I support amending 12VAC35-105-1840(C)(3) to allow crisis stabilization units to base nursing coverage on an individualized services plan (ISP)-driven, two-tier nursing model.

Since current regulations requiring in-person nursing services 24 hours a day, 7 days a week for all clients result in significant financial losses for providers, as the combined staffing costs of registered nurses, licensed practical nurses, and other behavioral health professionals exceed the DMAS daily reimbursement rate. The unsustainable gap risks reducing access to vital crisis stabilization services for individuals and families in need across Virginia. Adopting an ISP-driven, two-tier nursing model would align the Board’s regulations with established DMAS standards and ensure both safety and fiscal sustainability. It matches nursing coverage to the actual clinical needs of each client, rather than imposing a uniform standard on all admissions, making better use of limited resources without compromising quality of care. I would urge the Board to consider this amendment to preserve essential crisis stabilization programs and maintain timely, effective access to care throughout the Commonwealth.

I write in strong support of the petition requesting amendment of 12VAC35-105-1840(C)(3) to permit crisis stabilization units to base nursing coverage on an individualized services plan (ISP)-driven, two-tier nursing model.

This proposed change is both reasonable and necessary. It would align DBHDS regulations with existing DMAS Comprehensive Crisis Services Manual (Appendix G) standards, which already base nursing requirements on the initial nursing assessment and individualized service plan (ISP) rather than a rigid, one-size-fits-all 24-hour mandate. Adopting this model will help ensure crisis stabilization programs remain clinically safe, person-centered, and financially sustainable throughout the Commonwealth.

Rationale and Financial Considerations

Current DBHDS regulations require continuous 24/7 nursing coverage, regardless of a client’s assessed needs. This approach imposes costs that far exceed DMAS reimbursement rates, even for well-managed programs. The petitioner’s financial analysis highlights the following realities faced by crisis stabilization providers:

Even before adding employer costs (benefits, insurance, taxes), the total daily expense exceeds $1,400, while DMAS reimbursement is capped at $847.04 per day. After factoring in realistic market wages and overhead (roughly 30%), providers incur a loss of more than $1,000 per day per client, or $5,000 per typical five-day stay.

This structure is simply unsustainable. Maintaining mandatory 24/7 RN or LPN presence regardless of acuity places essential crisis stabilization services, and the patients who rely on them, at risk of reduction or closure.

Why the Amendment Is Needed

Alignment with DMAS Standards:
The Department of Medical Assistance Services already allows flexibility based on individual clinical need. DBHDS should harmonize its regulations to eliminate conflicting expectations.

Safety and Clinical Integrity:
The proposed two-tier model continues to ensure that individuals who clinically require 24-hour nursing receive it. It simply allows others, whose needs do not warrant constant presence, to be served safely under ISP-guided supervision.

Financial Sustainability:
Without regulatory flexibility, the financial model for crisis stabilization programs is unworkable, especially in regions where recruitment of licensed nurses is already difficult and costly.

Access to Care:
Continued regulatory misalignment risks program closures and reduced capacity limiting access to timely crisis services in communities already facing psychiatric workforce shortages.

This amendment represents a practical and evidence-based improvement to Virginia’s behavioral health system. It supports both fiscal responsibility and person-centered care, ensuring resources are deployed according to each individual’s assessed clinical need.

I respectfully urge the Board to approve the petitioner’s request to amend 12VAC35-105-1840(C)(3) and permit an ISP-driven, two-tier nursing model for crisis stabilization units. Doing so will sustain critical services, uphold safety, and bring DBHDS policy into alignment with DMAS and contemporary best practices in crisis care delivery.

Michael Moates, Ed.D.