Thank you for the opportunity to provide feedback on the draft service definition for CPST. Generally, this appears to be a positive addition to the service array. Our specific comments are listed below.

• In this proposal, the LMHP-types are the only qualified staff to complete assessments and individual service planning. What problem or issue currently exists by having QMHPs under oversight and guidance of LMHP supervisor that is prompting this change? How would requiring LMHP-types to complete these assessments and ISP address any current issue or concern? It seems that requiring LMHP-types will affect staffing, including hiring and retention of staff.
• There are no service components allowing Certified Peer Recovery Specialists (CPRS) to implement. How does peer services fit it and align with this proposal? Would like to see Peer Recovery Specialists included as staff allowed to provide the service for some areas.
• The role of the behavioral health tech (BHT) is listed only under the eighth service component (rehab skill practice and repetition). The eighth service component is currently designated for level 2 service. Is the vision that the least experienced/qualified staff is providing frequent skills services to the individuals deemed to have more intensive needs? Would the BHT be providing skills 1:1 in a home/community setting?
• Under agency level requirements, #6 indicates that there will be caseload limits for each staff level including across agencies. Why would DMAS limit caseload sizes? Would other measures such as productivity be utilized to speak to quantity of work? Recommend the agency can determine case load sizes, as a number of cases alone does not objectively speak to the volume of productivity. Furthermore, why is LMHP-types caseload counted across all agencies where employed? Why would LMHP-types be discouraged from being employed in a second or third role when it does not interfere with a primary position? What is the current problem that this proposed caseload limit is intended to address?
• Regarding the suggestion that the agency shall use a standardized assessment and treatment planning tool such as the CANS/ANSA, is there consideration for CSBs to utilize DLA20 given CSBs are currently trained and familiar with this EBP? Another option is allowing CSBs to utilize DLA20 for a period of time until staff can become trained on the other assessment tools.
• Under required trainings for all direct care staff, #9 states that there is a minimum field experience of at least two years for cases involving individuals with severe mental illness or serious emotional disturbance. This differs with the Virginia Board of Counseling requirements and would indicate that there will be some current QMHP-As and QMHP-Ts that do not meet this requirement. Have the QMHP-A credentials been updated with the Board?
• Regarding services including case management, the draft indicates that there will be two levels of participants, one with moderate needs and one with high needs. The concern is that the individuals we serve can vacillate between low, moderate, or high needs depending on their mental health status. For example, a person who typically works a full-time job and is low need has experienced exacerbation of symptoms multiple times due to major life events. The person did not fully recover from the last decompensation for over two years. The person was also someone who was closed to agency at one point and decompensated quickly once not connected to case management services. For this model, it would appear this person would not even be a candidate for services at this time as the person's mental health is stable and needs are low again. The key point is that the individuals we serve have lifelong illnesses with the potential for periods of stability and decompensation. Some individuals need long term services, their needs do not change much, and despite different interventions improvements do not occur. Does that mean we stop providing services if no progress is shown? This can be seen particularly for individuals with limited to no insight with regard to their illness. There is a concern that some people will be discharged or turned away based on this level of care model and that there needs to be documented progress and achievement of goals.