As a provider of community mental health services, I have a number of concerns about these regulations.

Re Coordination of care: I strongly concur with the acknowledgement of the family system as central to the individual’s functioning. However, Intensive In-Home services are not equivalent to family therapy at a high dosage. The service addresses complex social and emotional factors in the lives of individuals and families. Behavioral health problems are influenced by a wide range of social factors both inside and outside of the family. Best practice dictates that providers working with high-risk clients involve as much of the individual’s support network as possible. Reducing the focus solely to the individual’s health care, and ignoring other parties involved in the individual’s life, such as schools, courts, social service agencies, childcare providers, mentors, and so forth, will not result in better outcomes. Instead, I will see more fragmented and less effective treatment.

If a family is socially isolated, or has problematic ties to the community, focusing strictly on the immediate family can be a losing proposition. To strengthen such a family’s structure, providers cannot be limited to interacting only within the family system.  Preventing the involvement of other important individuals is antithetical to best practices as detailed in both wraparound and systems of care philosophies. Limiting providers’ ability to support the family in advocating for their needs with external stakeholders will also lead to a higher level of referrals for Medicaid-funded case management services.

I therefore recommend that the definition of care coordination be expanded to include collaboration with all agencies and individuals involved with the family, as required to improve individual and family functioning.  I also recommend that when formal case management services are necessary, private providers be allowed to provide these services. This will prevent overloading the Community Services Boards with referrals, improve access to care, and decrease care fragmentation.

Regarding services outside of the home: Requiring that the documentation describe “how the alternative community service location supports the identified clinical needs of the individual and facilitates the implementation of the ISP” seems to entail that the provider document a clinical rationale for the specific location chosen for every session in which any services are provided outside of the home. However, the specific location may have been chosen based on mere convenience or proximity to the home. This language creates an additional documentation burden for providers, without adding any clinically relevant information to the record.

Families may be sharing their residence with relatives or others, or have frequent visitors in the home. Some individuals need regular opportunities to consult with the provider outside of the presence of family members. The current regulations are specific enough to prevent inappropriate out-of-home services, while allowing for the flexibility that clinicians need to provide effective services when privacy is lacking in the home. In contrast, the draft regulations would open the door to subjective retractions and lengthy appeals processes, and could lead to less effective treatment for some individuals.

Re: the specification that clients must have “documented” repeated interventions in order to meet criteria for the service:  Parents, legal guardians, and referring agencies provide a verbal history of prior interventions during the intake process. Providers are required to obtain clinically important documentation such as VICAP assessments and recent psychological evaluations. However, expecting providers to obtain records from all prior providers cited in the intake documentation is not realistic. Former providers may be out of state, or no longer operating. Parents/guardians often do not recall dates, or the names of agencies and individuals. Service providers do not always respond to requests for records, despite proper authorization.

Providers already spend a great deal of time and expense compiling extensive documentation. Obtaining the records needed to meet the existing regulations and provide proper care often requires repeated requests and follow up. Providers are not reimbursed for this time. The new wording of this regulation places an additional and unnecessary burden on the provider.

Re: Documenting the clinical reason that a client is unable to sign an ISP: The current regulations were sufficiently specific to ensure that the individual is involved in the development of the ISP to the extent possible. The requirement that “signatures shall be obtained unless there is a clinical reason that renders the individual unable to sign the ISP” is unnecessary and subjective. Sometimes a child is clinically “able” to sign an ISP, but simply chooses not to do so. In such a case the draft regulation could, for example, allow a 7 year old to effectively cancel her own services.

A parent should be allowed to sign the ISP on behalf of a minor child. If a child refuses to sign the ISP, the service provider should be allowed to simply document that the child refused to sign the ISP. Likewise, an individual’s signature on the ISP should be sufficient if the individual is old enough to consent to treatment.

Re: Residents/Supervisees completing assessments: The stipulation that an LMHP must review and sign the intake within 24 hours of a Resident or Supervisee conducting an intake serves no apparent clinical purpose, creates a significant burden for providers, and decreases the quality and comprehensiveness of the documentation produced. Due to the extensive information required, the face-to-face interview may require two or more hours, and the document can take several hours to write. If a resident/supervisee conducts the intake in the evening after parents arrive home, and that clinician has appointments scheduled the next day, the clinician is forced to complete the documentation late at night and in the early hours of the morning, as well as consult with the licensed supervisor during that same time frame. The clinician has no opportunity to consult with or obtain documentation from other providers prior to completing the document. Residents/supervisees should therefore be allowed to complete assessments within the same seven day time frame as licensed providers.

I would also like to highlight the fact that the reimbursement to IIH providers for the provider-specific intake is a mere fraction of the amount that the Community Service Boards are reimbursed for an Independent Clinical Assessment (ICA).  IIH providers are required to work under much more challenging conditions, provide unreimbursed travel time, complete much lengthier assessments, and compile and review extensive external documentation. I feel that this situation is grossly unfair. IIH providers should receive the same or higher reimbursement for a service-provider specific intake as the CSBs receive for the ICA.  

Re: Services provided while a client is out of the home:  Providers are often invited to attend family meetings at a hospital or residential facility in anticipation of the client’s discharge. Many providers attend these sessions, and maintain phone contact with family members and facility clinicians, even though they cannot bill for these services. Other IIH providers decline to provide any unreimbursed services. However, collaborating with the family and the treating clinicians for discharge and safety planning is clinically necessary, and IIH providers should be reimbursed for providing this care. Providers should not be forced to choose between providing unreimbursed services, or failing to provide clinically necessary care.

Re: Lapse in services: It is unclear why a two-week gap in services would generally necessitate a change in the ISP. Children sometimes stay with relatives for a period of time, families take vacations, and individuals involved in the justice system are sometimes detained after a charge is adjudicated. Parents may place services on hold due to circumstances unrelated to the child’s mental health. In these cases, the same ISP goals and objectives would likely remain in effect when services resume. This regulation can induce providers to make unnecessary changes to an ISP in order to guard against retractions, which is antithetical to client-centered services. I therefore recommend rescinding the last sentence of the above regulation.

Re: Services provided at school: Providers should be able to intervene in the school environment when dictated by the individual’s needs, not by the school’s needs. For example, parents/guardians may be concerned that a child’s issues are being exacerbated by situations occurring at school. In addition, supportive school personnel can often be recruited to help a child cope with separation anxiety, or other issues stemming from the home situation. These scenarios are unlikely to precipitate a specific request for intervention from school personnel. Even when school personnel have requested help, it can be challenging to find an official who is authorized and willing to sign a form. Providers should be allowed to provide services in the school if they are clinically appropriate, and reasonable in frequency and duration, without fear of retractions.

Re: Services provided for a client pending placement out of the home:  This regulation needs to be clarified, as it is unclear what constitutes a family “being kept together until an out-of-home placement for the individual can be arranged.” For example, if a residential placement has been recommended but the individual has not yet been admitted, that individual is by definition at risk of out-of-home placement. Since funding for the residential placement may or may not be approved, providers should be able to continue services until the individual is actually admitted to a facility.

Final Comments: Every new mandate and restriction leads to increased effort, expense, and risk to providers, and further reduces the time and bandwidth available for clinical concerns. Providers are already struggling to manage the current regulatory environment, with nearly continuous involvement in audits and appeals, and the potential for crushing overpayments due to subjective findings or minor oversights in documentation. In response, some providers are considering closing their IIH programs due to the increased financial risk. This will open the market to more “bottom-feeder” agencies that will hire staff with the minimum credentials required, and focus on billing a high number of hours per client.  Thus, the overall effectiveness of IIH services will decline, and the cost of treatment will increase.

Psychiatric nurse pracitioners are not listed as a licensed mental health professional in this regulation. The provider handbook lists Psychiatric Nurse Practitioners as Licensed Mental Health Professionals. Currently the credential and board certification as a psychiatric mental health clinical nurse specialist is not available.  The clinical nurse specialist and the nurse practitioner, once separate credentials  have been collapsed to once credential which encompasses the scope of practice of both credentials.  All new advanced practice psychiatric nurses are now credentialed and board certified as Psychiatric Nurse Pracitioners. Please ensure that  the Psychiatric nurse practitioner is included as a Licensed Mental Health Professional. The clinical nurse specialist should remain as a provider category since those who obtained the credential are able to practice under it.

The definition of “care coordination” should be expanded to include coordination with non-medical entities, as it was previously when the term "case management" was used.

Provider feedback for CMHRS Draft Regulations

As a provider of community mental health services and the Treasurer of Virginia Association for Preservation Services (VAFP), I have concerns about proposed regulation changes pertaining to Intensive In-Home Services. Below I have referenced the specific Draft Regulations and my comments and recommendations.

12VAC30-50-130 (Draft Regulations)

Re: the addition of language "Care coordination" and elimination of “case management activities”

Comments/Recommendations:  The change in this language restricts the range of therapeutic activities allowed by the QMHP.  The new language only allows coordination of care with other health care providers and prevents coordination with schools, courts, social service agencies, childcare providers and probation officers.  This will significantly limit the role of the QMHP and result in a fragmented treatment model.  It undermines the intention of IIH services which is to stabilize an individual in their community setting.  I recommend that the definition of “Care coordination” include collaboration with all professional services to include but not limited to schools, courts, social service agencies, childcare providers and probation officers. 

 

12VAC30-50-226 (Draft Regulations)

Re: addition of language “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home”.

