The Children of Virginia need all the help that they can get from there insurance it’s hard to get help for the use of Virginia. I know because I have a seven year-old that I’ve been trying to get help for two years. Plus  

CHKD and surrounding areas will not take level to autism with aggression. The only place that would take my grandson. Why is CCCA Do not take things away from the children that are in need of mental health but add them instead they are the future and getting help is vital does that they don’t become a statistic but valued member of society Gloria Skowronski

Thank you for taking my comment.

Being a professional in IT Systems, workflow processes, and an analyst I was told and learned that you can throw money at something, but it unless the right people and the right processes are in place, it is wasted money.

The shortfall in mental health care is the providers.  There are not enough providers and the quality of providers is severely lacking.  For example:  Three of my family members (Mom, Dad and Sister) all passed away within 4 months.  In search of therapy to assist me in losing my entire family circle back-to-back, what I found were therapist who did the following either on visit 1 or visit 2.

• judging me for not having a service for my parent who specifically did not want one
• telling me 'I think you want to feel this way'.  
• stating that I was suicidal because I would rather have an DNR than to have my children deal with less than adequate care.

Calling around for an appointment is months out.  Then once you do have an appointment, you become a number in their calendar schedule.

I am all for quality of mental health care for everyone when it is needed.  But I do not believe RHRN addresses the above which is the core of mental health care.  

In reading the draft plan of care, I am concerned that those who truly need the defined care will be shortchanged by those who use mental health as an excuse and they pass thru the (new system) to show participation.  Life is hard and adults need to be adults not blame their feelings and circumstances on 'mental health'.  Honestly, we all have mental health issues - I have never met or known anyone with a perfect mind.  Maybe that is more having 'interpersonal skills' to adjust oneself to the circumstance /  environment.

In summary, Virginia needs quality providers.

As a consumer in the system, the system is all about reaction and not prevention. A service is being taken away from my son because he is "doing well" but without the service, he will backslide again, as he has in the past. More intensive programs like these would not be needed as much if you allowed more programs before the severe problem persisted. 

Clubhouses (fountain house model) have been pivotal in offering social and clinical support to folks with psychotic disorders who struggle with isolation: skill building through helping to run the building (unit work), community outings offering opportunities to connect safely in the community, and recovery groups where they are able to learn about their diagnoses and implement coping skills. Leading up to Covid, it became harder to provide PSR services as reimbursement rates dropped and more requirements were put on staff (i.e. daily notes, etc). This seemed to result in decreasing numbers as staff were not able to be as attentive to consumers. Several PSR programs closed down after Covid as a result. 

Continuing to support programs like this are important in preventing hospitalizations, violence, and police involvement. Increasing reimbursement rates and placing reasonable and realistic documentation requirements on staff would be the way to keep this service strong. They create a sense of community and connection where there otherwise wouldn't be. Psychotic populations often get pushed to the side and forgotten about especially current day with crisis services increasing. 

It was brought to my attention that an intake my agency did for a MHSS client and was denied by the insurance company, went missing about 10 days ago. This is evidence that long term supports are an important part of mental health. Maybe, just maybe, having the support would have made a difference in the events that have unfolded for this young lady. The current critieria for diagnosis are the three major MH diagnosis. How can a time stamp be put on any MH service. Please provide the opportunity for clients to have supports after the delegated "length of service" passes.  

In regards to the below in the treatment planning section on page 4 of 15

• Diagnoses, symptoms, challenges, and functional impairments indicating the need for the services

I would recommend changing the "and" to an "or" as the ongoing nature of the assessment and benefits of treatment would mean that as treatment continues some of these symptoms, challenges, or functional impairments may no longer be present yet treatment would need to continue to resolve other concerns. Language in the regulation that requires all of these to be listed, despite an individuals improved health status, could become a regulatory issue. 

I am expressing my concerns about the proposed changes to Targeted Case Management (TCM) for individuals with SMI and SED diagnoses. As anyone who works in this field knows, case management is the cornerstone of an effective service system for individuals with behavioral healthcare needs. Having listened in on the DMAS discussion that points to the need to change how TCM is currently delivered in favor of a tiered approach that could result in some people not having case management at all is disheartening, to say the least. It also fails to give credence to the fact that many people remain stable because they have TCM services.

My first concern is the statement that CSBs are billing for services that do not meet the definition of “case management.” The notion that CSBs are billing for services that fall outside the scope of TCM is not one that is well-informed or consistently supported. What indicates this? Reviewing the CMS guidance on the Medicaid definition of case management services, I found that some states have been fraudulent in their billing of TCM services. However, the fact that all TCM services come through CSBs provides additional layers of oversight in Virginia that may not have been in place in states where this fraudulent activity was widespread. The existing TCM rates were set with the intent to provide the service as prescribed by the federal definition, so to suggest reducing the rate because CSBs are doing more than intended is an incohesive argument.

One example given is that case managers should not be providing “counseling” services. While it may be referred to as “supportive counseling,” case managers assist individuals with processing information about the services available to them. They assist with processing information so that individuals can navigate day-to-day circumstances. If this needs to be called something else so that case managers can do it without it appearing to fall outside of the scope of their duties, then, let’s call it something else. But to take that away takes away the core of what it is to be a case manager. And if case managers are doing more, it is likely because other services are so scarce and difficult to authorize/maintain that they are doing whatever they can to try to care for the individuals they support. They should not be punished for that.

My next concern is the proposal of a tiered rate based on the needs of the unique individuals. The needs of the individuals we serve are not always predictable. Having a monthly rate in place ensures that whenever an individual reaches out, the case manager is expected to respond or follow-up in a reasonable time to assist the individual. This is not something that is easily navigated in services that have time limits and set meeting times. If the need is to justify the rate, then let’s continue to discuss reasonable approaches to documentation and case load sizes; but there should be no consideration of lowering these rates for any tier when in fact, we are supplementing the existing rates with STEP-VA funds.

This brings me to my next concern which is the expectation of STEP-VA and the goal of moving toward the CCBHC model. These things are mentioned in the DMAS meetings, but the conversation is clearly at odds with the direction that CSBs have been moving toward since the advent of STEP-VA. Is it possible to work toward strengthening case management for STEP-VA while dismantling it for this approach proposed by DMAS?

To be clear, I fully support a build out of community services which have failed in the past for many reasons. In fact, the community services being proposed such as intensive in-home, therapeutic day treatment, and mental health skill-building are not new services– these services have co-existed with TCM; however, over time, the administrative burden of these services and the denial of authorizations for services that were deemed clinically necessary by licensed professionals decimated these services for many CSBs. How can we overlook that? Why not look at why these services have failed or gone underutilized in the past and correct those issues? To try to work these services back into the system by compromising the one remaining service that we have been able to provide and mandated to provide is not fair to anyone involved. To take away the one service that has been a consistent source of service and support for many people in favor of services that have been unstable over the past several years is not logical.

If the issue is the need to build out of community-based services, let’s focus on that and leave TCM intact. At a minimum, these community services should be in place and proven to be accessible to the people who need them before any changes are made to case management. This conversation has to shift to supplementing case management rather than replacing it if we are going to be able to holistically care for Virginians who depend on our behavioral healthcare system. 

I agree with most of what one of the people who commented named Robin M. accountable. 

