24 comments
Some of the revisions within the ARTS manual are appreciated and positive; however, there are also some revisions that hinder clients access to care. It is noted that the "CATP" definition has been revised to omit CSAC/CSAC-Supervisees. With this revision CSAC/CSAC-Supervisees can no longer complete treatment planning and pieces of the assessment in some of the ASAM Levels of Care such as IOP and PHP. This language also directly conflicts with the "Board of Counseling Scopes of Practice for Persons Regulated by the Board to provide Substance Abuse Treatment." This document clearly states that CSAC/CSAC-Supervisees do have the ability to conduct pieces of the assessment and treatment planning. It is also noted that CSAC/CSAC-Supervisees are able to conduct these pieces in the higher/more intensive ASAM levels of care. If these revisions go through we will not be able to open individuals into treatment as quick as our CSAC/CSAC-Supervisees can no longer be supportive in this way. It should also be noted that it is difficult to find licensed and licensed-eligible individuals that are trained and have experience in addiction treatment; whereas, CSAC/CSAC-Supervisees specialize in working with the SUD population.
I am proposing that the language be revised and clearly define a CSAC/CSAC-Supervisee's ability to conduct pieces of the assessment and treatment planning under the direct supervision of a licensed professional for SUD Treatment in the ASAM levels of care such as IOP and PHP.
Thank you!
I am writing to express my agreement and support for the comments from Crystal Grooms, LPC. Given the difficulty in recruiting and retaining LMHPs, this unnecessary restriction on the scope of practice for CSACs is unreasonable and will limit the ability to provide needed services to consumers. Please consider the recommendation to revise this. Thank you.
Fairfax- Falls Church Community Services Board agrees and supports all the feedback/comments to date below:
Assure freedom of choice to individuals in seeking medical care from any institution, pharmacy, or practitioner qualified to perform the service(s) required and participating in the Medicaid Program at the time the service is performed;
Each therapy session must contain the dated co-signature of the supervising provider within three one business days from the date the service was rendered indicating that he or she has reviewed the note. The direct supervisor can be the licensed program supervisor/manager for the agency.
The Substance Abuse and Mental Health Services Administration (SAMHSA) describe the need for clinicians to use evidence-based screenings and assessments to appropriately and timely to identify individuals at risk for SUD and mental illnesses and be able to engage in treatment. The purpose of screenings for SUD are for individuals who do not have an established SUD diagnosis and to determine whether an individual needs further assessment. The purpose of assessments for SUD are to gather detailed information needed for defining or supporting a diagnosis and development of a treatment plan that is person-centered.
The comprehensive ISP shall be developed and documented within 30 calendar days of the initiation of services to address needs specific to the member's unique treatment as identified in the multidimensional assessment as applicable to the ASAM Level of Care. If members are discharged from the service prior to 14 the initial 30 calendar days, the provider is still required to have the ISP documented in the member’s medical record.
ASAM Level 3.5 to 3.1: The licensed CATPscredentialed addiction treatment professional including Residents in Counseling or Psychology and Supervisees in Social Work, as well as CSACs and CSAC-supervisees in collaboration with interdisciplinary team. The licensed CATPscredentialed addiction treatment professional must sign off on the ISP developed by a CSAC or CSAC-supervisee. CSACs and CSAC-supervisees may perform ISP reviews in Levels 3.1, 3.3, and 3.5 if the CATP signs and dates the ISP within one business day.
During months where a quarterly review is conducted, no additional documentation is necessary to meet 30 day ISP review requirements.
Retroactive requests for authorizations will not be approved with the exception of retroactive Medicaid eligibility for the individual. When retroactive eligibility is obtained, the request for authorization must be submitted to the service authorization contractor no later than thirty (30) days from the date that the individual’s Medicaid was activated; if the request is submitted later than thirty (30) days from the date of activation, the request will be authorized beginning on the date it was received.
