I wonder why a RN and a LPN are considered non-licensed. 

"Non-licensed team members include LMHP-Rs, LMHP-RPs, LMHP-Ss, QMHPs, QMHP-Ts, CSACs, CSAC-supervisees, RNs, LPNs RPRSs".

A caseload limit of 30 is restrictive in consideration of some of the research related to capacity in CSC teams across the country.  More than 1/4th of CSC teams operate caseloads between 40 and 100.  It is recommended that consideration be made for adjustments to the team composition that would allow for a larger caseload size.

As one of the DBHDS current funded teams we have operated with a caseload cap of 45, but have augmented minimum staffing to include additional Licensed and peer staff to accommodate.

Will the CANS Lifetime assessment replace the current comprehensive needs assessment? When will the CANS Lifetime assessment be available for review and training?

"The team caseload shall not exceed 30 individuals". Recommendation to reconsider of capping team caseload to 30. Restricting team caseloads would potentially impact implementing services. 

For Clarification: Crisis Support shall be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP, or QMHP-T available 24 hours per day, seven days per week, 365 days per year. The Crisis Support cannot be provided by the Mobile Crisis Response team or Emergency Services per Appendix G: Comprehensive Crisis Services. Recommendation to reconsider the use of Mobile Crisis Response team and Emergency Services to provide crisis supports which are already available 24 hours per day, seven days per week, 365 days per year. 

....Been in REALITY, Right Help, Right Now. EVER.

Not to mention the Massive Fraud and Abuse of Benefits and Administrative Costs vs. any REALIZED HELP by those who are SUPPOSED to be RECEIVING IT. 

Streamline and Cut Operational Costs by 50% so that Qualifying Beneficiaries (which do not include illegal aliens...) CAN actually benefit from any 'Right Help, Right Now'....

This program has been an abject FAILURE of support and resources for the Disabled Populations...It may look good on paper...but that is the extent of it. 

Clarification:  Does the 24 hours a day,7 days per week allow us to work with our agencies emergency services after program hours for crisis calls?  This could prove challenging  with staffing for on call schedules

The current census for our CSC team is 52, and we have a cap of 55.  We would have to send a number of individuals away from services or close them prematurely .  Based on the training that we have received and our understanding the importance of getting individuals involved in services after their experiencing symptoms for the first time we are concerned that we would have to turn individuals away.

The age limits in the draft are 15-30, and our limits are 15-25. We have been allowed to be flexible in the past, will each CSB be able to maintain that autonomy? 

Will the CANS be the only assessment or will it be in addition to the Comprehensive Needs Assessment?

Prince William County CS: Informal Public Comment DMAS Redesign Coordinated Specialty Care

1. Definitions

Comprehensive Assessment of Needs and Strengths (CANS Lifetime): CANS Lifetime

Comment -- Will this replace the current Comprehensive Needs Assessment?

Early Serious Mental Illness (Adults):

Comment -- We are unclear what exactly this is and how it is distinguishable from SMI? Is this referencing Clinical High-Risk population (pre psychosis?)

3. Required Service Components:

3.1 Standardized Comprehensive Assessment of Needs and Strengths (CANS) Lifetime

2. The assessment shall be conducted by a LMHP, LMHP-R, LMHP-RP or LMHP-S in-person with the individual in the individual’s home or another location of the individual’s/family’s choice.  Assessments completed by a LMHP-R, LMHP-RP or LMHP-S require a LMHP co-signature. 

Comment -- Can we remove the requirement for a co-signature since the document is being authored by a license eligible master’s level clinician? If no, in what timeframe must the document be co-signed? (i.e. same day, 24 hours, 7 days)

6. In addition to the above timeframes, assessments shall also be performed any time there is a significant change to the individual’s circumstances.  

Comment -- Can you please define or give examples of “significant change”?

3.2 Treatment Planning

7. At a minimum, the ISP shall be signed by:

1. The individual and the individual’s legally authorized representative. 
2. The CSC team members working with the individual; and
3. The LMHP Team Leader overseeing the services.

Comment -- Within what timeframe do all the signatures need to be there? Suggestion: within 30 days of creation

8. Needs identified in the CANS Lifetime shall be associated with identified goals and objectives as set forth in the ISP. Subsequent assessments and needs shall be reflected in updated ISPs with updated goals and objectives.

1. 1. ISP Reviews and Updates:
      1. ISPs shall be formally reviewed at a minimum of every 90 calendar days or more frequently depending on the individual’s needs. The ISP review shall be completed face-to-face and include the LMHP Team Leader, CSC team and the individual/family/caregiver. Refer to Chapter IV for additional guidance and documentation requirements for the 90-calendar day review as well as additional quarterly review requirements.

