I would strongly recommend that the criteria for the components of the Comprehensive Needs Assessment and the components of a psychiatric evaluation under the Psychiatric Services Manual should be alligned.  This is especially critical for individuals coming into services with CSBs through regional reinvestment projects who are being referred to bridge appointments with our pshyciatrists.  If an individual is seen for a psychiatric evaluation by a psychiatrist, they should not need to undergo a seperate Comprehensive Needs Assessment is there is a need for these individuals to receive CMHRS services.

Making it a requirement for ICT service providers to provide counseling by a LMHP or LMHP-type will make it difficult for teams to remain in compliance. LHMP and LMHP-type staff are difficult to recruit within the limited funds allotted to the programs for staffing. In addition, per 12VAC35-105-1370 the composition of the ICT Treatment Team includes only one LMHP Type (the psychiatrist).  Most of the providers on an ICT Team are QMHPs, not LMHPs and this requirement severely restricts the team’s ability to provide appropriate therapeutic interventions to individuals receiving ICT services.  If a team can provide the therapeutic counseling then it should be encouraged, but making it a requirement  is not realistic for all teams.

I am concerned that the new regulations would require crisis treatment to be provided by a LMHP or LMHP type for ICT services. We have a certified preadmission screener on our ICT team that is not an LMHP or LMHP type. Certainly this individual would be qualified to provide crisis intervention despite not being an LMHP or LMHP type. Also we have a mix of QMHPs and LMHPS. The definition of crisis treatment is so broad it could include a variety of services that a QMHP might be perfectly qualified to handle, especially under the supervision of the team lead. The severity of illnesses for individuals receiving ICT services is such that crisis occur on a regular basis. To have the number of LMHP and LMHP types on the team that would allow for only LMHP and LMHPs would require more recruitment of LMHP and LMHP tyes. This would only be financially feasible if reimbursement rates were increased.

I am also wondering why LPNs are not listed as being able to assist with medication management. It would seem to be that LPNs would be as qualified if not more qualifed than LMHPs to assist with medication management.

I am not sure if you are trying to draw a differentiation between Crisis Intervention and Crisis Treatment or Short Term Crisis Counseling. Crisis Treamtent is newly defined at the being of Chapter IV and Crisis Intervention is defined later under covered services.  Crisis Intervention can be provided by a certified prescreener. Crisis Treatment is defined as needing to be available 24 hours a day seven days a week to provide immediate assistance to individuals, which sounds like the old definition for Crisis Intervention. Furthermore, Crisis Treatment is listed as an activity of Crisis Intervention, however, the proposed revision does not include a certified prescreener as an approved provider for Crisis Treatment or Short Term Crisis Counseling. Only LMHPs and LMHP types are listed as approved providers.

I would also like to say that I believe the requirement to compete a Comprehensive Needs Assessment in the midst of a crisis does not faciltiate good clincial practice. I think it is unreasonable to gather the extent of the information required when we are trying to also conduct a suicide risk assessment and accomplish hospital diversion. It is also unreasonable to require us to register that we have provided crisis intervention services within 24 hours. Crisis intervention services often occur after hours and on the weekend when reimbursement staff are not available. I urge you to reduce the amount of information we are required to gather, include a assessment of risk to self or others and inability to care for or protect self, and allow more time to register that we have provided a crisis intervention service.

Chapter IV, page 59 states that assistance with medication management must be provided by a LMHP, LMHP-R, LMHP-S,LMHP-RP or RN. Why would a LPN not be permitted to perform this activity?  ICT services must be rendered by a team that meets the requirements of 12VAC35-105-1370.  ICT/PACT teams are not required to have a LMHP except the Psychiatrist.  Most teams only have one additional LMHP in order to complete the SSPI or Comprehensive Assessment.  The nursing requirement for ICT is one full time nurse, but is not required to be RN, he/she may be a LPN.  The requirement for PACT teams is to have three qualified full-time nurses at least one of whom shall be a qualified RN, the rest being LPNs.  On many teams there would not be sufficient qualified staffing to provide medication management if if QMHPs and/or LPNs are not able to provide this activity.

Chapter IV, page 6 defines the assessment for children, but not adults.

Chapter IV, page 18 states "When the initial comprehensive needs assessment recommends several services for an individual, one assessment will be allowed for all services provided within the same agency."  There does not seem to be similar language for annual assessments.  It presents barriers to services when individuals, especially children are required to have multiple assessments collecting the same information, regardless of it being an initial or annual assessment.  It is particularly problematic for children as parents either work, have transportation problems or may be non-compliant with their children's treatment and many parents find it difficult to participate in multiple assessments.

"The variance remains in effect as long as the staff person remains employed by the same DBHDS licensed provider or until the individual is registered by the Board of Counseling as a QHMP-C. ... Does this imply that once a varianced person is registered as QMHP-C that the variance supervision requirements, documentation, etc goes away?

Recommendation: Pull the start date for these and convene a workgroup that includes CSBs that provide these services. Our immediate concern is that these increases in services required to be provided by LMHP type providers will prevent /limit NorfolkCSB from being able to bill for PACT and Crisis Stab - the biggest area of our concern.

Comments / Concerns with CMHRS Manual for Norfolk CSB Services – Current or planned

(NCSB does not provided TDT, IIH, Day Tx/Partial, Psychosocial – so those areas are not reviewed)

Definition of LMHP: Several services are limited to services provided by LMHPs – The definition of LMHP does not include RN’s. (Chapter II p. 12)

Provider requirements for Mental Health Service Agencies (starts Chap II p. 15):

• Psychosocial Rehab: Does not include peers as providers in list of providers.
• ICT (PACT) teams must include staffing as defined in “12VAC35-105-1370. Treatment Team and Staffing Plan.” This reference is fine, but later in the Provider Manual – this is not consistently applied. - and services are significantly limited and many of the staffing types are not listed as billable services
• Crisis Stabilization Services: Does not include RN’s or Peers as providers.

Coordination Requirements of CMHRS Providers (Starts Chap IV p. 16):

CMHRS providers are responsible for care coordination activities that includes both behavioral health and medical needs as documented in the ISP. The concern with this is that the MCO’s responsibility to make primary care and outpatient psychiatric provider referrals available to clients receiving CMHRS services the responsibility of the CMHRS provider. This appears to shift this burden of locating providers in the MCO network. (This may not be the intention, but it should be clear that the MCO is actually responsible for assisting the member and case manager in locating providers in their network.) The significant limitations of the established networks for participating psychiatrists and primary care providers is highly problematic and the CMHRS provider does not have the authority to push providers to make appointments available.

