In response to the questions posed in the 12/16/24 DMAS Behavioral Health Redesign Project Update Meeting: 

1. What is your opinion on the two levels of rehabilitative services and the activities that each professional type would conduct? 

Overall I am in favor of the concept of levels of services. It is crucial to me that criteria for appropriateness for each service be established, while still being flexible enough to leave some judgment and discretion to the assessing clinician. Overall the levels as described in the draft seem appropriate. 

I was somewhat confused by the addition of the rehabilitation technician position and its inclusion in only the Level 2 category of services. It would make more sense to me that a less qualified/credentialed staff would be more appropriate to serve the lower-needs clients, rather than the more intensive clients. In individual services, higher-needs clients may not be appropriate to work alone with a less qualified/credentialed staff who may not have clinical training/education. The addition of this position may only be appropriate for center-based services where all staff are on site together.  

2. What is your opinion on the agency level requirements including supervision and caseloads? Do you have any specific recommendations? 

I feel that supervision requirements are appropriate. I do not feel that DMAS should dictate caseload requirements/sizes and especially not across agencies. For some programs, caseload size is not an accurate measure of capacity; instead, productivity may be a more accurate measure. Caseload requirements should be left to the agency to both structure and determine. 

3. What is your opinion on moving to a standardized assessment and the CANS/ANSA? 

I am in favor of a standardized assessment. I am not very familiar with CANS/ANSA, but would put forward DLA-20 for consideration instead, as it is a well-regarded evidence-based assessment that is comprehensive, has a low margin of variability when administered correctly, and quantifies data in a way that is easy for consumers and caregivers to understand. Many agencies have received training in the DLA-20 over the past few years, and the time and money spent on that training would go to waste if we moved away from using it. Cost to cover training and time to learn a standardized assessment tool would need to be built in to the new rates. 

4. Currently VA has a “standalone” peer benefit (individual and group). Given the proposed structure of the CPST, should agencies delivering the CPST be required to also provide peer services? 

It depends on how this question is meant. I do not believe that agencies should be required to provide standalone peer services. If this question is asking about embedding peer professionals into CPST activities, while I do see the benefit and am personally strongly in favor of incorporating peers into services wherever possible, I do not feel that this should be a requirement, and should be left to the discretion of the agency. This could be a challenging requirement to adhere to, depending on the availability of qualified peer professionals in the area and the way the agency structures its particular service. Turnover rates of peer professionals are very high and keeping an appropriate number of qualified staff employed is a challenge- even more so in more rural areas. Requiring the inclusion of peers in services would be handing agencies another hoop to jump through and another cost in time (hiring and training) and money. One suggestion could be including certified peers (CPRS) on the list of qualified individuals who can perform certain CPST activities, such as Restorative Life Skills Training and Rehabilitation Skill Practice and Repetition. This would allow and encourage agencies to utilize peer staff without making it a requirement.

5. What is your opinion on the proposed requirement for rehabilitative agencies to embed at least one evidence-based protocol into their services? What EBPs are relevant to the SMI/SED population that were not listed in this presentation? 

This proposed requirement needs to be clearer in what it is proposing. Is the proposal that services be completely modeled/structured after an EBP? Or is the incorporation of an EBP where appropriate sufficient? My suggestion is that if the inclusion of EBPs remains a requirement, that it be one available intervention used where appropriate to the consumer’s goals, functioning, and other situational factors, rather than an overarching, blanket model into which services may not fit neatly. The decision of whether or not to include an EBP tool on a client’s ISP would be made together between the consumer (and caregivers as appropriate) and clinician creating the ISP. 

This proposed requirement should also clarify the criteria for considering a treatment model an EBP. For example, one of the EBPs listed in the proposal, Illness Management & Recovery, appears to be considered an EBP based on its inclusion in the SAMSHA database. But upon closer review, it mainly cites one 2002 study to consider it evidence-based, and the manual even admits that the study focused mainly on individuals with schizophrenia. None of the references this practice cites is newer than 2005 (approaching 20 years old), with many of its references from the 90s or even 80s. Too much has changed about mental health and best practices in the past 20+ years to consider this an appropriate tool. 

The ability to provide and implement many EBPs requires training staff, which can be costly. 

Overall, I feel that there is too much ambiguity and too many unanswered questions regarding the implementation of EBPs to include this as a requirement in this proposal and I think it would be better as a suggested practice but not a requirement. 

However, if it does end up remaining as a requirement, additional EBPs that could be incorporated include: 

• CBT for psychosis 

• APPR 

• WRAP 

• CAMS 

• DBT 

Additional comments 

• I suggest reconsidering the amount of additional activities this proposal requires of LMHP-types. Some activities the draft is currently placing on LMHP-types, such as ISP development, are completely able to be done by QMHPs under the oversight/guidance of an LMHP supervisor. We are already facing a national and statewide shortage of licensed clinicians; adding more activities that can only be done by LMHPs does nothing to address this problem. Additionally, if the proposal stays as-is, reimbursement rates will need to increase significantly to cover the additional activities placed on the LMHP-type. This proposal places significantly more activities on LHMP-types, and agencies will need to be able to pay them adequately and in a way that will attract qualified and experienced staff. It would be more efficient and cost-effective, and agencies would be able to hire more staff to reach more consumers, if the proposal delegated more of its proposed activities to QMHPs or peer staff.

• I am happy to see coordination of care as a covered activity, but in practicality, what would it look like to get reimbursed for care coordination? Many care coordination events are short (under 10 minutes), whether that is a short phone call or even sending an email. Would there be a unit rate and a minimum amount of time that would be reached for reimbursement? This needs more clarification.