Comments/Recommendations:

The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.  Conducting a session in “an alternative community service location” is not always done to support the “identified clinical needs” of the client.  In fact, going outside the home is usually done for logistical purposes such as establishing privacy.  A QMHP will frequently relocate a session to the community (i.e. counselor’s vehicle, near-by park, school, restaurant, church or public space) because the home is crowded, unsafe, lacks seating, or has no privacy.  By requiring the burden of additional documentation to describe “how the alternative community service location supports the identified clinical needs of the individual and facilitates the implementation of the ISP” suggests that each specific location outside the home needs to be correlated to a treatment objective in the ISP.  It is the clinical intervention that correlates to the treatment objectives not the location of the session.      

 

12VAC30-60-61 (Draft Regulations)

Re: addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

Comments/Recommendations:

The addition of this language will create an unnecessary barrier to services.  Currently, the “treatment history” of the individual is obtained during the clinical interview (only reimbursed as a one hour session). During the interview the QMPH will collect the history of previous interventions by the mental health, social services, and judicial system by having the client and legal guardian give an oral account of the client’s treatment history.  The proposed language adds an additional burden of obtaining proof that the prior treatment was “documented”.  This requirement is not necessary to assess the risk level of an individual.  However it could significantly delay or prevent an individual to qualify for the service. 

 

As a member of the Virginia Association for Family Preservation, the following comments are offered for consideration:

12VAC30-50-130.  "Care coordination" means collaboration and sharing of information among health care providers, who are involved with an individual's health care, to improve the care.

These services provide crisis treatment; individual and family counseling; and communication skills (e.g., counseling to assist the child individual and his parents or guardians, as appropriate, to understand and practice appropriate problem solving, anger management, and interpersonal interaction, etc.); case management activities andcare coordination with other required services; and 24-hour emergency response. 

All interventions and the settings of the intervention shall be defined in the Individual Service Plan. All IIH services shall be designed to specifically improve family dynamics, provide modeling, and the clinically necessary interventions that increase functional and therapeutic interpersonal relations between family members in the home.  IIH services are designed to promote psychoeducational benefits in the home setting]

As a member of the Virginia Association for Family Preservation, the following comments are offered for consideration:

We strongly concur with the acknowledgement of the family system as central to the individual’s functioning. However, IIH services are not equivalent to family therapy at a higher dosage. The service addresses complex social and emotional factors in the lives of individuals and families.

Behavioral health problems are influenced by a wide range of social factors outside of the family. Best practice dictates that providers working with high-risk clients involve as much of the individual’s support network as possible. Reducing the focus solely to the individual’s health care, and ignoring other parties involved in the individual’s life such as schools, courts, social service agencies, childcare providers, mentors, and so forth will not result in better outcomes, but will instead result in fragmented and less effective or ineffective treatment.

If a family is socially isolated, or has problematic ties to the community, focusing strictly on the immediate family can be a losing proposition. To strengthen such a family’s structure, providers cannot be limited to interacting only within the family system.  Preventing the involvement of other important individuals is antithetical to best practices as detailed in both wraparound and systems of care philosophies. Limiting providers’ ability to support the family in advocating for their needs with external stakeholders will also lead to a higher level of referrals for Medicaid-funded case management services.

We therefore recommend that the definition of care coordination be expanded to include collaboration with all agencies and individuals involved with the family as required to improve individual and family functioning.  We also recommend that when formal case management services are necessary, private providers be allowed to provide these services. This will prevent overloading the Community Services Boards with referrals, improve access to care, and decrease care fragmentation.

12VAC30-50-226.  “The services  [ may be ] rendered in the community if there is documentation, on that date of service, of the necessity of providing services in the community. The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP. For services provided outside of the home, there shall be documentation reflecting therapeutic treatment as set forth in the ISP provided for that date of service in the appropriately signed and dated progress notes.”

We are concerned with the wording of the draft regulations. Requiring that the documentation describe “how the alternative community service location supports the identified clinical needs of the individual and facilitates the implementation of the ISP” seems to entail that the provider document a clinical rationale for the specific location chosen for every session in which any services are provided outside of the home. However, the specific location may have been chosen based on mere convenience or proximity to the home. This language creates an additional documentation burden for providers, without adding any clinically relevant information to the record. 

Families may be sharing their residence with relatives or others, or have frequent visitors in the home. Some individuals need regular opportunities to consult with the provider outside of the presence of family members. The current regulations are specific enough to prevent inappropriate out-of-home services, while allowing for the flexibility that clinicians need to provide effective services when privacy is lacking in the home. In contrast, the draft regulations would open the door to subjective retractions and lengthy appeals processes, and could lead to less effective treatment for some individual

.

12VAC30-60-61.  “1. 2. Individuals qualifying for this service must shall demonstrate a clinical necessity for the service arising from mental, behavioral or emotional illness which results in significant functional impairments in major life activities. Individuals must meet at least two of the following criteria on a continuing or intermittent basis to be authorized for these services:

a. Have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with family or community.

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.”

We are concerned with the new language adding the specification of “documented” repeated interventions. Parents, legal guardians, and referring agencies provide a verbal history of prior interventions during the intake process. Providers are required to obtain clinically important documentation such as VICAP assessments and recent psychological evaluations. However, expecting providers to obtain records from all prior providers cited in the intake documentation is not realistic. Former providers may be out of state, or no longer operating. Parents/guardians often do not recall dates, or the names of agencies and individuals. Service providers do not always respond to requests for records, despite proper authorization.

Providers already spend a great deal of time and expense compiling extensive documentation. Obtaining the records needed to meet the existing regulations and provide proper care often requires repeated requests and follow up. Providers are not reimbursed for this time. The new wording of this regulation places an additional and unnecessary burden on the provider.

12VAC30-60-143. 

“All ISPs shall be completed, signed, and contemporaneously dated by the LMHP as defined in 12VAC35-105-20, [ , LMHP-supervisee, LMHP-resident, LMHP-RP ]  QMHP-A  [ or , ]  QMHP-C[ or QMHP-E ] , preparing the ISP within a maximum of 30 days of the date of the completed [ assessment intake ] unless otherwise specified. The [ child's/adolescent's ]  ISP shall also be signed by the parent/legal guardian and [ the adult ] individual  [ shall sign his own ] .  [ Documentation shall be provided if the individual, who is a minor child, is unable or unwilling to sign the ISP. If the individual, whether a child, adolescent or an adult, is unwilling to sign the ISP, then the service provider shall document the clinical or other reasons why the individual was not able or willing to sign the ISP. Signatures shall be obtained unless there is a clinical reason that renders the individual unable to sign the ISP.  ]” 

The current regulations were sufficiently specific to ensure that the individual is involved in the development of the ISP to the extent possible. The requirement that “signatures shall be obtained unless there is a clinical reason that renders the individual unable to sign the ISP” is unnecessary and subjective. Sometimes a child is clinically “able” to sign an ISP, but simply chooses not to do so. In such a case the draft regulation could, for example, allow a 7 year old to effectively cancel her own services.

A parent should be allowed to sign the ISP on behalf of a minor child. If a child refuses to sign the ISP, the service provider should be allowed to simply document that the child refused to sign the ISP. Likewise, an individual’s signature on the ISP should be sufficient if the individual is old enough to consent to treatment.

“An LMHP or LMHP Supervisee or Resident under the supervision of an LMHP must perform the service specific provider intake to determine all necessary IIH services and determine that the individual’s service needs can best be met through interventions provided by this service. If an LMHP Supervisee or Resident performs the service specific provider intake, the service specific provider intake must be reviewed and signed/dated by the LMHP within 24 hours of conducting the service specific provider intake.”

The stipulation that an LMHP must review and sign the intake within 24 hours of a Resident or Supervisee conducting an intake serves no apparent clinical purpose, creates a significant burden for providers, and decreases the quality and comprehensiveness of the documentation produced. Due to the extensive information required, an intake assessment can take several hours to write. If a resident/supervisee conducts the intake in the evening when the parents are home, and the clinician has appointments scheduled the next day, that clinician is forced to complete the documentation late at night and in the early hours of the morning, as well as consult with the licensed supervisor during that time frame. The clinician has no opportunity to consult with or obtain documentation from other providers prior to completing the document. Residents/supervisees should therefore be allowed to complete assessments within the same seven day time frame as licensed providers.

 

We would also like to highlight the fact that the reimbursement to IIH providers for the provider-specific intake is a mere fraction of the amount that the Community Service Boards are reimbursed for an Independent Clinical Assessment (ICA).  IIH providers are required to work under much more challenging conditions, provide unreimbursed travel time, complete much lengthier assessments, and compile extensive documentation. We feel that this situation is grossly unfair. IIH providers should receive the same or higher reimbursement for a service-provider specific intake as the CSBs receive for the ICA. 

“This service may be billed for up to seven days, immediately upon admission to a psychiatric residential treatment facility or immediately prior to discharge from a psychiatric residential treatment facility, to transition the individual from home to the psychiatric residential treatment facility or from the psychiatric residential treatment facility to home, as applicable.

 

IIH may not be billed prior to discharge from any Level A, Level B, or inpatient hospitalization.”

