As a provider of community mental health services, I have a number of concerns about these regulations.

Re Coordination of care: I strongly concur with the acknowledgement of the family system as central to the individual’s functioning. However, Intensive In-Home services are not equivalent to family therapy at a high dosage. The service addresses complex social and emotional factors in the lives of individuals and families. Behavioral health problems are influenced by a wide range of social factors both inside and outside of the family. Best practice dictates that providers working with high-risk clients involve as much of the individual’s support network as possible. Reducing the focus solely to the individual’s health care, and ignoring other parties involved in the individual’s life, such as schools, courts, social service agencies, childcare providers, mentors, and so forth, will not result in better outcomes. Instead, I will see more fragmented and less effective treatment.

If a family is socially isolated, or has problematic ties to the community, focusing strictly on the immediate family can be a losing proposition. To strengthen such a family’s structure, providers cannot be limited to interacting only within the family system.  Preventing the involvement of other important individuals is antithetical to best practices as detailed in both wraparound and systems of care philosophies. Limiting providers’ ability to support the family in advocating for their needs with external stakeholders will also lead to a higher level of referrals for Medicaid-funded case management services.

I therefore recommend that the definition of care coordination be expanded to include collaboration with all agencies and individuals involved with the family, as required to improve individual and family functioning.  I also recommend that when formal case management services are necessary, private providers be allowed to provide these services. This will prevent overloading the Community Services Boards with referrals, improve access to care, and decrease care fragmentation.

Regarding services outside of the home: Requiring that the documentation describe “how the alternative community service location supports the identified clinical needs of the individual and facilitates the implementation of the ISP” seems to entail that the provider document a clinical rationale for the specific location chosen for every session in which any services are provided outside of the home. However, the specific location may have been chosen based on mere convenience or proximity to the home. This language creates an additional documentation burden for providers, without adding any clinically relevant information to the record.

Families may be sharing their residence with relatives or others, or have frequent visitors in the home. Some individuals need regular opportunities to consult with the provider outside of the presence of family members. The current regulations are specific enough to prevent inappropriate out-of-home services, while allowing for the flexibility that clinicians need to provide effective services when privacy is lacking in the home. In contrast, the draft regulations would open the door to subjective retractions and lengthy appeals processes, and could lead to less effective treatment for some individuals.

Re: the specification that clients must have “documented” repeated interventions in order to meet criteria for the service:  Parents, legal guardians, and referring agencies provide a verbal history of prior interventions during the intake process. Providers are required to obtain clinically important documentation such as VICAP assessments and recent psychological evaluations. However, expecting providers to obtain records from all prior providers cited in the intake documentation is not realistic. Former providers may be out of state, or no longer operating. Parents/guardians often do not recall dates, or the names of agencies and individuals. Service providers do not always respond to requests for records, despite proper authorization.

Providers already spend a great deal of time and expense compiling extensive documentation. Obtaining the records needed to meet the existing regulations and provide proper care often requires repeated requests and follow up. Providers are not reimbursed for this time. The new wording of this regulation places an additional and unnecessary burden on the provider.