I attended the VACSB session on Medicaid redesign and someone very astutely asked, "What problem are we trying to solve with the new regulations for Mental Health Case Management?"  That question kept ringing in my ears as I read these draft regulations.  There is a general lack of clarity in the regulations that make it difficult to understand the overall vision for this project (beyond saving the Commonwealth money).  A few examples:

   1.  On page 4, the regs state that mental health case management does not include the provision of direct clinical services.  However, on page 7 under the heading Staff Qualifications and Requirements they require case managers to be knowledgeable of treatment modalities, intervention techniques, supportive counseling, independent living skills training, and crisis intervention.  Why should they be required to b   2.  e knowledgeable in all these areas only to be told that they should not provide these types of interventions?  It would seem DMAS has a very poor understanding of what case management looks like "in the field".  Our case managers do all of these things to the great benefit of the individuals we serve.  Which is it? Should case managers provide effective care or not?  Please clarify.

On page 5,  it is stated that the case manager shall "continuously" monitor the appropriateness of the ISP.  What is meant by continuous?  Is this an increase in the expectation for quarterly reviews every three months?  Please clarify.

   2.  On page 12, under the case load requirements section,   item 4 references the "ratios" above, but items 1-3 do not make reference to ratios.  They reference total number of cases.  The whole thing is an unnecessarily complicated classification system that will prove difficult to track in our EHR.  It seems an attempt to strip case managers of the freedom to apply their own clinical knowledge and knowledge of the individuals on their caseload to act nimbly to meet the needs of those they serve.  It also creates an onerous expectation that we will track the average hours of service that each individual receives.  This seems misaligned with the notion that the intensity of the need drives the amount of service provided.  If everyone gets an average of two hours per month of service, why do we need classifications?  Again, what problem are we trying to solve?  

3.   On page 6, what, exactly, is meant by the case manager shall "revise the ISP whenever the amount, type, or frequency of services rendered by the individual's service providers change"?  What degree of granularity is indicated here?  Does this include all service providers, both internal to the agency and external?  If this is not clear, I could see us being cited because a medication change is not reflected in the individual's ISP, or a therapist begins EMDR with a client, etc.  If that is the expectation, we really will be treating the chart more than the individual.