Comment -- We do not agree that having all these members present in person every 90 days is possible, or client/family centered. We suggest it be an in-person meeting with lead therapist/clinician and licensed clinician; the other members could co-sign without being present. We can certainly encourage family member and CSC team member presence but believe requiring it is not client centered

3.3 Psychiatric Services

A psychiatrist, psychiatric nurse practitioner or a nurse practitioner or physician assistant working under the supervision of a psychiatrist shall provide the following:

• A comprehensive psychiatric evaluation completed as soon as possible but no later than 30 calendar days after admission;
• Medication prescription monitoring;
• Psychiatric Services shall occur at a minimum once every 30 calendar days. It is expected that contact during the first six months should occur at least twice a month and then taper in frequency.

Comment -- Taper in frequency to what? Does an individual need to be seen monthly for the duration of treatment? Individuals often need to demonstrate an ability to be seen less frequently in order to step down to less intensive services. For example, in the 18th month, seeing the psychiatrist every other month

3.6 Health Literacy Counseling

• Health literacy counseling means counseling on mental health and associated health risks including administration of medication, monitoring for adverse side effects or results of that medication, counseling on the role of prescription medications and their effects including side effects and the importance of compliance and adherence.  Services are provided with family/caregivers when it is for the direct benefit of the individual. 
• This component can be provided by the one of the following professionals acting within their scope of practice: LMHP, LMHP-R, LMHP-RP, LMHP-S, Nurse Practitioner, Occupational Therapist, CSAC, CSAC-supervisee or RN with at least one year of clinical experience involving medication management.

Comment-- Recommend use of an LPN which is sufficient for this intervention and function

3.7 Rehabilitation Skill-Building

Supported employment and education support are not Medicaid covered services but this component can include treatment integrated services that promote education or vocational success.  Rehabilitation skill-building activities such as assistance with social skills, communication skills, problem solving skills and community living skills necessary for an individual to be successful within these activities can be covered when provided by a qualified team member.

Comment -- Under 4.1 staffing requirements, we are required to have a supported employment and education specialist but the service is not covered? That is contradictory. What would that required position then do on this team?

Rehabilitation skill-building shall be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP, QMHP-T, Occupational Therapist, CSAC, CSAC-supervisee, RPRS.

Comment -- Consider adding LPN

1. Rehabilitation Skill-Building shall be provided in accordance with the frequency identified in the ISP.
2. Rehabilitation Skill-Building may be provided through telemedicine and in groups if deemed clinically appropriate and in consultation with the LMHP Team Leader and individual.

Comment -- Does consultation have to be documented somewhere in the ISP or progress notes?

3.8 Care Coordination

1. Care coordination shall be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP, QMHP-T, CSAC, CSAC-supervisee, RPRS.

Comment -- Add LPN for care coordination

3.9 Crisis Support

1. Crisis support shall be provided by a LMHP, LMHP-R, LMHP-RP, LMHP-S, QMHP or QMHP-T.
2. CSC providers are required to develop with the individual, crisis mitigation plans, which shall not include use of or referral to Comprehensive Crisis and Transition Services (Mental Health Services Manual, Appendix G).

Comment -- What does this mean? An individual cannot utilize emergency services at all? Does this mean all members of the CSC team must be a certified pre- screener? We need more detailed explanation of this section on what this looks like in practice.

If this practice is not followed and emergency services are utilized, does that mean we cannot bill for that individual?

Our understanding is that the FEPS (Fidelity for CSC) does not require this level of availability and intervention for crisis support.

3.10 Peer Recovery Support Services

1. Peer recovery support services shall be provided by a RPRS.  The RPRS shall be supervised by a professional who has completed the DBHDS Peer Recovery Specialist Training.

Comment -- Does this include the Licensed Team Lead? Or you want a peer specialist supervising a peer specialist?

4 Provider Qualification Requirements

4.1.1 Required team members

Teams shall include at a minimum the following four team members:

1. An individual is considered a member of the team if they fulfill one or more of the following roles and attend the majority (over 50%) of team meetings.
2. CSC for FEP is delivered by a multidisciplinary team. The team has staff who fulfill the following roles: 1. Team Leader 2. Psychiatrist / Licensed Psychiatric Medical Professional 3. Therapist 4. Family Education and Support Specialist 5. Case Manager / Care Coordinator 6. Supported Employment Specialist 7. Supported Education Specialist 8. Community Education and Outreach Specialist
3. At least one CSC team member shall have training in working with individuals with substance use disorders.
4. LMHP Team Leader
   1. The LMHP Team leader shall be a full-time employee.
   2. The team leader shall be a LMHP with at least three years experience in the provision of mental health services.
   3. The LMHP team leader shall hold a Virginia License from the Virginia Department of Health Professions that qualifies them as a LMHP.
   4. LMHP Team Leader shall have the ability to provide in-person services.
   5. The team leader shall oversee all aspects of team operations and shall routinely provide direct services to individuals in the community. The team leader will monitor, oversee, and supervise the team-based process.

