The proposed changes in the Guidance Document run counter to what was agreed upon by the Stakeholder Group at the outset of TCM for Severe TBI development. The group, including multiple represented state agencies, was in consensus that DBHDS would NOT be involved in licensure for TCM. There were reasons for this, and history with mental health system changes was discussed, but there was no argument or dissent: the team decided that providers would be CARF accredited organizations and DBHDS licensure would not be required. or even on the table.

A review of the minutes will note the absence of any movement, proposal or request to include DBHDS in the STBI TCM process. In fact, it was one of the very first points of agreement in the Stakeholder group. It simply does not appear as an issue or desired outcome anywhere in the development process, because it was agreed upon at the very start that this would not be a DBHDS licensed service. 

Unfortunately, the rollout of STBI TCM has been slow. There have been communication and onboarding issues and it has not been a particularly smooth process connecting the CARF accredited brain injury support professionals with the MCOs for billing and authorization. The numbers served thus far are very low.

Efforts are now being made to increase communication and mitigate issues. DMAS has taken an active and laudable role in getting STBI TCM back on track. However, in its desire to increase numbers served, DMAS has proposed the very thing the group agreed was not a good idea for this unique and challenging population: the introduction of DBHDS licensure as an alternative to CARF accreditation for providers.

I hope DMAS rethinks this. It was not a good idea at the outset and it is not a good idea now, and it is not the appropriate person-centered solution to the macro level issues involved in the STBI TCM rollout.

If DMAS declines to rethink this, there is a significant concern that must be addressed. The STBI TCM manual, despite requests during development, does not include any vigorous oversight, grievance process, or human rights protections. These elements are required in a CARF accredited organization. This population, by definition, has cognitive issues. They require clear and understandable and cognitively accessible policies and procedures. 

If they feel they are being treated without person centeredness, that they are being offered artificial "choices", or that they are being forced like square pegs into round holes, where does a survivor of severe TBI go? Who is their ombudsman, their human rights advocate? Is it the same Human Rights division and process as the one currently used for folks on the ID/DD waivers? If so, are they trained and ready to serve this population? Are they adequately staffed and prepared to begin protecting the rights of this unique population?

It was stated in a meeting on this topic not long ago that "case management is case management is case management". As in, it's all the same to us. It is NOT all the same!

Mental health case management has its own set of regulations, licensures and standards, as does ID/DD case management. Specialized brain injury case management does not involve applying a generic "case management" cookie cutter to supports for survivors of brain injury, or at least it shouldn't. This service was developed by a team of engaged stakeholders and the team agreed on provider requirements. 

I strongly encourage Virginia to follow the direction provided by the development team and to NOT add DBHDS licensure as an acceptable route to service provision. Work on the rollout difficulties and stay the course. If DBHDS licensure must be added, then increase other provider requirements and increase human rights/ombudsman protections. Ensure that this population receives the supports they need from professionals with verifiable experience and training in their needs, and ensure that there is an accessible human rights protection process in place.

Thank you for your time and consideration.

Rachel Evans, CBIS (Certified Brain Injury Specialist)

No Limits Eastern Shore Brain Injury Services