Comprehensive Needs Assessment (Starts Chap IV p. 17):

Comprehensive Needs Assessment (CNA) is now required to be repeated annually for ALL services and must be done by a LMHP type. The initial needs assessment (intake) no longer provides ongoing authorization. However, there is a separate case management assessment also required annually. (So, this means all clients in a CMHRS service must undergo a complete CNA annually. This is a significant increase in the number of LMHP-type assessments required). (Note, is there a fee structure for the CNA and does it have to be provided through the assessment unit of the CSB or can it be provided within the service area?)

Crisis Intervention (Starts Chap IV p. 54)

The Comprehensive Needs Assessment is required to be included in the Pre-Screening Document. Does this mean that if not all of the items (except the two waived later in the manual) in the 15 area CNA are available during the crisis assessment it is possible that the service will not be paid? (p. 55-56)

ICT/PACT (Starts Chap IV p, 57)

ICT definition is very limited in the first paragraph, does not mention community integration activities, medication monitoring, vocational services, peer support, skills training. However is does mention requirement to provide “counseling” that is previously defined as a service that is only available through a LMHP-type. PACT consumers may benefit from “Counseling” individual or group, but it is more appropriate to allow that service to be provided by a separate provider as well. It also requires that medication management and counseling be provided in the community – and medication management is restricted to LMHP-type.

Crisis Stabilization (Starts Chap IV p. 61)

Services include: Does not include psychosocial activities or education, peer support, non-clinical (QMHP-Provided) groups, case management activities, medication and symptom classes/groups by RN’s or LPNs, resource groups, etc. This is a one-hour billable service (unless daily rate established by MCO’s) so the approved activities in the Crisis Stab manual may not be billable time. The bullets later indicate “restorative facilitation” as required activity. Services provided by peers are not mentioned and therefore not billable time? This is very confusing and appears to provide a wide area for interpretation where the MCO may not be required to pay for service time.

In Chapter II, pages 14-15, it references staff varianced by DMAS/DBHDS back in 2010-2011.  In both the adult and children's variance sections, it states "The variance request remains in effect as long as the staff person remains employed by the same DBHDS licensed provider OR until the individual is registered by the Board of Counseling as a QMHP-A (or QMHP-C)".  This implies that once registered, the person is no longer considered varianced.  Therefore, does this relieve the supervisor of the weekly supervision requirement for varianced staff?  Of course, ongoing supervision is always provided regardless of registration status, but QMHP varianced staff are required to have weekly documented supervision. 

"Assessment" and "comprehensive needs assessment" are defined seperately in the definitions section.  There are multiple times each term is used throughout the chapter and at times they appear interchangeable and even used in the same paragraph.  It would be helpful to have more clarity about why these are defined seperately.

"Medication Management" is defined as "counseling on the role of prescription medications and their effects including side effects; the importance of compliance and adherence; and monitoring the use of and effects of medications." This term is seen throughout the chapter as a required activity in multiple services. It seems that this services could also be provided by other qualified staff such as psychiatrist,  RN's or nurse practitioners who are involved with the individuals care. 

Is there a minimum standard for how often this activity should be provided?  In rural areas where Licensed Type Staff are limited this regulation change could hinder services provided.

"Individual and family counseling is a required component of this service (IIH) and must be provided by a LMHP, LMHP-R, LMHP-RP, or LMHP-S;"

 Is there a recommended standard regarding the quantity or ratio of individual, group and/or family counseling required for IIH; TDT and or crisis stabilization services? If family's refuse this service or are unable to physically attend counseling appointments as is common in a rural area (transportation, lack of funds, etc) as a required part of a CMHR Service are we required to close them from the service?

Sorry for the mulitple entries without documentation - I have finally found a web browser that allows for comments to be added...

Comments:

Chap. II Page 9:

CMHRS Providers must report any knowledge of adverse outcomes for an individual currently receiving services or who have been discharged from services within 180 days of the incident.

Comment: It is not within the means of a provider to continue to be aware of or track adverse events of consumers once they have been discharged from services . This requirement puts an unjust burden on the provider and will likely be a requirement that the provider will always be out of compliance. It would make better sense to have this be an expectation of the Care Coordination activities of the Health Plans.

Chap II Page 13:

a. Effective January 1, 2019, DMAS and its contractors will deny reimbursement from services rendered by a QMHP and QMHP-Trainee staff who are not registered with the Board of Counselors

Comment:  This continues to be a subject that Agencies/Providers will feel the burden of having a hired staff who potentially cannot  bring in revenue for at least 1 mo’s time from hire while the registration process is taking place through the Board of Counselors. I would ask that DMAS and the Board of Counselor’s look at a compromise to this requirement. Positions that employ QMHPs tend to have a higher rate of turnover which could have a direct effect on the provision of care to the individuals served if there is a minimum of a 1 month time frame before new staff who meet the qualifications for QMHP and QMHP –Trainee can be used to provide the service.

Chap IV Page 9: Definition:

???????Medication Management” means counseling on the role of prescription medications and their effects including side effects; the importance of compliance and adherence; and monitoring the use and effects of medications. Assistance with medication management is only available to parents and guardians when it is for the direct benefit of the individual and the individual is present.

 Comment :In Chapter IV, this activity is relegated to LMHP and LMHP-Types only.  I understand that “counseling” falls within the scope of the LMHP/Type licenses and education, but I am puzzled by definition including the information on medication use and side effects as also falling within the scope of practice for an LMHP and LMHP-Type. An employee who is a registered nurse and may also be QMHP would seem to have better knowledge of medications and their side effects and would also fall within the scope of their license.  A large component of our QMHP’s and even our case managers at times is to provide education on medications, their potential side effects and monitoring of medication adherence in the community and  working closely with the Prescriber on these types of issues and activities.

Chap IV Page 18 :

When the initial comprehensive needs assessment recommends several services for an individual, one assessment will be allowed for all services provided within the same agency. An agency means the same as the DBHDS provider definition located in 12VAC35-105-20. If additional services are required after the completion of the initial comprehensive needs assessment, the provider may amend the initial comprehensive needs assessment or conduct a new comprehensive needs assessment.

Comment: The regulations do not address or clearly state if an agency who provides multiple CMHRS services can complete and use just one Comprehensive Needs Assessment  (CNS) annually after the initial one has been completed…(with amendments as needs and services change.) If this is the intent of the regualtions– then this should be more clearly stated within the regulations.

Chap IV  pages 18 and 20:             

Case Management assessments require different staff credentials than the staff credentials for direct MH services. Refer to Chapter II of this manual for additional information. MH Case Management assessments must be provided in accordance with the provider requirements defined in DBHDS licensing rules for case management services.

Comment: The CM Assessment is clearly stated on page 18 and is described as different that the CNA , however on page 20 the regs state … The comprehensive needs assessment must be completed annually for all services or when there is a need based on the medical, psychiatric or behavioral status of the individual.

