As a member of the Virginia Association for Family Preservation, the following comments are offered for consideration:

12VAC30-50-130.  "Care coordination" means collaboration and sharing of information among health care providers, who are involved with an individual's health care, to improve the care.

These services provide crisis treatment; individual and family counseling; and communication skills (e.g., counseling to assist the child individual and his parents or guardians, as appropriate, to understand and practice appropriate problem solving, anger management, and interpersonal interaction, etc.); case management activities andcare coordination with other required services; and 24-hour emergency response. 

All interventions and the settings of the intervention shall be defined in the Individual Service Plan. All IIH services shall be designed to specifically improve family dynamics, provide modeling, and the clinically necessary interventions that increase functional and therapeutic interpersonal relations between family members in the home.  IIH services are designed to promote psychoeducational benefits in the home setting]

As a member of the Virginia Association for Family Preservation, the following comments are offered for consideration:

We strongly concur with the acknowledgement of the family system as central to the individual’s functioning. However, IIH services are not equivalent to family therapy at a higher dosage. The service addresses complex social and emotional factors in the lives of individuals and families.

Behavioral health problems are influenced by a wide range of social factors outside of the family. Best practice dictates that providers working with high-risk clients involve as much of the individual’s support network as possible. Reducing the focus solely to the individual’s health care, and ignoring other parties involved in the individual’s life such as schools, courts, social service agencies, childcare providers, mentors, and so forth will not result in better outcomes, but will instead result in fragmented and less effective or ineffective treatment.

If a family is socially isolated, or has problematic ties to the community, focusing strictly on the immediate family can be a losing proposition. To strengthen such a family’s structure, providers cannot be limited to interacting only within the family system.  Preventing the involvement of other important individuals is antithetical to best practices as detailed in both wraparound and systems of care philosophies. Limiting providers’ ability to support the family in advocating for their needs with external stakeholders will also lead to a higher level of referrals for Medicaid-funded case management services.

We therefore recommend that the definition of care coordination be expanded to include collaboration with all agencies and individuals involved with the family as required to improve individual and family functioning.  We also recommend that when formal case management services are necessary, private providers be allowed to provide these services. This will prevent overloading the Community Services Boards with referrals, improve access to care, and decrease care fragmentation.

12VAC30-50-226.  “The services  [ may be ] rendered in the community if there is documentation, on that date of service, of the necessity of providing services in the community. The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP. For services provided outside of the home, there shall be documentation reflecting therapeutic treatment as set forth in the ISP provided for that date of service in the appropriately signed and dated progress notes.”

We are concerned with the wording of the draft regulations. Requiring that the documentation describe “how the alternative community service location supports the identified clinical needs of the individual and facilitates the implementation of the ISP” seems to entail that the provider document a clinical rationale for the specific location chosen for every session in which any services are provided outside of the home. However, the specific location may have been chosen based on mere convenience or proximity to the home. This language creates an additional documentation burden for providers, without adding any clinically relevant information to the record. 

Families may be sharing their residence with relatives or others, or have frequent visitors in the home. Some individuals need regular opportunities to consult with the provider outside of the presence of family members. The current regulations are specific enough to prevent inappropriate out-of-home services, while allowing for the flexibility that clinicians need to provide effective services when privacy is lacking in the home. In contrast, the draft regulations would open the door to subjective retractions and lengthy appeals processes, and could lead to less effective treatment for some individual

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12VAC30-60-61.  “1. 2. Individuals qualifying for this service must shall demonstrate a clinical necessity for the service arising from mental, behavioral or emotional illness which results in significant functional impairments in major life activities. Individuals must meet at least two of the following criteria on a continuing or intermittent basis to be authorized for these services:

a. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community.

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.”

We are concerned with the new language adding the specification of “documented” repeated interventions. Parents, legal guardians, and referring agencies provide a verbal history of prior interventions during the intake process. Providers are required to obtain clinically important documentation such as VICAP assessments and recent psychological evaluations. However, expecting providers to obtain records from all prior providers cited in the intake documentation is not realistic. Former providers may be out of state, or no longer operating. Parents/guardians often do not recall dates, or the names of agencies and individuals. Service providers do not always respond to requests for records, despite proper authorization.

Providers already spend a great deal of time and expense compiling extensive documentation. Obtaining the records needed to meet the existing regulations and provide proper care often requires repeated requests and follow up. Providers are not reimbursed for this time. The new wording of this regulation places an additional and unnecessary burden on the provider.

12VAC30-60-143. 

“All ISPs shall be completed, signed, and contemporaneously dated by the LMHP as defined in 12VAC35-105-20, [ , LMHP-supervisee, LMHP-resident, LMHP-RP ]  QMHP-A  [ or , ]  QMHP-C[ or QMHP-E ] , preparing the ISP within a maximum of 30 days of the date of the completed [ assessment intake ] unless otherwise specified. The [ child's/adolescent's ]  ISP shall also be signed by the parent/legal guardian and [ the adult ] individual  [ shall sign his own ] .  [ Documentation shall be provided if the individual, who is a minor child, is unable or unwilling to sign the ISP. If the individual, whether a child, adolescent or an adult, is unwilling to sign the ISP, then the service provider shall document the clinical or other reasons why the individual was not able or willing to sign the ISP. Signatures shall be obtained unless there is a clinical reason that renders the individual unable to sign the ISP.  ]” 

The current regulations were sufficiently specific to ensure that the individual is involved in the development of the ISP to the extent possible. The requirement that “signatures shall be obtained unless there is a clinical reason that renders the individual unable to sign the ISP” is unnecessary and subjective. Sometimes a child is clinically “able” to sign an ISP, but simply chooses not to do so. In such a case the draft regulation could, for example, allow a 7 year old to effectively cancel her own services.