Providers are often invited to attend family meetings at a hospital or residential facility in anticipation of the client’s discharge. Many providers attend these sessions, and maintain phone contact with family members and facility clinicians, even though they cannot bill for these services. Other IIH providers decline to provide any unreimbursed services. However, collaborating with the family and the treating clinicians for discharge and safety planning is clinically necessary, and IIH providers should be reimbursed for providing this care. Providers should not be forced to choose between providing unreimbursed services, or failing to provide clinically necessary care.

“If there is a lapse in IIH service for more than two weeks, the reason for the lapse and the rationale for the continued need for the service must be documented. The ISP must be reviewed and updated if there are changes, and signed by either the parent or legal guardian and if appropriate, the individual. Going without services for 2 weeks and no need for a change in the ISP may indicate a lack of need for this level of service.”

It is unclear why a two-week gap in services would generally necessitate a change in the ISP. Children sometimes stay with relatives for a period of time, families take vacations, and individuals involved in the justice system are sometimes detained after a charge is adjudicated. Parents may place services on hold due to circumstances unrelated to the child’s mental health. In these cases, the same ISP goals and objectives would likely remain in effect when services resume. This regulation can induce providers to make unnecessary changes to an ISP in order to guard against retractions, which is antithetical to client-centered services. We therefore recommend rescinding the last sentence of the above regulation. 

Currently, observation in the school environment is allowed for only 15 minutes.  Providers should be able to intervene in the school environment when dictated by the individual’s needs, not by the school’s needs. For example, parents/guardians may be concerned that a child’s issues are being exacerbated by situations occurring at school. In addition, supportive school personnel can often be recruited to help a child cope with separation anxiety, or other issues stemming from the home situation. These scenarios are unlikely to precipitate a specific request for intervention from school personnel. Even when school personnel have requested help, it can be challenging to find an official who is authorized and willing to sign a form. Providers should be allowed to provide services in the school if they are clinically appropriate, and reasonable in frequency and duration, without fear of retractions.

“Service is not appropriate for a family while the individual is not living in the home or for families being kept together until an out-of-home placement for the individual can be arranged.”  This regulation needs to be clarified, as it is unclear what constitutes a family “being kept together until an out-of-home placement for the individual can be arranged.” For example, if a residential placement has been recommended but the individual has not yet been admitted, that individual is by definition at risk of out-of-home placement. Since funding for the residential placement may or may not be approved, providers should be able to continue services until the individual is actually admitted to a facility.

FINAL COMMENTS:  Every new mandate and restriction leads to increased effort, expense, and risk to providers, and further reduces the time and bandwidth available for clinical concerns. Providers are already struggling to manage the current regulatory environment, with nearly continuous involvement in audits and appeals, and the potential for crushing overpayments due to subjective findings or minor oversights in documentation. In response, some providers are considering closing their IIH programs due to the increased financial risk. This will open the market to more “bottom-feeder” agencies that will hire staff with the minimum credentials required, and focus on billing a high number of hours per client.  Thus, the overall effectiveness of IIH services will decline, and the cost of treatment will increase.

Cynthia Agbayani, PhD

Vice President, VAFP

Co-Owner/Program Director, Lifeworks Outreach Services, Inc.

 

As a provider of community mental health services and the President of the Association for Community Based Services, I have concerns about proposed regulation changes pertaining to Intensive In-Home Services. I wholeheartedly agree with and support the arguments made by my colleague Mr. Slabaugh.

12VAC30-50-130 (Draft Regulations)

Re: the addition of language "Care coordination" and elimination of “case management activities”

Comments/Recommendations:  This change not only restricts activities allowed by the In Home worker which are essential to the well being of the family, but excludes non medical involved parties such as school and courts.  

Case management has long been a part of Intensive In Home as the families we serve have very complex needs that directly affect the emotional stability of the identified client.  

Furthermore, the CSB's are currently the only providers allowed to bill for case management so, to exclude case management from Intensive In Home would require the family to seek out the CSB for Case Management.  The CSB's do not have the capacity to handle the volume.  Therefore, case management should be opended up to private providers.

 

12VAC30-50-226 (Draft Regulations)

Re: addition of language “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home”.

Comments/Recommendations:

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist". 

 

12VAC30-60-61 (Draft Regulations)

Re: addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

Comments/Recommendations:

The addition of this language will create an unnecessary barrier to services.  This is clearly an attempt to prevent needy families from obtaining a service that, when done well, will prevent the familiy from seeking more costly services such as hospitalization.

I wil be the first to agree that Intensive In Home services as they stand are far from ideal. However, the proposed changes seek only to limit access and water down the service as opposed to strenghtening it.  I propose introducing interpretive guidelines to the DBHDS regluations (as has often been discussed). And thoroghly examining the utilization rates of case managemnt by the CSB's.

As ususal, there seems to be no other logical or data driven information to support the changes being proposed.  This seems simply an attempt to reduce utilization thus punishing the families who desperately need help.

 

 

Regulation changes pertaining to Intensive In Home services

As an employee of a community mental health services organization and having worked in direct service myself, I have concerns about the proposed regulation changes pertaining to Intensive In-Home Services and how this will impact the work organizations are able to do in and for their communities. I wholeheartedly agree with and support the arguments made by those in my field who have commeted before me.

12VAC30-50-130 (Draft Regulations)

Re: the addition of language "Care coordination" and elimination of “case management activities”

Comments/Recommendations:  The change, while seemingly insignificant, would inhibit the work that the In-Home worker is allowed to perform. 

Case management has long been a part of Intensive In Home Services as the families our organizations serve have extremely complex needs that often overlap and can directly affect the emotional, mental and physical stability of the participant. The ability to provide comprehensive Case Management Services (specific actions that lead providing the best care and improvements in quality of life for each inivdiual) is essential to the work that In-Home Services provide. Limiting it to "Care Coordination" will inhibit the specfic tasks these workers are allowed to perform, thus limiting their ability to provide the best services for their clients.     

In additon, the CSB's are currently the only entity allowed to bill for case management services. If this service were excluded from Intensive In Home Services, it would create a burden of work for the CSB's and our fear is that the CBS's will not be able to meet this new influx of clients thereby allowing many clients to fall through the crack. This would excerabate many of their mental, emotional and phyiscal states and cause further issues for them as indivdiuals but also for the state. 

12VAC30-50-226 (Draft Regulations)

Re: addition of language “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home”.

Comments/Recommendations:

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist". 

12VAC30-60-61 (Draft Regulations)

Re: addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

Comments/Recommendations:

Here I agree with Ms. Cheeks: "The addition of this language will create an unnecessary barrier to services.  This is clearly an attempt to prevent needy families from obtaining a service that, when done well, will prevent the familiy from seeking more costly services such as hospitalization...the proposed changes seek only to limit access and water down the service as opposed to strenghtening it.  I propose introducing interpretive guidelines to the DBHDS regluations (as has often been discussed). And thoroghly examining the utilization rates of case managemnt by the CSB's. As ususal, there seems to be no other logical or data driven information to support the changes being proposed.  This seems simply an attempt to reduce utilization thus punishing the families who desperately need help."

 

Children are our future. This new proposal will harm our future let alone harm the "less fortunate." Rethink this. How will this improve care for our children? Our future?

As a provider of community mental health services I have concerns about proposed regulation changes pertaining to Intensive In-Home Services for several reasons.  First, shifting “care coordination”  from I.I.H. providers to local community service boards will likely result in overburdening an already strained agency. It is unlikely that the local CSB will be able to meet this increased demand for case management services should these proposed amendments be approved. 

Second, many of the clients receiving IIH services come from families with limited financial resources, and chaotic home environments, which further impedes their ability to schedule and maintain much needed ongoing case management appointments in an outpatient setting. In considering these changes one must ask whether or not the family has reliable transportation, flexibility with work schedules, and day care for other children, that will allow them to maintain case management services in a remote location. 

 IIH providers generally have more flexibility with regard to their scheduling and are better able to accommodate changing family schedules in a way that community services boards cannot.  The added strain on the local community service board created by the increase in consumers, coupled with the barrier to families created by requiring case management services to be delivered through the CSB rather than the agency delivering IIH services, will result in a gap in services. Briefly stated, clients will not be able to consistently maintain scheduled appointments.

Third, IIH providers have an ongoing relationship with the client as well as an intimate understanding of the family dynamic and are therefore better situated to assess and provide the case management needs of the clients they serve.  

My objections to the removal of case management and addition of the term "care coordination" proposed to the DMAS regulations have already been brilliantly articulated by other commentators in this forum. I would like to place my support behind the statements of Andrew Slabaugh and Kathy Levenston.

The greatest challenge I perceive in the removal of "case management services" from in-home workers, other than those which have already been stated, is that very often the tasks performed through case management are the same tasks which require the therapeutic intervention targeted by the in-home intervention in the first place. By requiring an in-home worker to delegate these responsibilities to another provider, it necessarily slows and complicates treatment as well as reducing the effectiveness of the in-home therapy overall. Instead of using these opportunities to improve the overall family dynamic and function, the in-home worker would need to prepare the family to engage in these activities, then await a report from the case manager and the family on how the family performed. It would be far more efficient for the in-home worker to be present for these interactions and to be able to utilize these activities as both real-life training and coaching opportunities (as is currently done) and as real-time assessment techniques instead of relying on client self-report. Further, there is substantial literature to support the importance of rapport as a predictor of treatment success. By delegating these valuable interventional tasks to  a third-party, the rapport developed by the in-home worker (a primary benefit of the service) is lost. 