Based on the copied statement above, it appears the Comprehensive Needs Assessment is required by all services including case management… Also,  If an agency provides CM as well as other services, Can the Comprehensive Needs Assessment be utilized by the CM service as their assessment? I think the regulations would be clearer if the Case Management Service had its own section rather than weaving it in and out the fabric of all services being addressed in Chapter IV.

Chap IV Page 22:

All ISPs shall be completed, signed and contemporaneously dated by the LMHP, LMHP-Types, QMHP A/C/& Es.  In addition, there are similar regulations addressing TX Plan reviews on the same page.

Comment: MH CM do not always meet the qualifications for these credentials, nor are they required for this service. Clearer regulations are needed for the expectations for ISPs for case management services.

Chap IV: Psychosocial  Rehabilitation regulation (starting on page 51)

Comment: The term Restorative Facilitation is used several times throughout the manual– Can you clearly define the term.

Chap IV: Crisis Intervention, page 57:

Clarification requested: CI may be provided in settings other than the outpatient clinic if “clinically/programmatically appropriate based on the needs identified in the comprehensive needs assessment.”  For crisis intervention, will the prescreening if done to determine need for inpatient treatment meet the definition for “comprehensive needs assessment”?

Chap IV : Crisis Stabilization, Page 61

Service Requirements:

Psychiatric evaluation including medication evaluation provided by a licensed psychiatrist and including pharmaceutical assessment and treatment or prescription medication intervention and ongoing care to prevent future crises of a psychiatric nature.

Comment: A full Psychiatric Evaluation is not always warranted, particularly if the individual is already being treated by the provider’s prescriber . What is needed is the 24/7 support, counseling and structured environment to avert further decompensation and hospitalization. I would ask that this be on a as deemed necessary basis.

A Psych eval by a Psychiatrist puts an increased burden on the lack of available resources for Psychiatrists for Medicaid covered services.  Nurse Practitioners should be considered to meet the qualification and credential level to provide the Evaluation and medication services. This would be in line with the current health care trends . Even the recent regulation changes for Nurse Practitioners supports this trend.

page 64 - The provision of this service to an individual shall be registered with DMAS or its contractor within one calendar day of the completion of the comprehensive needs assessment. 

Comment : The CCC+ MCOs allow for 48 hours– Could this match the CCC+ Plan’s requirement for consistency.

Chap IV: MHSS,Page 72

TGH, mental health supervised living and assisted living facility providers shall not serve as the MHSS provider for individuals residing in the providers’ respective facility. Individuals residing in facilities may, however receive MHSS from another MHSS agency not affiliated with the owner of the facility in which they reside.

Comment: DBHDS licensed MH Supervised Residential Programs are not a billable CMHRS to Medicaid ; so I wonder what the rationale is to not allowing the same provider to provide MHSS services within the MH Supervised Residential Program.

Chap IV : MHCM, Page 75:

A comprehensive needs assessment must be completed by a qualified mental health case manager to determine the need for services. The CM comprehensive needs assessment is part of the first month of CM service and requires no service authorization.

Comments:  Earlier in the chapter the following is documented: Case Management assessments require different staff credentials than the staff credentials for direct MH services. Refer to Chapter II of this manual for additional information. MH Case Management assessments must be provided in accordance with the provider requirements defined in DBHDS licensing rules for case management services. And earlier in the chapter it also states that an LMHP or LMHP-Type must complete a Comprehensive Needs Assessment (CNA)– there is conflicting information in the regulations regarding the CNA and Case Management requirements for assessments.- Please address and clarify.

 Page 78:Request clarification to the following statement:

Making collateral contacts, which are non-therapy contacts, with significant others to promote implementation of the service plan and community adjustment.

Comment: Case Managers are often checking in with all providers of the client’s , even a  therapist, if needed,  to determine continued needs and progress of the individuals receiving case management service.

"Family involvement, including family counseling and contacts from the beginning of treatment is extremely important and, unless contraindicated, should occur at least weekly."  Does this statement imply family counseling weekly and weekly family contacts, or family counseling as determined by assessment of treatment need and documented in the individuals ISP and supplemented with weekly family contacts?

Please add reference to explain that for case management services, the Comprehensive Needs Assessment may be completed by a qualified mental health case manager in all the areas (throughout the manual) that state LMHP (types) must be the level of staff completing Comprehensive Needs Assessments.

 "Psychiatric evaulation provided by a licensed psychiatrist and including pharmaceutical assessment and treatment or prescription medication intervention and ongoing care to prevent future crises of a psychiatric nature."

In previous revisions, "psychiatric evaluations" also included "where appropriate."  This left the option of continuing the crisis stabilization service when a guardian refused medication evaluation or if they had recently seen their psychiatric provider.  Does the current revision require an individual who refuses the psychiatric evaluation to be closed from crisis stabilization services? 

In very rural areas of the Commonwealth there are few psychiatrists available, especially for children.  At current children often receive evaluation as a part of Crisis Stabilization services by a qualified Nurse Practitioner.  If this revision is left as is, the ability to provide quality services to our rural consumers would be hindered significantly.

Is it required that the individual who is receiving crisis stabilization services be on a medication regimen?  i.e. (assistance with medication management) is a required activity per page 63.

For IIH services, in Chapter IV on page 34 when referencing Individual and family counseling is a required component… please add this can be achieved by coordinating with an outpatient provider if the IIH provider is a QMHP-C (as documented in Chapter IV, page 37).

For IIH services, in Chapter IV on page 30 under Service Definition the following is included:  “IIH services are designed to promote benefits of psychoeducation in the home setting OF AN INDIVIDUAL WHO IS AT RISK OF BEING MOVED INTO AN OUT-OF-HOME PLACEMENT …… due to a documented medical need of the individual”.  The section in the current manual that defines “at risk of being moved into an out-of-home placement” is going to be removed in the proposed changes.  The definition for “out of home placement” in Chapter IV on pages 6 – 7 does not include how to define / justify / prove / document the individual ‘is at-risk of being moved into an out-of-home placement in one of the mentioned places.  Do providers use their definition of ‘at risk’; as long as the reasons are explained using Medical Necessity Criteria with clear documentation that medical necessity is met?

"Comprehensive needs assessment" is noted in the service definition of Mental Health Case Management.  Previously stated it is required to be completed by Licensed Type provider.  This language is confusing to intermix between services that require Licensed Type provider and ones who only require Qualified Case manager. 

Chapter VI- Page 10- "All services require a comprehensive needs assessment which is required at the onset of services.  The comprehensive needs assessment must be completed face to face by an LMHP, LMHP-S, LMHP-R, or LMHP-RP."  However later on the same page, case management services is not in the list of services that require a "comprehensive needs assessment" prior to initiating services.  This language is contradictory.