I am the Supervisor for the SMI, SED and SUD case management team with the Eastern Shore CSB.  So, my comment is from experience serving individuals who struggle with SMI, SED and SUD.  I have concerns regarding the tiered case management system.  Given the nature of SMI, SED and SUD, an individual's level of functioning can fluctuate due to various factors, including stressors, changes in medication, or life events.  The nature of SMI, SED and SUD makes it challenging to categorize individuals into fixed tiers.  A tier system may not adequately accommodate the changing needs of individuals.  Case managers should have the flexibility to adjust levels of service based on real-time needs rather than relying solely on predetermined tiers.  Individuals assessed at a lower level tier would be at risk because the unpredictable nature of SMI, SED and SUD is not taken into account when assigning a person to a rigid tier system.

To disallow psychoeducation as a component of Targeted Case Management is concerning. In many cases, there is no one in the client's life or parent of a child's life to assist them in understanding their mental illness and the need for services to address and stabilize symptoms.  With a constant focus on clinical stability and the importance of being able to manage symptoms for community living, the case manager establishes a trusting relationship with the client/family where there is open dialogue about the need for services and supports. A critical role of the case manager is to provide education to the client/family.  This goes hand in hand with reminders of the need to consider the recommendations of a psychiatrist and/or another medical provider about treatment and services.

A tiered system of Targeted Case Management with authorization processes will detract from the provision of the right level of service.  Mental illness can be cyclic, and the case manager is already required to provide the needed level of support during a crisis.  CSB's are currently providing this service without a cumbersome authorization process.  Case managers currently provide close monitoring of the Medicaid Rehabilitation Services which includes encouragement to participate, problem-solving with the provider, quality assurance, and ongoing discharge planning.  CSB's proudly serve as the single entity to provide Targeted Case Management and are heavily regulated.  Many of the clinical services on the rehab continuum have waiting lists and some of the services are short term in duration.  For these reasons, there are periods of time in which Targeted Case Management is the only service being provided and this is appropriate.   

During the DMAS discussion, some very specific information was provided about Virginia considering a SMI Waiver assessment and the use of the Child and Adolescent Strength and Needs (CANS)/Adult Needs and Strengths Assessment (ANSA) to determine the levels of case management.  It appears that critical decisions may have already been made about the use of these instruments as a component of the Managed Care Organization (MCO) authorization process within a level of care model.                                    

I would like to register concern for proposed changes to Targeted Case Management (TCM) for individuals with Serious Mental Illness (SMI) and Serious Emotional Disturbance (SED).  I support the need to address the Commonwealth’s “legacy” (IIHS, MHSS, Psychosocial Rehab, & TDT) services, which has experienced skyrocketing expenditures over the past couple decades influenced by provider behavior and inconsistent service provision.  It is important going forward to have effective controls, provider accountability and standards of care to optimize our system of care. 

However, I am vehemently opposed to TCM being lumped in in order for DMAS to exercise their temporary authorization by the GA to make changes if “budget neutral”. 

The absence of meaningful discussion or understanding regarding the role and benefit that TCM plays in every localities’ system of care and the anticipated consequence of such action is concerning given the speed in which DMAS’ timeline is moving.  As the public comment period ends, it is not clear how the new Community Psychiatric Support and Treatment (CPST) service will be managed or delivered.  The stated goal to have a final plan to overhaul “legacy” and case management services by July 2025 to accommodate a yearlong period implementation of July 2026 to exercise the authority granted by the GA is dangerously rushed.  

TCM, provided only by CSBs, accountable to our local and state government, has enabled layers of oversight protecting the integrity of the service and consistently addressing system gaps for some of the Commonwealth’s most vulnerable citizens in ALL communities.  It is illogical to believe there will not be substantial impact resulting from such action. 

It would lessen financial resources of the CSB, who time and time again have aggressively responded to address those gaps that have resulted from previous policy decisions while simultaneously addressing other system needs and mandates.  This will constrain supports available for our individual communities and the Commonwealth as CSBs serve individuals regardless of ability to pay. 

If believing it will lead to a “budget neutral” solution a few things need to be considered. 

First, the well-known escalating costs for the “legacy” services over the last two decades has been attributed to provider behavior and need for effective controls.  During this time a growing number of providers, without a shared respect for the system, have redirected their efforts from one legacy service to another following regulatory changes being introduced.  As a result, those easier to access services experienced ballooning costs without successfully achieving standards in care that were envisioned.  

Secondly, any financial estimates made to address this as a “budget neutral” approach will be highly skewed as those increasing Medicaid expenditures, year after year have exceeded budgeted amounts and have been connected to reimbursement claims influenced by aforementioned provider behavior and questionable service delivery.  This has impacted Virginia’s ability to apply resources to strengthen the statewide system of care as desired. 

Recognize that providers that follow new rules and regulations are those who have consistently followed and demonstrated respect for the previous ones as CSBs have consistently done for over 50 years. 

Thirdly, it should be noted that TCM rate increase years ago aligned to offset a significant reduction of State General Funds (SGF) to the CSBs from DBHDS in order to ensure that CSBs were capable to safely function as the community-based safety net for some of Virginia’s most vulnerable citizens.  This would certainly have a great impact for the CSBs already underfunded, providing millions of dollars in uncompensated care and are actively working to address other needs and mandates, including but not limited to STEP-VA.  This necessitates that the role of TCM be strengthened rather than dismantled.  Such action is inconsistent with other Virginia initiatives intended to improve the Commonwealth’s Behavioral Health System.       

Proposal of a tiered TCM rate based will not accurately account for or address system failures, but instead fails to recognize how pivotal the lynchpin of services has been across every system of care in Virginia.  CSBs have weathered their responsibility as the community safety net during very difficult times over 50 years for our individuals, communities, and the BH System as a whole which has resulted from policy decisions, system failures and the lack of recognition for impending challenges.  TCM has been integral in doing so.   

Please recognize that the needs of individuals served with SMI and SED are often unpredictable and may change rapidly.  TCM has assisted in maintaining stability for so many of these individuals preventing them from reentering crises and helping to mitigate them when they arise.  TCM must be able to provide crisis diversion (unanticipated, unscheduled situation) that require supportive assistance whether by phone and face to face to resolve immediate problems.  Attempting to create cost savings in this manner lumped in to address challenges experienced with “legacy” services is short-sited.  

References that Virginia’s State Plan Amendment “may or may not be approved again” is insufficient rationale to utilize the current authorization by the GA to make change.  Essentially CSBs, the community safety net would be adversely impacted as DMAS seeks a “budget neutral” solution to address challenges that have resulted from lack of accountability with legacy services spanning over several decades.    

Changing the model and access for TCM without accurate information or understanding of the role played and the repercussions to the system and most importantly individuals’ whom the CSBs have served for over 50 years would be a half- hazard approach for decision makers to take with dangerous consequences to our system that cannot be unwound.  From both a historical and simple mechanics perspective, this is nonsensible, impractical, inconsistent with the other BH efforts and is essentially pulling the lynchpin out of the wheels as we are moving.        

As a TDT Supervisor, I am very concerned regarding how the model that is being presented will be a replacement for TDT. The levels that are presented are very vague and confusing. What will the criteria be for school based interventions (i.e. replacement for TDT).  Due to increased behavioral needs at all ages and the increased intensity of the behaviors within the school setting TDT type services are showing an increase in need. Data shows that if the service is able to be implemented earlier that the service can be effective. The current criteria does not always allow for the service to be implemented in a proactive approach versus reactive.  Furthermore, the current inconsistencies with approvals by MCO's is making this service harder to get for students who are in desperate need of the service. With the new model implementation at this stage, the levels and criteria being presented is very confusing and it seems that the program may be harder to access which is not beneficial for our students and families, nor being proactive. 

