55 comments
On page 6 of the manual, it says that individuals have access to emergency assistance either directly or on call 24 hours per day, seven days per week, and holidays. Why the wording says emergency assistance and what is that include outside medical and mental health emergencies? What does "directly" mean? Is that face-to-face meeting with clients at any time of the day? Why this is required of our agency in which all of our services are non-emergency and our mission is to help clients become empowered and independent?
The draft states:
"Guarantee that individuals have access to emergency services assistance either directly or on-call 24 hours per day, seven days per week and holidays on a 24-hour basis. This may be done via telephone and face-to face contact a phone answering service and/or coordination with other MCOs providers and DBHDS administered crisis services"
Could there be clarification on what is meant by “emergency assistance” and how that differs from the previous version that stated “emergency services”. Current providers of brain injury case management do not and have never provided emergency assistance but do develop safety plans and direct clients to the use of 911 and 988 as needed. Requiring programs to provide 24/7 access would be a significant financial burden by adding costs for on call pay and will certainly lead to increased turnover and challenges with recruitment and staff retention which are already a significant issue for existing programs. As private non-profits we can not compete with the salaries of state agencies and CSB’s and attract staff because of the work life balance we promote. If staff are willing to work jobs where they will be on call then they will certainly choose to work at larger state agencies who can afford higher salaries. Brain injury case management services have been provided services to the community for decades without 24/7 coverage and we have seen no evidence that it’s a needed addition.
The draft states:
"BIS case managers must either hold at least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling OR be licensed by the Commonwealth as a registered nurse. BIS case managers must also be certified as a Qualified Brain Injury Services Provider (QBISP) or a Certified Brian Injury Specialist (CBIS) prior to independently delivering billable BIS case management services."
Can it be considered that a Case manager can provide TCM while under the supervision of a CBIS or QBIS while they await eligibility for certification? If there is turnover in a case management position, there will be no one to continue TCM services to existing clients if new staff are expected to have one of these certifications which will cause a gap in services to our clients. CBIS requires significant contact hours and currently there are not enough QBIS training options to have a staff complete the certification upon orientation- the in person requirement for training for QBISP makes that particularly challenging.
Additionally, opening up eligibility to any bachelor's degree is a wonderful edit but significant years of experience with a CBIS should also be considered as a qualified provider.
The draft states in two different places:
Assessment
"Upon receipt of a referral, and prior to the delivery of BIS case management services, the case manager must make an evaluation visit to where the individual resides to conduct an assessment for service planning and begin the MPAI-4 assessment of severity of the brain injury and the person-centered planning process."
VS.
Medical Necessity Criteria
"The MPAI-4 may be completed by individuals with BI, their significant other(s), medical or rehabilitation professionals, and other designated observers who know the individual well. Comparisons among independent ratings are critical for effective rehabilitation planning, and for revealing more subtle problem areas. Scoring and interpretation of the MPAI-4 require professional training and experience"
Can you clarify exactly who completes the MPAI for a client? From my understanding, MPAI should be completed by trained professionals so I find the statement that it can be “completed by individual with BI, their significant other” to be confusing and possibly misleading. What does a service provider do if the assessment the complete is significantly different that one a family member submits? I support the first paragraph but suggest you consider adding that the MPAI can be completed once there has been sufficient time to make such an assessment. I find the second paragraph in the “medical necessity” section conflicting and confusing and am unclear if a MPAI submitted by a client or a family member should be accepted?
On page 14 it states:
"Payment for BIS case management services under the State Plan for Medical Assistance shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose"
Could there be clarification on how this will affect contracts with current programs who receive state funding for case management. I would advocate for current funding to stay with providers so it can be used for additional unmet needs in our service areas.
I have several concerns with the following Case Management Agency Requirement: "Guarantee that individuals have access to emergency assistance either directly or on-call 24 hours per day, seven days per week and holidays. This may be done via telephone and face-to-face contact and/or coordination with other providers and DBHDS administered crisis services."
Could you please clarify what constitutes emergency assistance? Non-profit organizations such as Brain Injury Services (and others who provide case management for brain injury) do not provide emergency assistance, as we are not a medical nor emergency mental health provider. Because we are not an emergency/crisis resource, we educate and prepare clients about when and how to use 911 and 988 as needed. To my knowledge, there is no published empirical evidence that non-medical brain injury case management services would benefit from 24/7 availability.
Instead, this would be a disservice to not only the service providers, but also to the clients. As Lisa McCarthy stated, requiring 24/7 availability would lead to significant financial burdens for agencies and lead to even higher turnover rates in a profession already struggling with widespread burnout. Without significant funding increases from the state, agencies also could not afford to compensate employees who are required to be available for more than their 40 hour work week, or to hire staff for a 24/7 call center. This would certainly lead to a greater number of clients being underserved. At the end of the day, the clients are the ones who would be harmed by this.
Thank you for considering our feedback.
I have ethical concerns related to the following Case Management Agency Requirement: "Guarantee that individuals have access to emergency assistance either directly or on-call 24 hours per day, seven days per week and holidays. This may be done via telephone and face-to-face contact and/or coordination with other providers and DBHDS administered crisis services." I am also concerned with the requirement for face-to-face meetings.
As a Certified Rehabilitation Counselor through the CRCC, I am obligated to abide by the CRCC Code of Ethics. One of our guiding principles is "promoting empowerment through self-advocacy and self-determination." I am concerned that requiring non-medical, non-emergency service providers (i.e., non-profit organizations such as Brain Injury Services) to be available 24/7 does not align with this ethical principle, as it opens the possibility to boundary violations and dependency within client-counselor relationships.
CRCC Code C.1.c states "EMPOWERING THE CLIENT. CRCs/CCRCs work to ensure the voice of the client is heard, valued, and given full consideration by supporting informed choice and client engagement in decision-making and treatment planning. CRCs/CCRCs foster self-advocacy skills of clients to achieve maximum independence."
