4.1 Assessment 

• It is strongly requested by HopeLink that DMAS consider allowing, or requiring, the CANS-Lifetime as an assessment tool for Clubhouse services. While we appreciate the attempt to lessen the clinical burden for Clubhouse, we do not believe that the differences in assessment requirement achieve this goal, as a Comprehensive Needs Assessment still requires completion by L-type staff, and is still an intensive and involved assessment that requires just as much, if not more, clinical burden. It would be far easier for our agency, and we assume many others, to be able to use the same assessment tool that the other redesigned services also plan to use, for continuity and consistency across both staff and consumers. It is also preferred, and in our opinion, appropriate, to be reimbursed for assessments at the rate that the CANS-Lifetime assessment generates, since both assessment tools require the same level of clinical expertise, and both require similar levels of time and effort. 

• If DMAS decides to retain use of the Comprehensive Needs Assessment over the CANS-Lifetime, clarification/additional detail is requested regarding Item 2, “The Clubhouse may use an assessment completed within the 12 months prior to admission and update this assessment in-person with the member.” It is unclear how this would work in practice, including what types of assessments may be used, who may complete them, and how “updating” of the assessment should be documented. 

4.3 Rehabilitative Skill Building 

• Item 3- while the general staff-to-member ratio introduced in an earlier section is appreciated, it is recommended that the cap on group sizes introduced in this section be increased or removed. It is not uncommon for psychoeducational groups to exceed 20 members to 1 staff, and capping group sizes can affect client choice. Strategies for managing group sizes and identifying appropriate activities for larger groups should be left to the agency to manage. 

4.4 Crisis Support 

• As in our previous public comments, we would like to again recommend consideration that crisis plans are not required for all members, and instead, recommend that requirement of a crisis plan be based on clinical necessity and left to the discretion of the licensed staff oversight. It is neither client-centered nor clinically necessary/appropriate to require a crisis plan for an individual who has never had a crisis and who presents with very low crisis risk factors. Given the lower-intensity nature of Clubhouse services, we expect to have a number of individuals in programming to whom this applies. These individuals will not be able to provide information like warning signs and preventative/recovery strategies, because they have never had a crisis or a situation that would require them to know what crisis looks like for them. Many members who are at low risk for crisis are resistant to creating a crisis plan because they do not need one.  

• Recommendation: crisis plan requirements be updated, either to include a list of criteria that would necessitate a crisis plan (such as certain symptoms or history), or to include language that leaves determination of clinical necessity for crisis plan up to the licensed staff. 

• It is recommended that the requirement that the crisis plan be reviewed “with the member every 90 calendar days” be removed or updated, as this is inconsistent with the language in the CPST and CSC draft manuals, which both state instead that the crisis plan be reviewed “on a regular basis.” 

5.1.2 Age Requirements 

• 5.1.2- it is recommended that the requirement for utilizing the EPSDT be further clarified or removed. It is unclear to our organization how the EPSDT tool is able to be used to “review for medical necessity” as the draft manual states. It is unclear what the connection is between EPSDT screenings and Clubhouse, as Clubhouse does not appear to be a covered service under EPSDT. 

5.1.3 Diagnostic Criteria 

• It is again strongly recommended that the list of required DSM diagnoses be removed or significantly broadened, and that the requirement of a physician letter for necessity of services outside of that list be removed. This recommendation is for the following reasons: 

• Currently there is no similar requirement for PSR services, and medical necessity criteria including level of impairment relative to diagnosis is left up to the licensed clinician performing the assessment.  

• It is very common for psychosocial rehabilitation to be appropriate for individuals with a variety of other DSM diagnoses, including personality disorders, OCD, Major Depressive Disorder, and Specific phobia. Making diagnostic criteria more restrictive with the transition to Clubhouse will reduce access to services, not improve it. 

• The requirement of a physician letter carries an implication that the licensed clinician completing the admission assessment is incapable of using the functional impairment criteria to determine clinical appropriateness for services, which is untrue and somewhat insulting. 

• The requirement of a physician letter is a current requirement for MHSS services. HopeLink can share from experience that the requirement does nothing to ensure appropriateness for services, and instead simply acts as a barrier to services. Physicians almost never understand what they are being asked to write, they are usually unfamiliar with the service, and they are difficult to get ahold of and slow to provide the letter. Creating more hoops to jump through for arbitrary reasons is nothing but a barrier to service. 

5.3 Discharge Criteria 

• Item 4a- we appreciate the specifics regarding discharge for non-engagement and exactly what the terms of “non-engagement” should look like. 

7.1. Service Authorization- General Requirements 

• It is requested that the authorization timeframe be updated from 6 months to 12 months, which was the initial timeframe in the 1st draft of Clubhouse regulations and which was preferred. This seems reasonable for a lower-level maintenance program like Clubhouse, especially if MCOs are expected to authorize no fewer than 24 months of service (see next section). 

7.2.3 Minimum Service Requirement 

• It is suggested that the language in this section be updated, as there are many appropriate reasons why an individual would receive fewer than 24 months of service (client-elected discharge; relocation out of state; discharge due to non-engagement, etc). If this section was intended to state that MCOs should authorize no fewer than 24 months of service, the language should be updated to make this clearer. 

8.2 Weekly Progress Note 

• It is suggested that the requirements for this progress note be reconsidered as a monthly progress note rather than weekly, as the amount of information required for this progress note, on a weekly basis, is somewhat high for a low-touch program like Clubhouse.