CATP No longer includes:
CSAC The Code of Virginia § 54.1-3507.1 indicates that CSACs are “qualified to be responsible for client care of persons with a primary diagnosis of substance abuse or dependence. Providing counseling to persons for a mental health diagnosis other than substance abuse or dependency is outside the scope of practice for CSACs.”
Recommendation:
Page 41 Peers: New Peers need chance to get credentialed, most do not apply for jobs already certified and registered. The requirement can hinder growth of peer support.
Delete requirement for Peers certification and registration with the Board. Allow peers to gain these expertise over a 15 month period, similar to the time frame given for STEP-VA peers to become certified before billing Medicaid.
Recommend: Not require physician/psychiatrist consult for ISPs or Service Authorizations
If a Licensed Mental Health Professional and/or CATP is completing a SUD assessment for SUD services, no need for a psychiatrist or physician to consult and sign off, nor for it to be required to list their name for a service authorization. This can delay service authorizations and getting into treatment. This is also a concern cost wise and staffing wise during work force shortages. As it is already required to provide a multidisciplinary team, their input would be considered.
We strongly encourage CSAC’s to be able to provide SUD services within their scope of practice as outlined by the Board of Counseling’s most recent guidance document dated January 23, 2020, which states, in part
“A certified substance abuse counselor shall be (i) qualified to perform, under appropriate supervision or direction, the substance abuse treatment functions of screening, intake, orientation, the administration of substance abuse assessment instruments, recovery and relapse prevention planning, substance abuse treatment, case management, substance abuse or dependence crisis intervention, client education, referral activities, record keeping, and consultation with other professionals; (ii) qualified to be responsible for client care of persons with a primary diagnosis of substance abuse or dependence.”
We are asking to review CSAC's providing ASAM 1.0 outpatient services that are aligned with the scope of practice of a CSAC, such as individual SUD counseling and psychoeducational groups. Doing so would reduce barriers to treatment by creating more treatment opportunities for individuals, provide more staffing to serve our population, and increasing engagement.
CSAC no longer considered CATP. Short staffing is already an issue. If a CSAC or CSAC supervisee cannot provide SU counseling/psychoeducation services, it will hinder availability of services to the individuals. It is difficult to find licensed or licensed eligible staff that have SU experience. CSAC could provide some of the services to close this gap.
Requiring a psychiatrist/physician consult and include name on the service authorizations would be another hinderance to providing services that are already limited in availability. This would delay authorizations and individuals receiving treatment.
Giving the difficulties of finding both licensed and certified staff, I am disappointed that CSACs will no longer be considered credential addiction treatment professionals (CATP). Also with the additional responsibilities of a licensed staff, I propose that temporary rate increases become permanent. This may help with recruitment.
Please with the increase membership participation in groups. My major concern and a clarification that needs to be made is the conflict between the proposed DMAS regulation, as it relates to staffing, compared to the "draft" licensure regulations as it relates to 3.5 LOC (residential) staffing; especially, during i.e. midnight shifts.
DMAS: "Staff shall provide 24 hours per day awake supervision on site. The provider's staffing plan must be in compliance with DBHDS staffing plan regulations set forth in 12VAC35-105-590 and12VAC35-46-870. However, the DBHDS draft licensure reads: 12VAC35-107-980--clinically managed high-intensity residential services (ASAM LOC 3.5) staff criteria...offer onsite 24-hour a day clinical staffing by credentialed addiction treatment professionals..... Are saying licensed & certified need to be present on midnight shifts and shifts, usually after 8 pm when "treatment sessions" are not going on. Please note that I advocate for the application of the DMAS version versus the DBHDS licensure version.
Not allowing a CSAC to be considered a CATP: We are already struggling with staff shortage due to not being able to find qualified applicants that are licensed and/or licensed eligible that have the SU component experience in our area. Taking away the ability of a CSAC to provider SU services would hinder our services greatly.
Requiring a psychiatrist/physician to consult and be included on PAs could delay authorizations as well as individuals receiving treatment/services. We are already having difficulty with our psychiatrists being available.