Opening the door to potential boundary violations and dependency within relationships not only clashes with this ethical code, but also the mission of agencies like Brain Injury Services, where the goal is to empower clients to achieve independence. I am also concerned that requiring face-to-face contact works against this ethical code, as some clients either prefer to meet virtually or are unable to offer home visits due to safety concerns (i.e., domestic violence, pests, weakened immunity/susceptibility to illness). Given what we have learned from the COVID-19 pandemic about increasing accessibility, this feels like a step backwards for disability inclusivity and accessibility.
Justice is another foundational CRCC principle, which is defined by the as being "fair in the treatment of all clients; to provide appropriate services to all." By making ourselves available 24/7 to some clients but not others, my work would not be aligned with this principle. This could cause individuals like myself (CRCs, LCSWs, etc.) to risk losing our certifications and/or licenses.
I was previously a TCM in another state, and I have several questions about the manual that I am hoping to gain clarification on.
As other colleagues of mine have mentioned, are we able to get clarification on Provider Requirements that the provider agency must "Guarantee that individuals have access to emergency assistance either directly or on-call 24 hours per day, seven days per week and holidays. This can be done via telephone and face-to-face contact and/or coordination with other providers and DBHDS administered crisis services."
At my previous agency, being on-call meant answering a call service between the hours of 5PM to 9AM from all clients of our agency, not just those on our assigned caseload. If the client had a medical or mental health emergency and went to their local hospital, we were expected to present immediately, meaning we went to the hospital and helped coordinate admission or transfer. We were also expected to meet with them in person if there was a natural disaster or inclement weather. Will this be the expectation for TCM's here in Virginia? Thank you for your time.
As I mentioned previously, I was a TCM in another state and am hoping to gain clarification on Virginia's expectations for the TCM program.
In regards to billing, are only face-to-face interactions with the client considered billable? Will phone calls of a certain time be considered billable? At my previous agency, we could bill for phone calls over 7.5 minutes long. It is mentioned in the manual under Service Requirements that TCM's will "assist the individual to participate in appointments and community resources to ensure access to care and successful facilitation of service delivery," as well as under Service Monitoring "visit with the individual and their family, and providers of service for monitoring of health and welfare and ISP implementation." With these two statements, will it be within a TCM's scope of responsibility to attend medical/mental health/other appointments with a client? With the expectation of having "at least one face-to-face contact with the individual every 90 days, which may vary based on intensity of case," will we be able to bill for multiple visits with a client a month, especially if we are attending appointments with them outside of the community? If we do attend appointments with clients, will there be restrictions on billing, such as only being able to bill for when the client meets with the provider, but not being able to bill for sitting in the waiting room with the client? Is only physical face-to-face billable, or does telehealth count? There are instances where it is not safe to meet with a client in person due to infestations, illness, and other factors. What is the expectation if a client declines meeting in person? Thank you for your time.
As I was reviewing the most recent manual draft, I noticed in a lot of places the pronouns his/her were used when referring to clients. To ensure that we are being inclusive of all individuals that may utilize our services, would this be able to be changed to a non-gender specific term, such as "their" or "the individual's." For example, under Person Centered Planning, it states "...and practices to engage the individual and his or her (in which "or her" is struck out in red) circle of support..." To make it inclusive of all individuals regardless of gender identity or expression, would we be able to put "...and practices to engage the individual and their circle of support..."? Thank you for your time.
The revised manual still does not include any significant requirements and/or procedures to address human and/or civil rights concerns of persons served. The only mention of rights I could find is on page 7, BIS Case Manager Staff Qualifications, where under 'BIS case managers must have knowledge of:' there is a bullet point for "Individuals' civil and human rights" (i.e., case managers must have knowledge of civil & human rights).
While important, it is insufficient for case managers to have knowledge of civil and human rights. The persons served, who as survivors of severe TBI meeting medical necessity criteria can be expected to have cognitive challenges, need to be aware of their rights in an accessible manner AND of the processes in place to protect them. This is not something to skip past or ignore.
Individuals with mental health, developmental disability, &/or substance abuse diagnoses have documented protections when their rights are alleged to have been violated. These are authorized for DBHDS support recipients under Title 37.2-400 of the Code of Virginia (1950), as amended, and can be found in the Support Coordination/Case Management Manual, DD Specific, from DBHDS. There is an Office of Human Rights with regional representatives, and there are local Human Rights Committees. Additionally, there is a DMAS Appeals portal.
Surely the brain injury population of Virginia also deserves some clear and specific process to allow for protection and advocacy for persons served from this vulnerable population. This is particularly true given that brain injury survivor supports are new to the DMAS system and there may be multiple foreseen and unforeseen "hiccups" along the way that could negatively impact individual human and civil rights.
We were told by a high ranking state employee that the requirement for CARF accreditation of STBI TCM providers is expected to cover any human rights concerns. While rights education and grievance processes are indeed part of CARF accreditation, these will be specific to the accredited agency and its policies and actions. CARF cannot and will not address a statewide absence of uniform rights protections and grievance procedures. It is a mistake to ignore this critical element of brain injury support provision in Virginia.
The 1st version of this manual had an overly restrictive list of acceptable bachelor's degrees for TCM case managers. In this revision, the pendulum has swung all the way over to not requiring any specific degree, any degree will do.
There is a middle ground. I refer you to the DBHDS document, "Approved Degrees in Human Services and Related Fields" (ol approved degrees in human services 062017.pdf in the VA DBHDS Documents library) for a well thought out & reasonable approach to degree requirements. The document specifically addresses QMHPs (Qualified Mental Health Providers) in Virginia but survivors of brain injury require similar protections.
It makes no sense to allow someone with no experience and an unrelated degree to serve as support coordinators/gatekeepers to supports for this unique and challenging population. Under the proposed revised manual, an individual with a bachelor's in Theology or in Architecture, for example, could couple that with the 2 day direct care level QBISP certificate class and be considered a qualified brain injury case manager. This does a disservice to those it is intended to serve.
