The present CPST – Youth, School Setting draft creates jurisdictional and role-boundary concerns for LMHPs overseeing care. While collaboration between behavioral health providers, families, and schools is essential, several proposed requirements appear to extend the responsibilities of LMHPs into areas governed by the educational system.
The draft appears to require LMHPs to identify each IEP/504 goal related to behavioral, emotional, or social functioning; determine whether each goal is addressed by the IEP/504, CPST, or both; provide a clinical rationale for duplication or overlap; identify the school personnel responsible for implementing the educational component; attend an IEP/504 meeting as a condition of CPST authorization; submit clinical input to the IEP/504 team when attendance is not practicable; determine that a child’s mental health impairment adversely affects educational performance; and communicate that determination to the school team.
These requirements are problematic because an IEP/504 process is not a behavioral health treatment plan. It is an educational and legal process governed by the Virginia Department of Education and school-system procedures. While an LMHP can clinically assess whether symptoms of a mental health condition interfere with functioning, determining educational performance is not synonymous with determining clinical impairment and is part of an educational evaluation and process outside the scope of practice of an LMHP overseeing CPST care.
The proposed language stating that the LMHP “shall” attend at least one IEP or 504 team meeting per service authorization period also raises concerns. An IEP meeting is a school-governed process, and the school determines its team composition.
DBHDS regulates behavioral health services, while the Department of Education regulates the educational system. As such, CPST providers cannot establish requirements that govern how IEP/504 processes operate. CPST is distinct from educational services. Collaboration between behavioral health providers, families, and schools is an extremely important and necessary component of care; however, collaboration should not become regulatory role substitution.
Recommendation: DMAS should revise the final manual to include clear scope-of-practice language distinguishing behavioral health responsibilities from educational responsibilities. The final language should encourage LMHP participation and collaboration with schools and families when clinically appropriate, while making clear that LMHPs are not responsible for making educational determinations, directing IEP/504 processes, determining school-team composition, or otherwise assuming responsibilities governed by the educational system.
Sections 3.2.1 through 3.2.3 of the CPST draft manual concerning referral to standalone EBPs create ambiguity regarding the relationship between CPST and those services.
If an EBP is clinically appropriate but unavailable, it is reasonable for a provider to document barriers to access and, when appropriate, assist the youth and family in pursuing access. However, a CPST provider cannot control the availability of a standalone EBP, geographic access, waitlists, authorization decisions made by another entity, or whether the individual and family chooses to pursue the referred services.
Being held responsible for notifying the MCO of barriers, coordinating to address access as soon as practicable, documenting all care coordination, and including a plan to transition when the EBP becomes available appears to place systemic service-access problems onto the provider that are outside of the provider’s control.
Furthermore, if an EBP is deemed clinically inappropriate, availability would not change that clinical determination. Requiring an ISP to include a plan to transition to an EBP that the assessing LMHP has determined is clinically inappropriate creates an internal inconsistency within the proposed requirements.
The treating LMHP should be responsible for assessing the youth’s behavioral health needs, determining the medical necessity and clinical appropriateness of CPST, making clinically appropriate referrals, and documenting reasonable coordination efforts. The LMHP should not be made responsible for guaranteeing access to another provider’s service or resolving systemic capacity problems.
Recommendation: DMAS should revise these provisions to distinguish between a provider’s responsibility to make clinically appropriate referrals and document reasonable care coordination efforts and the provider’s inability to control another provider’s availability, geographic access, waitlists, authorization decisions, or family choice. The final manual should also clarify that an ISP transition plan to a standalone EBP should only be required when that EBP has been determined by the treating LMHP to be clinically appropriate and indicated.
The present CPST – Youth, School Setting draft raises significant concerns regarding the expectations placed upon LMHPs.
The draft recognizes that excessive caseloads can negatively impact service delivery, staff sustainability, and client safety. It establishes explicit weighted caseload limits of 20 for staff providing the primary CPST components, including Restorative Life Skills Training, Care Coordination, and Crisis Supports. This demonstrates that the Department recognizes the importance of measurable caseload protections for staff providing direct services.
However, comparable protections are not established for LMHPs despite the significantly broader and more clinically complex responsibilities assigned to them throughout the draft.
The limits addressing clinical caseload oversight in Section 3.2 do not fully resolve this concern. These limits do not necessarily account for the additional direct clinical responsibilities an LMHP may simultaneously carry.
The distinction between caseload and workload is therefore critical. For LMHPs, who carry significant clinical, supervisory, assessment, treatment-planning, psychotherapy, and crisis-related responsibilities, there is no objective minimum standard or measurable workload methodology to ensure that an LMHP is protected from excessive assignments. This is particularly concerning given the national shortage of LMHPs.
An LMHP may simultaneously be responsible for assessments, CANS requirements, treatment planning, required 90-day contacts, psychotherapy, clinical oversight, supervision, crisis consultation, documentation, and other clinical responsibilities. A numerical limit on clinical oversight cases does not necessarily account for these additional responsibilities.
Recommendation: DMAS should establish an objective LMHP workload standard in addition to the clinical-oversight case limits in Section 3.2. The final manual should recognize that an LMHP’s total workload includes both direct clinical responsibilities and clinical oversight responsibilities and should provide a mechanism for considering clinical complexity, psychotherapy frequency, crisis activity, supervision, and other required clinical duties.
The most significant concern is the requirement in Section 4.5 that each CPST provider maintain an experienced LMHP who is available for crisis consultation 24 hours per day, 7 days per week, 365 days per year.
