Thank you for the opportunity to be able to comment as a part of the Provider Manual drafting process.

Although Community Services Boards are used to the almost constant need for change, some of the requirements in the proposed manual introduce procedures and processes that will be challenging to meet without significant financial investments and significant changes to staff workflows that will limit the ability to continue to provide the Intensive In-Home service.

1. Additional clarification will need to be provided regarding the CANS Lifetime assessment.  When will it be ready testing and review? If it is required to move from tier to tier, will it be able to be billed each time it is administered?  Administering the CANS assessment will be new for some of our IIH staff.  We would like to prepare them for this new process as soon as possible.
2. As a clinician that has completed the CANS assessment for around seven years, this assessment is not one that clinicians are fond of.  It can be challenging to get the assessment's algorithms to match the actual youth's situation.  It will be important that the training module accurately and concisely explains how the assessment should be administered to reflect the level of care that is needed.  
3. At present, some of our staff administer the Virginia CANS 5.0+ to request CSA funding for some youth.  Is there a possibility that certain staff may need to be certified in two separate CANS assessments?
4. The CPST Clinical Director and LMHP Clinical Supervisor information will require additional flexibility for implementation.  There should also be acknowledgement that individuals in these roles may be serving in other roles, especially within Community Services Boards.
5. The supervision requirements set forth will impact the number of youths we are able to serve.  This also may require us to hire an additional supervisor to meet the requirements. 
6. Completing an algebraic equation to determine caseload requirements will be challenging.  Our agency will plan to either put this equation into a spreadsheet for implementation or assist our supervisory staff in developing a more practical way to determine caseloads.
7. The requirement to notify MCO's of each individual crisis that an individual experiences will lead to an influx of contacts with MCO's.  Unfortunately, the status of youth mental health has continued to be impacted by a variety of factors.  We will need an ongoing and accurate list of MCO contacts to accomplish this requirement.  It would be helpful if there was a streamlined way to do this (portal or some sort of link).
8. It appears that IIH services will be delivered in a more team-based approach.  Our IIH services are shifting to being provided in this manner.  We will need to hire more staff to reach the two to three or more staff per youth requirement, depending on their tier.
9. Rate levels should be increased, so that providers can increase their staffing levels and ensure that all staff are trained on all required practices.  This includes the significant investment required for the Managing and Adapting Practice (MAP) training and credentialing process.
10. I have not had a moment to check, but am hoping that the Foundational Skills Curriculum, Intermediate Skills Training Curriculum and Behavioral Health Technician Skills Curriculums are available in the DBHDS' Learning Management System.  I will verify this to ensure that staff can begin to review and incorporate this information into their daily practice.