While we support the goals of improving access, quality, and outcomes, we believe the proposal remains sufficiently complex and lacks the critical operational, fiscal, and implementation details needed to fully assess its impact on individuals receiving services, providers, workforce capacity, and long-term sustainability. At this stage, several key elements remain unclear, including:
The current draft significantly expands provider responsibilities through new requirements for implementing evidence-based practices, managing referrals, coordinating crises, measuring outcomes, communicating with MCOs, training and supervising the workforce, and providing administrative oversight. However, stakeholders have not yet received sufficient information about the assumptions underlying the proposed rates or how the expanded service expectations are intended to be operationalized. Additional transparency regarding these assumptions is necessary to evaluate implementation feasibility, workforce implications, financial sustainability, and the overall impact on the client experience. We remain concerned that the policy requirements and reimbursement structure may not yet be sufficiently aligned to support successful statewide implementation.
Before final implementation, we encourage DMAS to provide greater transparency into rate-development assumptions and to assess the redesign's cumulative impact on client access, provider capacity, workforce sustainability, and the overall client journey. The ultimate measure of success should be a system that is clinically effective, operationally feasible, financially sustainable, and easier for individuals and families to navigate.
Impact on the Client Journey: The redesigned model introduces several new decision points, including specialty service screening, referral requirements, crisis planning, treatment planning, reassessments, and transition evaluations. While each requirement may be appropriate on its own, the cumulative effect may create a more complex pathway to care than currently exists. We encourage DMAS to evaluate the redesign from the perspective of individuals and families seeking services and to ensure that implementation simplifies, rather than complicates, access to care. Success should ultimately be measured by whether individuals can access services more quickly, more easily, and more effectively.
Expansion of CPST Responsibilities: The revised draft substantially expands CPST's scope beyond traditional rehabilitative interventions. As proposed, CPST providers are expected to deliver treatment, coordinate care, manage referrals, participate in crisis planning and response, communicate with MCOs, monitor outcomes, and meet fidelity requirements. Collectively, these responsibilities encompass psychosocial rehabilitation, mental health skill-building, case management, care coordination, crisis prevention, and treatment planning. We encourage DMAS to clearly define CPST's intended role within the continuum and to ensure that reimbursement, staffing assumptions, and productivity expectations align with these responsibilities.
Crisis Response Responsibilities: We support proactive crisis planning and coordination. However, several provisions appear to expand CPST responsibilities into areas traditionally managed by Virginia's established crisis system, including 988, Mobile Crisis Response, CSB Emergency Services, Crisis Stabilization Units, and hospital-based emergency services. We recommend clarifying that CPST providers coordinate with existing crisis resources rather than serve as a primary crisis response entity, thereby reducing duplication and role confusion.
Continued Stay and Long-Term Recovery: We support measurement-based care and outcome monitoring. However, many individuals receiving CPST have serious and persistent mental illnesses that require long-term support to maintain stability and prevent deterioration. The policy should explicitly recognize outcomes such as avoiding hospitalization, maintaining housing, sustaining employment, remaining engaged in treatment, and preventing relapse as meaningful indicators of success. Individuals should not be required to demonstrate continuous functional improvement to retain medically necessary services.
Administrative Burden: The revised draft significantly expands requirements for documentation, reporting, referral tracking, crisis planning, MCO communication, and treatment planning. While accountability is important, excessive administrative requirements may reduce direct service time, contribute to workforce burnout, and divert resources from clinical care. We encourage DMAS to streamline documentation expectations and eliminate duplication wherever possible.
Workforce Capacity: We appreciate DMAS' recognition of workforce challenges and its temporary flexibility regarding Clinical Director and Clinical Supervisor qualifications. However, the redesigned model requires more supervision, training, documentation, care coordination, and clinical oversight, even as behavioral health workforce shortages remain significant. We encourage DMAS to closely monitor workforce impacts, provider capacity, network adequacy, and access-to-care indicators throughout implementation.
Coordinated Specialty Care and First Episode Psychosis: We strongly support Virginia's continued investment in Coordinated Specialty Care (CSC) and in developing a sustainable, Medicaid-funded service for individuals experiencing First-Episode Psychosis. As implementation progresses, we encourage DMAS to maintain flexibility in engagement strategies, family participation, telehealth use, transition planning, and fidelity expectations. Successful early psychosis intervention often requires individualized approaches that cannot always be captured by rigid service thresholds.