Please consider a staggered system similar to that seen in other services, where a case manager can be considered qualified under different combinations of degree + experience + certifications. This is especially important to honor the work of existing brain injury CMs, who may hold a CBIS certification and have years of experience but lack a degree & should have an avenue to be grandfathered in.
For example: a Qualified Brain Injury Case Manager must meet one of the following:
On page 7 of this revision it states that, "BIS case managers must also be certified as a Qualified Brain Injury Services Provider (QBISP) or a Certified Brain Injury Specialist (CBIS) prior to independently delivering billable BIS case management services."
It is wrong of DMAS to continue to treat the QBISP and the CBIS as equivalent qualifications. The QBISP is a CERTIFICATE and the CBIS is a CERTIFICATION and that is not expressed accurately on page 7.
Per DMAS' definition on page 5 of the manual under "Definitions", a "Qualified Brain Injury Support Provider (QBISP) means a certificate in a training program through the @Neurobehavioral Training Institute that promotes practical education for direct care staff that is supported by daily supervision to enhance care for persons with behavioral challenges. Training information can be found here: https://qbisp.training/." The bolding is mine, to emphasize that in DMAS' own definition this is clearly a direct care level certificate intended to be supported by daily supervision. The TCM Support Coordinator is not a direct care position and there is no provision for the required daily supervision in the manual.
Not only is the QBISP not intended for clinical/CM staff or any staff without daily supervision, it is also difficult to locate training. DARS told us that it is $10,000 + expenses to bring in the required out of state trainers, and there are currently no training sites in Virginia. If Virginia agencies spend the money to become QBISP trainers, they still have to pay a fee to the QBISP folks for every person trained and the trainer must complete a minimum of 4 trainings per year, which is prohibitive for smaller providers such as those in rural regions of the Commonwealth.
The CBIS, on the other hand, is defined by DMAS in Definitions in this manual, as ""Certified Brain Injury Specialist" (CBIS) means a certification through the Academy of Certified Brain Injury Specialists that includes 500 hours of direct work with individuals, giving staff ample experience in the core disciplines of behavior, speech, cognitive challenges, physical therapy, and community reintegration. Certification is valid per CBIS requirements, requiring staff to renew their status and stay current with treatment issues and protocols in the process. For more information see https://www.biausa.org/professionals/acbis.". Please note that the CBIS is valid for one year and requires documented submission of brain injury specific continuing education each year (10 units).
The QBISP certificate and the CBIS certification are not equivalent and should not be presented as such. The CBIS is a more rigorous professional level certification requiring direct experience and the QBISP is a direct care level certificate intended to be used under daily supervision.
With that said, Virginia needs something in between the two, given the challenges of staff turnover. The CBIS requires staff to pass a difficult exam and have 500 hours of direct experience with ABI survivors - it is not something a new hire can quickly or easily acquire. The QBISP can be acquired way more quickly, in only 2 days if training can be located, but the 'direct care level under daily supervision' aspect means it is a rather weak requirement for an ABI professional.
One solution would be to allow the QBISP + 3 years of direct ABI experience (or similar) to be considered qualifying. Another would be to establish a supervisory qualification system, as seen in other waivers, where a QBISP (or perhaps a person without a QBISP but with 5 or 10 years direct ABI experience) to operate & provide TCM under the supervision of a qualified ABI supervising case manager. The supervisor would be required to hold a CBIS certification and/or possibly a more advanced degree and would provide oversight.
This manual's case manager qualifications requirements raise the specter of an employee with no experience with survivors of brain injury, a degree in macroeconomics, and a 2 day direct care level training being let loose to provide specialized brain injury case management that is actually not specialized at all due to the flimsiness of their qualifications. We do not allow this with other unique populations and should not allow this with ABI survivors.
Please clarify what is required by the following on page 6-
"Guarantee that individuals have access to emergency assistance either directly or on-call 24 hours per day, seven days per week and holidays. This may be done via telephone and face-to face contact and/or coordination with other providers and DBHDS administered crisis services."
Brain Injury case management services are not crisis or emergency services. Our staff educate our consumers to the appropriate resources for emergency or crisis but do not provide or participate in these services.
Requiring staff to be available 24/7 would require additional funding/staffing. If you are requiring your staff to be on-call, they will need to be compensated for such.
These additional requirements will create continued undo hardship on a workforce landscape that is already deplete of qualified and willing candidates.
It should be noted there is an appreciation of the revision of hiring requirements for case managers to no longer be restricted by six degree fields when seeking appropriate candidates for case management positions.
With that being said, there is no mention of experience being a factor in the hiring process. Without that inclusion, you could be allowed to hiring someone with a degree in Art Design but has never worked "in the field." Vice versa, you could have a candidate that has 15 years of experience with case management and brain injury that might have an Associate's Degree that would be barred from being eligible.
In most positions there is an account for experience in lieu of a degree. Consideration should be made to include this as it pertains to eligibility for TCM CM positions.
On page 6 of the manual, under Case Management Agency requirements, it states that the provider agency must "Guarantee that individuals have access to emergency assistance either directly or on call 24 hours per day, seven days per week and holidays. This may be done via telephone and face to face contact and/or coordination with other providers and DBHDS administered crisis services."
This is a requirement that has changed over the course of the TCM development process, and one that we have received conflicting guidance on. We have been told that it is somehow related to a specific CMS and/or Medicaid requirement, that all Medicaid providers are required to meet it, and that smaller providers should investigate how "mom & pop" organizations in other Medicaid support areas meet it.
On it's face, it places a particularly harsh burden on smaller providers who have less staff available to "share the wealth" of being on call 24/7 including holidays. It is a truism that human services staff are already underpaid and overworked and requiring providers to require this from our staff is a huge barrier to our ability to continue to support this population, as we have done for decades without being on call at all times.
Initially we were told that this requirement could be met without having a live person available. We could, for example, have a 24 hour answering machine (as even doctor's offices do!) that states our operating hours and directs individuals to call 911 for medical emergencies and the local 24 hour CSB crisis intervention line for behavioral &/or mental health crises. That would make sense.
