SD CCBHC DCO Interest Form

CCBHC DCO Interest/Information Form
The Department of Social Services, Division of Behavioral Health, is requesting applications from eligible behavioral health organizations to provide Certified Community Behavioral Health Clinic (CCBHC) services for the State of South Dakota. The intent of this form is to identify organizations that may have an interest in having a DCO relationship with a CCBHC, and/or seeking more information about CCBHCs in South Dakota.

Click HERE to review SAMHSA requirements for CCBHC certification.
Organization Legal Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Primary Contact*
Email Address of Primary Contact*
Role/Title of Primary Contact

Core CCBHC Program Requirements

The following questions center around your organization's alignment with several of the core required components of Certified Community Behavioral Health Clinics.

DCOs must meet each of the following criteria and all identified Statutory Organizational Requirements in order to consider becoming certified as a CCBHC:

Rows	Yes/No	Have you held this accreditation for at least 2 years?
Accredited through the DSS Office of Licensing and Accreditation (OLA) as a Community Mental Health Center (CMHC) or accredited by a national accreditation body for relevant services such as National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), and the Commission on Accreditation or Rehabilitation Facilities (CARF)
Accredited through OLA as a Substance Use Disorder Treatment Program for Early Intervention, Outpatient, and Intensive Outpatient Treatment
Accredited through OLA as a Substance Use Disorder Treatment Program for Prevention

Is a non-profit organization, exempt from tax under Section 501(c)(3) of the United States Internal Revenue CodeIs part of a local government behavioral health authorityIs operated under the authority of the Indian Health Service, an Indian tribe, or tribal organization pursuant to a contract, grant, cooperative agreement, or compact with the Indian Health Service pursuant to the Indian Self-Determination Act (25 U.S.C. 450 et seq.)Is an urban Indian organization pursuant to a grant or contract with the Indian Health Service under Title V of the Indian Health Care Improvement Act (25 U.S.C. 1601 et seq.)None of the above

Core Service Components

The following questions center around your organization's current service delivery and its alignment with required CCBHC services.
CCBHC Services

The CCBHC Certification Criteria stipulates nine (9) required services that certified clinics must deliver or partner with a community-based agency to deliver on their behalf. The official Scope of Services can be reviewed in the Certification Criteria document available at the hyperlink below (beginning on page 25). Please reference this for any specific service definitions as you complete the matrix.

https://www.samhsa.gov/sites/default/files/ccbhc-criteria-2023.pdf

The following services are required to be provided by a CCBHC directly. Please indicate which of these services that your organization currently provides or plans to provide in the future.

Rows	Current Status
General Service: Access to Emergency / Crisis Care (immediate action)
General Service: Access to Urgent Needs Care (w/in 1 business day)
General Service: Access to routine needs care (w/in 10 business days)
2. Risk assessment / triage for behavioral health conditions
2. Initial evaluations that include diagnoses, immediate care needs, etc.
2. Comprehensive functional assessments (evaluations)
2. Brief intervention services in the event unsafe substance use is identified during screening
4. Outpatient mental health services including psychopharmacological treatment
4. Outpatient substance use disorder services in alignment with ASAM Levels 1 and 2.1

The following services are required to be provided directly or that can be contracted out by a CCBHC. Please indicate which of these services that your organization currently provides or plans to provide in the future.

Rows	Current Status
1. Able to provide same-day services to unscheduled clients
1. Emergency crisis intervention services
1. 24-hour mobile crisis care
1. Crisis receiving and stabilization services
1. Suicide prevention and intervention services
1. Overdose prevention including access to naloxone
5. Screening capable of identifing people receiving services that also have chronic diseases
5. Screening that ensures people receiving services are asked about physical health conditions
5. Care coordination with primary care and specialty health providers
5. Able to ensure ongoing periodic labratory testing and physical measurement of health indicators
6. Targeted case management services beyond care coordination
7. Psychiatric rehabilitation services for both mental health and substance use disorders
7. Supported employment programs designed to help obtain or maintain employment
7. Support for clients finding and maintaining safe and stable housing
9. Community-based mental healthcare for members of the Armed Forces and Veterans

Partnerships

Do you have partnerships with any of the following types of organizations?

Rows	Current partnership?
South Dakota's 988 Suicide and Crisis Lifeline call center
Federally Qualified Health Centers and Rural Health Clinics
Inpatient psychiatric treatment providers
Residential or inpatient facilities that serve children and youth (e.g, Psychiatric Residential Treatment Facilities)
Opioid Treatment Programs
Specialty providers including those who prescribe medications for the treatment of opioid and alcohol use disorders
Indian Health Service or other tribal programs
Medical withdrawal management facilities
Ambulatory medical withdrawal management providers for substance use disorders
Residential substance use disorder treatment programs, including tribally operated mental health, substance use, and crisis services
Emergency departments

Please indicate your organization's current status of the following partnerships for community or regional services and supports.

Rows	Current partnership?
Schools
Child welfare agencies
Juvenile and criminal justice agencies and facilities (including drug, mental health, veterans, and other speciality courts)
Indian Health Service youth regional treatment centers
State licensed and nationally accredited child placing agencies for therapeutic foster care service
Substance use prevention programs
Other social and human services

Please indicate your organization's current status of the following additional partnerships.

Rows	Current partnership?
Homeless shelters
Housing agencies
SUD recovery / transitional housing providers
Employment services systems
Peer-operated programs
Services for older adults, such as Area Agencies on Aging
Aging and Disability Resource Centers
State and local health departments and behavioral health and developmental disabilities agencies
Criminal and juvenile justice, including law enforcement, courts, jails, prisons, and detention centers
Legal aid
Programs and services for families with young children (e.g., WIC, Head Start)
Coordinated speciality care programs for first episode psychosis
Other social and human services

Thank you for your interest in becoming a DCO.

On behalf of the Division of Behavioral Health, SD Department of Social Services, thank you for your interest in the CCBHC model and its implementation across South Dakota. Your interest in becoming a DCO will be forwarded to leadership and relayed to entities that apply to be part of the 2026 cohort. Click "Submit" to close this form.
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CCBHC DCO Interest/Information Form

Designated Service Area

Core CCBHC Program Requirements

Core Service Components

Partnerships

Thank you for your interest in becoming a DCO.