The presented idea of using the modalities that are typically implemented by masters level staff are now going to be asked to be used by bachelors level staff is very concerning due to lack of education, experience, and training. Masters level staff typically gain experience and training through internships with such models where the utilization of bachelors level staff will not have that experience. 

There is information regarding restricted caseloads. If this level model is going to be implemented there should be consideration to caseload sizes based upon the level that each individual is on. A level one client would not require as much attention as a level 6 client. 

Thank you for the opportunity to provide feedback at an early stage in the development process of new services.  UMFS supports the inclusion of accreditation and at least one proposed evidence-based practice (EBP) for agencies providing CPST services. Additionally, we appreciate the effort to create a more standardized system of care with defined levels and intensities of treatment interventions. However, as with any well-intentioned proposal, unintended consequences could arise, potentially hindering the realization of these changes.

Specifically, it is critical to ensure that access is not restricted due to defined levels of care without clarity on how and by whom the standardized assessment tool will be implemented. For instance, while the CANS tool has been utilized for many years, its inconsistent application has led to disparities in the current locally administered CSA system. A thorough review and input from subject matter experts on CANS use at both the CSA and provider levels could provide valuable insights and lessons.  The value of a standardized assessment tool can be beneficial, but the implementation process and understanding the full implications of this assessment with existing protocols is necessary to flesh out.

The current proposal lacks sufficient detail to fully understand the implications of the two levels of services being suggested and how a standard assessment tool would layer into existing protocols and EBP assessments. We encourage further opportunities for review and input as the framework becomes more fully developed and detailed. 

Below is additional feedback on specific sections of the document for consideration.  As always, we appreciate the opportunity for discussion to ensure the goals of these new services can reach those individuals who would benefit from high quality services and supports.

Proposed change:

All CPST services are to be recommended and overseen by a Licensed Mental Health Professional (LMHP) and a part of an individual service plan (ISP). LMHPs assess, develop ISPs, provide counseling, and monitor each individual receiving CPST, and within the structure of collaborative behavioral health services, direct the treatment and interventions provided by unlicensed staff.

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. 

High-Fidelity Wraparound does not require a LMHP to oversee this service.  Adding this into the model would create barriers for access to this planning process as it’s not a clinical service and will require additional staffing at a higher salary which would need to be factored into the rate. 

Proposed change:

CPST is designed to provide office-based services as well as community-based services to individuals and families who can benefit from home and/or community based rehabilitative services, including those who may have difficulty engaging in formal office settings. CPST allows for delivery of services within a variety of permissible settings including, but not limited to, office and community locations where the individual lives, works, attends school, engages in services, and/or socializes such as homes and schools. Interventions are “hands on” and task oriented, intended to achieve the identified goals or objectives as set forth in the individual’s individualized service plan. CPST Allowed Mode(s) of Delivery 1. Individual 2. Group 3. Office/on-site (including schools) 4. Off-site/community/home 5. Without Individual present 

The proposed staffing structure, service settings, and delivery modes seem narrowly focused on replacing existing services, leaving unresolved questions about how current EBPs within the Medicaid benefit—such as Functional Family Therapy (FFT) and Multisystemic Therapy (MST)—would be impacted if included under the CPST framework. Additionally, introducing new models like High-Fidelity Wraparound requires a tailored approach. We recommend evaluating each model individually to align staffing requirements with the specific needs of EBP.

Regarding service delivery modes, it appears that telehealth is excluded. Telehealth is currently a critical component of FFT and Intensive Care Coordination (ICC) and removing it under CPST could present significant barriers to access. This is especially concerning families in rural areas or those facing transportation challenges. These EBPs often require the participation of specific family members to maintain fidelity, and excluding telehealth as an option may diminish families’ ability to engage fully in treatment. Additionally, eliminating telehealth may necessitate rate adjustments to account for extended travel time for providers.

We strongly recommend that telehealth remain an option for EBPs in situations where in-person participation is not feasible or at specific junctures in the intervention that do not require in-person/face to face interactions. Allowing telehealth where clinically indicated would improve access, increase family participation, and support the effectiveness of these services, particularly in areas with limited resources or logistical barriers.

Proposed change:

Standardized assessment tool for assessment and re-assessments (i.e CANS).

The proposed use of a standardized assessment tool offers valuable opportunities for improving care consistency, tracking outcomes, and enhancing data collection. However, critical questions about its implementation remain unresolved. Key concerns include determining who will conduct the assessments, how DMAS will ensure equitable and consistent application, maintaining fidelity to the assessment tools, and integrating these assessments seamlessly with existing tools required by evidence-based practices (EBPs). Without careful alignment, families may face unnecessary redundancies, completing multiple assessments that could hinder their engagement.

Historically, the introduction of standardized assessments into existing systems has, at times, unintentionally created barriers. These include reduced accessibility for families and youth, as well as administrative challenges for providers, which can compromise the effectiveness of intervention models. Misalignment with EBPs often leads to duplicated efforts and conflicting outcomes, further complicating care delivery.

To prevent these issues, it is essential to fully understand the implications of the proposed assessment tool and incorporate lessons learned from the current system. Without these considerations, the risk of creating additional barriers to access—rather than reducing them—is significant.

The framework of the CPST proposal provides descriptions of the services; however, the translation to addressing the complexities in supporting people who experience behavioral health challenges, raises some questions.

1. CPST may only be provided by a staff who is under the authority of a DBHDS agency license.

1. Workforce Challenges and LMHP Oversight

• The proposal seems to increase the demand for Licensed Mental Health Professionals (LMHPs), based on the following excerpt from the proposal “All CPST services are to be recommended and overseen by a Licensed Mental Health Professional (LMHP) and a part of an individual service plan (ISP)”.
• Recruitment and retention of LMHPs is already a challenge to the behavioral health service system and often results in long wait times to access services. New staffing requirements may increase the difficulty in obtaining services.

• There is a statement that shows a requirement that supervisors may only be independently licensed practitioners – does this pertain to all services in the CPST proposal?

• For the Strengths Based Individual Service Planning and Monitoring: 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. Again, if there is a workforce shortage of LMHPs, then services that can be carried out by non-licensed personnel based on proposal, will be on hold, and person cannot get the right help, right now.

2) Place of service:

• If all the services described, including counseling, can be executed in office and/ or community-based setting, this will be beneficial to many.

3) Standardized assessment tool:

• Agree with the need. Currently DLA 20 is widely used. To switch to the use of a different tool, time and money will need to be carved out to provide training on utilizing Child and Adolescent Needs and Strengths (CANS)/Adult Needs and Strengths Assessment (ANSA). This may be more of a cost than benefit in trying to improve the behavioral health support system.

4) Case Management

• Case management plays a critical role in preventing crises and supporting individuals in attaining community stability. Visits with the person in a variety of community settings is a critical piece, as well as knowing the breadth of resources available across multiple domains.

• To increase accountability and assurance that services fall within the scope of case management, require ISP to be submitted with the annual service authorization request.

5) Expanding Service Access and Availability

• The current availability of outpatient, community, and residential services is limited, with long waiting lists, creating a bottleneck in service access. The addition of services may increase the options for people, especially with the flexibility of where the services can be provided. However, the provider capacity concerns remain, and the redesign does not inherently offer solutions.