What doesn't make sense is having an already underpaid & overstretched employee being woken up in the middle of the night or interrupted in the middle of their holiday celebrations to take "emergency assistance" calls.
It is not clear if the emergency assistance is merely verbal - where the staff takes down info, offers advice/direction, & addresses it as soon as possible during normal business hours - or if this requirement means that staff must be prepared to leave their homes and travel to offer assistance. If it is the former, it can be accomplished via a voicemail system. If it is the latter, it is an undue burden that will erode staff morale and increase employee turnover/vacancies. On the rural Eastern Shore, for example, we employ 1 case manager. Even if the advent of TCM meant we could hire a PT case manager to work with him this would still require that these staff basically devote their lives to support provision, decreasing their availability for needed work during regular hours, and increasing their motivation to go work at Wal-Mart instead, where sometimes their life is their own.
Please consider sharing with stakeholders the specific language behind DMAS' need for this requirement and consider working with stakeholders to find workable solutions to meet the intent of that language without creating barriers to support provision.
There is no language in the manual that addresses the existing staff of the current brain injury case management providers. How do we address staff that may not have either QBIS/CBIS or may not have a Bachelor's degree but have been providing BI services for years?
How do we address either current staff or new hires that may not be CBIS/QBIS certified either due to the lack of required direct contact hours for certification or lack of available trainings/certifications?
Could it be considered that while someone is either working towards their certification or waiting for open training/certification dates, they are allowed to be supervised by someone with CBIS/QBIS certification?
The manual uses the validated Mayo-Portland Adaptability Index (MPAI-4) as the tool to determine that the Traumatic Brain Injury (TBI) is severe enough for TCM eligibility. DMAS provided a training this spring for potential TCM providers that was given by the MPAI-4 developers.
In that training, we were told that to correctly administer an MPAI-4 assessment we need to be familiar with the individual, have access to past records, and be experienced with the tool itself. This is supported by language in the Manual for the MPAI-4, which states on page 3, under Test Materials and Use: User Qualifications:
"User Qualifications - The MPAI-4 may be completed by people with ABI, their SO, medical or rehabilitation professionals, and other designated observers who know the individual well. People with very severe cognitive impairment should not be given the MPAI. Professional staff should review the rating guidelines provided in this manual prior to making ratings. People with ABI or their SO should have a professional who is experienced with the MPAI-4 review the rating guidelines with them prior to making ratings and be available to them to answer any questions that may arise during their completion of the inventory.
Currently we recommend that people with ABI and their SO complete the same version of the MPAI as staff. In clinical practice, comparisons among independent ratings by staff, people with ABI, and their SO can offer information about the varying perspectives of each of these rater groups. Examination and discussion of these varying perspectives are often critical for effective rehabilitation planning, as well as for revealing more subtle problem areas.
Scoring and interpretation of the MPAI-4 require professional training and experience. Ideally professionals with advanced training in tests and measurements will be available to clinical teams that use the MPAI-4 for clinical evaluations. Such a skilled psychometrician should also be involved when the MPAI-4 is used for program evaluation or research. Interpretation of the MPAI-4 by professionals in the clinical setting requires specific experience with the instrument and with ABI in addition to basic knowledge of tests and measurements."
Please note that it references that scoring & interpretation require professional training and experience & that ideally professionals with advanced training in tests & measurements will be available to clinical teams that use it for clinical evaluations. A professional with MPAI-4 experience is supposed to review the ratings with survivors & their support circle.
This dovetails with DMAS' own words, on page 11 of this manual revision, where they specifically state, "Scoring & interpretation of the MPAI-4 require professional training and experience."
Despite the words of the MPAI-4 creators and DMAS, this manual expects the TCM case manager (who, if we cross-reference the CM requirements, could be a person with zero ABI experience & a bachelor's degree in Aeronautical Engineering who took a 2 day direct care level QBISP training that expects them to operate under daily supervision) to administer the MPAI-4 as an entry point eligibility screening tool.
It was not designed to be used as a screening tool to determine service eligibility, or to be administered by someone unfamiliar with it, or to be administered by someone who has no familiarity with the individual &/or access to their history. The MPAI-4 Manual states, "The Mayo-Portland Adaptability Inventory (MPAI) was designed:
? to assist in the clinical evaluation of people during the postacute (posthospital) period following acquired brain injury (ABI),
? to assist in the evaluation of rehabilitation programs designed to serve these people, and
? to better understand the long-term outcomes of acquired brain injury (ABI). ".
If DMAS wants it to be used as the gateway to service entry, there needs to be clearer guidance and standards regarding who is qualified to administer it. Remember, a survivor of TBI could be denied supports based on the scoring & rating ability of the person administering the MPAI-4. Even more chillingly, per DMAS staff, the MPAI-4 will be required to be administered annually and if supports are effective & the individual's score increases they will be deemed ineligible for the service (I guess the plan is we wait for them to decompensate, test them again, & get them back into services?).
Perhaps the MCOs should be determining eligibility. It seems like there is a potential conflict of interest in allowing providers to rate individuals themselves, given that a less ethical or less trained provider could theoretically place their thumb on the scales by adjusting their scoring to ensure that an individual qualifies or doesn't qualify. At our agency, 2 qualified staff can come up with 2 different ratings scores for the same individual. The ratings can be subjective & rely on having good knowledge of the person & their history. Considering that, it seems like at a minimum this is an area where an individual should be allowed to appeal a rating or request a 'second opinion' screening by a different rater. What about when Mom's ratings conflict with the individual's ratings &/or the professional's ratings? How is that resolved in this system?
This is a sophisticated, validated, nuanced tool that by all accounts requires trained & experienced administrators. It might make more sense to allow preliminary entry into services based on medical records and a comprehensive functional assessment, especially considering the vast fluctuations that ABI survivors can have between 'good days' & 'bad days', with an MPAI-4 administered perhaps around the 90 day or 6 month mark to verify continued eligibility.
