Chapter II

Page 9:  Under Adverse Outcomes – it is unrealistic to expect that providers keep up with individuals who have been discharged for up to 180 days and report any serious incidents including serious complications from psychotropic meds that result in medical intervention.  In addition, the treatment, payment, operation (TPO) relationship between the provider and the MCO ends when the individual is discharged and there is no further payment for services rendered.

Chapter IV

Page 1:  Under Medicaid Manage Care – Please consider standardizing the authorization process/response across MCOs as different processes adds a significant burden to the providers.  In addition, consistency among MCOs makes comparisons/data analysis between MCOs easier.

Page 6, Definition Section

1.  Assessment:  adults are not included in the definition of assessment
    
2. At Risk of Hospitalization:  Please add certified prescreener to the list of credentialed staff who can conduct a screening.  Not all certified prescreeners are LMHP/LMHP-type
    
3. Comprehensive Need Assessment:  please add adult to the definition.  Only children are referenced
4. Counseling:  the definition states that the principles of the Counseling Profession must be applied however what if the professional is a social worker, clinical nurse specialist, NP or psychologist?  The definition is very narrow and disregards the principles, standards and methods of other professions.
    
5. Crisis Treatment:  Based on the definition, it appears as if crisis treatment will be a part of crisis intervention??? IF this definition must remain, please add certified prescreener to the list of credentials who can provide this intervention.  This requirement will be very problematic as it’s embedded in multiple CMHR services that are currently provided crisis response and supports.  It will limit the scope and capacity of the services for which crisis treatment is embedded.  In addition, please define immediate assistance.
    
6. Medication Management: the accepted definition of medication management is  outpatient treatment where the sole service rendered by a qualified physician, or others whose scope of practice includes prescribing medication, is the initial evaluation of the patient's need for psychotropic medications, the provision of a prescription, and, as-needed, ongoing medical monitoring/evaluation related to the patient’s use  of  the  psychotropic  medication.
    
   The  use of the word counseling in the definition is also  misleading.  According to the counseling definition, counseling includes treatment planning, assessment, etc.  The medication management here describes education and supports that may be provided in order to assist the individual with adhering to prescribed meds. Therefore, it is suggested that this intervention be changed to “Medication Supports” or “Medication Education and Supports”.  Lastly, this is an intervention that does not require advanced clinical knowledge; and it should not be required that is be  provided by LMHP/LMHP-type. Medication supports can be provide by a QMHP.
    
   Page 12 Psychoeducation:  If counseling can only be provided by LMHPs/Es, the add supportive counseling which is provided by QMHPs to the definition.
    
   Page 18, Comprehensive Needs Assessment Section: 

1. Modify the 3rd paragraph which states that ALL Mental Health Services shall be conducted by a LMHP/LMHP-type.  Please qualify and indicate that MH Case Management service assessments are maybe   conducted by QMHP…
2. Page 19, under Comprehensive Needs Assessment:  Add that the Comprehensive Needs Assessment is valid for one year/12 months/365 days or sooner as needs change…
    
   Page 22, under ISP requirements Section: 

1. Crisis plan, relapse plan and recovery plan can be one in the same.  Please clarify if they are intended to be different OR provide definitions for each.
2. Given turnover, it will be difficult to provide actual employee names who may be responsible for coordination and integration of services
    
   Page 25, under Additional Service Requirements for All Services section: 

1. 2nd bullet needs clarification regarding what clinical services are being referred to.  Assessment for MH Case Management services does not require LMHP/LMHP-type.  Medication support activities does not require advanced clinical knowledge based on definition therefore requesting the LMHP/LMHP-type be reconsidered or removed from credential requirements.  Medication Management is a service provided by a limited LMHP types, specifically MDs and Nurse practitioners
    
   Page 26, under Required Activities when and Individual is Screened Section

1. What screening is this referring to?  At risk criteria is found under IIH definition and does not have a criteria “i”.
2. Also states that the “screening” needs to be performed by a LMHP/LMHP-type.  Not clear on why a licensed staff needs to conduct this screening.  Please add certified prescreener to the credential that is accepted. 
3. Under #4, please clarify how the risk screening will be submitted to DMAS.  How will the provider be notified if the screening has been approved?
    
    
   Page 38, under TDT Section: 

1. “Family involvement, including family counseling,…should occur at least weekly.”  This sentence contradicts previous statements from DMAS indicating that the frequencies of individual, group and family counseling is at the sole discretion of the provider.  Please clarify.
2. Page 42, 3rd bullet under Service Requirements:  What happens if a child or parent is interested and needs TDT services but declines counseling?  Please clarify.
3. Page 43, Family meetings…Family counseling is required and weekly family meetings are required.  Is the expectation that these sessions be separate given that the frequency of family counseling is at the sole discretion of the licensed professional?
4. Under additional covered services:  Are these services mandated or optional and reimbursable if provided?  The language say what providers “must” do however it’s listed under covered services.
5. Page 50, assistance with “medication management” has traditionally consisted of education and support.  This is not an advanced clinical practice therefore not understanding why licensed staff are required to provide this intervention.  There isn’t enough licensed staff to provide counseling and to provide medication management interventions.
    
