Crisis regulations continue to be very contradictory to the Peer Support regulations. Some examples include: peers cannot provide care coordination under crisis regulation but must provide coordination under peer support regulation, peers cannot provided crisis services independently and must mobilize in a team but can run individual/group session under peer services, crisis does not allow for virtual services but peer regulations allow for virtual support. Required crisis documentation is also not inclusive of any peer specific documents such as the recovery, resiliency, and wellness plan, which regardless, would not be effective in a short team service such as mobile crisis or community stabilization. Crisis regulations dont reference the peer appendix or provide any context to their integration within the provision of crisis services. These contradictory components result in confusion of utilizing PRS in crisis services. The provision of services should more closely align within each appendix, but minimally the crisis appendix should speak to the nuances of integrating the use of another service into crisis services, including any exceptions, challenges, or changes. 

Providers have been told they can use 2 LMHPS and bill at the Team 5 level for mobile crisis, including during webinars.  The current manual also notes being able to use the HT modifier when using 2 LMHPS. Please make this clear by adding the 2 LMHPs to the Team Composition Table.

Certified Prescreeners have undergone education and training necessary to perform prescreening duties that should be independently billable. If not independently billable, recommend allowing indirect supervision of activities, meaning via the review and signing off on the prescreening by an LMHP.   

Community Stabilization draft regulations note- not eligible if attending another service "more intensive than standard outpatient counseling". Advocating that ARTS IOP be allowed to be provided at the same time as community stabilization. This service can fill the gaps as SUD IOP is only 3 days per week, especially if one service if focused more on MH and the other SUD. 

Prescreener training required to become a Virginia Preadmission Screener Clinican is quite rigourus  and has been standardized for years.  I have a QMHP Bachelor's level VCPASC that has been doing the work for over 30 years consecutively.  Billing should be permissable without requiring "invivo" observation.  Indirect supervision is already built into the entire Emergency Services Department, as a result of the standardized protocols established by DBHDS.  

I have the following concerns that in line with other comments that have been made regarding these changes:

Prescreenings by QMHP- not independently billable despite education and training

Certified Pre-screeners have extensive training prior to becoming certified that include education, hands-on training, and observation.  This certification is standardized across the state.  Pre-screeners should be able to bill for their services without having direct observation from a LMHP/LMHP-R.  If not able to bill independently, I agree with recommendation to allowing indirect supervision of activities, meaning review and sign off on prescreening by LMHP/LMHP-R.

Supervisors of Peer Recovery Specialists- required training

While training for people who supervise Peer Recovery Specialists is certainly helpful, to add the requirement in this manual, that the very specific "DBHDS Peer Recovery Specialist Training" must be taken, will create additional barriers for peer support service delivery. 

These trainings are not readily available.  Without the training being offered continuously and remotely,  it will delay being able to provide peer services.  It also does not allow for time for onboard new supervisors and getting them trained when there is staff turnover. 

It seems outside the scope of this manual to require a very specific training, for the supervisors of those directly delivering services. Many programs have long time embedded peers and supervisors that are doing an excellent job and this adds to regulatory burden, especially if not immediately and easily available.

In addition, it is suggested that Peer Recovery Services regulations should be reviewed to make the delivery of Peer Recovery Services easier across the board. If a person is a Certified and Registered Peer Recovery Specialist, they could most simply, be qualified to  deliver group or individual peer services, the same as an LMHP can deliver individual and group counseling.

We, the public policy committee of the Virginia Association for Behavior Analysis thank you for the opportunity to comment on this appendix.  We ask that you consider adding the skills and expertise of Licensed Behavior Analysts (LBAs) to the document in the following ways:

1. Adding the option of an LBA as part of the multidisciplinary team for 23-hour crisis stabilization and Residential Crisis Stabilization programs to assist with ameliorating behavioral health crises,
2. Including the option of an LBA on the team that treats an individual following a behavioral crisis to reduce the likelihood that the individual will require this more restrictive level of care in the future and to decrease the likelihood of hospitalization, and
3. Considering LBA training and/or oversight of Crisis Education and Prevention Plans (CEPPs), especially where there are more complex behavioral needs.

Background

Connections Health Solutions was recently awarded a contract from Prince William County to provide crisis receiving and stabilization services for the County. The Company will support the crisis receiving center's design and buildout and will operate the center located in Woodbridge, Virginia. Connections currently operates two of the largest and most studied behavioral health crisis receiving centers in the country and has expanded operations to include both rural and urban communities.