6) Addressing Needs for Care Coordination Outside Case Management

• For individuals not qualifying for case management, a service such as care coordination, may be beneficial to coordinate when someone has multiple providers such as: a combination of outpatient therapy, medication management, and primary/specialist medical care.
• It is unclear whether an LMHP or another provider would fulfill the coordination role for these individuals.

7) CPST - Integration with the 1115 SMI Waiver

• The relationship between the proposed redesign and the 1115 SMI waiver is unclear, especially regarding the integration of residential supports. How will the redesign and the 1115 SMI waiver work together to avoid duplication and ensure seamless service delivery?

8) Outreach and Engagement Reimbursement

• An important part of the continuum of supports starts with outreach and engagement, especially for individuals with Serious Mental Illness (SMI), who may be hesitant to enroll in services. Including reimbursement for outreach and engagement could help address barriers to enrollment, particularly in rural or underserved areas.

Scenario:

Person sees an independent licensed therapist and a psychiatric nurse practitioner at PCP office. Therapist and person determine that services and supports are needed to reach specified outcomes, resulting in referral to Case Management. What would be next step with new structure to assist in following areas? If referred to CPST service to address following needs, does the person have to get assessed by another LMHP that is under the CPST license?

• Obtaining and maintaining affordable housing.
• Assistance with benefit application process for Medicaid, SNAP, and social security.
• Get connected with DARS for employ support
• Connect with peer specialist
• Monitor and coordinate all supports
• Following up on medical and behavioral health appointments
• Going through court case due to multiple no trespassing charges.

       My main concern is the level of responsibility placed on LMHP staff. Putting them in charge of Assessments, ISPs, and Quarterlies in addition to running counseling groups and providing program and staff supervision will require the need for additional LMHPs to be hired, which will cost more for the agency. This will be tricky with the current workforce shortage.

        There is also some concern about potential ethical violations If a practitioner is working outside of their area of expertise. For example, with the vocational specific requirements, that is not something that the average LCSW is trained on, but a Licensed Rehabilitative Counselor is. We would need to have both on staff, which again would be difficult with the current workforce shortage and budget constraints.

It also seems as though it is reducing the workload of the QMHPs who are currently writing ISPs and Quarterlies on their own with approval from the LMHP. Some of the listed wording in the document is confusing, as it states that a QMHP should be able to make crisis plans and assist with writing assessments, but cannot assist or write ISPs. Is there a reason why QMHP’s can’t write ISPs?

             The other major concern I have is related to service limits and caseload limits. Currently, I run a psychosocial rehabilitation program that services the SMI population. Individuals with SMI often have long term needs and it can take many years to show real progress in their recovery. The document mentioning caseload limits is concerning. “The expectation is that recovery will be achieved over time.” Does this mean that there will have to be a waitlist instated and does it mean that there will be a hard cut off of service limits? This will also put a huge constraint on program budgets and either require more staff, or put individuals at risk for hospitalization if they are unable to receive long term care.

         Also, the hiring of Behavioral Techs, while nice in principle, according to the responsibilities listed in the document, seem to be taking on responsibilities previously handled by QMHP staff. But the document also states that they will require 2 years of experience. How will they get that experience and how will they be able to work with the SMI population with out it? Currently, the requirement is one year for QMHPs to work in PSR. Will the reimbursement rate be increased to reflect the need for all of these new staff? Are there any program modalities that will be recommended to assist with these changes? What is listed in the document are therapeutic modalities, not program models.

TDT services in the school setting is much needed to address the needs of many of our children. Although changes could be beneficial, the current proposals seem convoluted and counterproductive. Any such modifications to make it more difficult for children to access the program will be a disservice to the school and our children. Putting caseload restrictions in place so providers are unable to financially provide the program or different levels of treatment is not the answer. Recommendations for improvement should instead focus on clearer admission standards so us parents don’t have to shop insurers because one denies the service, and another approves it. Having an insurer tell us that the child needs “mentoring” to address our child’s needs in the school setting is ridiculous. Or having an insurer tell us the child only needs 1 unit a day after an appeal is also ridiculous. Please fix this broken system by making admission standards clearer and easier for children to get access to the program and making it more difficult for insurers to deny the service. Our number 1 goal should be focused on our children and providing them with whatever services is necessary to help them before it’s too late. Although counseling is helpful, 1 hour a week does not come close to addressing the needs. Having a TDT worker there for our children every day is what makes the biggest difference.   

The current monopoly that CSBs have on case management needs to be fixed. Making one phone call a month and then billing the state for the services is almost fraudulent. Whenever competition isn’t allowed complacency always runs rampant. Opening case management up to private providers will fix the program as CSBs will then be required to actually provide the service as intended. HFW is a perfect example of how it's growing and really making a positive difference with families, once it was opened up to private providers.  

Possible Agency Level Requirements

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.

Requiring an agency, that has met all DBHDS standards, to get accredited is counterproductive in filling the gaps in Virginia’s broken mental health system.  Virginia has a shortage of providers and not a superabundance of them.  Is DMAS not aware of the high threshold to meet licensing standards along with the enormous difficulty of agencies initially getting licensed?  Or the constant audits that DBHDS conducts on its licensed agencies to ensure adherence to such standards?  Our agency has been licensed for going on a decade and we’ve worked relentlessly to never receive one inspection infraction.  And now the state is proposing that we spend thousands of dollars to get accredited?  Is it not enough that we adhere to all DBHDS and Human Rights requirements as outlined by the state?  A possible solution to this would be to only add this requirement to those agencies that have constant inspection violations and/or receive provisional licenses.

Caseload limits for each staff level, including across agencies (i.e., licensed individual’s caseload is counted across all agencies where employed).

Caseload limits is problematic for some programs such as Therapeutic Day Treatment and let’s not forget that it was attempted before.  For example, our middle school staff typically maintain a caseload of 10-12 in order for the agency to maintain competitive salaries.  Although this caseload may seem high, they typically only work with 6-8 children daily for several reasons (e.g., sick, suspensions, probation appointments, limited SA approvals, etc.).  If the state is adamant on implementing such requirements, then they need to allow for such reasons and increase prospective caseload limits to 12 or more.  The other solution would be to drastically increase reimbursement rates.  The state must also realize that in order for agencies to retain staff we must pay our staff for when the school isn’t in session.  Putting additional caseload restrictions in place when it’s already difficult to turn a profit will only harm such programs and make it challenging to retain qualified clinicians.

There are concerns with the proposed caseload restrictions. Financially, this can place a burden on agencies already struggling to sustain programs with the low reimbursement rates. When comparing programs, caseloads vary widely. HFW allows for 12 clients; however, MST carries an average of 5. TDT previously only allowed 6 clients per caseload, but this was eliminated due to the fact that there are varying needs among clients and levels of intensity so higher caseloads could be managed with an array of clients.  When factoring in school-based services with attendance and suspensions, staff often need to carry a higher caseload to actually have half of their caseload present to work with. Community based services face issues with cancellations as well, especially after driving to the home, thus, having higher caseloads allows for staff to be able to schedule with another client as a replacement for missed sessions with others. Caseload limits should be high enough to allow for cancellations and absences so that programs can be sustainable.