   Page 54, under Psychosocial Rehabilitation Services Section

1. Assistance with “Medication Management” is identified under covered services.  This is a typical and traditional intervention provided under psychosocial rehab services.  This intervention does not require advanced clinical knowledge, therefore requesting that the LMHP/LMHP-type be removed or reconsidered.  There aren’t enough licensed staff to perform these functions nor is it necessary that it be provided by this specific credentialed professional.
2. Medication Monitoring is permitted by a QMHP however Medication Management is only permitted by LMHP/LMHP-type.  There are very few times and opportunities where a professional will monitor medication compliance and not provide some level of education and support.  There is huge overlap between monitoring and management.  This credential requirement for medication management should be reconsidered.  Both interventions go hand-in-hand.
    
   Page 54, under Crisis Intervention Services Section

1. Please define the difference between crisis treatment and short term crisis counseling,
2. Crisis Treatment only lists LMHP/LMHP-type.  As a part of crisis intervention services, certified prescreeners are often non-licensed staff.  Please add this credential to this definition.
3. Page 57, 4th bullet:  “Short-term clinical care and counseling designed to stabilize the individual or family unit provided by LMHP, LMHP-R….” is now under Required Services instead of covered services.  There is NO way that licensed staff will be able to provide counseling in all settings with all recipients who receive crisis intervention services.  Additionally, certified prescreeners are not all licensed staff and would not be able to perform this intervention if this remains.  Please remove or reconsider.
4. Crisis Treatment should be removed from Required Services or please add certified prescreener to list of accepted credentialed providers
    
   Page 59, under Intensive Community Treatment Services Section

1. Adding Counseling, which by definition requires provision by LMHP/LMHP-type, is problematic as many staff on ICT teams are not licensed or licensed eligible.  Mostly QMHPs provide this service. Also, depending on the population served for the particular team, some individuals may not be appropriate for therapy/counseling however they often receive supportive counseling and problem-solving interventions.
2. Crisis treatment or intervention has been a standing component of ICT/PACT teams.  However, many teams do not have LMHP/LMHP-type staff to perform these functions.  This will limit the capacity and stagnate the effectiveness of the team.  As we all know, ICT teams are very critical to state psychiatric hospital reduction efforts so creating barriers to provide this service is problematic. 
3. The credentials for professionals who can provide the ICT service (QMHP, etc.) contradict your requirements of LMHP/LMHP-type to provide crisis treatment.  PACT/ICT is a multidisciplinary team where all staff provide all clinical services with the exception of nursing and psychiatric eval interventions.  The structure of the team does not allow for hard lines in what credentialed provider can provide a very specific intervention.  Please remove or reconsider.
4. Page 60, under Continuation of ICT Services:  “The results of the review must be submitted to receive approval of reimbursement for continued services.”  Please clarify as there is no review that is currently required.  The only review that I am aware of is the review of the ISP. CCC+ plans require a registration for continuation of services so who would we submit a review too?
    
   Page 61, under Crisis Stabilization Services Section

1. “The goal of this service is to stabilize acute mental health needs at the earliest possible time to avert hospitalizations however counseling has been added as a requirement for this service.”  Counseling is contraindicated for an individual experiencing a crisis.  Crisis stabilization services are very short term which are solely focused on resolving the crisis and connecting to ongoing community-based services.  Additionally, counseling requires LMHP/LMHP-type.  Many CSUs have a limited number of LMHP/LMHP-types in their program.  THIS IS PROBLEMATIC AS CSBs USE THIS SERVICE AS DIVERSION FOR HOSPITALIZATIONS AND STATE HOSPITAL ADMISSIONS.
2. Assistance with Medication Management must be performed by LMHP/LMHP-type professionals.  Based on the definition, this is not an advanced clinical intervention therefore not clear on why licensed staff must perform this function/intervention.  CSU does not have enough licensed staff to be the sole staff to provide this intervention.
3. Psychiatric nurse practitioners are trained and can legally provide psychiatric evaluation and medication evaluation services.  Limiting these services to a license psychiatrist will cause a barrier to services given the shortage of qualified psychiatrists.
    
   Page 64, under Mental Health Skill-Building Services Section

1. #2 under Service Requirements:  For services that continue beyond six months must have a “review” completed by LMHP/LMHP-type.  Please provide clarification on what the review consists of.  Also, how does the “review” differentiate from the Comprehensive Needs Assessment in this case?
2. Page 71, under Covered Services-3rd bullet:  Assistance with Medication Management does not require advance clinical knowledge or skills.  Please reconsider or remove the requirement that this intervention be performed by LMHP/LMHP-type.  CSBs will not have a licensed workforce to perform these interventions if many service interventions are required by LMHP/LMHP-types.
3. Medication monitoring and Medication Management as defined in the draft regulations appear to essentially the same intervention.  There are very few opportunities to provide monitoring of meds without engaging in medication management.  In terms of the flow of service provision, it is not practical to separate the interventions and require different credentials for each.
4. The accepted definition of medication management is  outpatient treatment where the sole service rendered by a qualified physician, or others whose scope of practice includes prescribing medication, is the initial evaluation of the patient's need for psychotropic medications, the provision of a prescription, and, as-needed, ongoing medical monitoring/evaluation related to the patient’s use  of  the  psychotropic  medication.
    
   Page 74, under Mental Health Case Management Services

1. In second paragraph, please add clarification that professionals conducting the assessments for this service do not have to be licensed.
2. Under Service Requirements:  1st bullet – remove comprehensive needs assessment from the entire Mental Health Case Management services section OR clarify that MH Case Management services assessment does not require a licensed professional to complete it. 
    
   Chapter VI

1. Page 10:  Please include disclaimer that all CMHRS services require a Comprehensive Needs Assessments with the exception of MH Case Management services.  It has been stated inconsistently in Chapter IV that case management services assessments are not required to be completed by licensed/licensed-eligible staff.