Chapter VI-page 13- "If the provider feels an additional comprehensive needs assessment is needed and there are remaining assessments available for the fiscal year, they may choose to complete a comprehensive needs assessment and bill the appropriate-- comprehensive needs assessment code that cooresponds to the service/treatment."  Please specify how many comprehensive needs assessments can be billed per year? Are there a specific number of comprehensive needs assessments allotted for each CMHRS service per year?

Consider removing the requirement for the Comprehensive Needs Assessment for crisis intervention and 30 days of short term crisis counseling contacts.  This would create a venue to improve outcomes with crisis situations; preventing or reducing a cycle of episodes related to the same stressor.

Related to crisis intervention, please specify what services Certified PreScreeners are able to perform to meet these guidelines.  At some places in chapter IV  LHMP (types) only are referenced as providers; and at other places LHMP (types) and Certified PreScreeners are both referenced.  Are there some crisis intervention services Certified PreScreeners are not eligible to provide?

Regarding crisis stabilization services, in Chapter IV on page 62 under Service Requirements, the second bullet references a psychiatric evaluation with a medication evaluation must be provided by a licensed psychiatrist; please consider adding a Family Nurse Practitioner as a provider to meet this requirement. In rural Southwest Virginia accessing psychiatrists is extremely difficult, and when referring to providers a FNP could be the provider used the day of the evaluation. If the provider used a FNP that day for the evaluation, would this meet the requirement?

On the same page (Chapter IV page 62), the seventh bullet references counseling provided by a LMHP (types) but the frequency is not included.  Is there a minimum requirement for this service?

Please include the language from Chapter IV on page 77 from the first bullet under Service Requirements to all places in the manual that reference who is eligible to complete Comprehensive Needs Assessments.  Please clarify that for case management services a ‘qualified mental health case manager’ is eligible to complete this Certified Needs Assessment; but for all other services a LMHP (type) must complete the Certified Needs Assessment

Comprehensive Needs Assessment – From a parent/grandparent perspective, the required repeated repetition of the entire Comprehensive Needs Assessment within a service setting and across service settings is not only time consuming (for the family and the providers), but was also traumatic for our family us as my son had to talk about his brother’s suicide each time an assessment was done.  There was no reason that most of the information on the Comprehensive Needs Assessment needed to be repeated. In addition, I didn’t see anything on the CNA that would guide providers to explore the possibly of childhood trauma, or the possibly of sensory or auditory sensitivities that could be setting off behavior issues.

Medical Necessity Criteria for IIH Individuals receiving IIH Services must have the functional capability to understand and benefit from the required activities and counseling of this service.  These services are rehabilitative and are intended to improve the individual’s functioning.  It is unlikely that individuals with severe cognitive and developmental delays/impairments would clinically benefit and meet the service eligibility criteria. 

In light of what we continue to learn from adults who were diagnosed with severe disabilities due to their inability to communicate, but who were actually very intelligent, I hope that this criteria will be re-evaluated.  Even for those children who truly do have severe cognitive and developmental delays, their parents need guidance on how to deal with the real-life situations that occur in the home. Our focus needs to be on equipping providers with the skills to help these individuals and their families, not on denying services to these individuals whose dual diagnoses make them too difficult for our systems to meet their challenges.

Chapter IV, Page 43: Service provider care coordination including consultation, collaboration, and coordination with teachers, concurrent service providers, and others involved in the individual’s treatment to include scheduling appointments and meetings to improve care; planning and implementing individualized behavior modification programs; and monitoring treatment and ISP progress. The provider will be asked to explain what care coordination has taken place during treatment as well as in preparation for discharge and step down to lower levels of care with every request for services.

Behavior Modification is a form of treatment designed to make the individual conform to what others would like to see – often without fully understanding the underpinnings of the individual’s reasons for their unusual or “unacceptable” behavior.  I would love to see DMAS move to evidence based relationship-based, methods of supporting and helping neuro-diverse individuals.  Please see:  https://www.monadelahooke.com/new-lens-understanding-behavior-problems/  and https://www.monadelahooke.com/consider-starting-childhood-behavioral-therapies/

Providers – it appears that all of the case management must be done by CSB or BH (state) employees.  Is that correct? What is the rationale for this?  It wasn’t as clear to me about the role of private mental health providers.  I hope that the regulations will provide for ease of participation of ALL providers (public and private) with smooth interaction and communication between the two groups for the benefit of the families served. 

http://townhall.virginia.gov/L/entercomment.cfm?generalnoticeid=858

1. Please clarify age restrictions for QMHP:
   1. In chapter II, they identify a QMHP-Child can only work with individuals under the age of “22years old”.
   2. In chapter IV, they define an “adolescent or child” as someone who is adolescent means an individual 12-20 years of age.  
   3. This can cause some problems.  One example may be while our youth services folks are used to having a QMHP-A in order to work with young adults, ages 18-21yo, we are completely unprepared for our adult services folks to have to meet the criteria of QMHP-C in order to work with someone 18-22 years old.  
   4. Chapter IV in the definitions section, they quote the Code of Virginia’s definition of a QMHP-A, which does not identify any age for that credential.
   5. Magellan of Virginia’s and MCO authorizations form for MHSb says that the cut off is 21 years old.
       
2. Chapter IV, page 6, the definition for “Assessment” and on page 9 for “Comprehensive Needs Assessment” only refers to children and adolescents, but not adults.
    
3. Ch IV, page 9, the definition for Medication Management describes the activity as “counseling” which is otherwise defined as an activity that can only be done by a LMHP or LMHP E.
    
4. In Chapter IV, they took out SSPI and replaced it with “Comprehensive Needs Assessment”—which looks like the same definition. So, does that mean one per agency/provider, or one per service?  On page 19—“When the initial comprehensive needs assessment recommends several services for an individual, one assessment will be allowed for all services provided within the same agency.  An agency means the same as the DBHDS provider definition located in 12VAC35-105-20.  If additional services are required after the completion of the initial comprehensive needs assessment, the provider may amend the initial comprehensive needs assessment or conduct a new comprehensive needs assessment.”
    
   1. On page 18, the language contradicts this by saying: “A comprehensive needs assessment must be completed prior to initiating each of the following services:
      1. Intensive In-home Services for Children and Adolescents
      2. Therapeutic Day Treatment for Children and Adolescents
      3. Mental Health Crisis Intervention* (only if an ISP is developed:  refer to service details)
      4. Mental Health Crisis Stabilization
      5. Mental Health Day Treatment/Partial Hospitalization Services
      6. Psychosocial Rehabilitation
      7. Intensive Community Treatment
      8. Mental Health Skill-building Services”
          
   2. On page 34 and 42, in the sections on IIH and TDT respectively: “Prior to admission, a comprehensive needs assessment, as defined  earlier in this chapter, shall be conducted by the LMHP, LMHP-S, LMHP-R, or LMHP-RP, documenting the individual's diagnosis and describing how service needs match the level of care criteria.  Assessments shall be required at the initiation of services and ISPs shall be required during the entire duration of services.”
       
