Concerned about the 3 individual sessions per week provided by a clinician. Not exactly sure there is any therapeutic value of the  3 individual sessions per week. It’s possible that 1 session a week is as valuable.  The requirement of the 3 sessions and the duration is not necessary. If treatment is to be more individualized then requiring the 3 sessions per week to contradictory to the goal of providing indiviudalized treatment.

I would urge decision makers to think critically about the overall goals/results to be achieved and utilize the latest research in determining how to adminstrate behavioral health benefits to Virginia Medicaid consumers. With the addition of Magellan, a forward-thinking and long established MCO, we have an opportunity to truly shape services that will result in lower cost, higher efficiency, and outcomes-oriented services.  For years, Virginia has mandated a one-size fits all, prescriptive approach to inpatient psychiatric residential treatment and community based group homes. This is in lieu of the emergence of evidence-based practices for specific patient populations and profiles that suggest better outcomes when treatment is specifically tailored to individual needs.  It seems that the regulation re-writes have been more focused on preserving most of what has already been in place (with a few inconsequential concessions) instead of focusing on how to reconcile the diverse needs, innovation in the marketplace, and outcomes in these levels of care. Intellectually disabled youth with co-occurring mental illness are not going to respond to insight-oriented therapies just as high functioning youth with addiction aren't going to respond to applied behavioral analysis.  A prescriptive approach strangles innovation and diverts resources. Programs are forced to orient their services and resources around following the prescription, instead of having the freedom and flexibility to find whatever works and achieve optimal outcomes for individual patients.  The result has been a system-wide focus on compliance as a means of providing patient care instead of effective patient care as a means of delivering positive outcomes for youth who require more intensive psychiatric treatment.  As a partner in serving those with significant behavioral health needs, there are enough expertise on the provider and payor side of things to create a system of care that is cost-effective, evidence-based, and outcomes-oriented.  The regulations, as written, prescribe frequency and intensity levels that are applied across the state, across all level B/C programs and patient populations, and without regard to innovation or flexibility within the system, much less any evidence based practice approach.  If the goal is truly efficient and effective behavioral healthcare for an entire cadre of youth in Virginia, providers must be given the flexibility to achieve the desired results and be accountable to those results.  These regulations make us accountable to the prescribed process, not the outcomes that could be achieved with a collaborative care model and truly individualized services.   The arbitrary requirements do not truly speak to the need for individualized programming.  I would recommend that the Behavioral Health Services Administrator be granted the authority to review each Service Authorization Request, and review admission and continued stay based on the programming that is being proposed by the provider.  Allow the provider to justify their clinical decisions and create the environments that improve the mental health of the individual.  Active treatment should be the focus of care.  To this end, I also recommend that we consider speaking with individuals here in Virginia that receive services.  Seek their feedback regarding the current regulations and treatment regimen.  How do they feel about the current academic and therapeutic structure while in treatment?  

Virginia Coalition of Private Providers

Public Comment Regarding Psychiatric Residential Treatment Services Program Changes

(12 VAC 30-130, 12 VAC 30-10 and 12 VAC 30-50)

March 22, 2017

On behalf of the Virginia Coalition of Private Provider Associations (VCOPPA), we would like to offer the following public comments regarding the changes in regulations regarding psychiatric residential treatment services programs (12 VAC 30-130, 12 VAC 30-10 and 12 VAC 30-50).  We appreciate and acknowledge the many hours that have been spent over the last year leading up to this point and for the assistance and cooperation of DMAS, Magellan of Virginia and the Office of the Governor as we worked through the many issues surrounding these regulations.

Training issues

Before we address the specific regulatory changes themselves, we do want to make a comment on the training schedule for providers to assist them become ready for full implementation on July 1, 2017.  As of the date of these comments, we are not aware of any specific training sessions being scheduled for providers.  While there have been some individual visits to providers, and more in the works, there still have not been any official overall trainings scheduled of which we are aware.  This is causing great concern within the provider community, as the July 1st date is rapidly approaching.  Training needs to occur as soon as possible, to give providers plenty of time to implement and put into to practice and test out new systems well before the effective date.  We are confident that these trainings will eventually occur, but we urge that these be scheduled as soon as possible to help insure a successful transition.

Residential Regulations

Our comments regarding the new regulations will be mostly general observations regarding the philosophy being taken in this systems change.  While there will be a few specific references, most of our previous concerns have been raised on numerous occasions with the appropriate parties involved.  In many instances, our concerns have been addressed in a satisfactory manner; however, some general concerns still remain.

Regarding interventions, there has been agreement that situations may arise in which an intervention may not be possible or even therapeutically advisable.  We have been advised that in these situations, with proper documentation, a provider would not be required to make up a missed intervention.  However, further work needs to be done to clarify definitions of “interventions” and to refine the documentation needed to make sure providers are not penalized for missed interventions.