The concern is not with ensuring that youth and families have access to appropriate crisis support. Continuous access to crisis support is important. The concern is the manner in which the proposed requirement assigns responsibility for that continuous availability to LMHPs without establishing corresponding staffing or workload protections.
The draft goes beyond simply requiring that an LMHP be available. During the instructional day, the LMHP must be reachable through an immediate and direct method and respond to a consultation request within a timeframe appropriate to an escalating in-person situation, not to exceed 15 minutes.
Outside the instructional day, including evenings, weekends, school breaks, and periods when school is not in session, the on-call LMHP must be reachable and able to respond to consultation requests within 30 minutes. Furthermore, in-person response is required when clinically necessary or indicated by the youth’s crisis mitigation plan.
An LMHP who must remain available for a 15-minute response during the instructional day cannot necessarily be treated as fully available for other clinical responsibilities during that same period. The LMHP may be conducting psychotherapy, completing an assessment, participating in treatment planning, supervising staff, traveling, or providing another clinical service.
Similarly, an LMHP who is required to remain available for a 30-minute response outside normal business hours may have significant restrictions on where they can be, what other responsibilities they can undertake, and their ability to disengage from work-related responsibilities.
The 24/7 requirement requires a staffing model, not merely an on-call policy.
There are 168 hours in every week that must be covered. If an agency relies upon a single LMHP to provide that availability, the practical expectation would be continuous responsibility for crisis consultation in addition to the individual’s normal workweek. Such an arrangement is not a sustainable staffing model and creates obvious concerns regarding fatigue, burnout, clinical judgment, and patient safety.
Even if multiple LMHPs rotate on-call duties, the CPST agency must account for the fact that the on-call LMHP may receive an actual crisis consultation during the assigned period and that the response can involve substantially more than a telephone call.
Recommendation: The final manual should establish or clarify the staffing methodology necessary to provide reliable 24/7/365 LMHP coverage without placing an unreasonable burden on individual LMHPs. The manual should also clarify how on-call responsibilities affect an LMHP’s allowable direct-service and supervisory workload.
The requirement for in-person assistance creates additional workload as well. If an LMHP is expected to be available for in-person crisis intervention, geographic coverage becomes a significant staffing consideration.
An LMHP cannot reasonably be considered available for an in-person response if that individual is providing services at another location, traveling, engaged in another crisis, conducting psychotherapy, or outside a reasonable travel radius.
Therefore, an agency’s ability to comply with the requirement depends not only on the number of LMHPs employed, but also upon their geographic distribution, schedules, existing caseloads, and availability.
Recommendation: DMAS should clarify the geographic and response-time expectations associated with in-person LMHP assistance and how agencies are expected to provide this coverage when an LMHP is already engaged in another clinical service or crisis response.
The draft recognizes that caseloads should vary based on team composition, Level of Need, experience, and staff qualifications. However, that principle should be extended to LMHP workload.
DMAS should reconsider the LMHP workload provisions before finalizing the draft. At a minimum, the final manual should:
Establish objective LMHP workload standards in addition to the clinical-oversight case limits;
Establish how 24/7/365 on-call responsibilities affect an LMHP’s allowable direct-service and supervisory workload;
Clarify whether an LMHP who is actively providing psychotherapy, assessment, supervision, or another clinical service can simultaneously be considered available for the required 15-minute crisis consultation response;
Establish a minimum staffing expectation or staffing methodology sufficient to provide reliable 24/7/365 LMHP coverage without placing an unreasonable burden on individual LMHPs;
Clarify the geographic and response-time expectations associated with the requirement for in-person LMHP assistance;
Establish safeguards for LMHPs who have responded to significant or prolonged crises so that crisis response responsibilities do not simply become additional uncompensated workload layered on top of an already full caseload; and
Clarify how agencies will demonstrate during an audit that an LMHP’s total workload is clinically reasonable and does not compromise quality, safety, or continuity of care.
The intent of the proposed regulations—to improve access, coordination, continuity, clinical oversight, and quality of behavioral health services—is important and commendable. However, the practical ability of LMHPs to fulfill these requirements must also be considered.
The draft explicitly recognizes the need to protect other CPST staff from excessive caseloads and establishes measurable limits for those providing primary CPST components. It also establishes numerical limits for LMHP clinical oversight. However, these provisions do not adequately address the total workload of LMHPs who may simultaneously be responsible for assessment, treatment planning, psychotherapy, supervision, clinical oversight, crisis consultation, and other required functions.
Likewise, collaboration between CPST providers and schools is essential, but collaboration should not result in LMHPs assuming responsibilities that belong to educational systems. Similarly, LMHPs should be responsible for clinically appropriate referrals and reasonable care coordination but should not be held responsible for guaranteeing access to services controlled by other providers or systems.
The 24/7/365 crisis consultation requirement, including a 15-minute instructional-day response, a 30-minute after-hours response, and potential in-person assistance, represents a substantial staffing and workload obligation. These requirements should be accompanied by an appropriate staffing and workload model to ensure that LMHPs can fulfill their crisis responsibilities without compromising their other clinical obligations.
Protecting LMHPs from unsustainable workloads is not merely an employee-welfare issue. It is directly related to patient safety, quality of care, clinical judgment, workforce retention, and the ability of providers to comply with the regulations themselves.
For these reasons, it is respectfully requested that DMAS revise the final CPST – Youth, School Setting manual to establish clear role boundaries, distinguish provider responsibilities from systemic limitations, and create measurable LMHP workload and staffing protections. These revisions would support the Department’s goal of providing high-quality, accessible, and clinically appropriate services to Virginia’s youth and families while ensuring that the professionals responsible for delivering those services have the capacity to do so safely and effectively.