The current service definition for Community Psychiatric Support and Treatment (CPST) does not provide enough detail to foster effective feedback. Additional guidance is needed regarding medical necessity criteria, use of measure-based care, staff requirements, accreditation, and guardrails to ensure ethical service delivery and protect our provider community from further administrative burden and authorization restrictions than those already presented within the proposed service definition. Furthermore, without a collaborative understanding of service rates the sustainability of any proposed business model remains unknown and risks the unraveling of our current CMHRS services.

 Medical Necessity Criteria:

            The current service definition fails to offer clarity regarding anticipated criteria for proposed level of care. Without a clear understanding of the client population each level is attempting to access, our providers are unable to apply MNC to the populations they currently serve and assess readiness or sustainability of investing in CPST service delivery. Also, leveled MNC cannot be extracted from service authorization guidance. When services are implemented what would be the reality of a client who improved and required a lower level of care half-way through an authorization period? Or suddenly needed a higher level? Authorization protocols and allowances are critical if DMAS wants providers to own the fluidity of clinical response.

Measure-Based Care:

While measure-based care offers standardized assessment it does not eliminate issues with application. Our providers are concerned by the degree to which “scores” will drive level of care, reimbursement, and service authorizations. Initial guardrails around the application of this measure are needed to promote ethical application of scores for evidence-based/ leveled care. As scores will likely impact authorizations, provider assurances are also needed for adequate authorization for clients within certain score ranges and should not be reviewed without comprehensive information provided by the CNA and ISP progress updates.

Staffing Requirements:

            Staffing requirements would also benefit from further clarity including the use of LMHP to include LMHP-types (pages 2, 3, & 12) and the requirements for a clinical director’s license status. Requirements for supervisors restricts current allowances for LMHP-types to “supervise” QMHP-types. The requirements here seem to default to board-defined requirements for clinical supervision toward licensure and not supervision of clinical care delivery. Current workforce conditions will likely limit access to CPTS services if “[s]upervisors may only be independently licensed practitioners” according to current “licensing board requirement[s].” We would also encourage discussion across licensing boards and state agencies before establishing caseload limits as these were previously removed to improve access to care and reinstatement may have the opposite effect.

            In addition ,the application of BHT to the service definition is premature. Allowances for the “substitution” of BHTs for certain elements of care may provide enough of a flexibility for providers and allow for the development of this potential pipeline. BHTs remain an underdeveloped and relatively unknown labor pool with limited utilization in our community services and elevated risk for our licensed programs. The necessary oversight and development of this workforce population will undoubtedly fall to our providers.

            Possible Agency Level Requirements for Virginia # 9 increased the field experience requirement beyond current expectations and does not clarify which role this requirement is to be applied to.

Accreditation Requirement:

            Accreditation requirements layer another expensive (current estimates of cost for a small - revenue ~ $500,000 - agency are well over $15,000 just for the accreditation fee) and involved administrative effort on provider plates. This requirement outsources the burden of quality assurance without fiscal or administrative relief elsewhere. Furthermore, accreditation is often unequitable in its institution, unduly burdening our smaller providers and placing access to services at risk in the niche communities they serve. Consideration is needed for both initial accreditation and accreditation maintenance costs as well as safeguards for service delivery if external factors (such as pandemic) impact credentialling efforts.  

Missing Guardrails:

The flexibility and adaptability of this proposed service definition removes programmatic barriers of licensed-location and caregiver/stakeholder engagement (without client present) and offers benefits of team-based care (with potential for clinical staff development) staffing capacities. However, this guidance requires more control points for accessing services, establishing predictability for authorization criteria, and promoting consistent and ethical application of each requirement. Each of the enhancements offered include additional cost and administrative burden (accreditation, clinical measures, supervision, agency system revisions, EMR revisions, training requirements, etc.) escalating potential for vague guidance to result in unintended (at best) or unethical (at worst) application of guidance risking erosion of trust in our larger provider community. Historically, when broad allowances escalated Medicaid spending, agency oversight has responded with broad sweeping restrictions or requirements that have crippled providers. Appropriate guardrails would serve the reliability of CPTS services and protect the providers who will ultimately recruit, train, supervise, and deliver care.

The renovation of our CMHRS services is no small task, and attempts to include a multitude of clinical enhancements (everything but the kitchen sink) may lead to more damage than progress. Providers must be able to crosswalk current business models to some degree if DMAS would like to retain the experience and localized-expertise of its provider community.

Perhaps the transition of CMHRS services could benefit from the successful implementation of 1-2 of these elements revised under the name CPTS and leave future enhancements for future administrations to ensure the successful transition and sustainability of our community services and the thousands of Virginias they serve every year. 

As we have learned, design and implementation are two entirely different things – it is not entirely clear the goals of this transition nor the implementation (which falls primarily with the MCOs) will be aligned.  And, as stated above, the information is insufficient to make judgements.  VNPP looks forward to ongoing collaboration with DMAS and their contractor to help refine the proposal.