The Hampton Newport News Community Services Board appreciates the opportunity to provide feedback on the proposed Mental Health Clubhouse Services as part of the Commonwealth's Right Help, Right Now behavioral health redesign initiative. We recognize the value of psychosocial rehabilitation and community integration models, and remain committed to working collaboratively with DMAS to ensure that the implementation of Mental Health Clubhouse Services enhances access to care while maintaining services quality, workforce stability and provider sustainability. However, we have several concerns regarding the structure and implementation of the proposed Clubhouse model and its potential impact on service delivery, ethical concerns, fiscal responsibility, workforce stability, and access to care. Additionally, the requirement to obtain and maintain Clubhouse International accreditation introduces both financial and operational challenges. We have reviewed all policy changes and have the following recommendations;
3.1 Clubhouse Staff Requirements:
The policy states a full-time Program Direction with the Clubhouse International training who holds a current, active, and unrestricted Virginia registration or license from the Department of Health Professions. *Recommend that the Program Director with QMHP be eligible to complete required assessments noted in Section 4.1. This will lessen the fiscal impact and allow programs to operate more cohesively with full-time Program Director responsible for overseeing operations to include admitting new members and ongoing authorization of services.
*The staffing and leadership requirements may present challenges for provider sustainability. The requirement for full-time Program Direction with specialized training, along with ongoing LMHP involvement introduces additional staffing costs. Given current workforce shortages, particularly among licensed professionals, these requirements may limit the number of providers able to successfully implement this model.
*The Services Definition and Critical Features is contradicted by the Provider Qualification Requirements and several burdens with Services Authorization, Documentation Requirements and Utilization Reviews outlined in the various sections of a very clinical approach to the Clubhouse International Model which is supposed to be a member driven, collaborative approach to rehabilitation services.
3.3 Staff Training Requirements
The policy states all staff are required to receive training as required by Clubhouse International and all newly DMAS enrolled Clubhouses shall send a team to an authorized Clubhouse International training based within the first 12-18 months of operation, and staff are expected to participate in training or specialized tracks as a conditional of maintaining accreditation in good standing. *The required comprehensive clubhouse training and ongoing training to maintain accreditation is very costly- will funding or grants be made available? The suggested per diem rate of reimbursement does not support staff training requirements, please consider rate of reimbursement review.
3.4 Licensing and Enrollment Requirements
The policy states that providers shall submit with their DMAS enrollment application evidence of their initiation of the accreditation process or their formal accreditation with Clubhouse International. *However, if the service requires external accreditation for Clubhouse Internation, there should be consideration for alignment with DBHDS licensing requirements to reduce administration burden for annual review.
3.6 Clubhouse Operation Requirements
The policy states the Clubhouse shall have an independent board of directors, or if affiliated with a sponsoring agency, shall have a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support, and advocacy for the Clubhouse. *However, an independent board of directors requirement is a difficulty requirement for CSBs who have existing board of directors. Recommend that you consider an advisory council comprised of program leadership and members.
4.2 Service Planning
The policy states at a minimum, the ISP shall be signed within 30 days of admission and 15 days of an ISP review by the Program Director or LMHP/LMHP-type performing the assessments. *The Clubhouse International Medel is not a clinical service therefore, recommend allowing the staff providing the service to sign it instead of the Program Director or LMHP.
5.1 Admission Criteria
Clubhouse International standards are very specific to membership in standards 1-7 so this section, as well as most others, are asking us to do additional requirements for DMAS on top of the already stringent CI standards and training. Membership is voluntary and part of the success of Clubhouse Internation is the members choice and active involvement in the community which does not involve criteria and assessment to become a part of, so this contradicts their standards and poses many ethical dilemmas for service providers.
7.1 Service Authorization Requirements
The policy states for both Preservice and Concurrent Authorization Requests that the DMAS form be completed along with initial assessment or addendum to the initial assessment and initial ISP or updated ISP, which again is an additional requirement than current PSR policy. *Recommend that DMAS waive the service authorization requirements due to additional training requirements and documentation demands. This is another burden for programs that are operating on minimal staff and increased member enrollment to ensure funding to support program operations. Services registration via MCP or Kepro portal should be sufficient for the change in level of care and additional expectations of providers for clubhouse services. If not willing to consider registration only for clubhouse, please consider revision to the service authorization request form to condense the process and allow for providers to submit the Comprehensive Needs Assessment, Treatment Plan and corresponding quarterly review in place of the DMAS authorization form for clubhouse services. Notable, all the information included in the CNA and ISP for new admissions is duplicated in the service authorization forms and just creates more documentation when current assessment and treatment plans meet criteria.
Section 8. Additional Documentation Requirements and Utilization Review
The proposed documentation and operational requirements represent a notable increase in administrative burden. The introduction of daily attendance logs, weekly progress notes, structured service planning timelines, supervision requirements, and ongoing accreditation processes will require significant administrative oversight. While accountability is important, these expectations may divert resources away from direct service delivery if not supported by appropriate reimbursement structures.
8.3 LMHP Review
The policy states that an LMHP must review the documentation of all non-LMHP staff at least every 30 calendar days. *LMHPS currently provide assessment initially and every 6 months ongoing with progress notes and CNAs annually. Program Director or QMHP supervisor providing supervision should be sufficient for oversight of services provided at clubhouse to include review of documentation, specifically Program Direction who can be a QMHP per staff requirements and already doing monthly supervisions per 3.2 Staff Supervision Requirements and 3.1 Clubhouse Staff Requirements.
Furthermore, significant ethical concerns related to the double bind we are put in by being required to obtain a specific accreditation and then knowingly bill for the services which are directly in conflict of the standards of that accreditation. This is in relation to how the draft requirements do not align with clubhouse international standards however, we are expected to gain accreditation and uphold those clubhouse standards but not in their entirety per DMAS interpretation. Further ethical concerns are in regard to multiple psychosocial programs having already shuttered in anticipation of unaffordable transitions, leaving individuals in those areas without vital support. We fear this trend will continue unless meaningful changes are made, and we want to ensure DMAS understands the very real human impact of these regulations.
Thank you for allowing us the opportunity to offer recommendations and comments to this policy.