   3. So, “as defined earlier in this chapter,” (highlighted above) says that if the initial comprehensive needs assessment identified the need for multiple services, one CA is sufficient, AND that if we identify an additional service after the completion of the initial, we can amend the initial OR conduct a new one… this wording in the IIH and TDT sections seems to contradict that definition on page 19. 
       
   4. Page 23, it refers to the SSPI at the bottom of the page.
       
5. Ch IV, page 20:  “The comprehensive needs assessment must be completed annually for all services or when there is a need based on the medical, psychiatric or behavioral status of the individual”—this also appears to contradict the statement on page 19.  Does this mean one CNA counts for all services annually, or does this mean every service must do a new CNA annually?
    
6. MCO authorization form continues to list the SSPI, not the Comprehensive Needs Assessment.
    
7. Ch IV, page 26, please provide more clarification about the section on screening for risk of physical injury.
    
   1. What is meant by an “emergency services assessment,” seeing how it goes on to distinguish that from the requirement to seek a prescreening for inpatient psychiatric treatment.  Does this mean an ER visit or Urgent Care visit?
   2. In #2: “Once the individual is referred for community based services the comprehensive needs assessment must be completed by the provider selected by the individual’s caregivers.”  Please clarify what is meant by “caregivers” assuming this section is about all ages in CMHR services.
       
8. Ch IV, page 49—“continued stay requests longer than 90 days” requires face-to-face assessments. if we do the request less than 90 days, face-to-face is not required?
    
9. Ch IV, page 57—under the Crisis Intervention section—it says that CI may be provided in settings other than the outpatient clinic if “clinically/programmatically appropriate based on the needs identified in the comprehensive needs assessment.”  For crisis intervention, will the prescreening (if done to determine need for inpatient treatment prior to referal for CI) meet the definition for “comprehensive needs assessment”?
    
10. Ch IV, page 58 – ICT provides long term needed treatment, rehabilitation, and support services to identified individuals with severe and persistent mental illness especially those who have severe symptoms that are not effectively remedied by available treatments or who because of reasons related to their mental illness resist or avoid involvement with mental health services in the community.  ICT services are offered to outpatients outside of clinic, hospital, or program office settings for individuals who are best served in the community.  ICT services include assessment, counseling, assistance with medication management, crisis treatment, and care coordination activities through a designated multidisciplinary team of mental health professionals.  

1. 1. Is it true that only LMHP can provide medication management?
   2. With the clarification on “counseling”—this means that a person in ICT services also has to be in outpatient counseling services? While we do not see this as new language within ICT description, however, the recent clarification of “counseling” in relation to TDT services puts this in new light. If it is truly intended that a person must be in outpatient counseling in order to participate in ICT, this presents a concern and a barrier.

1. Ch IV, page 59 --Service Requirements for ICT

• “Prior to admission, an appropriate comprehensive needs assessment, as defined earlier in this chapter, shall be conducted by the LMHP, LMHP-S, LMHP-R, or LMHP-RP, documenting the individual's diagnosis and describing how service needs match the level of care criteria. Comprehensive needs assessments shall be required at the onset of services.” This statement appears to contradict previous statement that one CNA is required within certain expectations.
• Counseling provided by LMHP, LMHP-R, LMHP-RP, LMHP-S. With the clarification on “counseling”—this means that a person in ICT services also has to be in outpatient counseling services?  This presents a concern and a possible barrier.

• Continuation of Services:  ICT may be reauthorized based on a written assessment and certification of need by a LMHP, LMHP-S, LMHP-R, and LMHP-RP that determines if the individual continues to meet the medical necessity criteria. The results of the review must be submitted to receive approval of reimbursement for continued services. Does this mean an authorization will be required? 

1.  Ch IV, page 61 – Crisis Stabilization Services: The comprehensive needs assessment must document the need for crisis stabilization services. Previously, it was not required to do a full comprehensive assessment in order to open someone to a crisis service, only a prescreening for admission or similar.  This may be a barrier to individuals with urgent needs to get a less restrictive level of care rapidly.
    
   1. Medication management is provided by licensed staff only.  Monitoring by QMHP.  Please clarify, who can administer the medication?
       
2. Ch IV, page 64 - The provision of this service to an individual shall be registered with DMAS or its contractor within one calendar day of the completion of the comprehensive needs assessment.  Individuals are admitted to residential crisis stabilization on Saturdays. Should this be Business or calendar day??
    
3. Ch IV, page 66 –states “a comprehensive needs assessment must be completed,” which contradicts initial clarification that only one is required within certain expectations and time frames.
    
4. Ch IV, page 78 – “The CM comprehensive needs assessment is part of the first month of CM service and requires no service authorization.”  This implies that a comprehensive needs assessment has to be completed at the on-set of the CM service. 
    
5. Ch VI, page 10 – “All services require a comprehensive needs assessment which is required at the onset of services.” This appears to contradict initial definition.  Does it mean that every service is required to complete a CNA?

Comment: Throughout the Manual – Please add reference to explain that for case management services, a qualified mental health case manager may complete the “Comprehensive Needs Assessment” in all the areas that state LMHP (types) must be the level of staff completing Comprehensive Needs Assessments.

Comment: Throughout the Manual – A Certified Preadmission Screener (CPAS) may complete the Comprehensive Needs Assessment (CNA) for Crisis Intervention only.  These staff, by virtue of preadmission screening, are assessing among the highest risk public mental health needs.  Their clinical assessment skills must meet the highest of standards.  Most Certified Preadmission Screeners also work in other areas of the CSBs, providing a variety of outpatient services; the majority are already licensed or license eligible.  To infer that the CPAS has a lesser ability to assess an individual for clinical outpatient needs is to cast doubt in the direction of their ability to attend to any other clinically based service.  Is that is anyone’s best interest as we attend to the front line of public safety?  I recommend that a CPAS be added to complete the CNA alongside the LMHP-type.

Comment: Chapter II, pp. 14-15 – QMHP by Variance: Need clarification if once an individual with a variance registers as a QMHP whether the variance requirements of weekly supervision and remaining in the same position go away.

Comment: Chapter IV, pp. 6 & 9 – Definition of “Assessment” and “Comprehensive Needs Assessment”: The definition section defines these terms separately.  Each term appears multiple times and appear to be interchangeable.  It would be helpful to know what services require an “assessment” and when a “comprehensive needs assessment” is required without using the other term interchangeably.

Comment: Chapter IV, p. 6 – Definition of “Assessment”: This definition only addresses children/adolescents; does this definition only apply to children/adolescent services?

Comment: Chapter IV, p. 9 – Credentials to Complete a Comprehensive Needs Assessment: Certified Pre-Screeners are not listed as being able to conduct a “Comprehensive Needs Assessment”; however, the Pre-admission Screening (PAS) covers all the elements of a Comprehensive Needs Assessment.

