Requiring mobile crisis be provided 24/7: Requiring programs to provide 24/7 coverage may not be possible as programs are being implemented. 24/7 may not be possible due to work force shortages. Providing some coverage, versus no coverage, should be allowable in order to benefit the community, as long as other service provisions are met. Alternatively, less than 24/7 could be allowable for a designated period of time of implementation and allowances made for good faith efforts to staff.
Page 11, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services” This is contradictory to the statement “At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service.” This requirement will lead to decreased response time, increased call volume that call centers do not have capacity to receive. It is recommended that the requirement be removed totally or amended to require engagement with the data platform only.
On Page 15, under Staff Requirements, the billing structure and team composition only allows a peer to provide services when paired with another professional. In crisis response, there are many instances that a peer can independently engage, support, transport and perform activities that will assist with the de-escalation of a crisis episode. It is recommended that peers be allowed to bill independently for Mobile Crisis Response services if the individual has been assessed and determined that peer recovery services are appropriate to assist with crisis resolution.
On Page 18, under Service Authorization, it states that the registration permits eight hours (32 units) in a 72 hour period”. Billing should be allowed for the entire time that the service is permitted, which is 72 hours. It is recommended that Mobile Crisis Response be permitted for billing up to 72 hours.
The manual notes Preadmission Screening Clinicians (prescreeners) who are not LMHP or in supervision need to have their assessments signed off by a LMHP.
We continue to advocate that billing for this level of staff be allowed based on existing State Level Certifications (suggest attempting to get a waiver to make it allowable). Staff that meet the 2016 certification document standards are well trained and qualified to provide the service, many have been doing so competently for many years. The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building the crisis system of care.
“Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be required which includes care coordination and communication with the individual's MCO or FFS contractor, service providers and other collateral contacts.” It is not clear what this means in terms of MCO and FFS and why this is included? There are times a one-time intervention will be all that is needed to de-escalate for mobile crisis, or, collateral and provider contact may not be allowed per patient request. Recommend rewording throughout: “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be provided as appropriate and which can include other service providers and collateral contacts.”
Community Stabilization:
On Page 24, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis data platform prior to initiating services.” Please define the term “engage”. It is recommended that “prior to initiating services” be removed and replaced with “as services are initiated”. Services should be client-centered and aim to assess prior to engaging with data platform. The revision gives flexibility to providers as services are being started.
On Page 32, under Staff Requirements, peers are not allowed to provide services independently. It is recommended that peers be allowed to provide Peer Recovery Services without the presence of another professional. The best engagement is often times when peer-to-peer services are provided independently.
On Page 34-35, under Service Authorization, Community Stabilization no longer allows for registration. It is recommended that the registration process remain for this service in order to provide services to individuals in an efficient, time sensitive manner that does not focus on paperwork.
Page 35, where it indicates a documented referral from a discharge provider… this is another requirement that takes away from focusing on the individual and addressing their crisis in a timely, efficient manner. Also a requirement to contact the MCO to determine what other services are being provided before starting services is a deterrent to the individual who is in crisis and the provider as it is an inefficient use of time and resources to ensure the individual is receiving timely services to address the crisis.
23 Hour Crisis:
Several places in the manual refer specifically to use of a Psychiatric Nurse Practitioner. Many Nurse Practitioners have provided psychiatric care for numerous years. Psychiatric NPs are more rare, and relatively newer. Nurse Practitioners in general should be allowed to complete evaluations for RCSU and 23 hour observation units if they are operating within their scope of practice. This is particularly appropriate in these settings that may see a number of individuals who have medical comorbidities and SUD problems at admission. Recommend broadening the ability to utilize Nurse Practitioner throughout
Page 48, requiring a LMHP to supervise the program. There is no reason why an LMHP resident or social work supervisee could not supervise the programming when under supervision of an LMHP. The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building this system of care.