Comment -- What four team members? 8 roles are listed as team members under #2. This is contradictory and confusing. What positions are required?

5. Medical Necessity Criteria

5.1 Admission Criteria

1. Age Requirements
   1. The individual shall be between the ages of 15-35 at admission.  Individuals under the age of 15 shall be reviewed for medical necessity under EPSDT.

Comment -- What does this stand for? EPSDT

2. Diagnostic Criteria: shall meet all criteria a-d.

6. 2. Duration of untreated psychosis (DUP): at least one week but less than 24 months from first emergence of psychotic symptoms; The individual is experiencing symptoms such as auditory or visual hallucinations, delusions and thought disorder that causes significant functional impairment.
   3. Current episode represents first or second psychotic episode requiring clinical intervention

Comment -- Second psychotic episode. Please explain. This is confusing and feels contradictory to the bullet before it.

6. Exclusions and Service Limitations

7. Other Limitations:

2. 1. The following employment supports are not allowable in the CSC Program:
      1. Skills training related to a specific job (how to operate equipment, use computer programs, fill customer orders, etc.).
      2. Team member presence in the workplace to assist with supervision or teaching of routine work duties.

Comment -- These duties and services are part of the evidenced based model. Why are they not allowable?

Limiting a caseload size to 30 individuals will be challenging for many of the existing CSC teams in the state.  We are one of the smallest teams and are caseload size is already above 30.  This also does not allow the flexibility to serve individuals with varying levels of acuity.  For example, caseloads can be higher if there are clients who are further along in their treatment with less clinical need.  The same goes for monthly the contact requirements.  In my 11 years of working on an FEP team I have seen that it is crucial to slowly transition our clients to less and less monthly contact as they get closer to discharge because that level of care more closely aligns with the care they will receive after an FEP program.  Clients who go from numerous contacts a month to more traditional programs often decompensate without a transition period.  To try to better prepare our clients for this transition when clinically appropriate we may only see them once or twice a month for the last 4-6 months of their treatment.  I've also found that if we force FEP clients to meet with us too often they will often choose to discharge prematurely.  Engagement is very delicate balance with this population and, therefore, more flexibility in the contact requirements and caseload sizes will lead to better outcomes and the ability to serve more of those in need. 

We have some comments, questions, or suggestions. Under 8.4 (Additional Documentation Requirements and Utilization Review), it includes RNs and LPNs as “non-licensed team members” who require sign off. They are licensed by the Board of Nursing. Under 3.3, we are interested in some additional definition of “medication prescription monitoring” please—is this referring to the PMP or does this simply mean monitoring for side effects? It appears that the requirements of these regulations go above the EBP, we’d request some reconsideration of that. Lastly, what is the rate for each “encounter” (H2041) please? Thank you

Section 2, Service Definition/Critical Features
- I am concerned that Supported Employment and Education Specialist is not listed as a critical feature of CSC as CSC is an evidence-based model that includes an SEES, and would recommend reconsideration of this piece of CSC.

Section 3, Required Service Components

- 3.5- Concern about the group cap of 10 individuals for Family group- I feel this cap is too small as it could easily be met with just 2-3 clients + their families. I would suggest increasing the cap or introducing a ratio, such as 10 individuals to 1 staff member, with the flexibility of increasing staff and participants.

- 3.7- again, I am concerned about the downplay of the SEES component of CSC and the language in this section that states it is not a Medicaid-covered service. If CSC is becoming a Medicaid-covered service and SEES is a component of CSC, I would request reconsideration about its inclusion in these regs.

- 3.9- As with CPST, I remain concerned about the expectation for CSC to operate as a crisis service without sufficient funding or training and would recommend more flexible language or updating requirements for 24/7/365 in-person crisis support as crisis support services are a separate service that already exist.

Section 4, Provider Qualification Requirements

- 4.1- SEES staff role is listed here which is contradictory to the language in 3.7 where it is stated that supported education and employment are not allowable. Updated language and/or clarification are needed.

- 4.1- further clarification is requested regarding what the DBHDS criteria are for a co-occurring disorder specialist.

- 4.2- I echo others' concern for the team caseload cap is 30 and would suggest reconsideration to an increase in this cap. Additionally, further clarification is needed. Will the cap be 30 regardless of clients' Medicaid status? Remember that the majority of CSC recipients do not have Medicaid.

