As as provider of community based services, formerly an employee of a company, and now an owner, I would like to add my concerns about the proposed changes.  Since my colleagues have been very articulate and I support their commentary I would like to make a general comment regarding Intensive In-Home services.  The goal of IIH is to support individuals and their families with managing challenges related to mental health diagnoses.  I believe our goal is to keep the client and family at the center of the picture while the language of the regulations, in my opinion, presents an effort to control outcomes rather than to guide the process. 

If we are serving the best interests of the client and continuity of care is an objective, it would seem in the best interest of the client to collaborate with the entities that the client and family wish to have as part of their support system or with whom they need to relate to and avoid fragmentation of services. 

Regarding repeated interventions, the clients that we serve have often escalated, sometimes gradually, to behavior that is of significant concern.  If families cannot receive services prior to "hospitalization, incarceration, multiple suspensions/interventions, it is often at such a clinically critical point that IIH intervention can be like a bandaid effect.  The children in our community need and deserve service intervention at a much earlier juncture, not after multiple failed attempts in out-patient therapy, etc. 

ISP signatures:  once again, if the client and family are at the center of the picture, this should be a matter of clinical concern for the client, family, and team, an indication that possibly goals and objectives need to be revised.....this is clinical information and a working document for the client.

I have worked with families where identified individuals have had the opportunity to visit with a grandparent or other relative as a break from the conflictual relationships.  Once again, if the individual and family are at the center of the picture, the concern should be focused on the effectiveness of the interventions - there are no hard and fast rules about families.  And, where continuity of care is concerned and individuals are transitioning from a facility/hospital to home I believe IIH counselors need to begin services where the clients are, at least one to two weeks prior to discharge.  Individuals and families are desperate at this point - they need supportive intervention and to know and begin to build a relationship with their counselor.  Anticipation, preparation, and prevention and safety are very important components in the initial stages, especially, in the provision of services. 

Finally, regarding the 24 hour signature on the intake asessment. This is unrealistic given the expectations and documentation requirements at the present time.  In my agency there are certainly verbal and consultative exchanges that begin with referral and I would like to think this is a common practice in many agencies. 

Finally, in the revision of regulations I hope the committee will be focused on what is in the best interest of the individual and family.  Each situation is unique and requires significant clinical insight and ongoing evaluation to effect interventions that are going to lead toward accomplishing the goals of each individual ISP.