According to the draft, all agencies must be accredited to provide any level of service under this new model. DBHDS does not require accreditation in order to be licensed for the service, but this implements the requirement for accreditation under DMAS so that you can be paid. For small agencies, this poses an extreme hardship as accreditation cost upwards of $10,000. That is an astronomical cost to absorb for a small agency especially with low reimbursement rates. If an agency is licensed by DBHDS and not required to be accredited, why would there be a need to be accredited for all providers. Requiring accreditation for those agencies that are not licensed by DBHDS and provide services such as ICC, FFT, MST, etc. that are not DBHDS services but fall under this draft would help hold those to the applicable standards, but it should not be required across the board. Accreditation requirements are time consuming and adding this requirement to the standards that have to be upheld by DBHDS licensing would add redundant work to agencies. 

I have had the privilege of working primarily in a psychosocial rehabilitation setting while also having the opportunity to work in crisis stabilization and outpatient therapy. As such, I have worked with clients with varying levels of acuity and needs. A common complaint I have heard from clients is not having enough time to make adequate progress towards recovery in relation to the amount of time they are allowed treatment.

One of my primary critiques of CPST is that it is being designed to be a time-limited treatment modality which will only further complaints from clients about only having access to time-limited services. Recovery is a deeply personalized process and putting a time-constraint before even starting services may not be conducive to treatment. The reality is some clients may need significantly more time in services compared to others and if we are to support the autonomy of the client, we should avoid imposing an expectation that a client must be at certain point in recovery at a specific time. In addition, individuals with SMI (serious mental illness) generally have complex needs (housing, legal, health, nutrition, relational) that can take a significant amount of time to resolve before they might have an opportunity to adequately benefit from treatment.

Anyone who has been involved with Virginia's current behavioral health system (even clients) will note that access to treatment and and staffing seems to be one of the most pressing concerns with our state's behavioral health system. CPST's proposal for the staffing of such a program are especially concerning as it ignores the national behavioral health staffing crisis that we are experiencing. Where will all the staffing for CPST come from if we are already having issues staffing existing programs?

CPST means to do well but I think this treatment modality can fit into enhancing current services offered. CPST notes that housing is one of the needs to be addressed by the program. Why not instead provide enhancement to existing PSH (permanent supportive housing) programs? CPST seems to sound like a blend of ACT (Assertive Community Treatment), PSH, and PSR (Psychosocial Rehabilitation) all put together. Why should we create a new program that could potentially result in redundancies when we can enhance and strengthen existing programs. Not to mention, that there is scientific evidence that these existing programs work. If we are not seeing the results that we are expecting from these programs, perhaps we need to focus on enhancing and reworking some of the programs rather than introducing a new one. I think we could address many of the needs of the community outlined by CPST if we enhanced interdisciplinary collaboration between programs such as PSH, ACT, and PSR.

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.

1. The tiered levels of rehab services could be positive.  Would like a strong orientation that stability is a viable goal and incorporate the premise that some consumers require a low level of services to maintain stability over the course of their lifetime.  The mention of longer-term maintenance support and clubhouse model in regards to PSR services is critical to building out the entirety of the care model.  We would like to see more wrap around supports within PSR (peer/CM/therapy) without losing PSR billing to provide more integrative services for our members.
2. Artificially capping caseload sizes does not account for - individual acuity/clinical needs of consumer, tenure/seasoned vs new clinicians, supervision needs of the Qs or Ls (or even BHA/Ts) / how many employees can be under one supervisor, sudden changes in workforce resources, and overall business operation demands (short & long-term).  Caseload sizes should be recommendations not regulated by DMAS.
3. NOT the CANS.  The CANS is not a clinical assessment that focuses on diagnostic and psychosocial to determine the diagnosis and mental health needs; only reflects surface strengths and weaknesses and misses underlying issues.
4. Strongly support building peer services into the structure of services such that the cost is built into the reimbursement rate.  Note - it is very difficult to find peers for youth.  Maybe this should be optional versus built in; or at the very least a tiered model with and without peers.
5. Strongly support incorporating EBPs - EMDR, PCIT, CBT, DBT, etc.  The struggle is the cost of the training - actual training fees and cost of taking clinicians off-line for the training and the on-going required (specialized) supervision, refresh-type training, and the turnover within departments that equates to an on-going cycle of training costs for the same service....all non-billable.  So if EBPs are mandated, there should be a long lead time to get clinicians adequately trained to provide the service in a responsible manner across the Commonwealth.

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. 

The level of care model, in theory, would provide various levels of services for clients to access. Ideally, this should make access to services more accessible and help to be more proactive versus reactive; however, this structure appears to make services less accessible and more reactive. Services included in the most intensive levels such as FFT, MST, and HFW are all services that should be able to be accessed at a lower level, not simply waiting until the house is completely on fire with no way to recover. These services are not intended to be implemented at the lowest level, but over time they should decrease to lower levels as progress is made. This structure shown appears problematic when considering the fluid nature of such programs. Another concern with the presented levels is that services that follow evidenced based models that should be in place for specific timeframes may be presented with issues by categorizing them into certain levels. HFW for example is a 12–18-month service, but by this presentation, can only be accessed in level 5 or 6 when in reality it should be accessible in all levels as it moves through the model.

This then brings into question about the nature of implementation for providers. Currently there are separate services, but this new model shows that it will be one service with varying levels. Are providers going to be credentialed in all levels of care for CPST or only credentialed in certain ones? How are services going to move between levels? More consideration needs to be given to these areas. As a provider of services as well as a FAPT member, I am concerned with completely overhauling the current system versus addressing the areas within each program that need changes to be made. FAPT also approves many of these services if Medicaid is not accessible for a family, so it is important that there are clear standards for the services as it appears that it is not being replaced, but completely changing all of the requirements. 

After reading the VA Draft Service Definition, I have several concerns about the CPST proposal.  First of all, my concern is the state wide shortage of applicants in this profession.  I also noticed that CSAC-A positions were not mentioned and a majority of the SUD case managers in our CSB are CSAC-A s, not CSAC or CSAC supervisees.  The entire proposal appears to have unrealistic expectations and does not read as though it is person centered as my fear is that the individual’s needs or goals will be lost in the bureaucracy of these tiers.  I completely agree with Diane Farlow’s extremely well written comment posted on 12/30/24.

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.

Pages 7 and 9:  Restorative Life Skills Training and Rehabilitation Skill Practice and Repetition

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.

In this draft, assessments/reassessments, and individualized service plans are to be completed by LMHP type staff. Currently, a QMHP-A can complete the case management reassessments and ISP. Recruitment of LMHP staff is challenging in the current workforce. It is concerning that this could result in long wait times for getting individuals started in needed services. It is also concerning putting individuals with a SMI in a certain tier level as often an individual's level of services needed can fluctuate.  

In this proposal, the amount of additional requirements placed on LMHP-types would be unrealistic and would, more than likely, have a negative impact on LMHP staff retention.  Agencies would be required to be able to pay LMHP-types suitably and in a way that would attract experienced LMHP-type staff.  LMHP-type staff requirements, such as ISP development, would be able to be completed by QMHPs with the assistance of an LMHP, which would be more cost-effective.  Regarding peer services, I do not feel that this should be made a requirement and should be left to the discretion of the agency.  If peer services are made a requirement, this could be difficult to adhere to due to the limited availability of qualified peer recovery specialists and turnover rates in rural areas. 