I am submitting comment to strongly encourage that CSAC's continue to be considered CATP's. The "Board of Counseling Scopes of Practice for Persons Regulated by the Board to provide Substance Abuse Treatment" states that CSAC/CSAC-Supervisees are able to conduct pieces of the assessment and treatment planning in various levels of care and these individuals specialize in SUD treatment. As a provider, this would significantly impact our ability to provide the necessary services for the population by individuals who are fully qualified, impact our ability to grow and expand services in process, and this would cause significant barriers in access to the care that is so desperately needed.
I ask that you please consider CSAC/CSAC-Supervisees as CATP's.
Thank you!
It is our intention to reiterate what has been stated by other providers regarding the limitations placed on CSAC/CSAC-Supervisee scope of practice.
It is with extreme concern that we strongly suggest the Department rethinks its plan to remove the CSAC as a CATP in our ARTS programs and requiring only Licensed individuals or individuals under supervision for licensure. We have been effectively employing Bachelors and Masters level CSACs in primary roles, performing ISPs , multidimensional assessments, etc. - many are individuals in recovery, individuals from diverse backgrounds with years of experience , who should not be replaced with individuals just completing a Master’s degree. Our CSACS’s work under the supervision of licensed supervisors and we believe that should be feasible going forward. They could work in the same capacity as a Masters level individual under supervision for licensure. The consequence for this change will likely create an equity staffing issue and possible termination of long term, quality employees who are not licensed or currently license eligible. These qualified, experienced staff members would then be replaced with novice, Master's level clinicians who are not as competent to work with our population. Thus, this change would cause a reduction in the quality of services and likely a dramatic reduction in the number of patients able to be served.
We’ve reviewed the proposed chapters in depth and have feedback.
The feedback for Chapter 1 is as follows:
We’ve reviewed the proposed chapters in depth and have feedback.
The feedback for Chapter 2 is as follows:
The feedback for Chapter 4 is as follows:
We will further discuss our concerns about the placement of CSAC and CSAC Supervisees within this category in a different comment.
The feedback for Chapter 5 is as follows:
The feedback for Chapter 6 is as follows:
The feedback for the OBOT Supplement is as follows:
Comments and Questions to ARTS Manual Draft-
Chapter IV Outpatient Services (ASAM Level 1) p. 47-48
“Outpatient services (ASAM Level 1) as defined in 12VAC30-130-5080 shall be provided by a Licensed CATP or a registered nurse or a practical nurse who is licensed by the Commonwealth with at least one year of clinical experience involving medication management
Comments: although the above description includes RNs and LPNs, the outline of the outpatient services that follows it does not identify RNs or LPNs as eligible to perform any of the services. Is this an oversight? Please clarify.
Chapter IV p. 43
“Preferred Office Based Opioid Addiction Treatment (OBAOT) Preferred Office-Based Opioid Treatment (OBAOT services), as defined in 12VAC30-130-5060, shall be provided by a buprenorphine-waivered practitioner in collaboration with co-located licensed mental health professional and may be provided in a variety of practice settings. Opioid Preferred OBAT treatment services are allowable in ASAM Levels 1.0 through 3.7 excluding inpatient services. Please reference the Opioid Treatment Services Preferred OBAT and OTP Supplement to this provider manual for more detailed information.”
Comments: We are unable to find the supplement that defines addiction treatment services in addition to the opioid treatment services. The only supplement available to review is titled: Opioid Treatment Services Supplement. How can we review that important detailed information?
For SUD treated at a preferred OBAT, are we able to provide and be paid for care coordination? (We thought this would be addressed in the OBAT supplement, but although there are a number of changes to the OTS supplement, there is no mention of other substance use disorders.)
Did you intend for case management to be applied for SUD other than opioid? If yes, please consider providing care coordination regardless of primary substance use. This eliminates confusion, and possible additional required licensing and staff. The needs are the same for patients seeking treatment, regardless of their primary drug of choice. Care coordination is appropriate for all. As you know, a majority of SUD patients use multiple substances. OUD does not need to be separated from how we treat all SUD patients.