The regulations read " brain damage due to a blunt blow to the head; a penetrating head injury; crush injury resulting in compression to the brain; severe whiplash causing internal damage to the brain; or head injury secondary to an explosion. " The Brain Injury Association of America also defines acquired brain injury, as a non-traumatic brain injury that causes damage to the brain by internal factors, such as a lack of oxygen, exposure to toxins, pressure from a tumor, etc.
Both of these definitions should be included.
Unpaid or informal caregivers include relatives, friends, or others who volunteer to help. Family caregivers are not volunteers! They give up everything for the care of their loved one and should be compensated. The financial difficulties each family faces is staggering and in this climate where caregivers are scarce and burnt out we need to recognize the services of these caregivers.
The degree requirement changed from specific fields to only “must hold a bachelor’s degree OR…registered nurse.”
We suggest to replace bachelor’s degree with two or more years’ experience which in the opinion of the executive director (or hiring employee) is sufficient to allow the individual to perform the job.
QBIS and CBIS are totally different certifications: CBIS requires one to have worked 500+ hours with people with brain injuries. There are currently not enough QBIS training options to have a staff complete the certification upon orientation- the in-person requirement for training for QBISP makes that particularly challenging
What is the timeframe that a person has to get these certifications in?
We recommend that the supervisor should be CBIS certified and the new employee has a certain time frame within they need to get either certification. This will also prevent clients experiencing a gap in services when a case manager leaves their position or waits for their certification.
1. Guarantee that individuals have access to emergency services assistance either directly or on-call 24 hours per day, seven days per week and holidays on a 24-hour basis…
Please clarify what “emergency assistance” entails and how that differs from the previous version that stated “emergency services”. We currently do not provide all emergencies assistance but have safety plans for clients to call 911 and 988 when needed. A 24/7 would be a financial burden to the current non-profit brain injury providers.
2. Ability to serve: ‘Demonstrate the ability to serve individuals in need of comprehensive services regardless of an individual’s ability to pay or eligibility for Medicaid reimbursement. (i.e., lapse in coverage, transitional care, etc.)’
For clarification, we believe it should read ‘Demonstrate the ability to serve individuals in need of non-medial comprehensive brain injury services regardless of an individual’s ability to pay or eligibility for Medicaid reimbursement. (i.e., lapse in coverage, transitional care, etc.).
Question: How will the organization get reimbursed if a client is not able to pay or eligible for Medicaid reimbursement? This could be costly. This was a question last time and has not been addressed. Thank you for clarifying.
Page 7 Conflict of Interest – has not been changed although there is contradicting information: Please clarify this: ‘Pursuant to 42 CFR 441.301(c)(1)(vi), … and/or develop person-centered plan of cares in a geographic area also provides HCBS.
In order to meet this requirement an individual that provides case management services must not be employed (directly, or as a contractor) by an entity that provides other HCBS services.
Furthermore, an individual or entity that provides case management/support coordination services must not have an interest (as defined in 42 CFR 411.354) in a provider of other HCBS services.’
While throughout the development of TCM services this COI was emphasized, in the most recent meeting with DMAS is was said at three different occasions that an agency could provide both, TCM and other direct brain injury services but the agency could not provide TCM and other services to the same person.
This is contradicting information and has great consequences for the current brain injury providers.
Does either one applies to all providers (including CSBs)? It should, otherwise it will create an unfair (financial) situation between CSBs and all other service providers which will be certainly interesting to all stakeholders.
Payment for BIS case management services under the State Plan for Medical Assistance shall not duplicate payments made to public agencies or private entities under other program authorities for this same purpose (page 14)
Can you please clarify how this will affect current state contracts that fund case management?
Page 10
In our 20+ years’ experience, a diagnosis often includes a Neuropsychological Evaluation. If that is needed, it would be helpful if it is covered my Medicaid.
Can you please clarify exactly who completes the MPAI for a client? What does a service provider do if the assessment is significantly different that a family member submits? We suggest to consider adding that the MPAI can be completed once there has been sufficient time to make such an assessment. Will the I MPAI submitted by a client or a family member should be accepted and if so, does it hold the same value?
Pages 7 and 8:This was mentioned before but not clarified or addressed:
Knowledge
a. Generally: Is all this knowledge required at the time when we hire them? It is more than unlikely that anyone will apply with all the knowledge and skills required in their document. It would be helpful if there are guidelines / timeframes by when to acquire the knowledge, credentials, some skills.
b. Applicant location: If a person to be interviewed for the position as a case manager has to have the knowledge of ‘local community resources’, etc., one could only hire experienced case manager who have worked locally for years. The wording should be less stringent and allow to hire applicants from out of the area.
Skills :
a. ‘Gathering information from other sources, such as family members, medical providers, social workers, and educators (if necessary) to conduct a complete needs assessment of the eligible individual. ‘ Mental Health Care provider should be added as a source.
b. ‘Observing, recording, and reporting and documenting an individual's behaviors.’ Physical, cognitive, and emotional challenge should be added to this sentence.
Page 1 Certified Brain Injury Specialist (CBIS): It should read ‘Certification is valid for one year, requiring…’.
Page 2 Commonwealth Coordinated Care Plus (CCC Plus) program means….
For consistency words should be capitalized, i.e. it should read...or from the Department’s Home and Community-Based Services (HCBS)1915© waivers.
CM Skills: CPR/FA needs to be included into skill section.
Page 19 7. Last Line: Change POC to ISP
Page 20: BIS Case Management Billing Requirements: Second paragraph: change POC to ISP
Other: Throughout the document, communication with family and others (professional and not) is mentioned. It should be pointed out that this always requires the consent of the client.
There is no mention of covering neuropsychological testing which is pivotal to the majority of the consumers we serve. Please add.
Using the MPAI-4 as the screening tool for eligibility of services is acceptable only if the screening requirements of the screener are met. According to the language used by the developers of the MPAI-4, highly trained professionals are the only acceptable screeners able to use this tool.
Who does DMAS intend to be the screeners using this assessment tool?
It can't be the TCM case managers. They are not qualified to do so.
Anyone using this screening tool for service eligibility purposes must meet the requirements or the outcome of the assessment is not valid and poses some decent ethical concerns.