Finally, if the intention behind this change is financial, I am afraid that any gain made by shifting the workload to case-management providers will be offset by a reduction in effectiveness of the overall treatment and an increase in time spent working to resolve the presenting issues. This benefits neither the taxpayers nor the clients.

As a provider of community-based mental health services for a private provider, I too, share the concerns that my colleagues have stated regarding the proposed regulation changes pertaining to Intensive In-Home Services.

12VAC30-50-130 - The addition of language "Care coordination" and elimination of “case management activities”)

This change in semantics aims to restrict the covered activities performed by In-Home workers which provide family and individual stabilization and support. The change in semantics also purposes to eliminate support by IIH workers being provided in environments that are “non-medical,” but are nevertheless often contribute to the individuals eligibility for IIH services in the first place (i.e., judicial involvement under eligibility criteria 2). Since the CSB's are currently the only providers allowed to bill for case management, eliminating case management from Intensive In Home would require the family to additionally seek out the CSB for Case Management. As evidenced by the challenges experienced by CSB’s in the wake of the initial implementation of the VICAP assessments (for which they eventually had to contract out to private providers (e.g., United Methodist Family Services) for assistance), the CSB’s do not have the capacity to handle the volume/influx of clients that will require case management and it will result in disruption in the continuum of care, gaps in services, and functional regression of the clients and their families. The CSB case managers already have caseloads of upwards of 40-50 that they are unable to serve within the confines of a regular work week (i.e., a case manager with 50 clients would be unable to devote even 1 hour per client per week and I can assure you that most court proceedings exceed that. Because of their high caseloads, it is impossible for these professionals to be as knowledgeable about the client’s needs and strengths as the in-home workers with a caseload of 4 or less. In court, our in-home workers have been able to testify on behalf of the clients’ strengths, goals and interventions, and treatment outcomes, which in some cases has decreased the level of the clients’ judicial involvement. This would be unlikely if a case manager just dropped the client off at the court house because they did not have time to adequately address the client’s needs or worse, have to detract from another client’s treatment.

I agree with Ms. Cheek that case management has been a part of Intensive In-Home since it’s conception; the families we serve present with exceedingly complex needs that directly affect, often negatively when we first encounter them, the emotional stability of the identified client.  

12VAC30-50-226 – The addition of language, “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language, “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home.”

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.” 

 12VAC30-60-61 - The addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

The addition of this language will create an unnecessary barrier to obtaining necessary that, when properly executed, will prevent clients and families for having to seek more costly services such as hospitalization, inpatient services, and residential care. This is a direct attempt to prevent needy families from obtaining these services as it has with its implementation for Mental Health Skill Building Services. This puts the burden on medical providers to provide this information in an expedient manner and in our experience since the implementation of these criteria for adults, the medical providers have been unable to keep up with the demand. HCA hospitals have had to contract out and it can take up to a month, with daily follow ups by the workers, for private providers to receive these records. The clients we serve are often poor historians and cannot remember timeframes of treatment, which at most medical providers is a requirement for them to furnish the records (we have been told that the request with the clients’ demographic information is insufficient for them to provide records) or at a cost to private providers of upwards of $60 per page for records (yes, this is illegal as the law states that you can only change up to $15 for documents that are under 50 pages, but we have addressed it with the provider, Panic, Anxiety & Depression Center, and nothing has been done to change their practices).

Instead of introducing language meant to, I support Ms. Cheek’s call to action to introduce interpretive guidelines to the DBHDS service regulations, rather than semantics to limit access and further dilute IIH services as opposed to improving them. I agree that there seems to be no data driven information to support neither the proposed changes nor the CSB’s ability to functionally manage the influx of clients as well or better than private providers have been.  This seems simply an attempt to reduce utilization by introducing additional hoops for private providers to jump through and further punishing and discouraging the families who desperately need intervention.

To Whom It May Concern, 

I have been working as a provider for nearly 8 years. I started off working with clients and familiies recieving Intensive In home services and now work in an agency that provides IIH among other programs. As a provider of community mental health services I have concerns about the proposed regulation changes pertaining to Intensive In Home Services.  I am appaulled at the idea of depending on “care coordination”  from the local community service boards. In my professional experience, I have come to realize that Virginia's CSBs are already overburdened with clients and currently have been unable to meet the high demands for case management services for our underserved populations. To schedule a case management appointment to date takes 1 month or more. All of the client's we work with already report unable to meet effectively with their CSB case managers. I have even been told by CSB professionals that community based programs can do more. The CSBs are strained and as a result quality case management services are not being provided to the capacity our client's need them to be. Shifting care coordiantion, case management from IIH solely to CSBs will have adverse effects in the long run. 

It is safe to say that 90% of the clients receiving IIH services come from families who are on the poverty line with limited resources (financial, health, housing,etc.). Most often, IIH clients reside in chaotic home environments surroung by drugs and violence. At times these risk factors contribute to their inability to successfully follow through with scheduled in home sessions. This proposed change will only further impede their ability to schedule and maintain much needed ongoing case management appointments in an outpatient setting. Most of our families do not have reliable transportation, most do no know how to navigate a bus line, most are unable to cope with their current mental health issues to even begin to try and track appointments, etc. IIH providers are able to assist when these instances occur. CSB do no have the capacity to be flexible enough in changing appointments, coordinating transportation, calling and reminding clients. 

The proposed changes are inevitably going to cause a further gap in services. Are we now okay with a case mangement appointment being scheduled 2-3 months out when a family is in need with presenting problems at their time of assessment??? Are we now okay with clients mental health issues deteriorating because they can not focus on practicing coping skills when their basic needs are not met because the CSB case managers are overworked and are not following up as they should???

Working in the a social work driven agency we believe wholeheartedly in the concept "person in environment." The person-in-environment perspective in social work is a practice-guiding principle that highlights the importance of understanding an individual and individual behavior in light of the environmental contexts in which that person lives and acts. The perspective has historical roots in the profession, starting with early debates over the proper attention to be given to individual or environmental change. IIH providers have dedicated their profeessional to providing this proper attentions. Please do not take this away!!! 

As a Provider/Director of various psychiatric and substance abuse services in diverse contexts for over 20-years, I am again concerned that the Department may be short-sighted and has not fully evaluated the the impact that such a change may have on IIH Clients, their Families and the Community-At-large. 

It is well known and documented that our CSB's have been overwhelmed for 10+ years and have not been able to provide timely services for consumers. Their "Waiting List" have grown to at least 4-6 months in the past few years, which poses a health risk for the public. Additionally, it is well known and documented by public and private provider alike that CSB's "Case Management" is not sufficient for the IIH population, which requires intensive services BEYOND 10-hours weekly to stabilize the family system and prevent an out-of-home placements. Case Management is usually one (1) time monthly and their caseloads are very high. Conversely, PACT MAY only provide as similar service at 1-3x weekly. 

Ms. Youmell, (License Eligible) from our Agency, succinctly provides River City's concerns regarding this matter:

12VAC30-50-130 - The addition of language "Care coordination" and elimination of “case management activities”)

This change in semantics aims to restrict the covered activities performed by In-Home workers which provide family and individual stabilization and support. The change in semantics also purposes to eliminate support by IIH workers being provided in environments that are “non-medical,” but are nevertheless often contribute to the individuals eligibility for IIH services in the first place (i.e., judicial involvement under eligibility criteria 2). Since the CSB's are currently the only providers allowed to bill for case management, eliminating case management from Intensive In Home would require the family to additionally seek out the CSB for Case Management. As evidenced by the challenges experienced by CSB’s in the wake of the initial implementation of the VICAP assessments (for which they eventually had to contract out to private providers (e.g., United Methodist Family Services) for assistance), the CSB’s do not have the capacity to handle the volume/influx of clients that will require case management and it will result in disruption in the continuum of care, gaps in services, and functional regression of the clients and their families. The CSB case managers already have caseloads of upwards of 40-50 that they are unable to serve within the confines of a regular work week (i.e., a case manager with 50 clients would be unable to devote even 1 hour per client per week and I can assure you that most court proceedings exceed that. Because of their high caseloads, it is impossible for these professionals to be as knowledgeable about the client’s needs and strengths as the in-home workers with a caseload of 4 or less. In court, our in-home workers have been able to testify on behalf of the clients’ strengths, goals and interventions, and treatment outcomes, which in some cases has decreased the level of the clients’ judicial involvement. This would be unlikely if a case manager just dropped the client off at the court house because they did not have time to adequately address the client’s needs or worse, have to detract from another client’s treatment.

I agree with Ms. Cheek that case management has been a part of Intensive In-Home since it’s conception; the families we serve present with exceedingly complex needs that directly affect, often negatively when we first encounter them, the emotional stability of the identified client.  

12VAC30-50-226 – The addition of language, “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language, “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home.”

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.” 

 12VAC30-60-61 - The addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

The addition of this language will create an unnecessary barrier to obtaining necessary that, when properly executed, will prevent clients and families for having to seek more costly services such as hospitalization, inpatient services, and residential care. This is a direct attempt to prevent needy families from obtaining these services as it has with its implementation for Mental Health Skill Building Services. This puts the burden on medical providers to provide this information in an expedient manner and in our experience since the implementation of these criteria for adults, the medical providers have been unable to keep up with the demand. HCA hospitals have had to contract out and it can take up to a month, with daily follow ups by the workers, for private providers to receive these records. The clients we serve are often poor historians and cannot remember timeframes of treatment, which at most medical providers is a requirement for them to furnish the records (we have been told that the request with the clients’ demographic information is insufficient for them to provide records) or at a cost to private providers of upwards of $60 per page for records (yes, this is illegal as the law states that you can only change up to $15 for documents that are under 50 pages, but we have addressed it with the provider, Panic, Anxiety & Depression Center, and nothing has been done to change their practices).