Feedback on 23-Hour Crisis Stabilization Level of Care Guidelines as a whole

Connections recommends that the language throughout the 23-Hour Crisis Stabilization section referring to “up to 23 hours” be changed to “up to 23 hours and 59 minutes.” The 23-Hour Crisis Stabilization model is intended to provide services and be billable for any time less than 24 hours. So, there are instances where individuals will receive services for over 23 hours, but less than 24 hours and the Manual’s language should reflect that.

Feedback on 23-Hour Crisis Stabilization Medical Necessity Criteria

In Appendix G of the Mental Health Services Manual the exclusion criteria for 23-Hour Crisis Stabilization specifies that those with “a presence of sufficient severity to require acute psychiatric inpatient, medical, or surgical care” are not appropriate for 23-Hour Crisis Stabilization. Connections recommends removing “sufficient severity to require acute psychiatric inpatient” from the exclusion criteria.

All patients admitted to Connections’ 23-Hour Crisis Stabilization units (~20k annually) are suitable for admission to an inpatient level of care. Even so, 60 – 70% are released to the community in lieu of an inpatient stay. These outcomes are driven by a commitment to patient-centered care and the belief that even high acuity patients can improve clinically. As the clinical picture improves, Connections transfers patients to the least restrictive environment which will still support the patient’s needs. In essence, without a stay in a 23-Hour Stabilization unit for assessment and treatment, a determination cannot truly be made with respect to the need for psychiatric inpatient care.

The exclusion criteria as listed above runs the risk of violating the “no wrong door” policy. The “no wrong door” policy is in part successful due to the ease of communication with all stakeholders. Law enforcement understands that they can drop-off any patient for treatment. Individuals can walk in through the front door and know they can be treated. The exclusionary criteria as it stands now may open the door to crisis receiving centers refusing to accept certain high acuity patients. If law enforcement and the community aren’t clear on who is suitable for crisis receiving centers or meet challenges in gaining access to crisis receiving centers, they will be less likely to use the crisis receiving center and the system falls apart.

In addition, the Mental Health Services Manual stipulates individuals under a temporary detention order, who according to Virginia statute may need inpatient hospitalization, can receive treatment in 23-hour crisis stabilization. Virginia code §37.2-809 B states: “A magistrate shall issue, . . . a temporary detention order if it appears from all evidence readily available, . . . that the person (i) has a mental illness and that there exists a substantial likelihood that, as a result of mental illness, the person will, in the near future, (a) cause serious physical harm to himself or others as evidenced by recent behavior causing, attempting, or threatening harm and other relevant information, if any, or (b) suffer serious harm due to his lack of capacity to protect himself from harm or to provide for his basic human needs; (ii) is in need of hospitalization or treatment; and (iii) is unwilling to volunteer or incapable of volunteering for hospitalization or treatment.” Thus, individuals under a temporary detention order that are treated in 23-hour crisis stabilization may be of “sufficient severity to require acute psychiatric inpatient, medical, or surgical care”—counter to the current exclusion criteria.

Feedback on Residential Crisis Stabilization Medical Necessity Criteria:

In Appendix G of the Mental Health Services Manual the exclusion criteria for Residential Crisis Stabilization states “the individual’s psychiatric condition is of such severity that it can only be safely treated in an inpatient setting due to violent aggression or other anticipated need for physical restraint, seclusion or other involuntary control.” This guidance is reflective of current Virginia administrative codes that do not provide for seclusion and restraint capabilities in 23-Hour Crisis Stabilization and Residential Crisis Stabilization. Regardless, Connections urges DMAS in cooperation with DBHDS to work to create a path to allow 23-Hour and Residential Crisis Stabilization to perform seclusion and restraint where necessary.

In order for a crisis center to be “no wrong door” and take the most behaviorally acute (e.g. agitated and violent) patients, it needs the ability to do seclusion and restraint. Otherwise, crisis centers will likely refuse to take anyone who might need seclusion or restraint, and then those patients end up in ERs or jails, where they are likely to be restrained because those settings are not equipped to treat behavioral health conditions.

Crisis receiving centers have the trained clinical staff (no security) and physical layout to have a better chance of de-escalating the patient (including the highly acute/agitated) without having to use seclusion or restraint. Connections tracks use of seclusion and restraint closely and our rates are at or below the Joint Commission’s national averages for inpatient units, despite the fact that patients come in highly agitated directly from the field.

Seclusion and restraint is a function of the level of care more than the license. Emergency rooms are outpatient and perform restraints. A primary care clinic is also an outpatient setting, however it wouldn’t be appropriate to perform restraints in that setting. For these reasons, Connections encourages revision of the exclusionary criteria to include patients requiring seclusion and restraint in both 23-Hour Crisis Stabilization and Residential Crisis Stabilization.