The Conflict of Interest component of TCM has been an area of much confusion, concern, and conflicting guidance throughout the STBI TCM development process. It is not an minor issue. There is an existing state-funded (to the tune of approximately $8 million/year authorized in funding from the General Assembly) award-winning nonprofit brain injury support provider network that has been nurtured & developed by Virginia for decades through dedicated state dollars administered by DARS. This is not insignificant or irrelevant.
This network, which represents thousands of ABI survivors served and hundreds of Virginian employees contributing millions to our state's economy, will be significantly impacted by the final determination and interpretation of TCM conflict of interest rules. It is economically and ethically imperative that there be clear and correct communication of how the rules will work. It is not as simple, as DMAS staff have told state-funded BIS providers, as "choosing a lane". These are existing organizations with actual employees serving real live people and actions/interpretations that will negatively impact support provision in the Commonwealth must be well thought out and accurately and consistently communicated.
In this iteration of the draft TCM manual it states the following on page 7 addressing conflict of interest:
Please note that on page 4 of the draft manual, under Defintions, HCBS services are defined as:
“Home and Community Based Services (HCBS)” or "waiver services" means the range of community services approved by CMS pursuant to § 1915(c) of the Social Security Act to be offered to persons as an alternative to institutionalization. They provide opportunities for Medicaid beneficiaries to receive services in their own home or community rather than institutions or other isolated settings. These programs serve a variety of targeted populations groups, such as people with intellectual or developmental disabilities, physical disabilities, and/or mental illnesses.
On it's face, this language is quite clear. The language, "In order to meet this requirement an individual that provides case management services must not be employed (directly or as a contractor) by an entity that provides other HCBS services" & "Furthermore, an individual or entity that provides case management/support coordination services must not have an interest (as defined in 42 CFR 411.354) in a provider of other HCBS services" is not ambiguous, and neither is the DMAS provided definition of HCBS services listed above, which clearly indicates that "HCBS services" encompasses the "range of community services" that "serve a variety of targeted populations groups [sic]" as listed and as approved by CMS.
This language, if taken literally, excludes employees of & those who hold an interest in providers of other HCBS services. Full stop. It will prohibit any organization (i.e., most if not all CSBs, many mental health providers, existing providers who provide other HCBS services) from being an STBI TCM provider, as it is written. There is nothing in this language that limits the HCBS services in question to those specifically designated as targeting brain injury survivors. Even if it did, that would be problematic, considering that it is not uncommon to have survivors dually diagnosed and eligible for non ABI-targeted HCBS services, including a large number of individuals who were disabled by ABI prior to their 22nd birthday who have developmental disability services & waiver eligibility.
There is a 'willing and qualified" provider exception, where if the state can demonstrate that the only willing & qualified entity to provide TCM/develop ISPs in a geographic area also provides "HCBS". The process for making this determination should be explicitly spelled out. Virginia has granted the CSBs a monopoly on case management provision for the ID/DD population statewide based on this exception, which serves to severely restrict choice of providers for that population as well as inhibiting the development of independent conflict-free potential case management providers who are locked out of the system due to this determination. It does not serve to promote person-centered choice for persons served or meet either the letter or the intent of CMS conflict free case management regulations and should be exercised only with caution and clear and transparent guidelines as TCM is introduced to the brain injury survivor population. Any such determinations should include a plan to promote the development of additional qualified and willing providers in the identified region as soon as realistically feasible.
Other than advising great care and sensitivity to genuine consumer choice, I am not commenting specifically to request revision of the conflict of interest language. If that is the language needed to meet CMS requirements, so be it. It must be applied universally and consistently, however, without fear or favor.
This is complicated by the ongoing conflicting guidance from DMAS. A high-ranking DMAS employee was specifically asked, during the current public comment period, how the conflict of interest rules as written would be implemented/how the prohibitions indicated would apply to potential providers of STBI TCM who are already providing other HCBS services through the ID/DD waivers.
The written response from the DMAS official was, "At this time, there are no brain injury waiver service [sic] so the conflict would not exist when providing TCM services.", and, "There is no 'provider of HCBS' (waiver services), therefore there is no conflict consistent with this section because the TCM entity can't provide something that doesn't exist (waiver services).". When further pressed, all the DMAS official would say was, "Please read the information again. I did answer the question. DD waiver is not the same as nor has anything to do with the BIS waiver.".
With all due respect, not only is this interpretation not reflected in the manual language, it is directly contradicted by the manual language, and by the truth that HCBS and/or waiver services do, in fact, exist for persons served. I cannot emphasize enough how critical it is that this fundamental information be transmitted in a clear and consistent manner that meets CMS requirements. It is crucial information to both persons served and existing business entities across Virginia and no one reading the rules should have any doubt as to what it means and how/where/to whom it applies, which unfortunately is not currently the case.
It is worth noting that the DMAS official quoted also provided a citation from the eCFR (Electronic Code of Federal Regulations) underneath their response. Here is the federal code cited ( https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-441/subpart-G ):
§441.301 (c)(1)(vi)- “Providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual must not provide case management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered service plans in a geographic area also provides HCBS. In these cases, the State must devise conflict of interest protections including separation of entity and provider functions within provider entities, which must be approved by CMS. Individuals must be provided with a clear and accessible alternative dispute resolution process.”
Please note that the federal code cited refers to "a provider of HCBS" and "also provides HCBS" without any distinctions regarding whether the HCBS is targeted towards any specific disability population (which makes sense, considering the overlap created by comorbid conditions).
It goes on to specifically require that if an 'only willing and qualified' entity exception is applied the State must also devise conflict of interest protections including separation of entity & provider functions within provider entities, which must be approved by CMS.
Finally, the federal code requires that individuals must be provided with a clear and accessible alternative dispute resolution process". Neither the dispute resolution process nor the CMS-approved conflict of interest safeguards appear in the draft manual. This is a significant omission. These elements are required to protect the persons served, promote person-centered processes, and prevent system-centered actions that impede human and civil rights and it is not okay to only include a portion of the relevant requirements in this plan.