A parent should be allowed to sign the ISP on behalf of a minor child. If a child refuses to sign the ISP, the service provider should be allowed to simply document that the child refused to sign the ISP. Likewise, an individual’s signature on the ISP should be sufficient if the individual is old enough to consent to treatment.

“An LMHP or LMHP Supervisee or Resident under the supervision of an LMHP must perform the service specific provider intake to determine all necessary IIH services and determine that the individual’s service needs can best be met through interventions provided by this service. If an LMHP Supervisee or Resident performs the service specific provider intake, the service specific provider intake must be reviewed and signed/dated by the LMHP within 24 hours of conducting the service specific provider intake.”

The stipulation that an LMHP must review and sign the intake within 24 hours of a Resident or Supervisee conducting an intake serves no apparent clinical purpose, creates a significant burden for providers, and decreases the quality and comprehensiveness of the documentation produced. Due to the extensive information required, an intake assessment can take several hours to write. If a resident/supervisee conducts the intake in the evening when the parents are home, and the clinician has appointments scheduled the next day, that clinician is forced to complete the documentation late at night and in the early hours of the morning, as well as consult with the licensed supervisor during that time frame. The clinician has no opportunity to consult with or obtain documentation from other providers prior to completing the document. Residents/supervisees should therefore be allowed to complete assessments within the same seven day time frame as licensed providers.

We would also like to highlight the fact that the reimbursement to IIH providers for the provider-specific intake is a mere fraction of the amount that the Community Service Boards are reimbursed for an Independent Clinical Assessment (ICA).  IIH providers are required to work under much more challenging conditions, provide unreimbursed travel time, complete much lengthier assessments, and compile extensive documentation. We feel that this situation is grossly unfair. IIH providers should receive the same or higher reimbursement for a service-provider specific intake as the CSBs receive for the ICA. 

“This service may be billed for up to seven days, immediately upon admission to a psychiatric residential treatment facility or immediately prior to discharge from a psychiatric residential treatment facility, to transition the individual from home to the psychiatric residential treatment facility or from the psychiatric residential treatment facility to home, as applicable.

IIH may not be billed prior to discharge from any Level A, Level B, or inpatient hospitalization.”

Providers are often invited to attend family meetings at a hospital or residential facility in anticipation of the client’s discharge. Many providers attend these sessions, and maintain phone contact with family members and facility clinicians, even though they cannot bill for these services. Other IIH providers decline to provide any unreimbursed services. However, collaborating with the family and the treating clinicians for discharge and safety planning is clinically necessary, and IIH providers should be reimbursed for providing this care. Providers should not be forced to choose between providing unreimbursed services, or failing to provide clinically necessary care.

“If there is a lapse in IIH service for more than two weeks, the reason for the lapse and the rationale for the continued need for the service must be documented. The ISP must be reviewed and updated if there are changes, and signed by either the parent or legal guardian and if appropriate, the individual. Going without services for 2 weeks and no need for a change in the ISP may indicate a lack of need for this level of service.”

It is unclear why a two-week gap in services would generally necessitate a change in the ISP. Children sometimes stay with relatives for a period of time, families take vacations, and individuals involved in the justice system are sometimes detained after a charge is adjudicated. Parents may place services on hold due to circumstances unrelated to the child’s mental health. In these cases, the same ISP goals and objectives would likely remain in effect when services resume. This regulation can induce providers to make unnecessary changes to an ISP in order to guard against retractions, which is antithetical to client-centered services. We therefore recommend rescinding the last sentence of the above regulation. 

Currently, observation in the school environment is allowed for only 15 minutes.  Providers should be able to intervene in the school environment when dictated by the individual’s needs, not by the school’s needs. For example, parents/guardians may be concerned that a child’s issues are being exacerbated by situations occurring at school. In addition, supportive school personnel can often be recruited to help a child cope with separation anxiety, or other issues stemming from the home situation. These scenarios are unlikely to precipitate a specific request for intervention from school personnel. Even when school personnel have requested help, it can be challenging to find an official who is authorized and willing to sign a form. Providers should be allowed to provide services in the school if they are clinically appropriate, and reasonable in frequency and duration, without fear of retractions.

“Service is not appropriate for a family while the individual is not living in the home or for families being kept together until an out-of-home placement for the individual can be arranged.”  This regulation needs to be clarified, as it is unclear what constitutes a family “being kept together until an out-of-home placement for the individual can be arranged.” For example, if a residential placement has been recommended but the individual has not yet been admitted, that individual is by definition at risk of out-of-home placement. Since funding for the residential placement may or may not be approved, providers should be able to continue services until the individual is actually admitted to a facility.

FINAL COMMENTS:  Every new mandate and restriction leads to increased effort, expense, and risk to providers, and further reduces the time and bandwidth available for clinical concerns. Providers are already struggling to manage the current regulatory environment, with nearly continuous involvement in audits and appeals, and the potential for crushing overpayments due to subjective findings or minor oversights in documentation. In response, some providers are considering closing their IIH programs due to the increased financial risk. This will open the market to more “bottom-feeder” agencies that will hire staff with the minimum credentials required, and focus on billing a high number of hours per client.  Thus, the overall effectiveness of IIH services will decline, and the cost of treatment will increase.

Cynthia Agbayani, PhD

Vice President, VAFP

Co-Owner/Program Director, Lifeworks Outreach Services, Inc.