Comment: Chapter IV, pp. 11, 44, 61 – “Medication management”: Medication Management is defined as counseling on the role of prescription medications and their effects including side effects…this term is seen throughout the chapter in multiple services.  Should state the minimum recommended number of times medication management is provided to an individual during treatment.  Requiring medication management be provided by a licensed individual limits our ability to provide quality care in a rural area as we are staffed with few licensed type individuals.  

Comment: Chapter IV, p. 18 – “Case management “assessments”: CM Assessment requires different staff credentials than the staff credentials for direct MH services.  Does “assessment” reference back to the definition term for “assessment”?  The CM section of Chapter IV references a “Comprehensive Needs Assessment” multiple times as a requirement.  This is confusing since at other locations a “comprehensive needs assessment” requires a Licensed-Type Individual to complete.

Comment: Chapter IV, p. 18 – Comprehensive Needs Assessment: Certified Pre-Screeners are not listed as being able to conduct a “Comprehensive Needs Assessment” but the list of services includes MH Crisis Intervention.

Comment: Chapter IV, p. 22 – Service Requirements: The 3rd bullet states that “identification of employees or contractors responsible for coordination and integration of services, including employees of other agencies”, please clarify if this mean that the name of each staff person involved in providing services or the positions of individuals involved must be documented.

Comment: Chapter IV, p. 26 – “At Risk of Physical Injury”: What services are included in “Required Activities when individual is screened and determined to be ‘at risk of physical injury’.”  Does this apply to child/adolescents, adults or both?  Both populations can be at risk of physical injury.

Comment: Chapter IV, p. 30 – “Service Definition for IIH”: The following is included “…of an individual who is at risk of being moved into an out-of-home placement…due to a documented medical need of the individual”.  The definition for “out of home placement” on pages 6 – 7 does not include how to define or justify how to prove / document the individual is at risk of placement in one of the mentioned places.  Do providers use their definition of ‘at risk’; as long as the reasons are explained with Medical Necessity Criteria documented?

Comment: Chapter IV, p. 34 – Intensive In-Home Services: When referencing Individual and family counseling as a required component… please add that this can be achieved by coordinating with an outpatient provider if the IIH provider is a QMHP-C (as documented in Chapter IV, page 37).

Comment: Chapter IV, p. 34 – TDT: There is no recommended minimum standard regarding the number of individual, group and/or family counseling that is required for TDT.  Additionally, what if a family refuses or is unable to get to appointments for counseling as a required part of TDT; will this require closure to TDT?  Families in rural areas have major transportation issues.

Comment: Chapter IV, p. 38 – TDT: In the TDT service definition, “assessment” is a required service.  Is this referencing back to definitions that defines “assessment” as “face-to-face interaction in which the provider obtains information from the child or adolescent, and parent, guardian, or other family member or members, as appropriate, about the child’s or adolescent’s mental health status. It included documented history of the severity, intensity, and duration of mental health problems and behavioral and emotional needs,” or is this in reference to continual assessment of needs, progress toward goals and objectives, etc. that typically occurs in treatment.

Comment: Chapter IV, p. 38 – TDT: “Family involvement, including family counseling and contacts from the beginning of treatment is extremely important and, unless contraindicated, should occur at least weekly.”  Needs to clarify required frequency for family counseling.

Comment: Chapter IV, p. 42 – TDT: In the same paragraph “Comprehensive needs assessment” and “assessments” are required before starting the service.  This creates confusion since they are defined differently in the definitions section of the manual.

Comment: CMHRS, pp. 54-57 – Crisis Intervention: Need to specify what services Certified Pre-Screeners are able to perform to meet these guidelines.  At some places in chapter IV, LMHP (types) are referenced as providers; and at other places, LHMP (types) and Certified Pre-Screeners are referenced.  Need to specify services that Certified Pre-Screeners are eligible to provide.

Consider removing the requirement for the Comprehensive Needs Assessment for crisis intervention and 30 days of short-term crisis counseling contacts.  This would create a venue to improve outcomes with crisis situations related to preventing a cycle of episodes related to the same stressor.

Comment: CMHRS, p. 56 – Pre-Admission Screenings: Preadmission screenings occur in a variety of settings and within different circumstances.  In an effort to reduce the burden on law enforcement and uphold an individual’s right to self-determination when feasible, the preadmission screening can and does occur without an ECO.  Not all preadmission screenings result in a TDO; often, the skilled CPAS uses interventions designed to ameliorate the crisis and assure safety.  References within the manual attach service coverage only to preadmission screening events involving an ECO or TDO.  This is unfair to people who desire to direct their mental health care without undue attention from law enforcement, to hospitals who rely on CPAS’ to evaluate an individual without involving law enforcement, and to those in-patient psychiatric facilities who simply need the assessment to facilitate admission.  The preadmission screening event does not need to require a TDO or ECO in order to be a covered and, therefore, reimbursable service.

Comment: CMHRS, pp. 57 and pp. 62 & 63 – Crisis Intervention and Crisis Stabilization: CSBs face a significant challenge in workforce development.  This is particularly true in rural areas.  Allowing the CPAS to function alongside the LMHP, LMHP-S, LMHP-R, and LMHP-RP will help address this need.  The CPAS should be able to complete the CNA and provide the clinical services associated with them.  Many already do so in the process of attending to the preadmission screening event. The CPAS understands well the necessity and dynamics of clinical follow-up and collaborative service planning.  They can and do develop ISPs involving multiple constituents, and they provide the crisis intervention services associated with them.  The CPAS should be able to provide short-term clinical care and counseling, any form of crisis intervention and crisis stabilization treatment, and, when necessary, co-develop and implement ISPs.

Comment: Chapter IV, p. 61 – Crisis Stabilization: In previous revisions “psychiatric evaluations” also included “where appropriate.”  This left the option of continuing the service when a family refused medication evaluation or if they had just seen their psychiatric provider.  Does the current revision of the manual require an individual to have the psychiatric evaluation even when they are refusing medication, etc.?  Does the individual have to be taking medication? (“assistance with medication management”)

Comment: Chapter IV, p. 62 – Crisis Stabilization: The requirement for a Psychiatrist to perform a psychiatric and medication evaluation will result in rural CSBs to stop providing this service due to not having access to a full time Psychiatrist.  We recommend that this be changed to allow a “Psychiatrist or Nurse Practitioner can perform the psychiatric and medication evaluation”.

Comment: Chapter IV, p. 62 – Crisis Stabilization: The seventh bullet references counseling provided by a LMHP-type but the frequency is not included.  Is there a minimum requirement for this service?