Issues surrounding family engagement continue to be a concern, with need for more detailed clarification on what a provider must do to successfully meet requirements for this service.  In our earlier discussions with DMAS and Magellan, we identified as issues needing further detail for implementation the need for coordination between different state agencies to resolve potential licensing and operational conflicts, as well as liability concerns.  In addition, with much of the family engagement requirements in the new regulations based on the concepts imbedded within the Building Bridges Initiative (BBI), this implementation requires significant cultural change in the residential setting.  The integration of parents and families more closely into the programmatic structure must be done in ways that do not engender confusion or risk.  Therefore, it is imperative that trainings for providers on these concepts must be robust and readily available.

We also continue to have concerns on the issue of therapeutic leave.  While recognizing the importance of this component in treatment, we must ensure that providers have amble time for an assessment period to make appropriate clinical judgments, provide for a cooling off period for the child after admission and minimize liability issues that could arise from a child in an uncontrolled public setting when they are not ready for this level of interaction.  This issue needs to be further clarified before implementation to make sure there is no misunderstanding or misinterpretation during the authorization or reauthorization process.

Finally, as private providers, we ask that you consider the environment we will create for the individuals receiving services.  We must balance treatment without overburdening the individuals receiving services.  With 5½ hours of direct educational services, in addition to formulaic therapeutic processes outlined in the proposed regulations, it is difficult to ensure improvement or hope.   We fear this approach may bind providers to a rigid system that will not allow adequately for individualized treatment, where the patient is at the center of their treatment plan.  Requirements for three individual therapy sessions per week, regardless of the individualized need, or the status of the individual during that week of services; or the requirement of three interventions per day, versus allowing the provider to meet the individual’s specific needs as the treatment team deems appropriate, seem overly prescriptive and tie the hands of the provider.  While we do appreciate that the new regulations do now allow for the provider to “miss” interventions relative to what is occurring that day for the individual, these arbitrary requirements do not truly speak to the need for individualized programming.  We would recommend that the Behavioral Health Services Administrator be granted the authority to review each Service Authorization Request, and review admission and continued stay based on the programming that is being proposed by the provider.  This would allow the provider to justify their clinical decisions, and create the nurturing environment to improve the mental health of the individual. 

We thank you for this opportunity to present our comments on these new regulations.  As we said before, we appreciate all the effort that has been put into reaching this point and we also appreciate the collaborative spirit that allowed us great input into this process from the start.  Many of the concerns we raised along the way have been addressed, but some issues still remain.  Of those remaining issues, many may be able to be resolved during the training process.  Therefore, again, we renew our original request that trainings on the new regulations begin as soon as possible.  This is imperative to the eventual success of this transition and implementation.

Thank you for your attention and consideration.

The newly proposed regulations do not promote individualized treatment, where the resident is at the center of their treatment plan.  Providers should be allowed the flexibility to provide services that achieve the desired goals and outcomes for each individual.  I would recommend that the Behavioral Health Services Administrator be granted the authority to review each Service Authorization Request, and review admission and continued stay based on the programming that is being proposed by the provider.  Providers should have the opportunity to justify their clinical decisions based on the individualized needs of the resident.  Additionally, active treatment should be the focus of care.  To this end, I also recommend that we consider speaking with individuals here in Virginia that receive services.  Seek their feedback regarding the current regulations and treatment regimen.  How do they feel about the current academic and therapeutic structure while in treatment? 

As a private provider, I ask that we consider the environment we create for the individuals receiving services.  We must balance treatment without overburdening the individuals receiving services.  5.5 hours of direct educational services, coupled with formulaic therapeutic processes outlined in the proposed regulations do not ensure improvement or hope.   It binds providers to a rigid system that do not allow for individualized treatment, where the patient is at the center of their treatment plan.  Requirements for three individual therapy sessions per week, regardless of the individualized need, or the status of the individual during that week of services.  Three interventions per day, versus allowing the provider to meet the individuals specific needs as the treatment team deems appropriate.  I do appreciate that the regulations do now allow for the provider to “miss” interventions relative to what is occurring that day for the individual.  However, these arbitrary requirements do not truly speak to the need for individualized programming.  I would recommend that the Behavioral Health Services Administrator be granted the authority to review each Service Authorization Request, and review admission and continued stay based on the programming that is being proposed by the provider.  Allow the provider to justify their clinical decisions, and create the nurturing environment to improve the mental health of the individual.  Active treatment should be the focus of treatment.  To this end, I also recommend that we consider speaking with individuals here in Virginia that receive services.  Seek their feedback regarding their treatment regimen.  How do they feel, relative to the academic and therapeutic structure while in treatment.