As an LPC working in community based mental health services, I have the following comments related to the various proposed regulatory changes:

1. Regarding the proposed regulation which states that LMHP, LMHP- Supervisee, or LMHP- resident shall complete, sign and date an ISP:

With a shortage of LMHPs, especially in the rural areas of Virginia, I am concerned that this requirement will significantly limit mental health services to clients in these areas. In addition, LMHP-types will not be able to count writing ISPs for  MHSS as a part of the direct clinical services they need in order to meet requirements for their Residencies, as MHSS is not recognized as "clinical" experience by the governing boards for these health professionals. Furthermore, often LMHPs will not take these positions due to the intense paperwork requirements involved, when most have entered the field to work with people, not push paper. I am not clear why MHSS will be the only service that is provided by QMHPs and/or QMHP-Es but also requires a LMHP/LMHP-type to complete the ISP. If the clinicians working directly with the client day in and day out are qualified to provide community based interventions with appropriate support and clinical supervision, then why can they not work collaboratively with their clients to craft a treatment plan with the same support and supervision? Finally, due to the higher cost of LMHP/LMHP-types, companies will be forced to find ways to make this regulation work through increased "efficiency" and "productivity" of the LMHPs, which translates in the ISPs being completed with minimal input from the client. This is not person centered.

2. Regarding the proposed regulation requiring an authorization for Crisis Intervention and Crisis Stabilization:

The very nature of these services indicates that an individual is in need of timely intervention to prevent higher level of care, which is also more costly. The current registration process allows communication and timely oversight of individuals receiving this service, without delaying the services. With a minimum of 2 day waiting periods for authorizations for other mental health services, I am very concerned that requiring an authorization for these crisis services will significantly and negatively impact individuals suffering from acute mental health crises. If this regulation does go through, please provide clarification on how this will be implemented without causing harm to residents of Virginia. Will there be a separate authorization line to get authorization for these time sensitive services in real time? Will providers have a certain grace period where services can be rendered with reimbursement prior to the authorization being approved? If these clarifications are not provided and considered and these authorizations are completed as they are for the other mental health services, I am concerned that more individuals will be forced to enter more costly, higher level of care options, and/or individuals will decompensate in the community leading to increased risk of harm toward self and/or others.

3. Regarding the proposed regulation that Service Specific Provider Intakes (SSPI’s) shall be “repeated” for all individuals who have received at least six months of MHSS to determine the continued need for the service:

Forcing clients to undergo a full SSPI every six months seems unnecessary, when LMHPs could complete an appropriate review of the original SSPI to determine any updates to the client's diagnosis, treatment needs, and appropriateness for services. Focus should be on review of services, treatment recommendations, and determination of appropriate services for the client, rather than on completing a more lengthy, paperwork intensive SSPI.

4. Regarding the proposed regulation on the number of days per week and hours per week required to carry out the goals in the ISP:

Will there be any flexibility to this, if there is documented need in the client's medical record? Clients' needs vary over the course of treatment and services should be provided based on need versus a pre-prescribed number of days and hours per week.

5. Regarding the deletion of the change in the billing unit structure that was formerly mentioned in the proposed regulations:

I support removing this revision from the regulations. The unit structure and rate reimbursement outlined in the Economic Impact Analysis would significantly impact providers being able to continue this service, which would again lead to Virginian residents not receiving needed care.

6. Regarding the proposed change in which Non-Residential Crisis Stabilization may be used as a higher level of care in the consideration of MHSS eligibility criteria:

I also support this change in the regulations, as it will allow individuals receiving this higher level of care to be eligible for MHSS as a step down in services, providing more continuity of care and greater community support for individuals suffering from severe mental illness.

Thank you for your time and consideration in reviewing my thoughts and concerns.

Sincerely,

Zizi LoFaro, LPC