Pg 5 - CPST Clinical Director has to be available to provide in-person support at the individual's location when clinically needed. 1 person can't possibly be constantly available as needed...vacation, illness, other work responsibilities. Draft manual does not discuss delegation to another LMHP. At every tier, an LMHP is on the team, so it's unclear why another LMHP, who is the CPST Clinical Director, would be needed in person. We recommend adding language such as “or designee who is an LMHP qualified to represent the clinical director”. There are also concerns about the broad nature of required activities by the “clinical director,” including being available in-person for service provision, for quarterly review, for assessment, assess for readiness of step-down, and to complete the ISP, in addition to providing supervision and administrative oversight of the program.
Pg. 5- Need clarification please if CPST Clinical Director serve both CPST and Clubhouse within same agency. It only specifies that can serve both an adult and child program within the same agency.
Pg. 7- What is the definition/frequency to qualify as “regularly”? Individual auditors will come up with their own definition.
Pg. 7- Some individuals may require more than “minimal” ongoing professional intervention…what is defined as “optimal community integration”? This is also vague and up to interpretation.
Pg. 8- Evidenced based policies and protocols- This broad statement would require an extensive update of all of our policies and protocols. We would have to develop detailed protocols/specifications of treatment.
Pg 8 — It's unclear if the CANS Lifetime is replacing the CNA or in addition to the CAN, which is still required by all other MH services. Is DBHDS changing licensing regulations to minimize the impact of lengthy assessments for individuals? There are so many additional assessments recommended.
Pg 10 — If the CSB doesn't provide Assertive Community Treatment, Coordinated Specialty Care, Functional Family Therapy, or Multisystemic Therapy and the service is indicated then the CSB must refer out. Will there be private providers for all these services? Are CSBs going to accept and serve out-of-catchment referrals? Rural areas or large geographic areas in particular cannot meet this requirement or need.
Pg 10-Documentation of referrals to standalone EBPs- Significant concerns in this huge additional documentation. Also, the delay could be significant to accessing services. Does not take into account individual preferences for services and may result in increased need for crisis services and inpatient treatment.
Pg 11 — Requires availability of an on-call LMHP 24/7, and unclear whether this can be provided by CSB Emergency Services or must be part of CPST Team. At times, this version refers to "internal" crisis supports, which sounds like the CSB's own emergency services could be used. If ES staff can be used, it looks like licensed-eligible staff (who are DBHDS approved prescreeners) would not qualify to provide this coverage.
Does a DBHDS Licensed facility (residential location or clubhouse “count” as an office) for the three hour limit?
Pg 12 — Has a copy of the CANS Lifetime been provided yet to be able to assess/review the tool??
Pg 12 — If a CANS Lifetime has been completed by another DMAS provider in the previous 12 months it must be used, but Licensing requires an initial and comprehensive CNA upon admission to a service. So this is either an additional assessment or won't meet Licensing.
Pg 13 — Any information on the length or cost of CANS training and recertification requirements??
Pg 14- Documenting each EBP protocol within ISP-New expectation to document each EBP Protocol. Increased expectations and would require changes to ISP
Pg 14- Documenting/updating each EBP protocol every quarterly. Same as comment above. Would require changes to quarterly.
Pg 14-Does the face to face review requirement every 90 days mean a full team meeting, or just a review with the client and direct staff which can be signed off on by the LMHP? Where does care coordination come in? Who is determining “clinical need or appropriateness” of a team meeting.
Pg 14 - Requires the involvement of the LMHP Clinical Supervisor if the individual is making limited or no progress or is not engaged in order to review and update the ISP or to refer to a different service. Same concern as previously noted above in relation to the required activities of the clinical director.
Pg 15- D. Is this referring to the CPST provider agency? Or are they requiring their specific provider/team?
Pg 15- Crisis plan requirements are extensive, Will require significant training and alteration of our documentation to ensure includes all the required components, which also make a crisis plan complex and not easy to use for an individual in crisis. This also impacts the ease of use of 988 response.
Pg 16—requiring individuals to contact DMAS’s preferred crisis provider as a CPST LMHP is not person-centered and does not encourage self-directed care. Does this allow MCOs to not reimburse necessary emergent/urgent medical care.
Pg 17- Adds requirement to contact MCO every time the individual accesses the crisis continuum which is also not conducive to addressing crises efficiently.
Pg 18 - Care coordination should be able to be provided by qualified mental health case managers who do not need to be QMHPs. Care coordination by a CPST team member is duplicative of what an MHCM can do and does.