The Child and Family Services Council of the Virginia Association of Community Services Boards appreciates the opportunity to provide comment on the Draft Service definition for Community Psychiatric Support and Treatment, currently under development.

Due to the ambiguity of some of the areas that are still being developed, our first question would be on page 1, regarding Medical Necessity Criteria (MNC). Once the criteria is developed, would the LMHP assessing the client determine the appropriate MNC, or would that be determined through the Service Authorization Request?

On page 3, the initial assessment and regular re-assessment tool identified is the Child and Adolescent Needs and Strengths (CANS). The CFS Council opposes the use of this as an assessment instrument, due to the concerns that it is highly subjective and is not a clinical tool. In fact, it is often difficult for licensed professionals to navigate because it is not intended to make clinical assumptions, nor can it appropriately drive treatment recommendations, as it does not effectively capture diagnostic symptoms as they relate a child or youth’s ability to function in the core areas of their areas of daily living.

Some additional concerns regarding the CANS:

• Challenges with Navigating the CANS System: The system can be difficult to navigate, which may hinder efficient assessments.
• Adequacy for Diverse Families and Communities: There are concerns about whether the CANS system adequately addresses the needs of diverse families and communities.
• Limited Resources for Families: The system may not fully account for the limited resources available to some families.
• Data Accuracy and Accessibility: There are concerns about the accuracy and accessibility of data within the CANS system, which could lead to potential delays in intervention.

Another area of concern is that the ISP must be developed by the LMHP. We oppose that and feel like it should remain that it can be developed by a QMHP with LMHP sign- off.

With regard to agency accreditation with 24 months of licensing, the providers are in need of additional information regarding this expectation, and specifically the rationale of choosing one accreditation over another, and the purpose of such accreditation.

1. Medical Necessity Criteria Development

• As medical necessity criteria remain “not yet developed,” we urge the state to expedite this process. Clear and transparent medical necessity criteria are vital to:
• Prevent inconsistent service authorization and delivery.
• Provide clarity for providers regarding eligibility thresholds for Level 1 and Level 2 services.

2. Staffing and Supervision Standards

• While LMHP oversight is appropriate, we recommend further clarity and specific limits for staffing and supervision to ensure quality care:

• Supervisor-to-Staff Ratios: Establish clear ratios for LMHPs overseeing unlicensed practitioners (e.g., QMHPs, QMHP-Trainees).
• Caseload Limits: Define caseload maximums for licensed and unlicensed staff to prevent staff burnout and safeguard quality.
• Supervision Requirements: Specify required hours of clinical supervision for QMHP-Trainees and CSACs on a monthly basis.

3. Accreditation Timeline

• While accreditation ensures high standards, the proposed 24-month timeline may present challenges.
• Recommendation: Extend the timeline to 36 months with interim milestones to allow agencies to prepare adequately while continuing service delivery.

4. Documentation and Quality Metrics

• The draft emphasizes ISP development and monitoring but lacks standardized guidelines for required documentation.
• Recommendations:
• Develop ISP requirements and provide examples to create clear documentation guidelines for crisis plans and progress notes.
• Define specific, measurable quality benchmarks and outcomes to monitor program performance.

5. Training and Workforce Development

• Required staff trainings (e.g., Trauma-Informed Care, Motivational Interviewing) are critical, but funding and accessibility may be barriers for smaller agencies.
• Recommendations:
• Provide state-funded training opportunities or grants for providers to meet the required training mandates.
• Create a centralized training hub to ensure consistent and equitable access to approved programs.

6. Financial and Operational Sustainability

• The requirements for accreditation, evidence-based practices, and advanced training introduce significant financial and operational burdens.
• Recommendations:
• Adjust the rate structure to reflect the cost of compliance, accreditation, and workforce development.
• Establish startup funding opportunities or technical assistance grants for smaller agencies.
• Clarify billing guidelines for concurrent services to minimize reimbursement denials.

7. Implementation of Evidence-Based Practices (EBPs)

• While embedding EBPs is crucial, smaller agencies may struggle to meet the one-year timeline due to cost and training barriers.
• Recommendations:
• Allow a phased implementation approach for EBP integration over 24 months.
• Provide guidance on selecting EBPs tailored to the populations served
• Support reliability monitoring and technical assistance to ensure successful adoption of EBPs.

8. Service Delivery for Complex Needs

• CPST services will often overlap with other specialized services (e.g., for developmental disabilities or substance use).
• Recommendation: Develop clear coordination protocols for individuals with co-occurring or complex needs to ensure integrated, non-duplicative care.

CARF accreditation required; although the manual indicates that rates include fiscal support for this process, there are additional administrative burdens with needing to have another regulatory body. Is there a plan to have the CARF reviews replace DBHDS and/or DMAS audits?

If agency is not yet CARF accredited, does this fall under the “new” agency needing to be within 24 months?

Is there a ratio of LMHP-type to non-licensed staff or caseload size? It says that caseload limits for each staff level but does not designate what these are.

Do we need to update the CNA to clearly outline barriers? Or is this information on the CANS/ASNA?

Is there required training on the CANS/ASNA before a LMHP can complete it?

Service Components 1-8 – the information says “include” but are all required? 

Services can be provided in individual and group settings – what are they envisioning is done in group settings? Counseling, Psych Rehab

Crisis Avoidance/Intervention/Plan Development – will we need to do some additional training with all staff for this?

For services that can be provided by QMHP or CSAC – can a CSAC work with someone with MH diagnoses only or does there need to be co-occuring? Can CQMHP work with those with SUD diagnoses? (Obviously the services require a MH diagnosis.)

Minimum field experience of 2 years for clients with SMI/SED – what position levels is this for?

In reviewing this document several times, it seems that a tremendous amount of responsibility is being placed on the LMHP. There seems to be specifics in relation to treatment planning, overseeing of the ISP and the overall requirements of a LMHP. There is a real concern as this is an unrealistic expectation due to several factors:

1. Staff shortages – When speaking with and attending trainings throughout the state, there is no denial of staff shortages – this has been a concern in every area of Virginia. There would need to be additional staff hired to meet these requirements and that is a challenge currently without the additional requirements.
2. Time – with the current requirement of LMHP’s, time is a true concern. LMHP’s currently provide same day access and the required paperwork that accompanies intake, individual therapy, group therapy, reassessments, the list goes on and on – this is not to mention the requirements to remain licensed yearly.
3. I recommend the ISP development, monitoring, and adjustment needs to remain with the assigned provider regardless if the provider is a LMHP.  This appears to be more person-centered as the everyday provider knows the client and the clients need the best. 

Peaceable Life Therapeutic Services, Inc would like to submit the following comments for feedback to the proposed CPST services.

As a Licensed Professional Counselor working with children of all ages and adults with complex behavioral health needs, often co-occurring with neurodevelopmental needs as well, I would be very excited to have comprehensive services to refer people I support. I welcome the opportunity to work alongside DMAS and other providers to accomplish this goal.

Please consider these comments below as you continue forward with service development for CPST:

• PROVIDER AVAILABILITY
  Is the goal, along with enhancing comprehensive service structure, to increase provider availability? Because if this is part of the goal, we have several things that prevent growth of providers who take Medicaid:
  
  1) credentialling issues with insurances including Medicare and all Medicaid providers
  2) complex billing, error tracking, appealing, and remit processes
  3) timely reimbursement of claims
  4) time-extensive “non-billable” services such as research, treatment planning, collaboration with other supports in place for the individual
  5) reimbursement rates that are well below market rates for behavioral health services and that do not reflect increased cost of living expenses for providers
  
  These challenges are causing providers to leave Medicaid and Medicare billing and transition to private pay. We are already actively losing skilled providers, how is CPST going to attract providers to stay in the service, continue to bill through Medicaid, and continue to serve within a managed care structure?
  