Comment: Chapter IV, p. 77 – Case Management: Please include the language from Chapter IV on page 77 from the first bullet under ‘Service Requirements’ to all places in the manual that reference who is eligible to complete Comprehensive Needs Assessments.  Please clarify that for case management services a ‘qualified mental health case manager’ is eligible to complete this Comprehensive Needs Assessment, but for all other services a LMHP (type) must complete the Comprehensive Needs Assessment.

Comment: Chapter VI, p. 10 – Documentation Requirements for CMHRS and CM: The second and last bullet states that the Comprehensive Needs Assessment must be completed by a LMHP type, what about Case Management?

Comment: Chapter VI, p. 13 – Comprehensive Needs Assessment: “If the provider feels an additional comprehensive needs assessment is needed and there are remaining assessments available for the fiscal year, they may choose to complete a comprehensive needs assessment and bill the appropriate—comprehensive needs assessment code that corresponds to the service/treatment.”  Need to specify how many comprehensive needs assessments can be billed and completed each year.

Chapter IV

Page 1 : Medicaid managed Care:  MCOs may have different service authorization criteria. I am concerned about this issue as we already have to work with 7 different entities and this should be standard based on the regulations not the MCOs.

Page 18: Case Management Assessments : need a clear definition of the requirements it is the same document and compressive needs assessment just with different credentials

 Page 29“all services that do not require service authorizations require registration and refer to appendix C. In appendix C page 5 there is strike through on Psychosocial Rehab services under service auths. Does this mean we go back to registrations?

Page 77: The CM compressive needs assessment is referenced again.

Page 78: new language for CM activities. Increasing a more direct role for CM in the service ie : not just giving referrals but assisting the individual directly, enhancing community integration by contacting other entities to arrange….community access and involvement…to learn community living skills, and use vocational, civic, and recreational services.

Chapter VI page 14

For services where group counseling is allowed, reimbursement is not allowed for more than 10 individuals regardless of Medicaid eligibility: not sure if this means if you have 12 people in a group and they all Medicaid you can only bill for 10?  We don’t  usually have more than 10 in a group but sometimes as people are moving from one group to another we might have some overlap of members making the total more than 10.

Page 16 under PSR it states notes shall be individualized and child- specific instead of adult/person specific

The comment on “Crisis Treatment:”

Chapter IV, p. 10

“Crisis Treatment” means behavioral health care, available 24-hours per day, seven days per week, to provide immediate assistance to individuals experiencing acute behavioral health problems that require immediate intervention to stabilize and prevent harm and higher level of acuity.

This language should be clarified to reflect the current VACSB performance contracts, stating that “Immediate access means as soon as possible and within no more than 15 minutes.” 

My Question:  Is the C.N.A. now the only billable assessment per service or are we still allotted the 2 billable assessments per year (at least for PSR this was what it was) – Will the 6 month month mark of the ISP when “Psychosocial rehabilitation services of any individual that continue more than six months shall be reviewed by an LMHP, LMHP-Supervisee, LMHP-Resident, or LMHP-RP to determine if the individual continues to meet the medical necessity criteria.  The results of the review must be presented to receive approval of reimbursement for continued services.” Count as the second or the first?  Can we admend the C.N.A. or another smaller ‘blurb?’

p.53 – same input and questions…What does “must be presented” mean?

• New language is certainly person centered but am I to read more in to this than is presented…are there PSR focuses that are no longer reimbursable…it does not specifically state ‘independent living skills’ or ‘psychoeducation’ replaces “to teach” with “restorative facilitation”

Page 8 indicates records are to be maintained for 5 years.  The DMAS MCO contract requires records to be maintained for a period of 10 years.  CMCSB recommends maintining records for 5 years.

The section for Adverse Outcomes states that we are to keep up with individuals for 180 days after discharge and report any serious incidents.  This posed multiple problems as it is financially impossible to maintain contact with an individual who is no longer in services and we are not being paid for a service.  In almost all cases an individual has no desire to maintain contact with an agency they no longer receives services from.  We recommend that this requirement be removed.

The revision indicated that a LMHP-Type must perform medication management.  This seems too restrictive since medication management does not require advanced clinical knowledge.  Please consider changing this requirement. 

An individual may met requirements for TDT services based on their need for year-round care. A yearly assessment is completed and authorization for services is determined and approved after the submission of the SRA. Yet, the regulations state that DBHDS and DMAS require another assessment if an individual transitions between school based TDT services and non-school based services. If clients receiving school TDT services must be discharged, as indicated by DMAS, and another assessment completed before starting services during the summer, many clients in rural areas who already struggle with transportation to assessments may not receive services. The original service may have been approved based on the need for year-round care. What additional information would a new assessment include that the original assessment would not have already determined? Updating the individual service plan as clients move within TDT service types/locations during an authorized period of service is already required. The TDT Service Request Chart does not include all possible examples of services. If regulations are approved to begin August 1, 2018, are agencies required to discharge all clients who are still participating in summer TDT programs, leaving individuals without services for several weeks? Discharging a client who has already been approved for services, only to require another intake assessment immediately following discharge, is not fiscally responsible. 

General Comments

Many of the proposed language changes represent significant shifts in policy, credentialing, service delivery, etc. that should be managed through a full regulatory process, not just through revisions to the CMHRS manual, since the manual is designed to be a guidance document.

DBHDS is mentioned and quoted throughout the manual.  Given that DBHDS standards/expectations are mentioned, will DMAS be holding providers accountable to DBHDS standards?  It is very confusing to providers to quote DBHDS standards in the DMAS provider manual as it is perceived to have duplicative accountability and oversight of DBHDS licensure standards.

Please provide clarification throughout manual that MH Case Management services do not require LMHP/LMHP-type to conduct the assessment.  This is not clear in the MH Case Management section of the manual.  Please provide further clarification between the assessment (MH Case Management Services) and the comprehensive needs assessment.

In addition, general questions about the comprehensive needs assessment include:

1. 1. Are providers still allotted the one billable comprehensive needs assessment per year? 
   2. Is the rate going to be the same given that the addendums are allowed within the year? 
   3. Please provide more guidance regarding the addendum as it relates to credentialed professionals who can complete the addendum and if reimbursement will be allowed for each addendum.

There are multiple issues regarding medication management vs. medication monitoring, which can be considered the same intervention in many cases.  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, and it is impractical to require licensed staff to perform medication monitoring/management.

Perhaps outside the scope of these comments but worth investigating is what DMAS believes should be the role of the QMHP in the system given that there are so many duties/services/assessments that DMAS seems to believe can only be performed by licensed staff?  If all of these changes were to go into effect, the critical role that QMHPs have played in the system will be greatly diminished and we’ll struggle to be able to provide some of the very services that keep individuals out of more costly, high end services.

