initial Treatment Plan Overview

ADULT Preliminary CCBHC Treatment Plan (@ 10 days)

Short Term Goal: Access to Care & Orientation
Client will be oriented to CCBHC services and complete intake and assessment within 60 days.

Action Steps:
1. Client will attend scheduled intake appointment and complete diagnostic and functional assessments.
2. Care Coordinator and/or Intake Clinician will provide overview of available CCBHC services, including therapy, psychiatry, peer support,
    substance use treatment, primary care, and case management.
3. Client and clinician will begin developing a person-centered treatment plan.  

Check box and statement at bottom: 
This plan was reviewed with the client (and caregiver, if applicable), who gave verbal consent to the services and goals discussed.

Adult Initial CCBHC Treatment Plan (@ Comp Assessment)

• Problem(s) to port over from Initial Eval
• Problem Statement over LTG will be hidden
• As Evidenced By sections will be hidden
• All other sections of the treatment plan will need to be completed other than the pre-population of LTG and STGs as below

LTG: Overall Long-Term Goal
Client will engage in comprehensive CCBHC services to support emotional, physical, and social wellness. With support from a person-centered care team, the client will work toward improved stability, daily functioning, and recovery over the next 12 months.

STG:  Short-Term Goal #1 – Engagement in Core Services
Client will begin participating in at least one appropriate CCBHC service areas within 60 days to support behavioral health stability.

Action Steps:

1. Clinician will initiate internal referrals based on client needs (e.g., therapy, SUD treatment, psychiatric, peer support, etc.).
2. Client will attend at least one appointment with a referred provider.
3. Care team members will collaborate with the client to identify and address participation barriers (e.g., transportation, scheduling, readiness).

Short-Term Goal #2 – Crisis Support Awareness

Client will understand how to access 24/7 crisis services and identify when and how to seek emergency behavioral health support within 30 days.

Action Steps:

1. Clinician or care coordinator will review CCBHC's 24/7 crisis service options (e.g., crisis phone line, walk-in center, mobile crisis team).
2. Client will be provided with crisis contact information in both written and verbal formats.
3. Clinician and client will identify individual signs of crisis and develop a brief individual response or safety plan, if appropriate.

Short-Term Goal #3 – Care Coordination & Whole-Person Support

Client will be screened for medical, housing, and other social needs, and referred to appropriate internal or external supports within 90 days.

Action Steps:

1. CCBHC staff will complete screenings related to physical health and social determinants of health (e.g., housing, income, food insecurity).
2. Client will be referred to internal or external services based on identified needs (e.g., housing support, employment assistance, transportation).
3. Care coordination staff will follow up on referrals and assist with addressing any access barriers.

CHILD/YOUTH Preliminary CCBHC Treatment Plan (@ 10 days)

Client and parent/guardian will complete intake and assessment and be oriented to available CCBHC services within 30 days.

Action Steps:

1. Clinician will complete diagnostic and functional assessments with youth and caregiver.
2. Staff will provide overview of services (e.g., individual/family therapy, psychiatric, school coordination, care management, etc.).
3. Caregiver and client will participate in developing a person- and family-centered treatment plan with clinician.

Check Box and statement at bottom:
This plan was reviewed with the client (and caregiver, if applicable), who gave verbal consent to the services and goals discussed.

CHILD/ YOUTH Initial CCBHC Treatment Plan (@ Comp Assessment)

• Problem(s) to port over from Initial Eval
• Problem Statement over LTG will be hidden
• As Evidenced By sections will be hidden
• All other sections of the treatment plan will need to be completed other than the pre-population of LTG and STGs as below

LTG: Overall Long-Term Goal
Client and family will engage in age-appropriate, family-supported behavioral health services to improve emotional stability, functioning at home and school, and overall well-being over the next 12 months, with support from a person-centered care team.

STGs:

Short-Term Goal #1 – Engagement in Core Services
Client will begin participating in at least one appropriate CCBHC service area within 30 days, with caregiver involvement as appropriate.

Action Steps:

1. Clinician will initiate internal referrals based on client needs (e.g., therapy, psychiatry, care    coordination, peer support). 
2. Client will attend at least one appointment with a referred service provider.
3. Care team members will collaborate with the family to identify and address any barriers to participation (e.g., transportation, caregiver support, school schedule).

Short-Term Goal #2 – Crisis Support Awareness
Caregiver and client (as age-appropriate) will understand how to access 24/7 crisis services and identify when and how to seek emergency behavioral health support within 30 days.

Action Steps:

1. Clinician or care coordinator will review CCBHC’s 24/7 crisis service options (e.g., crisis phone line, walk-in center, mobile crisis team).
2. Client and caregiver will receive crisis contact information in both written and verbal formats.
3. Clinician will assist in creating a youth-specific safety or individual response plan, with caregiver input as needed.

Short-Term Goal #3 – Care Coordination & Whole-Person Support
Client will be screened for social needs and referred to appropriate supports (internal or external) within 30 days.

Action Steps:

1. CCBHC staff will complete screening related to physical health and social determinants of health.
2. Client will be referred to internal and/or external supports as appropriate (e.g., school-based services, primary care, housing, or other community resources). 
3. Care team will collaborate with natural, formal and community supports to advance the youth’s care plan and follow up on progress.