  CPST will need to address these issues as it is developed. Currently there are limited providers of behavior health services across the state that will be willing to provide Medicaid billable services, especially small providers who cannot afford the cost of administrative and billing specialists to understand and navigate the complex billing process. The cost to provide the services often exceed the receivables.
  
  
• CLARITY OF SERVICE
  There are several criteria which state they are in development or do not have clear definitions:
  
  - Medical Necessity: who will determine medical necessity? As an LPC, we can refer to some services, but other services or assessments require a PCP? How many professionals will need to be involved to make referrals to CPST? Will those providers feel equally competent to make those referrals? Will the assessment criteria capture all of the destabilizing factors? The vagueness is concerning as well as the concern of there being complicated referral and access processes.
  
  - Measure-Based Care: Will eligibility and service be driven by scores? Will services be pulled based on improved scores when the services are the stabilization that assure the improved scores? What about individuals who are not accurately reflected in scoring assessments? Though we fully support evidence based care, providers are often bogged down by justifications and documentation that "show our work" so to speak, demand our time, but do not necessarily contribute to the services the person is receiving.
  
  - Staffing: The professional staffing lists are only part of the staff that is required to be able to operate CPST as we are understanding it. The cost of the professional staff as well as support staff, Quality Assurance and Quality Improvement, Risk Management, etc, will need to be reflected in the billing.
  
  - Accreditation: That is a huge cost! Again, going back to PROVIDER AVAILABILITY, if we are going to try to attract providers to this service and all of the red tape and complexities that it will entail, we cannot also throw a requirement to be accredited. Perhaps an incentive for accredited providers?

Thank you for your consideration.

Thank you for the opportunity to provide input on the proposed changes to CMHRS services and their impact on the behavioral health community we serve. With nearly two decades of experience delivering legacy CMHRS and other mental health services across Virginia, Compass has developed a deep understanding of the complexities of service delivery, billing, operational implementation, and regulatory compliance. From this perspective, we recognize and support the need to overhaul CMHRS legacy services to address existing gaps and inefficiencies. However, we strongly urge the Commonwealth to carefully consider the unique needs of the populations we serve. Overcomplicated processes or burdensome requirements risk disrupting service delivery and jeopardizing access to quality mental health care for those who need it most.

The proposed regulations lack sufficient detail to enable meaningful and constructive feedback. Critical aspects, such as medical necessity criteria, service delivery expectations, and operational requirements, are either vague or missing entirely. This leaves providers unable to assess the feasibility, sustainability, or potential impact of these regulations. Without more clarity and comprehensive guidance, it is challenging to offer informed commentary or evaluate how these changes will affect service delivery, client outcomes, and provider operations.

While the flexibility to serve clients in various settings is a positive and necessary step, the proposed regulations fail to address practical limitations adequately. For instance, school-based services currently require formal agreements, such as a MOU, between the school and the provider/agencies conducting these services. As written, the regulations assume universal access without considering how such permissions would be obtained or outlining the requirements for providing school-based services. 

Similarly, while tiered services tailored to individual needs are conceptually appealing, the operational realities of accessing workplaces or schools to deliver these services make implementation highly unrealistic. It is crucial to ensure clarity and feasibility in these regulations to avoid inadvertently creating barriers and confusion to care.

Concerns and Recommendations

DBHDS Involvement in Regulations

• Lack of Specificity: The proposal provides insufficient detail about DBHDS’s role in shaping or enforcing the regulations. This oversight creates ambiguity, particularly for providers who rely on DBHDS guidance to ensure compliance with Virginia-specific requirements.
  
  
• Inconsistencies and Duplication: Adding accreditation to DBHDS oversight results in redundant processes, creating confusion for providers. DBHDS already has robust regulatory mechanisms tailored to Virginia’s needs, and an external accreditation layer dilutes this expertise.

• Recommendation: Keep oversight strictly within DBHDS to maintain consistency with Virginia’s standards and avoid unnecessary financial and administrative burdens. Work with DBHDS to refine service definitions and regulations.

Accreditation vs. DBHDS Licensing

• Feasibility for Home-Based Services: Accreditation is ill-suited for home-based services due to their decentralized nature and lack of infrastructure for traditional accreditation standards.

• Cost Concerns: Accreditation imposes significant costs without clear benefits, disproportionately affecting smaller providers and reducing service availability in underserved areas.

• Recommendation: Eliminate the dual requirement of DBHDS licensing and accreditation. If accreditation is necessary, integrate it into DBHDS processes to avoid duplication and conflict.

CANS Assessments

• Chapter 4 Regulations and Shared CNA: Mental health service programs that adhere to Chapter 4 regulations can use a single 15-point Comprehensive Needs Assessment (CNA) across multiple services provided by the same organization. This flexibility has been essential for enhancing efficiency, improving access to services, reducing the administrative burden on providers, and minimizing redundant paperwork for clients and caregivers. In contrast, the CANS assessment may not be suitable for every program or client population, which could disrupt the streamlined processes that providers have established. Implementing CANS without allowing for alternative assessments could undermine the efficiency gains achieved under the current regulations.

• Recommendation: Retain the flexibility to use the same intake assessment, such as the CNA, across multiple programs under Chapter 4 regulations. Allow for alternatives to CANS in programs where it is not the best fit, ensuring assessments are person-centered to meet specific client needs and can be seamlessly shared between services. Preserve the existing structure that enables providers to coordinate services efficiently while minimizing duplication, reducing administrative strain, and lowering barriers to care.

Definition of LMHP

• Clarification Needed: The proposal does not clearly define whether LMHP-types, including residents (LMHP-R, LMHP-S, LMHP-RP), are eligible for supervisory roles.

• Recommendation: Provide a clear and inclusive definition of LMHPs, explicitly stating the eligibility of LMHP-types for specific responsibilities.

Caseload Limits

• Unnecessary Constraints: Imposing caseload limits is restrictive and fails to account for variations in provider capacity or client needs. This decision should be left to professional licensing boards that understand the nuances of clinical practice.

• Impact on Access: Mandating caseload limits could exacerbate workforce shortages by reducing the number of clients each provider can serve, further straining already limited resources.

• Recommendation: Remove caseload limits from the regulations and defer this decision to licensing boards, allowing flexibility based on agency needs and professional judgment.

Field Experience Requirement

• Restrictive for SMI/SED Cases: Requiring at least two years of field experience for cases involving Severe Mental Illness (SMI) or Serious Emotional Disturbance (SED) could limit workforce availability, particularly for newer providers or those serving underserved populations.

• Workforce Concerns: This requirement may disincentivize entry-level professionals from pursuing roles in CPST, reducing the overall talent pool and increasing recruitment challenges.

• Recommendation: Relax or phase in the two-year experience requirement to allow for a broader talent pool while ensuring adequate training and supervision for less experienced staff.

Training in EBPs

• Challenges of Implementation: While EBPs are crucial for quality care, their implementation is complicated by high staff turnover and training costs. Onboarding new staff represents a significant financial and administrative burden and maintaining fidelity to EBPs requires ongoing supervision and retraining, which further raises expenses.