Instead of introducing language meant to, I support Ms. Cheek’s call to action to introduce interpretive guidelines to the DBHDS service regulations, rather than semantics to limit access and further dilute IIH services as opposed to improving them. I agree that there seems to be no data driven information to support neither the proposed changes nor the CSB’s ability to functionally manage the influx of clients as well or better than private providers have been.  This seems simply an attempt to reduce utilization by introducing additional hoops for private providers to jump through and further punishing and discouraging the families who desperately need intervention.

Sincerely, Jimmy Christmas, LCSW, ADS, RYT

 

 

As a Provider/Director of various psychiatric and substance abuse services in diverse contexts for over 20-years, I am again concerned that the Department may be short-sighted and has not fully evaluated  the impact that such a change may have on IIH Clients, their Families and the Community-At-large. I believe that it is prudent that the Department engage Key Stakeholders, such as Private Providers, Clients, their Families and the host of private physicians, psychiatrist, educatiors, etc. that provide these services.

It is well known and documented that our CSB's have been overwhelmed for 10+ years and have not been able to provide timely services for consumers. Their "Waiting List" have grown to at least 4-6 months in the past few years, which poses a health risk for the public. Additionally, it is well known and documented by public and private provider alike that CSB's "Case Management" is not sufficient for the IIH population, which requires intensive services BEYOND 10-hours weekly to stabilize the family system and prevent an out-of-home placements. Case Management is usually one (1) time monthly and their caseloads are very high. Conversely, PACT MAY only provide as similar service at 1-3x weekly. 

Ms. Youmell, (License Eligible) from our Agency, succinctly provides River City's concerns regarding this matter:

12VAC30-50-130 - The addition of language "Care coordination" and elimination of “case management activities”)

This change in semantics aims to restrict the covered activities performed by In-Home workers which provide family and individual stabilization and support. The change in semantics also purposes to eliminate support by IIH workers being provided in environments that are “non-medical,” but are nevertheless often contribute to the individuals eligibility for IIH services in the first place (i.e., judicial involvement under eligibility criteria 2). Since the CSB's are currently the only providers allowed to bill for case management, eliminating case management from Intensive In Home would require the family to additionally seek out the CSB for Case Management. As evidenced by the challenges experienced by CSB’s in the wake of the initial implementation of the VICAP assessments (for which they eventually had to contract out to private providers (e.g., United Methodist Family Services) for assistance), the CSB’s do not have the capacity to handle the volume/influx of clients that will require case management and it will result in disruption in the continuum of care, gaps in services, and functional regression of the clients and their families. The CSB case managers already have caseloads of upwards of 40-50 that they are unable to serve within the confines of a regular work week (i.e., a case manager with 50 clients would be unable to devote even 1 hour per client per week and I can assure you that most court proceedings exceed that. Because of their high caseloads, it is impossible for these professionals to be as knowledgeable about the client’s needs and strengths as the in-home workers with a caseload of 4 or less. In court, our in-home workers have been able to testify on behalf of the clients’ strengths, goals and interventions, and treatment outcomes, which in some cases has decreased the level of the clients’ judicial involvement. This would be unlikely if a case manager just dropped the client off at the court house because they did not have time to adequately address the client’s needs or worse, have to detract from another client’s treatment.

I agree with Ms. Cheek that case management has been a part of Intensive In-Home since it’s conception; the families we serve present with exceedingly complex needs that directly affect, often negatively when we first encounter them, the emotional stability of the identified client.  

12VAC30-50-226 – The addition of language, “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language, “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home.”

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.” 

 12VAC30-60-61 - The addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

The addition of this language will create an unnecessary barrier to obtaining necessary that, when properly executed, will prevent clients and families for having to seek more costly services such as hospitalization, inpatient services, and residential care. This is a direct attempt to prevent needy families from obtaining these services as it has with its implementation for Mental Health Skill Building Services. This puts the burden on medical providers to provide this information in an expedient manner and in our experience since the implementation of these criteria for adults, the medical providers have been unable to keep up with the demand. HCA hospitals have had to contract out and it can take up to a month, with daily follow ups by the workers, for private providers to receive these records. The clients we serve are often poor historians and cannot remember timeframes of treatment, which at most medical providers is a requirement for them to furnish the records (we have been told that the request with the clients’ demographic information is insufficient for them to provide records) or at a cost to private providers of upwards of $60 per page for records (yes, this is illegal as the law states that you can only change up to $15 for documents that are under 50 pages, but we have addressed it with the provider, Panic, Anxiety & Depression Center, and nothing has been done to change their practices).

Instead of introducing language meant to, I support Ms. Cheek’s call to action to introduce interpretive guidelines to the DBHDS service regulations, rather than semantics to limit access and further dilute IIH services as opposed to improving them. I agree that there seems to be no data driven information to support neither the proposed changes nor the CSB’s ability to functionally manage the influx of clients as well or better than private providers have been.  This seems simply an attempt to reduce utilization by introducing additional hoops for private providers to jump through and further punishing and discouraging the families who desperately need intervention.

Sincerely, Jimmy Christmas, LCSW, ADS, RYT

As a provider of community-based mental health services for a private provider, I too, share the concerns that my colleagues have stated regarding the proposed regulation changes pertaining to Intensive In-Home Services.

12VAC30-50-130 - The addition of language "Care coordination" and elimination of “case management activities”)

This change in language aims to restrict the covered activities performed by In-Home workers, which provide family and individual stabilization and support. The change in language also purposes to eliminate support by IIH workers being provided in environments that are “non-medical,” but are nevertheless often contribute to the individuals eligibility for IIH services in the first place (i.e., judicial involvement under eligibility criteria 2). Since the CSB's are currently the only providers allowed to bill for case management, eliminating case management from Intensive In Home would require the family to additionally seek out the CSB for Case Management. As evidenced by the challenges experienced by CSB’s in the wake of the initial implementation of the VICAP assessments (for which they eventually had to contract out to private providers (e.g., United Methodist Family Services) for assistance), the CSB’s do not have the capacity to handle the volume/influx of clients that will require case management and it will result in disruption in the continuum of care, gaps in services, and functional regression of the clients and their families. The CSB case managers already have caseloads of upwards of 40-50 that they are unable to serve within the confines of a regular work week (i.e., a case manager with 50 clients would be unable to devote even 1 hour per client per week and I can assure you that most court proceedings exceed that. Because of their high caseloads, it is impossible for these professionals to be as knowledgeable about the client’s needs and strengths as the in-home workers with a caseload of 4 or less. In court, our in-home workers have been able to testify on behalf of the clients’ strengths, goals and interventions, and treatment outcomes, which in some cases has decreased the level of the clients’ judicial involvement. This would be unlikely if a case manager just dropped the client off at the court house because they did not have time to adequately address the client’s needs or worse, have to detract from another client’s treatment.

I agree with Ms. Cheek that case management has been a part of Intensive In-Home since it’s conception; the families we serve present with exceedingly complex needs that directly affect, often negatively when we first encounter them, the emotional stability of the identified client.  

12VAC30-50-226 – The addition of language, “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language, “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home.”

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.” 

 12VAC30-60-61 - The addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

The addition of this language will create an unnecessary barrier to obtaining necessary that, when properly executed, will prevent clients and families for having to seek more costly services such as hospitalization, inpatient services, and residential care. This is a direct attempt to prevent needy families from obtaining these services as it has with its implementation for Mental Health Skill Building Services. This puts the burden on medical providers to provide this information in an expedient manner and in our experience since the implementation of these criteria for adults, the medical providers have been unable to keep up with the demand. HCA hospitals have had to contract out and it can take up to a month, with daily follow ups by the workers, for private providers to receive these records. The clients we serve are often poor historians and cannot remember timeframes of treatment, which at most medical providers is a requirement for them to furnish the records (we have been told that the request with the clients’ demographic information is insufficient for them to provide records) or at a cost to private providers of upwards of $60 per page for records (yes, this is illegal as the law states that you can only change up to $15 for documents that are under 50 pages, but we have addressed it with the provider, Panic, Anxiety & Depression Center, and nothing has been done to change their practices).

Instead of introducing language meant to, I support Ms. Cheek’s call to action to introduce interpretive guidelines to the DBHDS service regulations, rather than semantics to limit access and further dilute IIH services as opposed to improving them. I agree that there seems to be no data driven information to support neither the proposed changes nor the CSB’s ability to functionally manage the influx of clients as well or better than private providers have been.  This seems simply an attempt to reduce utilization by introducing additional hoops for private providers to jump through and further punishing and discouraging the families who desperately need intervention.