Supplement p.38
“Substance Use Care Coordination does not include maintaining service waiting lists, scheduling transportation rides or periodically contacting or tracking members to determine potential service needs that do not meet the requirements for the monthly billing.”
Comments: Care Coordination should absolutely include assisting patients with Medicaid transportation because the service is horrible. Patients are stranded for hours and unable to get anyone to help them despite repeated calls from the patient and our staff.
Page 16:
“Please note that Preferred OBOTs and OTPs are required to develop an Individual Service Plan (ISP) within 24 hours from intake and an Interdisciplinary Plan of Care (IPOC) within 30 calendar days an updated at a minimum every 90 calendar days.”
VS.
Page 24:
“Develop and maintain the DMAS Individualized Plan of Care (IPOC) within 30 calendar days from the ISP assessment date if billing Substance Use Care Coordination and ongoing every 90 calendar days. Providers may use the DMAS IPOC form but not required.”
Comments: Clarification is needed between these 2 statements as current standards require updates to IPOC every 30 days. Does this effect billing being limited to every 90 days or 30-90 days? Programs should not be limited to only providing this service every 90 days as evidence shows that we are able to provide a better level of care when care coordination includes IPOC review monthly.
Page 26:
“o DMAS requires individualized substance use disorder counseling and/or psychotherapy to be provided along with pharmacotherapy. However, DMAS recognizes not all members are ready to engage in counseling or psychotherapy. Providers shall document continuous efforts to engage members in treatment utilizing motivational interviewing techniques, relapse prevention strategies, etc. and are not required to discharge members from pharmacotherapy during this period.”
Comments: Clearer definition is needed as it stated as a requirement, but programs are also not required to discharge members if not engaging. Is there a time frame for which members are given the opportunity to participate in counseling or is it just not a requirement at all if the member prefers not to? How is a program supposed to encourage a member to participate in counseling if they cannot be discharged or referred to a higher level of care- then it is not a requirement. Isn’t this also part of the ”evidence based” treatment model? We fear members will understand this to say that therapy is optional, and many will decide not to participate, simple human nature of “I am too busy” etc. We fear this then could lead to higher relapse rates. As suggestion would be to allow for a longer time to enroll in counseling, a new member shall enroll, participate within perhaps 30 to 90 days of starting the program.
It is also noted in accordance with other commenters that changes in the definition to CATP’s exclude CSAC’s and throughout the manual CSAC’s have been restricted in services they are able to provide. In acknowledging that staffing requirements are one of the largest obstacles in expanding services and programs, we urge that CSAC’s not be limited in this way so that they may be fully utilized by providers.
Under Medical Necessity Criteria section, it indicates that the patient must have a primary diagnosis of OUD. That means that patients who are being treated here for other substance use disorders, other than Opioids, don't get reimbursed for ARTS covered services, such as Care Coordination G9012. We perform the care coordination services on patients with Opioid Use Disorders as well as other Substance Use Disorders and this diagnosis should be expanded to cover services for providers who treat a variety of drug abuse. Suggestion to modify this section and update from OUD diagnosis to SUD diagnosis to meet the coverage guidelines. Thank you for your consideration.
Clear distinction between screening and assessment in terms of timelines. Screening and assessments are not always completed in the same setting. In Chapter 4, it states that the Comprehensive ISP is to be completed 30 days from initiation of services, is this at the screening or assessment, or first visit?
Clarification on functions a CSAC and CSAC-Supervise can perform. Recommended that CSACs/S been given additional functions as long as it fits into their scope. There is contradictory language on page 25 and 28 concerning function of CSAC. Page 25 states that “The member shall be assessed by a CATP, as defined in 12VAC30-130-5020, acting within the scope of their practice…”, however on page 38 it states that the member meets medical necessity based on “multidimensional assessment completed by a CATP or CSAC/CSAC-Supervisee.” However, the new definition of the CATP, does not include CSAC or CSAC-S.
Clarification or revision should be consistent in utilizing terms clinical assessment and multidimensional assessment. Are these being used interchangeably or do they differ based on who can perform them?