• Impact of High Turnover: High turnover rates often diminish the benefits of training investments, as staff may leave before they can fully contribute. This not only undermines the effectiveness of training efforts but also creates a continuous cycle of resource expenditure on new hires.

• Recommendation: DMAS should explore options to mitigate these challenges, such as subsidized training programs, reimbursement adjustments, and retention incentives to offset training costs. Collaborative training initiatives and phased implementation timelines could assist providers in gradually building their EBP capacity while ensuring service continuity. These measures would support providers in integrating EBPs into the CPST model without compromising workforce stability or quality of care. DMAS should consider these challenges and explore options to support training costs, such as subsidized programs or reimbursement adjustments. 

Key Risks Without Revisions

• Some providers may exit the Medicaid system due to the combined financial and administrative burden of accreditation and other requirements. Which may lead to reduced access to care
• Workforce shortages, delays in assessments, and service interruptions due to unclear or restrictive regulations will harm clients needing timely care.
• General operational confusion due to inconsistent definitions and overlapping regulatory requirements will create administrative inefficiencies and compliance risks.

I appreciate the opportunity to provide feedback concerning the implementation of Community Psychiatric Support and Treatment (CPST).  As most of my nearly two decades of work experience has been with adults with serious mental illness, my feedback targets service provision for the SMI population.

The proposed changes place significantly greater responsibilities on LMHP- type staff versus the current systems of care for SMI population.  Expecting LMHP to provide program oversight, staff supervision, direct services, complete assessments, treatment plans and quarterly reviews, in addition to the existing obligations of service authorization requests, will require a dramatic increase in LMHP staffing.  Consequently, program salaries and related costs will also significantly increase.   Behavioral healthcare agencies currently struggle to fill vacancies in their workforce, especially for LMHP positions.  If the demand for LMHP drastically increases, as it appears to need to in order to meet the new CPST staffing demands, agencies will experience an even greater workforce shortfall.  

We will likely experience a shift in underutilizing Qualified Mental Health Professionals (QMHP).  Many QMHP have years of experience in addition to Bachelor’s degrees.  Their ability to write service plans under the direction of an LMHP and based off an assessment has already been clearly established in current CMHRS services.   Improving the use of evidence-based practices and outcome driven services, can occur with LMHP overseeing programs, completing assessments, and providing specific types of therapeutic services within their scope of practice.  However, QMHP staff can still develop service plans and quarterly updates, provide rehabilitative/restorative, and psychoeducational services, and crisis interventions all under the direction of an LMHP. 

I appreciate the introduction of Behavioral Health Technicians into the field.  I believe BHT create a great opportunity for supporting intensive, wrap around services, while implementing a needed step in the behavioral healthcare career ladder.  The draft CPST service definition states that a minimum of 2 years’ experience will be required for working with SMI/SED individuals.  Are there any opportunities for BHT to acquire 2 years of related work experience within the proposed CPST system? The two years of experience is not a current requirement for BHT professional registration.

Caseload size limits, while in theory, support quality of services, cannot meet universal standards.  Client acuity and current needs dictate providers’ time commitments. 

Under “Workplace or Instructional Setting Assistance” it appears to articulate work readiness type activities including limited components of job coaching.  Will these activities and reimbursement be impacted if clients have been referred to or receiving employment readiness/placement services from DARS or a contracted job coaching service?  Will a behavioral healthcare agency need to be contracted with DARS as an Employment Service Organization or follow any specific vocational rehabilitation/employment services models (i.e. individualized placement services, supported employment, etc.)?

How will approval for an agency’s selection or implementation of a research-based model of service delivery work?  Are there any recommended program models for serving individuals with serious mental illness?    What happens if the fidelity to a rehabilitative, EBP service model does not align with the CPST service definition?  Will DMAS identify the appropriate level based on the fidelity of the service modality? 

Service providers will need funds to provide required CPST trainings, pivot to other systems of care, train and hire new staff.  How will technical and financial support be provided?

I appreciate the efforts to develop a new system of support for some of the state’s most vulnerable individuals.  Thank you for any and all efforts to respond to the feedback regarding the CPST Draft Service Definition.

Thank you for the opportunity to express concerns and suggestions related to the redesign of many CMHR services. 

Requiring a LMHP to complete the assessment, develop the treatment plans, complete quarterly reviews of the TX plans, and also provide direct services while result in an increased turnover rate.  The additional responsibilities will become overwhelming to our LMHP staff and lead to burn out.  Due to workforce shortages, CSBs are already challenged with hiring and retaining staff.  If these changes are made, CSBs are going to need additional LMHP staff.  CSBs will experience an increase in salary expenses as a result of hiring more LMHP level staff.

There is a benefit to the LMHP completing the assessment (CNA).  When the assessment is completed by a LMHP, it can be utilized by other program areas.  Currently, the QMHP level staff are developing the TX plans, conducting the reviews, and providing direct services.  These responsibilities should remain with the QMHP role.  The QMHP will most likely spend the most time with the consumer.  The QMHP will have the most accurate knowledge of the consumer’s needs, desired goals, and strengths to develop a person-centered TX plan.    

Introducing another assessment tool to staff will lead to many challenges.  Staff have many concerns about the amount of documentation that is required currently to meet both DMAS, MCOs, and licensure regulations.   One of the retention efforts, was to reduce documentation when possible.  STEP-VA (DBHDS) already requires the DLA-20 to be used by CSBs.  The DLA-20 helps to assess the consumer’s level of functioning.  The results of the assessment tool would support the criteria for SMI or SED.  Instead of using the CANS/ANSA, could the DLA-20 in conjunction with the CNA also met the recommendation of a standardized assessment. The CANS/ANSA is completed in another database.  The DLA-20 is completed within the CSBs electronic health records.  Data is already being collected directly from the EHR.

 Peer recovery support services is an EBP and is proven to be an effective component of treatment.  Peer services can be provided to both the youth and adult population. Peer recovery support services are included in STEP-VA but not included in the CPST model.  There are not any services the CPRS staff are able to provide.  To include Peer services would be very beneficial to the consumers. 

The Case Management service is the hub of a consumer’s mental and physical health care.  Case Management is very beneficial to consumers and providers.  Case Management service includes care coordination between all providers linked to the consumer.  This service ensure that all providers have up-to-date, accurate information which is necessary to deliver effective treatment and services to the consumer.  Case management arranges, links and monitors the services the consumer needs to improve their level of functioning in the community.  There are many times case management is the only service a consumer is engaging in even when there is a need for additional supports.   To remove the ability for a case manager to provide brief counseling, psychoeducation, community integration, and the option to make collateral contacts would be a disadvantage to the consumer.  Due to waitlists and limited resources in the community, the consumer will not have their immediate needs met.  There are also times, the consumer refuses to participate in multiple services or speak to different providers.  Case management has been able to fill in the gaps until the consumer is ready to purse the appropriate level of care or it becomes available. The current case management model allows for staff to help the consumer maintain their mental stability in the community, even when the consumer is not in crisis or have an immediate need but to serve as a prevention measure.  Some consumers may need supports long-term to remain independent in the community.

Redesigning services has its benefits and challenges.  Making changes to so many service areas at one time is going to be very overwhelming to consumers, CSBs, and other providers.  It will also be costly.  Communities do not have all the resources needed to provide the quantity of CPST services that will be needed, if case management becomes limited.