 

As a behavioral health provider, I too, share the concerns that my colleagues have stated regarding the proposed regulation changes pertaining to Intensive In-Home Services.Removing case management from the scope of Intensive In-Home services would be a disfavor to the individuals and families receiving services and would not be best practice.   Doing so would require that individuals add yet another provider to what can already be a complex treatment team in order to receive case management services that are so often needed.    Research shows the need for a multi-systemic and collaborative approach when working with children and their families which case management is an integral part of.   However, by soley allowing CSB’s to provide this service we would be fragmenting treatment even more and making it more difficult for individuals to get connected to the services they need in a timely manner.   I concur with Youmell’s concerns about the CSB’s capacity to meet case management needs of Intensive In-Home individuals.  By definition, Intensive In-Home services are time limited and provided to individuals who are currently at-risk.  How would case management services through a CSB address this immediate need if it typically takes a month or more just to get in for an initial case management session?  Additionally, because of the current caseload CSB Case Managers have, they are unable to provide the intensive level of case management services needed for these individuals who are at-risk.  By leaving the current definition of case management services, it would allow individuals and their families to have increased access to the services they need in at the intensity/frequency they are needed in order to prevent an out-of-home placement which is the ultimate goal.  In addition, it would streamline the process for the families rather than adding the requirement of an additional step and provider. 

The unnecessary change in the language of the description of IIH services will ultimately limit what the In-Home worker is able to do, and will continue to burden an already overrun CSB. In-Home services are imperative to giving at-risk children the opportunity to thrive and succeed in their own home and school environment, and the change in semantics would further restrict how the In-Home counselor can assist the child and his/her family. Being that the work that QMHP-Cs do includes care givers and other family members in the child’s treatment and is in the child’s home environment, In-Home Counselors have the unique opportunity to develop a healthy and strong therapeutic bond with the child and form a relationship of mutual trust with family members. Requiring these families to seek case management services from the CSB rather than their in-home worker may fracture the bond that takes significant time to develop, and ultimately hinder the child’s treatment. Furthermore, the work that In-Home counselors do render them the most knowledgeable in regards to the child’s needs and best interest, at a level that a CSB case worker cannot match because of the high volume caseloads that they carry. Many clients receiving in-home services have limited financial capacity and chaotic home environments, which complicates their ability to schedule and attend outside appointments. Please consider that many of the parents that In-Home counselors work with have more than one child, work full-time or multiple jobs, and often have limited transportation options. Requiring CSBs to provide case management services adds not only another burden for the child’s caregiver, but also adds another worker involved with the child’s care that is ultimately wasteful and unnecessary, as the In-Home worker is able, and often more suited to provide the family with case management services. It is imperative that the Department consider the long-term effects that a change like this would have on the psychiatric treatment of children, and if our ultimate goal is to allow this children to live fulfilling and successful lives, we must give them the opportunity to work with one In-Home counselor with whom they have developed a therapeutic bond and deep level of trust, who is able to not only meet their behavioral and psychiatric needs, but can also meet their needs regarding case management services.

The unnecessary change in the language of the description of IIH services will ultimately limit what the In-Home worker is able to do, and will continue to burden an already overrun CSB. In-Home services are imperative to giving at-risk children the opportunity to thrive and succeed in their own home and school environment, and the change in semantics would further restrict how the In-Home counselor can assist the child and his/her family. Being that the work that QMHP-Cs do includes care givers and other family members in the child’s treatment and is in the child’s home environment, In-Home Counselors have the unique opportunity to develop a healthy and strong therapeutic bond with the child and form a relationship of mutual trust with family members. Requiring these families to seek case management services from the CSB rather than their in-home worker may fracture the bond that takes significant time to develop, and ultimately hinder the child’s treatment. Furthermore, the work that In-Home counselors do render them the most knowledgeable in regards to the child’s needs and best interest, at a level that a CSB case worker cannot match because of the high volume caseloads that they carry. Many clients receiving in-home services have limited financial capacity and chaotic home environments, which complicates their ability to schedule and attend outside appointments. Please consider that many of the parents that In-Home counselors work with have more than one child, work full-time or multiple jobs, and often have limited transportation options. Requiring CSBs to provide case management services adds not only another burden for the child’s caregiver, but also adds another worker involved with the child’s care that is ultimately wasteful and unnecessary, as the In-Home worker is able, and often more suited to provide the family with case management services. It is imperative that the Department consider the long-term effects that a change like this would have on the psychiatric treatment of children, and if our ultimate goal is to allow this children to live fulfilling and successful lives, we must give them the opportunity to work with one In-Home counselor with whom they have developed a therapeutic bond and deep level of trust, who is able to not only meet their behavioral and psychiatric needs, but can also meet their needs regarding case management services.

Please do not remove the language case management from the aforementioned bill.

As a mental health practitioner within the community, I would advise against changing the terminology from Case Management to Care Coordination for services provided to IIH clients. The work we do with clients and their families is important and should not be limited due to the wording of the regulations. I agree with a colleague of mine Chris James, MSW who provided the following post:

In-Home regulation changes: My objections to the removal of case management and addition of the term "care coordination" proposed to the DMAS regulations have already been brilliantly articulated by other commentators in this forum. I would like to place my support behind the statements of Andrew Slabaugh and Kathy Levenston.

The greatest challenge I perceive in the removal of "case management services" from in-home workers, other than those which have already been stated, is that very often the tasks performed through case management are the same tasks which require the therapeutic intervention targeted by the in-home intervention in the first place. By requiring an in-home worker to delegate these responsibilities to another provider, it necessarily slows and complicates treatment as well as reducing the effectiveness of the in-home therapy overall. Instead of using these opportunities to improve the overall family dynamic and function, the in-home worker would need to prepare the family to engage in these activities, then await a report from the case manager and the family on how the family performed. It would be far more efficient for the in-home worker to be present for these interactions and to be able to utilize these activities as both real-life training and coaching opportunities (as is currently done) and as real-time assessment techniques instead of relying on client self-report. Further, there is substantial literature to support the importance of rapport as a predictor of treatment success. By delegating these valuable interventional tasks to  a third-party, the rapport developed by the in-home worker (a primary benefit of the service) is lost. 

Finally, if the intention behind this change is financial, I am afraid that any gain made by shifting the workload to case-management providers will be offset by a reduction in effectiveness of the overall treatment and an increase in time spent working to resolve the presenting issues. This benefits neither the taxpayers nor the clients.

It is truly a sad day when we are back to defending the need to preserve quality mental health services for the children, who truly are the future of our country. Have we not seen enough travesties within our communities of children killing children and adults? Have we not seen enough child suicides and self mutilation cases? What will it take before we can realize that restricting services is not the answer? What will it take before people understand that saving a dollar is not more valuable than saving a persons life.

I myself worked for a local CSB many years ago. After several years of employment with this agency, I made a moral decision to leave, due to an enormous caseload that was assigned to me. I knew that I would not be able to provide quality case management services to the more than 50 + cases that had been assigned to me. I know all too well that CSB workers are given the daunting task of trying to provide quality services, while juggling unrealistic caseloads, which is impossible to do. With these situations you have children and families falling through the cracks on a consistent basis, which I saw all too often. Intensive In Home Services which have been a saving grace to families, have afforded children and their families the  opportunity to receive 24/7 service provision. Intensive In Home Service providers assist the family by continually assessing them and meeting all of their needs. This is where the term "case management" is most important. Despite this term being downplayed for the name sake of finances, case management services are an integral part of services, as it affords the worker the opportunity to link the families to additional services that are needed. In addition, the family can then be fully supported by other service providers as well. Without the addition of case management services, the families who are already at a disadvantage for numerous reasons, are left to receive watered down service provision. 

Please leave semantics out of the mental health world, as any true service provider is well aware, dealing with mental health is not a game and should not be plagued by irrational political decisions.  We owe it to the children and families of our communities, to continue to fight for them and provide great quality mental health services. Let Intensive In Home Services continue to provide case management services, in addition to all of the other services they provide, to help save our children and their families.     

 

 

 
As a provider of community-based mental health services for a private provider, I too, share the concerns that my colleagues have stated regarding the proposed regulation changes pertaining to Intensive In-Home Services.
12VAC30-50-130 - The addition of language "Care coordination" and elimination of “case management activities”)

This change in language aims to restrict the covered activities performed by In-Home workers, which provide family and individual stabilization and support. The change in language also purposes to eliminate support by IIH workers being provided in environments that are “non-medical,” but are nevertheless often contribute to the individuals eligibility for IIH services in the first place (i.e., judicial involvement under eligibility criteria 2). Since the CSB's are currently the only providers allowed to bill for case management, eliminating case management from Intensive In Home would require the family to additionally seek out the CSB for Case Management. As evidenced by the challenges experienced by CSB’s in the wake of the initial implementation of the VICAP assessments (for which they eventually had to contract out to private providers (e.g., United Methodist Family Services) for assistance), the CSB’s do not have the capacity to handle the volume/influx of clients that will require case management and it will result in disruption in the continuum of care, gaps in services, and functional regression of the clients and their families. The CSB case managers already have caseloads of upwards of 40-50 that they are unable to serve within the confines of a regular work week (i.e., a case manager with 50 clients would be unable to devote even 1 hour per client per week and I can assure you that most court proceedings exceed that. Because of their high caseloads, it is impossible for these professionals to be as knowledgeable about the client’s needs and strengths as the in-home workers with a caseload of 4 or less. In court, our in-home workers have been able to testify on behalf of the clients’ strengths, goals and interventions, and treatment outcomes, which in some cases has decreased the level of the clients’ judicial involvement. This would be unlikely if a case manager just dropped the client off at the court house because they did not have time to adequately address the client’s needs or worse, have to detract from another client’s treatment.
I agree with Ms. Cheek that case management has been a part of Intensive In-Home since it’s conception; the families we serve present with exceedingly complex needs that directly affect, often negatively when we first encounter them, the emotional stability of the identified client.  
12VAC30-50-226 – The addition of language, “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language, “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home.”

