Thank you for the information provided in the Open Office Hours today. Based on that conversation, I wanted to compile some of my thoughts on the supervision requirements and possibly some suggestions. I also want to ensure that my reading/understanding of the regulations is correct.

My understanding of supervision requirements:

Based on my reading of the requirements, here is what I see being asked of LMHPs for supervision. 

1. There is 1 Clinical Director, the LMHP who is over the whole program. This director must at-minimum provide 1 hour of supervision to each other LMHP involved in CPST. They may or may not supervise direct care staff depending on factors like the size of the agency/number of staff.

2. Underneath the clinical director are clinical supervisors, also LMHPs, who can supervise LMHP-Es/QMHPs/BHTs. They can supervise up to 9 staff.

3. Each week, team meetings must occur. These can count towards group supervision hours. Though a minimum time is not established, there has to be enough time to allow for brief discussion of each client as needed (is it required to discuss each client, or are staff able to select the clients they need to staff?)

4. At least 1 hour per month must be individual supervision for all non-licensed staff.

5. At least half of the supervision hours must be in-person for all non-licensed staff.

6. This means that at-minimum, 1 team meeting is in-person each week, and clinical directors are meeting in-person for 1 hour per month with each staff member they supervise.

Supervision Implications: 

1. Clinical directors who have a full 9 staff will spend at least 3-4 hours in supervision each week, not including travel time for in-person supervisions, research, and preparation (i.e. planning a topic for skill-building and researching the information for that topic). That is

   • 1 hour per week for team meetings (if more time is not necessary, which it could be if multiple clients need to be discussed);

   • 2-3 hours per week for individual supervisions to see all 9 staff throughout the month;

   • And 1 hour of individual supervision with the clinical director each month. 

   • Plus any required research, planning, preparation, travel, etc.

2. Staff will likely be receiving closer to 5 hours of supervision each month at minimum (4 hours in team meetings + 1 hour of individual supervision). 

3. Staff must meet in-person for at least 1 team meeting, or must plan for additional supervision, in order to meet the in-person requirements. Travel will be either put onto the staff to go to the clinical supervisor or the supervisor to go to the staff, further increasing time devoted to supervision.

Supervision Questions:

1. What happens if staff are on PTO for a week? Is the supervision required to be made-up at some point in the month. That would add additional hours of supervision requirements for Clinical supervisors and further decrease flexibility in their schedule.

2. What provisions are made if a Clinical Supervisor is on PTO for a week and a team meeting must occur?

Supervision Ideas/Suggestions:

1. I fully support LMHP oversight and understand the intentions behind that! However, I have some ideas on how the demand on LMHPs could be decreased while still allowing for clinical integrity.

2. One idea is to differentiate between some of the clinical supervision hours, which could occur during team meetings, versus other areas of supervision.

   1. For example, team meetings can specifically focus on clinical improvement such as teaching skills/strategies/tools to staff, ensuring clinical interventions are being applied appropriately, reviewing ISPs and progress/lack of progress, staffing major client concerns, etc. 

   2. Other forms of supervision such as administrative (overseeing paperwork, reviewing documentation, etc.) and restorative supervision (checking on staff well-being, job satisfaction, preventing burnout) could be done by LMHP-Es and qualified QMHPs. Having LMHPs involved in weekly team meetings while individual supervision is done by other staff members would significantly decrease the amount of time LMHPs have to spend in supervision and would increase availability for other clinical oversight such as staff who need to discuss a specific client in more detail or when crises arise. 

   3. Additionally, if LMHP-Es and QMHPs are providing supervision, this could streamline treatment questions to LMHPs. Rather than having 9 staff trying to discuss various clients and personal needs, some of these questions can be resolved by the LMHP-Es and QMHPs. Then, any significant client issues or staff needs could be taken to the LMHP directly through one source rather than each staff member going to the LMHP. Considering that LMHPs could have extremely high numbers of clients that they are responsible for, this again is more likely to improve services as LMHPs could focus more on the biggest clinical needs rather than spending time in supervision or traveling around to each staff individually.

   4. If this were the case, there could be site supervisors directly available on-site to staff for supervision. This could decrease travel time and increase in-person availability. For example, an LMHP-E or qualified QMHP could serve as the supervisor traveling to different sites to meet with their staff. They resolve certain issues (can't get in touch with guardian, staff is struggling with paperwork, unsure of how to support client with specific problem, conflict with a teacher, etc.). Then team meetings would allow LMHPs to focus on bigger client needs (crises, lack of progress, needed changes to ISP, etc.) and still provide direct LMHP oversight.

Ultimately, I believe that the biggest concerns for the current draft supervision structure are the following:

• There are concerns about being able to staff enough LMHPs to sustain the amount of services needed in our area. Many LMHPs do not want to spend that much time in supervision if they want to work in community-based services at all. The high level of administrative burden has the chance to decrease the amount of Licensed staff available even further.

• Similarly, although the supervision is stated to have been included in the rate reimbursements, I have seen many comments questioning if those rates will be competitive enough for LMHPs to be retained. In addition to the supervision, there are other nonreimbursable activities such as likely being on-call at times (as part of the crisis requirements), attending every quarterly ISP review for each client they are supervising (per the regs), and traveling to various school sites. How many LMHPs will be willing to do this instead of the outpatient side with more flexibility and likely more money?

• The administrative requirements also require a lot of scheduling and planning, including relying on guardians to respond to requests and keep appointments (i.e. intakes, reassessments, 90-day reviews, etc.)

I am hoping that some adjustments can be made to make better use of licensed staffs’ time and skills. I think there are several areas where LMHP-Es and QMHPs are capable of high-level services, so allowing their involvement would be an improvement to quality rather than a detriment. Thank you for your consideration and request for ideas on this matter.