- 4.4 Further clarification is requested regarding the clinical consultation requirements for the psychiatric provider. If the prescriber is the only prescriber in the agency, from where should they receive their clinical consultation? Who is considered qualified to provide the clinical consultation?

Section 7, Service Authorization

- Clarification is requested regarding language surrounding group sizes. In this section, the language uses ratios- 1 staff for every 6 youth, and 1 staff for 10 adults. The language is not the same in other parts of the regs where it just said groups are limited to 6 or 10 people. 

- Updated language is needed to address caps for groups of youth and adults mixed.

- Level of Need- There needs to be flexibility to "toggle" between a monthly and an encounter rate both with billing and with the authorizations. As a current provider of CSC, I want to explain how significant the inconsistency is with client engagement to this service. Due to their age, significant symptoms, and where they're at in their recovery, they are unlike any other population that we serve. DMAS and DBHDS need to be aware of their own unique engagement style and needs. It is incredibly difficult for most clients to make all or even most of their scheduled appointments due to these barriers. I am certain that no matter how hard we try and how much advanced planning we do for services to meet the monthly encounter frequency, from month to month there will be inconsistencies where clients only meet 6 times, or 5 times. If that occurs, and we have an auth in place for a monthly rate with no flexibility to bill the encounter rate, that means we will get $0 reimbursement for that month for that client, even though we will have seen them 5 or 6 times. For the authorization, please clarify in the regs if one authorization will cover both the monthly and the encounter billing codes, or if there will be 2 separate auths. I would be happy to be contacted to provide more information about encounter and engagement rates and/or data of our current clients' engagement rates.

Section 8, Additional Documentation...

- Please clarify how #4 will be operationalized. What counts as a "progress note in the individual's chart" as sufficient for the LMHP to have reviewed the nonlicensed staff's documentation? Would that just be a monthly attestation document where the LMHP attests that they have reviewed the staff's documentation? Or do you mean an actual progress note by the LMHP documenting an encounter with the client?

• We have concerns about the requirement for a high number of licensed staff. It will be difficult to fill these positions.
• We have concerns with the limit of access to other evidence-based services.  We want individuals to get the services they need early in the course of illness and not limit them to CSC.
• We have received guidance that the CANS Lifetime for adults won't be available until after the go-live date of this redesign.  What guidance does DMAS have for meeting this requirement?
• Can the service provider use Emergency Services to meet the requirement for 24-hour crisis support?
• This question comes from our difficulty understanding the crisis support requirements.  In item 3.9, 2., it states that crisis mitigation plans shall not include use of or referral to Comprehensive Crisis and Transition Services.

• Recommend alphabetizing the definitions.
• Edit: Encounter means a face-to-face interaction....

The CANS must be completed initially and every 12 months.? Will this replace the CNA and annual reassessments and the DLA-20?? Or is this adding another assessment to the list??

3.2.8.a.iii  Assessing tThe individual’s level of progress and improved functioning may be assessed…. 

Qualified Mental Health Case Managers are capable of providing both Rehabilitation Skill-Building and Care Coordination, but are not listed as acceptable providers for either. A QMHP credential is not required to be a QMHCM.  It would require additional cost and administrative burden to seek QMHP for QMHCMs in order to use current staff to fulfill roles and activities on a CSC team.

Yes, crisis support is best provided by the team that serves the individual during business hours. However, expecting there to be 24/7/365 coverage by the CSC Team for providers such as CSBs who are already mandated to provide such crisis coverage is an undue burden and decreases the feasibility of providing CSC service. Providers should be able to use any 24/7/365 crisis personnel already employed or contracted by them.? There seems to be a discrepancy with 6.6.a.i. Exclusions and Limitations where CSBs can use Mobile Crisis Response or maybe one section was updated, but the other missed. 

There is no information on the time commitment or fees associated with training by either Navigate or OnTrackNY. 

What is the program readiness check list? It would be best to see it in order to be able to comment.

It is an extra administrative burden that CSC providers must update agency info at enrollment and quarterly thereafter. 

• It is unclear who is doing the fidelity monitoring. This may result in an extra administrative burden or increase risk of a PHI breach if data is transmitted. 
• Score less than 116 is poor fidelity and “would impact a team being listed in the EBP Finder.”  This language is vague.  State if the provider would be removed for scores less than 116 or what would happen instead.

Edit: There is only a-c. “Diagnostic Criteria: shall meet all criteria a-d.” 

CSBs should be allowed to use their full range of crisis services and bill for the appropriate service needed to stabilize the individual.  Otherwise, you are restricting the services available to the individual.