The only aspect of the cited codes that seems to possibly introduce "wiggle room" is the part where the code states, "providers of HCBS for the individual" but this does not seem to be the aspect DMAS is emphasizing. Focusing on the "for the individual" component would mean that providers of other (non TCM) HCBS would be allowed to provide TCM to an individual AS LONG AS they do not provide any other HCBS services TO THAT INDIVIDUAL. That interpretation hews to the code language and would prevent the dissolution of existing nonprofit organizations as it would allow providers to provide specialized brain injury support coordination without first divesting of any other HCBS provision within their agencies, as long as they don't provide both to the same person in the absence of an only willing & qualified provider exception.
That is not how the manual is written nor is it reflected in the most recent DMAS guidance, however, although it does align with what we were briefly advised by DMAS in the spring of this year at a stakeholder meeting.
This is such an important issue and it has created a great deal of consternation and conflict throughout the entire year of brain injury TCM and potential waiver development. I recommend, for the sake of transparency and to promote confidence in a final rule interpretation, that DMAS review these conflicts with CMS in the presence of process stakeholders (such as the existing support providers, brain injury specific or not, who will be economically and operationally impacted) and provide one last clear, final, and comprehensive conflict-free case management rule. Inscrutability is not an asset here.
I'm concerned that there are many BIS case managers currently providing excellent service to our population that do not have a bachelors degree. It would be tragic to lose the experience, relationships, and skill these case managers provide in the service of our population simply because they don't have a degree. Many professions are seeing the benefits of experience in lieu of formal education. With the ongoing struggle for the state to fill needed positions with qualified persons it would seem necessary to consider a provision to replace education with an equivalent level of experience.
Please clarify what is required by the following on page 6-
"Guarantee that individuals have access to emergency assistance either directly or on-call 24 hours per day, seven days per week and holidays. This may be done via telephone and face-to face contact and/or coordination with other providers and DBHDS administered crisis services."
Brain Injury case management services are not crisis or emergency services. Our staff educate our consumers to the appropriate resources for emergency or crisis but do not provide or participate in these services.
Requiring staff to be available 24/7 would require additional funding and additional staffing. If you are requiring staff to be on-call, they will need to be compensated and also need additional accommodations other than personal cell phones.
These additional accommodations may cause undo hardship on the workforce that is already depleted of qualified and low number of candidates.
Page 6:
CM Agency/provider requirements:
1. Guarantee that individuals have access to emergency services assistance either directly or on-call 24 hours per day, seven days per week and holidays on a 24-hour basis…
Please clarify “emergency assistance”
***We currently do not provide all emergencies assistance but have safety plans for clients to call 911 and 988 when needed. A 24/7 would be a financial burden to the current non-profit brain injury providers.
Question: How will the organization get reimbursed if a client is not able to pay or eligible for Medicaid reimbursement?
Page 7
Conflict of Interest – has not been changed although there is contradicting information: Please clarify this: ‘Pursuant to 42 CFR 441.301(c)(1)(vi), … and/or develop person-centered plan of cares in a geographic area also provides HCBS.
Please clarify the timeframe in which a person has to obtain a CBIS or QBIS. Since CBIS requires 500+ hours of direct service, and there are not currently enough CBIS training options for new staff members to complete during the orientation process, I am concerned that this will lead to staffing challenges for agencies serving this population. As a result, many clients would likely be underserved, held on waiting lists, or frequently transferred to new CMs due to increased turnover. The clients would ultimately be harmed by this consequence.
Pages 7/8
Brain Injury Services Case Manager Staff Qualification/Credentials:
i) The degree requirement changed from specific fields to only “must hold a bachelor’s degree OR…registered nurse.”
QUESTION: Does that mean any Bachelor’s degree, even if it is completely unrelated to human services?
Clarification needed.
***It would be more beneficial to replace bachelor's degree with two or more years' experience.
QUESTION:
Will current employees without the specified credentials grandfathered in or do we have to terminate them after years of experience in this field? This would cause current providers to lose many staff members.
***QBIS and CBIS are totally different certifications:
QUESTION What is the timeframe that a person has to get these certifications in?
***It would make more sense if new employees had two years to obtain certifications.
Please explain what is meant by "emergency assistance".
We are not a crisis agency and do not provide crisis services. However, we do ensure that all consumers have safety plans in place. These are updated as needed and annually. Our consumers are provided critical contact numbers for services including 911 and 988 if they have an after hours emergency. We do not have the staff to provide 24/7 on call services to our consumers.
If new staff have not obtained either certification, is it possible to have a CBIS/QBIS supervise until they are certified?
"Guarantee that individuals have access to emergency services assistance either directly or on-call 24 hours per day, seven days per week and holidays on a 24-hour basis. This may be done via telephone and face-to face contact a phone answering service and/or coordination with other MCOs providers and DBHDS administered crisis services."
Could you provide clarification on this? Brain injury service providers are not trained mental health providers, nor are we crisis response clinicians. Placing this burden on BI case management providers is first and foremost outside the scope of the services we are trained to provide. Contracting for this service is also very expensive and places additional burden on state agencies. There are already established 24/7 mental health emergency service providers in our communities. Can this requirement be interpreted to mean that we will ensure clients have access to/information needed to contact emergency/crisis service providers? If contracting is required, is this sufficient to meet the need or does this imply that having a staff person on call will be required? If so, this requirement will be significantly burdensome on all state BI service providers.
"BIS case managers must either hold at least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling OR be licensed by the Commonwealth as a registered nurse. BIS case managers must also be certified as a Qualified Brain Injury Services Provider (QBISP) or a Certified Brian Injury Specialist (CBIS) prior to independently delivering billable BIS case management services."
Please consider including a pathway for existing or future staff persons who do not have a Bachelor's degree but instead demonstrate both expertise and significant (2+ years) experience in case management (especially brain injury case management).