In Chapter II on page 9, there is language stating that providers must report adverse outcomes for individuals who have been discharged within 180 days of an adverse outcome.  We do not remain in contact with clients post discharge as we are no longer providing services, we do not consider their information to be able to be used by us based on human rights regulations, and many times they do not wish to remain in contact.  We do not have the manpower to remain in contact with clients for 180 days post discharge with no compensation.

Throughout the manual, Trainees at the QMHP level are referred to as QMHP-E.  Our understanding is that these are now referred to as Trainees by the Board of Licensing who are now governing the qualifications of this level of prospective employee. 

In chapter IV on page 62, there are changes to the service requirements for Crisis Stabilization.  One change is removing the language, "as appropriate" in reference to a psychiatric evaluation and making it a requirement for every admission.  While there are certainly times in which a psychiatric evaluation and pharmaceutical assessment are indicated, there are many times in which it would be redundant or unnecessary.  Most of the clients who come into Crisis Stabilization already have an established relationship with a psychiatrist and while there are certainly cases in which a client may be experiencing heightened symptoms due to a need for a change of medication regimen, the nature of crisis stabilization is that they have had a precipitating factor which has necessitated the need for Crisis, not a needed medication change.

Crisis Stabilization is a valuable option to clients who are being disharged from a pschiatric hospital admission as a step-down service to get them reconnected into the community and provide support through the transition back home.  In these instances, they have been seen regularly throughout their psychiatric admission and would have a follow-up appointment already scheduled.    In these instances, an evaluation is not always needed.  Lastly, Crisis admissions can be very short and there may not be opportunity for the client to see a psychiatrist in the time that they are in services. 

Also, in this section, it states that counseling should be provided by LMHP or LMHP-type.  There is no indication of frequency or if the services would be billed as counseling or under the code for Crisis Stabilization.  In other words, is this coordination of services to a counselor, or counseling given as a part of the service.  Clarification on this would be helpful.

Thank you for your consideration of all comments on the proposed changes. 

Please provide clarification throughout the manaul that MH Case Management services do not require LMHP/LMHP-type to conduct the assessment.  This is not clear in the MH Case Management section of the manual.  Please provide further clarification between the assessment (MH Case Management Services) and the comprehensive needs assessment.

On page 6 of the manual, you have omitted certified prescreener in the list of credentialed staff who can conduct a screening.  Not all certified prescreeners are LMHP/LMHP-type and requiring this would negatively impact the ability of our CSB to comply with our code mandated responsibilities.  The prescreeners are required to have extensive training for their certification.  Please add certified prescreeners to the list of credentialed staff who can conduct a screening. 

The counseling definition in this manual is limited to licensed individuals.  Many of the educational and supportive counseling services are currently appropriately delivered by QMHPs .  The multiple changes to this practice as proposed in this manual will create additional workforce challenges and barriers to care.  Please consider revising this language.

Service Requirements:

Psychiatric evaluation including medication evaluation provided by a licensed psychiatrist and including pharmaceutical assessment and treatment or prescription medication intervention and ongoing care to prevent future crises of a psychiatric nature.

Comment: Often individuals who meet medical necessity for Crisis Stabilization services to avoid hospitalization or re-hospitalization are already connected with a psychiatric provider and/or recently participated in a psychiatric evaluation. Requiring a psychiatric evaluation would be redundant and unnecessary in some situations. Maintaining the original language of "where appropriate" is recommended.  Additionally, some individuals or guardians may refuse a psychiatric evaluation, but are agreeable to participating in a crisis stabilization service. Are these individuals still eligible for Crisis Stabilization services?

There is a significant shortage of licensed psychiatrists available to provide Medicaid funded services, especially for children and adolescents. Nurse Practitioners and Physician Assistants should be considered as qualified providers to meet this service requirement. 

1. TDT:
   1. a) Restorative Facilitation is listed as a service requirement under communication for individual and family. This is a specific modality. Is the requirement on providers to use only this model or is the term used out of context
   2. Medication Management: this is a requirement of the service, but yet there is limitation of what a QMHP level staff can provide (only medication adherence). This increased expectation places responsibility on a license or type to provide medication compliance/adherence education for all consumer’s taking medication for a mental health condition…this is unreasonable. A QMHP can provide this information with support from LHMP type supervisor
2. PSR:
   1. Restorative facilitation is mentioned again as well as Medication Management: Once again, we feel that a QMHP can provide this information with support from an LMHP type supervisor.
3. CI: The units were changed from 15 minute units to 1 hour units. Will this be changed back? 
4. Crisis Stab/MHSS: Restorative facilitation and medication management concern

We do have a concern for the restorative facilitation language. We are not sure at this time the requirements or how detailed the model is. Are you requiring this as a theraputic model? Will training be offered to providers? Or is the term being used without recognizing the context.

• An exclusion has been added to include  MH supervised living to those facililties which cannot receive MHSB from the “owner” of the supervised living site.  The addition of supervised living into language affects those of us who own apartment buildings and provide MHSB.  Would directly impact current programs and decrease community services available to those discharging from facilities.  Ww would be unable to continue to operate a CSB owned 24 hour program that has been in existence over 15 years, which was originally designed to assist in hospital discharge planning.

• Chapter II, page 16

  Concerned that Certified Peer Specialists are not listed as allowable providers of CMHRS services (psychosocial, crisis, MHSS, etc. 
• Clarity is needed around the comprehensive needs assessment and how it differs from the case management needs assessment - which is not required to be completed by an LMHP or LMHP-type.  Further, it is much appreciated that the effort has been made to streamline when the needs assessment is completed; however, there seems to be some contradicting information.  For example, on page 18, the language contradicts the need for one assessment by saying: “A comprehensive needs assessment must be completed prior to initiating each of the following services:
  1. Intensive In-home Services for Children and Adolescents
  2. Therapeutic Day Treatment for Children and Adolescents
  3. Mental Health Crisis Intervention* (only if an ISP is developed:  refer to service details)
  4. Mental Health Crisis Stabilization
  5. Mental Health Day Treatment/Partial Hospitalization Services
  6. Psychosocial Rehabilitation
  7. Intensive Community Treatment
• -Please clarify age restrictions for QMHP- A and QMHP-C
• We are concerned that counseling has been addeded to the required services for ICT without further clarification of where that counseling needs to occur and how often.  We do not have enough licensed or licensed -type staff to meet the defintion of counseling and this could pose a barrier to access of services.
• Chapter II, page 9 - reporting of knowledge of adverse outcomes up to 180 days post discharge is difficult if not impossible given the number of individuals served by the CSB. 

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.
    
    

• Concerned about the new language "restorative facilitation" and what the clinical expectation is of that definition. 
• The new definition of medication management found throughout the manual is problemmatic as it is a service which does not need to be provided by a LMHP or LMHP-type.  There are not enough licensed providers.  A QMHP can perform that function in all CMHRS services.

We are concerned that the role of QMHPs have been diminished throughout the manual.