Thank you for the opportunity to provide feedback on the proposed CPST service array. More information is needed surrounding medical necessity criteria. Additionally, complete and discreet service descriptions are needed in order to make a fully informed decision about feedback for the CPST services.
It is my understanding that there will be multiple services under the CPST umbrella. RBHA is in full support of separating the services that specialize in serving children separate from adults so that skills can be habilitated and rehabilitated, respectively. Additionally, child-serving services must also have a system component and have a strong emphasis on addressing the entire family/caregiver system.
Page 1: Note: Medical necessity criteria have not yet been developed. There will be two levels of this service (Level 1 and Level 2). There will be different criteria for each, with Level 1 representing a less intensive (moderate intensity) service that includes components 1-7 below and Level 2 representing a more intensive (high intensity) service that includes components 1-7 below as well as component 8. Component 8 represents additional time/units doing direct repetition and practice of skills in natural settings being developed through counseling, crisis planning, and restorative life skills training components of the service.
It is recommended that the movement between levels 1 and 2 be flexible and allow timely adjustment as often as needed (monthly) and have minimal barriers and burden to the provider as individuals’ and families’ needs are fluid. It is recommended that the authorization process be streamlined so that the movement between levels does not create additional administrative burden. We also advocate that assessments be allowed via telehealth as a tool to ensure equitable access to services. There are many parents/caregivers who lack transportation to get to a school or to an assessment at the office.
Page 2: The LMHP shall be responsible for monitoring and adjusting the ISP over time as goals are addressed with the eventual goal of individuals achieving recovery and titration of service volume over time to address additional needs.
Given Virginia’s workforce shortage, it is recommended that LMHP not be required to develop and monitor ISP. The credential staff (QMHP) who is implementing the ISP should be allowed to develop the ISP as they are now. Please reserve our advanced clinical staff (LMHPs) for advanced clinical work (therapy and assessments) as they are very limited in number.
Please include school personnel in this list. There are many times that TDT staff are working closely with teachers, principals, school social workers and attending meetings to advocate for the youth, and collaborating for treatment planning. It is recommended that school-based services be allowable when working with other school personnel. It is also recommended that telehealth be allowed for assessments for CPST services.
Page 3: Providers use a standard assessment tool for level of intensity with regular re-assessments using the Child and Adolescent Needs and Strengths (CANS)/Adult Needs and Strengths Assessment (ANSA).
RBHA advocates against the use of CANS for an assessment. Please include a menu of allowable assessments to include the Comprehensive Needs Assessment.
Page 4/#6: Monitoring of the individual by the LMHP-Type includes a face-to-face interaction with the individual before other service components by unlicensed team members begin at least quarterly (except under extenuating or emergent circumstances that are reflected in the supervisory notes)
Please remove this requirement that LMHP must monitor quarterly and in person. We have a workforce shortage and it is not an advanced clinical activity. QMHPs should be able to monitor ISPs quarterly.
Please consider adding Resilience-building and/or Habilitative skill-building for children. Many children served do not have the skills developed to rehabilitate. They need to learn the skill which may be developed via service provision.
Page 12: All agencies shall be accredited within 24 months of the approval of the State Plan or within 24 months of establishment of a new agency by the Council on Accreditation, The Joint Commission, DNV Healthcare, or the Commission on Accreditation of Rehabilitation Facilities. Certification/accreditation shall be initiated and submitted to DMAS during enrollment or within 24 months if the agency is new. $10,000 for costs for this requirement is typically added to rates.
It is strongly recommended that the requirement for accreditation be removed. This is a huge administrative burden. Investment (of time to maintain the accreditation) and expense that will cost beyond $10,000 for CSBs who serve a large amount of individuals. There are many back-office processes that are involved in maintaining accreditation and comes with an exorbitant amount of costs. Please remove this requirement.
Use of evidence-based principles, practices, and protocols will also be required for all agencies providing Level 1 and Level 2 Community Psychiatric Supports and Treatment
It is recommended that EBPs not be required as many EBPs narrow the population that can be served. EBPs also come with additional administrative burden and cost to implement and maintain. EBPs definitely have its place and should be used for specialized services (ACT, MST, Outpatient therapy) however should not be required in CPST services. It decreases access to services.
What is your opinion on the two levels of rehabilitative services and the activities that each professional type would conduct?
We support the two levels of care within CPST services however would ask that QMHP maintain the same role/responsibilities as they do now such as developing and monitoring the ISP. Please reserve the LMHP for advanced clinical activities such as assessments and therapy. We also recommend that reimbursement rates be aligned with the credentialed staff who is actually providing the service.
Currently Virginia has a “stand alone” peer benefit (individual and group). Given the proposed structure of CPST, should agencies delivering CPST be required to also provide peer services?
We recommend that CPST not require peer services. We highly value peer services and supports and have them embedded in many of our programs. However, there are not enough peers accessible to mandate them in programming for CPST. Possibly allow for a rate that includes peers, if a provider chooses to have them, but do no make it a requirement.
What is your opinion on the agency level requirements including supervision and caseloads?
Caseload size should be driven by the clinical acuity of the individuals served and also have a payment rate that supports the number of individuals served. We are in support of limiting caseload sizes as long as the rate supports the additional staffing and administrative (including supervision and back-office processes) costs that will accompany it.
Lastly, reimagining CMHRS services as well as TCM services within the proposed timeline is a huge undertaking for CSBs as business models, staffing, and program structure will all have to be significantly amended. Please consider making these changes in an incremental manner to allow CSBs the time to make meaningful and effective adjustments.