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.” 
 12VAC30-60-61 - The addition of the language “documented” in the follow policy:
b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

The addition of this language will create an unnecessary barrier to obtaining necessary that, when properly executed, will prevent clients and families for having to seek more costly services such as hospitalization, inpatient services, and residential care. This is a direct attempt to prevent needy families from obtaining these services as it has with its implementation for Mental Health Skill Building Services. This puts the burden on medical providers to provide this information in an expedient manner and in our experience since the implementation of these criteria for adults, the medical providers have been unable to keep up with the demand. HCA hospitals have had to contract out and it can take up to a month, with daily follow ups by the workers, for private providers to receive these records. The clients we serve are often poor historians and cannot remember timeframes of treatment, which at most medical providers is a requirement for them to furnish the records (we have been told that the request with the clients’ demographic information is insufficient for them to provide records) or at a cost to private providers of upwards of $60 per page for records (yes, this is illegal as the law states that you can only change up to $15 for documents that are under 50 pages, but we have addressed it with the provider, Panic, Anxiety & Depression Center, and nothing has been done to change their practices).
Instead of introducing language meant to, I support Ms. Cheek’s call to action to introduce interpretive guidelines to the DBHDS service regulations, rather than semantics to limit access and further dilute IIH services as opposed to improving them. I agree that there seems to be no data driven information to support neither the proposed changes nor the CSB’s ability to functionally manage the influx of clients as well or better than private providers have been.  This seems simply an attempt to reduce utilization by introducing additional hoops for private providers to jump through and further punishing and discouraging the families who desperately need intervention.
 

As an Office Coordinator who provides support for community-based mental health services through a private provider, I too, share the concerns that my colleagues have stated regarding the proposed regulation changes pertaining to Intensive In-Home Services.
12VAC30-50-130 - The addition of language "Care coordination" and elimination of “case management activities”)

This change in language aims to restrict the covered activities performed by In-Home workers, which provide family and individual stabilization and support. The change in language also purposes to eliminate support by IIH workers being provided in environments that are “non-medical,” but are nevertheless often contribute to the individuals eligibility for IIH services in the first place (i.e., judicial involvement under eligibility criteria 2). Since the CSB's are currently the only providers allowed to bill for case management, eliminating case management from Intensive In Home would require the family to additionally seek out the CSB for Case Management. As evidenced by the challenges experienced by CSB’s in the wake of the initial implementation of the VICAP assessments (for which they eventually had to contract out to private providers (e.g., United Methodist Family Services) for assistance), the CSB’s do not have the capacity to handle the volume/influx of clients that will require case management and it will result in disruption in the continuum of care, gaps in services, and functional regression of the clients and their families. The CSB case managers already have caseloads of upwards of 40-50 that they are unable to serve within the confines of a regular work week (i.e., a case manager with 50 clients would be unable to devote even 1 hour per client per week and I can assure you that most court proceedings exceed that. Because of their high caseloads, it is impossible for these professionals to be as knowledgeable about the client’s needs and strengths as the in-home workers with a caseload of 4 or less. In court, our in-home workers have been able to testify on behalf of the clients’ strengths, goals and interventions, and treatment outcomes, which in some cases has decreased the level of the clients’ judicial involvement. This would be unlikely if a case manager just dropped the client off at the court house because they did not have time to adequately address the client’s needs or worse, have to detract from another client’s treatment.
I agree with Ms. Cheek that case management has been a part of Intensive In-Home since it’s conception; the families we serve present with exceedingly complex needs that directly affect, often negatively when we first encounter them, the emotional stability of the identified client.  
12VAC30-50-226 – The addition of language, “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language, “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home.”

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.” 
 12VAC30-60-61 - The addition of the language “documented” in the follow policy:
b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

The addition of this language will create an unnecessary barrier to obtaining necessary that, when properly executed, will prevent clients and families for having to seek more costly services such as hospitalization, inpatient services, and residential care. This is a direct attempt to prevent needy families from obtaining these services as it has with its implementation for Mental Health Skill Building Services. This puts the burden on medical providers to provide this information in an expedient manner and in our experience since the implementation of these criteria for adults, the medical providers have been unable to keep up with the demand. HCA hospitals have had to contract out and it can take up to a month, with daily follow ups by the workers, for private providers to receive these records. The clients we serve are often poor historians and cannot remember timeframes of treatment, which at most medical providers is a requirement for them to furnish the records (we have been told that the request with the clients’ demographic information is insufficient for them to provide records) or at a cost to private providers of upwards of $60 per page for records (yes, this is illegal as the law states that you can only change up to $15 for documents that are under 50 pages, but we have addressed it with the provider, Panic, Anxiety & Depression Center, and nothing has been done to change their practices).
Instead of introducing language meant to, I support Ms. Cheek’s call to action to introduce interpretive guidelines to the DBHDS service regulations, rather than semantics to limit access and further dilute IIH services as opposed to improving them. I agree that there seems to be no data driven information to support neither the proposed changes nor the CSB’s ability to functionally manage the influx of clients as well or better than private providers have been.  This seems simply an attempt to reduce utilization by introducing additional hoops for private providers to jump through and further punishing and discouraging the families who desperately need intervention.
 

 

I very much concur with Andrew K. Slabaugh, LCSW and Kathy Levenston, LCSW.  Having care cordination being limited to only medical providers will stall treatment for individuals receiving these services since more time and resources would have to be diverted towards coordinating with other providers and waiting for outcomes.  This will also further inundate Community Service Boards who are already under stress providing for their current client case loads.  In additon, several agencies have a "wrap-around" or "holistic" approach to mental health treatment which would encompass case managment activities.  Stymying agencies from case management activites will result in reduced quality care for clients.  IIH providers must be able to continue with providing case management services.  On a side note, some CSBs have policies to not share their treatment notes (whether it be for case management services, psychiatric progress notes, etc.) with other agencies involved in the client's care. Again, this will result in further delays and less efficient care.  

I also agree that having to justify the location of an IIH session provides a documentation burden for providers.  In order to establish privacy and ensure appropriate confidentiality sessions may have to be relocated to a different setting that may not directly relate to an "identified need" other than the implicit need/right to privacy and safety.  

I share the concerns about the proposed documentation requirement of all previous interventions.  This creates an additional burden not only to the providers but also the caretakers of the potential client.  I agree in trying to obtain as much documentation as possible of previous interventions for the client's chart in order to better determine necessarily revisions of a treatment plan.  However, requiring this information up front before services can take place will cause delays potentially resulting in avoidable crises.  

Ans a provider of IIH services, Case Management services are integral to the treatment process of IIH. The need for a client to recieve IIH services is precluded by a client having significant concerns regarding behaviors at home and in the community to such as extent that multiple interventions are needed and they are at risk for out of home placement. With these compounding concerns for an individual, these client's generally have numerous contacts of intervention (i.e., probation officers, judges, psychiatrists, school counselors, day treatment counselors, physicians, psychologists, etc.) that require solidfied and continues colalboration. It is unrealistic to think that this amount of collaboration can occur effectively with one hour of case management provided by a CSB. In addition, the most effective provider of this case managment need would be the professional with the most contact with the client and the family. This professional, in this case IIH, at 10 hours per week, would have the most accurate information regarding the client's behaviors and needs, the most rapport with the family, and the most opportunities to provide feedback regarding needs. When a child is involved in IIH services, the IIH provider is the most effective professional to provide this service. Removing this job function from IIH services, would do a great disservice to the clients whose intensive needs surpass what is manageable for a CSB to provide alone.

 

I'm in agreement with my collegues that any changes made will hinder the service that IIH workers provided. Why would we change to an already overburden system? The majority of the population we serve have multiple issues that are rarely met due to high caseload that CSB workers have. Let's not make hasty choices that will effect the lives of people who service. 

Working in the a social work driven agency we believe wholeheartedly in the concept "person in environment." The person-in-environment perspective in social work is a practice-guiding principle that highlights the importance of understanding an individual and individual behavior in light of the environmental contexts in which that person lives and acts. The perspective has historical roots in the profession, starting with early debates over the proper attention to be given to individual or environmental change. IIH providers have dedicated their profeessional to providing this proper attentions. Please do not take this away.

As a provider of community mental health services, I have a number of concerns about the regulations pertaining to Intensive In-Home Services.

Re: Coordination of care: I strongly concur with the acknowledgement of the family system as central to the individual’s functioning. However, Intensive In-Home services are not equivalent to family therapy at a high dosage. The service addresses complex social and emotional factors in the lives of individuals and families. Behavioral health problems are influenced by a wide range of social factors both inside and outside of the family. Best practice dictates that providers working with high-risk clients involve as much of the individual’s support network as possible. Reducing the focus solely to the individual’s health care, and ignoring other parties involved in the individual’s life, such as schools, courts, social service agencies, childcare providers, mentors, and so forth, will not result in better outcomes. Instead, I will see more fragmented and less effective treatment.If a family is socially isolated, or has problematic ties to the community, focusing strictly on the immediate family can be a losing proposition. To strengthen such a family’s structure, providers cannot be limited to interacting only within the family system.  Preventing the involvement of other important individuals is antithetical to best practices as detailed in both wraparound and systems of care philosophies. Limiting providers’ ability to support the family in advocating for their needs with external stakeholders will also lead to a higher level of referrals for Medicaid-funded case management services.

