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.