Virginia Regulatory Town Hall View Comments

Department of Behavioral Health and Developmental Services

State Board of Behavioral Health and Developmental Services

Guidance Document Change: The Department of Behavioral Health and Developmental Services is proposing revisions to the Infant & Toddler Connection of Virginia Practice Manual to address these topics: implementation of Virginia’s new statewide early intervention data system, TRAC-IT; use of telehealth in early intervention; new national guidance/clarifications; clarifications requested by early intervention providers; and newly recommended social-emotional screening and assessment practices. Chapters 3-9, 11-12 and the Glossary include updates to reflect Virginia’s new statewide early intervention data system, TRAC-IT, and the resulting shift from paper forms and/or the old data system, ITOTS, to online data entry in TRAC-IT. Other chapter-specific revisions include the following: 1. A note about references to TRAC-IT in the Practice Manual has been added on page 2 to explain that references in the Practice Manual to TRAC-IT data entry are not a complete guide or manual for using TRAC-IT or for all required data entry. 2. Revisions in Chapter 3 – Referral: VISITS links, contact information and procedures have been updated on page 16. 3. Revisions in Chapter 4 – Intake: An explanation of new Medicaid coverage types was added on page 19. Procedures for collecting race/ethnicity were updated on page 20 to align with new federal guidelines. New recommendations for social-emotional screening were added on page 23 to support early identification of delays or concerns in this area of development. 4. Revisions in Chapter 5 – Eligibility Determination: Changes on page 43 clarify that CMV and toxoplasmosis automatically qualify a child for early intervention if symptomatic, to ensure consistency with the definition of “congenital infection, symptomatic” on page 40. 5. Revisions in Chapter 6 – Assessment for Service Planning: Two new recommended family assessment questions were added on page 55 to help the IFSP team better understand the child in the context of their family as the team, including the family, considers IFSP outcomes and services that will increase the family’s competence and confidence to help their child develop and learn. On page 56, recommended social-emotional screening and assessment practices were added to support early identification of delays or concerns in this area of development. 6. Revisions in Chapter 7 – IFSP Development: Information about virtual IFSP meetings and telehealth service delivery was added on pages 65-67. Consequences of not receiving a timely physician certification for the IFSP are now delineated on page 70. The new wording explains existing policy that was not previously included in the manual. Changes on page 72 update the steps to take when documenting a family’s decision not to receive a service(s) recommended by other IFSP team members. 7. Revisions in Chapter 8 – IFSP Implementation and Review: Recommended practices for ongoing social-emotional screening was added on page 108 to support early identification of delays or concerns in this area of development. Consistent with the revisions in Chapter 7, pages 118-119 and page 127 update the steps to take when documenting a family’s decision not to receive a service(s) recommended by other IFSP team members. Additional language on page 137 clarifies expectations for actions and documentation when the local school division does not respond or fails to attend the transition conference. This wording was added to ensure alignment with updated federal guidance documents. 8. Revisions in Chapter 10 – Dispute Resolution: Revisions were made on pages 154 and 157 to align the timing for signing a confidentiality pledge in mediation with federal requirements. 9. Revisions in Chapter 11 – Finance and Billing: Early intervention rates were updated on pages 162, 190 and 194 to reflect a January 1, 2024 Medicaid rate increase. An explanation of new Medicaid coverage types was added on page 180. Telehealth service delivery and billing requirements have been added on pages 181-182 and mirror the requirements already in place and specified in the DMAS Provider Manual: Telehealth Services Supplement. 10. Revisions in Chapter 12 – Personnel: The list of online modules required for early intervention certification was revised (page 196) to include Authentic Assessment, which has been required for many years but had not yet been added in the manual.

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11/13/25 4:43 pm

Commenter: Mariam Cherry, Cherry Blossom Speech, PLLC

Assistive Technology

To the Practice Manual Review Committee,

Thank you for the opportunity to provide public comment on the revised Virginia Early Intervention Practice Manual!

I am a speech-language pathologist/early intervention provider in Virginia, and I am writing specifically about the “Assistive Technology” section.

Under this section (Chapter 7, page 5), the current draft states:

“First consider or try simple, low- or non-tech modifications or solutions and then build up to mid-tech and to high-tech modifications or devices as needed.”

I respectfully request that the committee consider revising this sentence. As written, it implies a required progression from low-tech to high-tech AAC, which is not consistent with current evidence-based practice or ASHA guidance regarding augmentative and alternative communication (AAC).

Rationale

1. Current best practice emphasizes feature matching—not a low-to-high-tech hierarchy.
ASHA’s Practice Portal states that AAC assessment should be based on feature matching: selecting tools and systems according to the individual child’s strengths, needs, and environments. This approach does not require “starting” with low-tech before moving to more robust options.

2. Evidence supports early access to robust, high-tech AAC when indicated.
Research shows that children with complex communication needs benefit from early AAC access—including high-tech speech-generating devices (SGDs) in toddler and preschool years. Delaying high-tech AAC until lower-tech options have been “tried first” is not an evidence-based requirement and may actually slow a child’s communication and language development.

3. Presuming competence and the “least dangerous assumption.”
AAC best practice emphasizes presuming competence and applying the least dangerous assumption—making decisions that minimize the risk of limiting a child’s learning opportunities. A mandated low-to-high-tech progression can inadvertently require children to “prove readiness” at lower-tech levels before accessing a robust system. This is particularly concerning for children with limited or unreliable speech who need a full, generative language system from the start.

4. Practical implications in Virginia EI (Part C).
A statement that appears to require starting with low-tech solutions can unintentionally:

Delay appropriate referrals for high-tech AAC trials or funding,
Create confusion about eligibility or “readiness,” and
Pressure providers to follow a stepwise hierarchy even when their clinical judgment, family input, and evidence indicate that a high-tech option is the most appropriate starting point.

In my own caseload, more than half of the children I serve require some form of AAC beyond simple, low-tech supports. For many families, high-tech AAC (e.g., a robust speech-generating device app on a tablet) has been the most effective and functional way to support communication progress during daily routines.

Suggested Alternative Language

If the committee wishes to retain language about considering the full range of technology, I recommend wording that reflects feature matching and avoids implying a required progression:

“Teams should consider a full range of assistive technology options, including no-tech, low-tech, mid-tech, and high-tech AAC. Decisions should be based on an individualized, feature-matching assessment of the child’s strengths, needs, environments, and family priorities. There are no prerequisite skills or required steps (e.g., success with low-tech) before considering high-tech AAC when a more robust system is indicated.”

This language is consistent with Virginia’s flexibility around assistive technology while aligning more closely with ASHA guidance and the broader AAC evidence base.

Thank you again for inviting public comment and for your continued work to ensure that Virginia’s Early Intervention system reflects best practices and supports young children with complex communication needs and their families.

Sincerely,

Mariam Cherry, M.S., CCC-SLP

Speech-Language Pathologist

Cherry Blossom Speech, PLLC

CommentID: 237622