Pg 19- Care coordination required consistent and regular communication with MCO- How is consistent and regular communication defined?
Pg. 20- Documentation around why standalone EBPs not available/not appropriate is burdensome as well as the requirement to coordinate with the MCOs as required referrals to standalone EBP. Are the MCOs going to staff call lines? After hours? Is this billable?
Pg 21 — No other service is required to report DBHDS CAPs to MCOs.
Pg 21- would have to submit DHP license within 30 days of Clinical Director change—we already do credentialing with DMAS and MCOs, why this duplication? Same timeline for every accreditation change (CARF).
Pg. 21- Has to submit provider qualifications and documentation to CEP-VA and keep updated which we are finding to be a very cumbersome process. Same statement—we are already doing credentialing with DMAS, MCOs, and their vendors. Individual providers are also maintaining qualifications with their respective Boards of health professionals.
Pg. 29- : If an individual has remained at the same Level of Need for 18 calendar months without improvement, the provider shall notify the individual'sMCO and, in coordination with the MCO, develop a plan to refer the individual to an appropriate evidence-based practice, as set forth in Section 3.2 and Section 8.6 (Continued Stay Criteria). Documentation of this referral process shall be maintained in the individual's record, and the ISP shall be updated to reflect theplan.- This wording makes it seem like the individual has no choice in their services changing. What if the individual doesn’t want to be referred elsewhere? What is the plan for if an individual declines to accept new services? Is the intention to discharge them regardless of them finding alternative services?
Pg 30 — A CANS Lifetime is needed to step down from Tier 1 to 2, and Pg 31 refers to monitoring the individual for 90 days post step down for a worsening CANS score. So how often is a CANS done and then the length of the assessment becomes even more important. Can we bill every time we complete a CANs?
Pg 34- MCOs can either approve authorization or recommend a more clinically appropriate service- This also creates significant administrative burden that is unfunded, while we continue to provide the necessary service to the individual without reimbursement. If we follow the extensive process outlined above and develop recommendations/establish eligibility in a person-centered way with a team of professionals, it is the MCO leading care and not the person or their medical professionals.
Pg 36 requires an LMHP to write a progress note in the individual's chart every 30 calendar days to document review of documentation OR co-sign every progress note of anyone less than an LMHP. No other community-based service requires this level of documentation oversight.
Pg 36 seems to indicate that though care coordination is required, it's not billable unless it's F-F w/ the individual or family/caregiver. How is this different from MHCM? The individual can choose to have case management and services.
Pg 40 requires all LMHP/LMHP-Types providing CPST Youth services to be credentialed in Managing and Adapting Practice (MAP) w/in 18 months of the agency's enrollment w/ DMAS for specialty 925. New hires have 18 mos as well. Credentialing requires curriculum training, 6 months of consultation, and a portfolio review. More training is described on pg 41 provided through DBHDS Learning Management System that must be completed w/in 12 calendar months of enrollment or new hire. Who is funding this training and consultation? $915/LMHP and not being able to provide services during the 52 hours of training is going to be cost prohibitive. How is this more substantive than their masters level education and licensure supervision?
Pg 41-42 describes EBP training requirements for CPST Adults and DBHDS training—similar concerns.
Pg 41- Required to have DBHDS BHT academy training- Should this be required or have the credential been established by DHP for BHTs rather than limited to only one of the options available? This will restrict the workforce available.
Pg 41- Requiring submitting this in both DBHDS LMS and to CEP-VA is overly burdensome, especially when most providers maintain their own robust LMS systems. Would DMAS consider requiring providers to provide this documentation at time of audit?
Pg 45- Supervision expectations for LMHP-E, QMHPs, and BHTs still are overly burdensome, especially for the L’s and the Q’s
Pg 46-47 discuss caseload limits and the need to keep an ongoing formal log of each staff's caseload to calculate an average per month over 6 month period to demonstrate compliance w/ limits. The caseload limits and supervision limits are confusing and complex. It does protect staff from being overloaded with complex cases. However, individuals’ needs are fluid and can change in varying timelines. Can we see an example?
PG 46-47- Caseload matrices, limits, and composition is restrictive, and remain a huge increase in admin overhead. Is this another required duty of the clinical director or supervisor, in addition to the many service requirements of an LMHP for this service.
Psychosocial Rehab is still on the list of exclusionary programs but if the idea is to eliminate Psychosocial Rehab, does this actually mean club, or is clubhouse allowed in addition to CPST?
For the people who need a MH Skill-building service, not this level of service, where do they go?
The extensive nature of these requirements is going to be cost prohibitive for providers to offer this service.