Additionally, please consider allowing case management staff persons who are supervised by a CBIS and working toward either their QBIS or CBIS (to be attained within the next 12 months) to be considered as qualified providers for TCM CM. This will allow continuation of services if there is staff turnover and/or new hires as we expand services across Virginia.
The MPAI-4 should be completed by a trained professional, not by a client or caregiver. Client and caregiver input should be considered/provided to the professional completing the MPAI, but all BI CM's undergo training in order to know how to most accurately and consistently complete the MPAI. Allowing clients and caregivers to complete this assessment tool would create significant inconsistencies in scoring, results, and interpretation.
A neuropsychological evaluation has been a long-standing acceptable form of medical documentation of a BI in the brain injury community. It also provides diagnostic support and BI rehabilitation/recovery recommendations/guidance for individuals specifically as it relates to their brain injury. This should be included both as an acceptable form of medical documentation for TCM eligibility as well as be a service covered by Medicaid.
On page 19 of the draft manual, under Documentation Requirements, Item #5 states:
5. There must be an ISP from each provider rendering services to the individual. The ISP is developed by the individual service provider related solely to the specific tasks required of that service provider and the desired outcomes. Plans of care help to determine the overall goals for the individual. The plans must state long-term service goals and specified short-term objectives in measurable terms. For case management services, specific objectives for monitoring, linking, and coordinating must be included.
There are 2 concerns here. The first is simple: "plans of care" is not the correct term for support plans for brain injury survivor. It was omitted in most places in the draft document when it was revised but it reappears here.
The 2nd concern is the requirement that each provider must develop a separate ISP. This is not the accepted practice for ISP development. It is not how it works in the ID/DD waivers.
General best practices dictate that there will be ONE individual support plan (ISP) developed using a person-centered process by the Support Coordinator (Case Manager - CM). The process starts with assessment, followed by shared planning to develop one ISP. The one ISP is then shared with all non-CM providers chosen by the individual to provide the supports identified as needed in the ISP. Each of those providers then works with the individual & stakeholders to develop a Plan of Supports (called the Part V Plan of Supports in that system).
Please refer to Document DD01 from DBHDS, issued 6/7/21, "Person Centered ISP Guidance", Provider Development, Developmental Services, DBHDS, for a detailed overview of the process in the ID/DD system.
This language would result in the development of multiple ISPs. This makes no sense. It creates the possibility of conflicting ISPs, waters down the whole concept of an ISP, and will end up with a cognitively impaired individual sitting through multiple "person centered" ISP development processes resulting in multiple ISPs.
There should be ONE person-centered individual plan of support developed with the individual, their chosen circle of support, and any relevant other stakeholders agreed to by the person whose ISP it is. Strengths, needs, goals & wishes are identified & an ISP is created. Providers are chosen by the individual (from available options) to meet identified needs and those providers then develop, with the individual, a plan of supports based on the identified needs from the shared planning.
Multiple ISPs will only confuse a population with cognitive challenges by definition. It would be system-centered, not person-centered, to require multiple ISPs for one individual. I would personally go even further, given the cognitive impacts of brain injury & the frequency with which survivors report being overwhelmed by "walls of text" (long wordy documents that strain focus, attention & comprehension), and include a requirement that the ISP and Plan of Supports be summarized in a cognitively accessible manner (we use a plain language highlights cover sheet) & reviewed with the individual carefully to ensure it is understood.
The one ISP is the raison d'etre of the Support Coordinator and a big part of the reason for the conflict of interest provision that case management cannot be provided by a provider of other HCBS services. Requiring all providers to produce separate ISPs really just returns the case manager's role to the other HCBS providers, creating confusion and potential conflict.
Cognitive accessibility is crucial when serving a population with cognitive deficits. Please don't single the brain injury population out for multiple ISPs when other targeted groups are not burdened with such confusion. One ISP, developed with the Support Coordinator/Case Manager, then as many plans of support as needed to address the needs and goals identified in the one ISP.
Clarification on the degree requirements would be helpful. How would current staff who do not have a bachelor's degree, but have years of BI related experience be handled? I think work experience should be considered as well as educational.
The MPAI-4 screening tool requires a "highly trained professional" to complete the assessment. Case managers do not meet these qualifications as they have not been "highly trained". Who will be completing the MPAI-4 screening?
“Brain Injury” or “Traumatic Brain Injury” (TBI) means, a brain injury for purposes of this program, is defined as brain damage due to a blunt blow to the head; a penetrating head injury; crush injury resulting in compression to the brain; severe whiplash causing internal damage to the brain; or head injury secondary to an explosion.
Why are ABI (acquired brain injuries) specifically excluded? They are also brain injuries and are (cause) lifetime issues for those who have them. While my ABI was not Traumatic in the conventional sense, I can assure you, it is still a brain injury, that has traumatically altered my entire life, and left me with permanent deficits too.
Per the Brain Injury Association of America…..
“An acquired brain injury (ABI) is an injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma. Essentially, this type of brain injury is one that has occurred after birth. The injury results in a change to the brain’s neuronal activity, which affects the physical integrity, metabolic activity, or functional ability of nerve cells in the brain. An acquired brain injury is the umbrella term for all brain injuries.
There are two types of acquired brain injury: traumatic and non-traumatic.”
https://www.biausa.org/brain-injury/about-brain-injury/nbiic/what-is-the-difference-between-an-acquired-brain-injury-and-a-traumatic-brain-injury
As mentioned earlier, the Bachelor degree should be replaced by several years of experience.
Directly from the Governor of VA - immediate Release on May 30th 2023:
RICHMOND, VA - Governor Glenn Youngkin announced today a landmark change in how state agencies will recruit and compete for talent by eliminating degree requirements, preferences or both for almost 90% of state classified positions. The new Commonwealth hiring practices will expand opportunities for Virginians and give equal consideration to all qualified job applicants. See here
The question is why then a BI Case Manger needs a degree when it can be replaced with valuable years of experience, i.e. why are they held to different standards than state employees?
Many of our consumers require neuropsychological testing. At this time, there is no mention of this in the manual. It would be beneficial if this was a covered service.