I therefore recommend that the definition of care coordination be expanded to include collaboration with all agencies and individuals involved with the family, as required to improve individual and family functioning.  I also recommend that when formal case management services are necessary, private providers be allowed to provide these services. This will prevent overloading the Community Services Boards with referrals, improve access to care, and decrease care fragmentation.

Re: services outside of the home: Requiring that the documentation describe “how the alternative community service location supports the identified clinical needs of the individual and facilitates the implementation of the ISP” seems to entail that the provider document a clinical rationale for the specific location chosen for every session in which any services are provided outside of the home. However, the specific location may have been chosen based on mere convenience or proximity to the home. This language creates an additional documentation burden for providers, without adding any clinically relevant information to the record. 

Families may be sharing their residence with relatives or others, or have frequent visitors in the home. Some individuals need regular opportunities to consult with the provider outside of the presence of family members. The current regulations are specific enough to prevent inappropriate out-of-home services, while allowing for the flexibility that clinicians need to provide effective services when privacy is lacking in the home. In contrast, the draft regulations would open the door to subjective retractions and lengthy appeals processes, and could lead to less effective treatment for some individuals. 

Re: the specification that clients must have “documented” repeated interventions in order to meet criteria for the service:  Parents, legal guardians, and referring agencies provide a verbal history of prior interventions during the intake process. Providers are required to obtain clinically important documentation such as VICAP assessments and recent psychological evaluations. However, expecting providers to obtain records from all prior providers cited in the intake documentation is not realistic. Former providers may be out of state, or no longer operating. Parents/guardians often do not recall dates, or the names of agencies and individuals. Service providers do not always respond to requests for records, despite proper authorization.

Providers already spend a great deal of time and expense compiling extensive documentation. Obtaining the records needed to meet the existing regulations and provide proper care often requires repeated requests and follow up. Providers are not reimbursed for this time. The new wording of this regulation places an additional and unnecessary burden on the provider.

PART 2:

Re: Documenting the clinical reason that a client is unable to sign an ISP: The current regulations were sufficiently specific to ensure that the individual is involved in the development of the ISP to the extent possible. The requirement that “signatures shall be obtained unless there is a clinical reason that renders the individual unable to sign the ISP” is unnecessary and subjective. Sometimes a child is clinically “able” to sign an ISP, but simply chooses not to do so. In such a case the draft regulation could, for example, allow a 7 year old to effectively cancel her own services.

A parent should be allowed to sign the ISP on behalf of a minor child. If a child refuses to sign the ISP, the service provider should be allowed to simply document that the child refused to sign the ISP. Likewise, an individual’s signature on the ISP should be sufficient if the individual is old enough to consent to treatment.

Re: Residents/Supervisees completing assessments: The stipulation that an LMHP must review and sign the intake within 24 hours of a Resident or Supervisee conducting an intake serves no apparent clinical purpose, creates a significant burden for providers, and decreases the quality and comprehensiveness of the documentation produced. Due to the extensive information required, the face-to-face interview may require two or more hours, and the document can take several hours to write. If a resident/supervisee conducts the intake in the evening after parents arrive home, and that clinician has appointments scheduled the next day, the clinician is forced to complete the documentation late at night and in the early hours of the morning, as well as consult with the licensed supervisor during that same time frame. The clinician has no opportunity to consult with or obtain documentation from other providers prior to completing the document. Residents/supervisees should therefore be allowed to complete assessments within the same seven day time frame as licensed providers.

I would also like to highlight the fact that the reimbursement to IIH providers for the provider-specific intake is a mere fraction of the amount that the Community Service Boards are reimbursed for an Independent Clinical Assessment (ICA).  IIH providers are required to work under much more challenging conditions, provide unreimbursed travel time, complete much lengthier assessments, and compile and review extensive external documentation. I feel that this situation is grossly unfair. IIH providers should receive the same or higher reimbursement for a service-provider specific intake as the CSBs receive for the ICA.   

Re: Services provided while a client is out of the home:  Providers are often invited to attend family meetings at a hospital or residential facility in anticipation of the client’s discharge. Many providers attend these sessions, and maintain phone contact with family members and facility clinicians, even though they cannot bill for these services. Other IIH providers decline to provide any unreimbursed services. However, collaborating with the family and the treating clinicians for discharge and safety planning is clinically necessary, and IIH providers should be reimbursed for providing this care. Providers should not be forced to choose between providing unreimbursed services, or failing to provide clinically necessary care.

Re: Lapse in services: It is unclear why a two-week gap in services would generally necessitate a change in the ISP. Children sometimes stay with relatives for a period of time, families take vacations, and individuals involved in the justice system are sometimes detained after a charge is adjudicated. Parents may place services on hold due to circumstances unrelated to the child’s mental health. In these cases, the same ISP goals and objectives would likely remain in effect when services resume. This regulation can induce providers to make unnecessary changes to an ISP in order to guard against retractions, which is antithetical to client-centered services. I therefore recommend rescinding the last sentence of the above regulation. 

Re: Services provided at school: Providers should be able to intervene in the school environment when dictated by the individual’s needs, not by the school’s needs. For example, parents/guardians may be concerned that a child’s issues are being exacerbated by situations occurring at school. In addition, supportive school personnel can often be recruited to help a child cope with separation anxiety, or other issues stemming from the home situation. These scenarios are unlikely to precipitate a specific request for intervention from school personnel. Even when school personnel have requested help, it can be challenging to find an official who is authorized and willing to sign a form. Providers should be allowed to provide services in the school if they are clinically appropriate, and reasonable in frequency and duration, without fear of retractions.

Re: Services provided for a client pending placement out of the home:  This regulation needs to be clarified, as it is unclear what constitutes a family “being kept together until an out-of-home placement for the individual can be arranged.” For example, if a residential placement has been recommended but the individual has not yet been admitted, that individual is by definition at risk of out-of-home placement. Since funding for the residential placement may or may not be approved, providers should be able to continue services until the individual is actually admitted to a facility. 

Final Comments: Every new mandate and restriction leads to increased effort, expense, and risk to providers, and further reduces the time and bandwidth available for clinical concerns. Providers are already struggling to manage the current regulatory environment, with nearly continuous involvement in audits and appeals, and the potential for crushing overpayments due to subjective findings or minor oversights in documentation. In response, some providers are considering closing their IIH programs due to the increased financial risk. This will open the market to more “bottom-feeder” agencies that will hire staff with the minimum credentials required, and focus on billing a high number of hours per client.  Thus, the overall effectiveness of IIH services will decline, and the cost of treatment will increase.

I agree with my colleagues over this matter. Any proposed changes would greatly impact our service delivery and our obligations to clients that we graciously serve. The ethical truths of beneficence, justice, fairness, and nonmaleficence would be violated if these proposed changes were to come to pass. Effective service delivery and support to clients is a human service workers' priority. These changes would do more harm than good. 

 

Proposed Definition:

"Care coordination" means collaboration and sharing of information among health care providers, who are involved with an individual's health care, to improve the care.”

Comment:

Allowing case management for children, adolescents and families receiving IIH to be provided by the CSB case manager (if there is one) and limiting the scope of what the IIH provider offers to “care coordination” (as defined above) has the potential to result in disjointed case management that misses the scope of collaboration required for successful outcomes.  For the following reasons, the definition of care coordination needs to be expanded to include all treating/associated professionals invested in the child/adolescent and the IIH provider needs to remain primary in facilitating care management:

1. Not all children and adolescents eligible for IIH will have a CSB case manager, resulting in some receiving case management and some being denied case management while they receive IIH Services.
2. Many CSBs continue to manage waiting lists out of necessity to fulfill the need of those requesting services, including case management.
3. IIH providers will be able to discuss case management needs and provide case management weekly as deemed appropriate for the child/adolescent, rather than only during scheduled appointment times.
4. IIH providers are in the home working with families multiple times weekly and are in a position to report on current needs/progress and coordinate with associated treatment team members (health care and non-health care providers) as needed to assist families in meeting treatment goals.
5. Children and adolescents receiving IIH are typically involved with a variety of agencies including those required to meet eligibility, including DSS, Court Services Units and schools.  
6. The continuity of care has the potential to suffer if case management is not coordinated regularly and with the goal of having all players on the same page.  This proposed model will only complicate things for the family who may end up confused at times about who to go to for what purpose.

The reconsideration of the scope of “Care Coordination” for IIH providers is vital to preserving the spirit of collaboration and the continuity of care needed for sucessful treatment planning and service outcomes for those participating in the program.

The proposed revision to eliminate "case management" from intensive in-home services would greatly inhibit the continuity of care provided to clients by intensive in-home service providers. Maintaining "case managment" roles to intensive in-home counselors/service providers is imperative to ensure the highest quality of care and the greatest chance of success for the client. 

As a Provider/Director for Intensive In-Home Services, we too, share the same concerns that our colleagues have stated in regard to the proposed regulation changes to remove case management as a function of In-Home Services. This change would be a disservice to individuals and families in care. Delegating case management services to the CSBs would affect the timeliness of these individuals’ needs being met, effectiveness of treatment, rapport, and further place them at risk.  From our observation, it already appears that the CSBs are overwhelmed with their caseloads and they lack the flexibility needed to provide immediate care. Many of the families we serve are faced with an array of challenges that impede their ability to schedule and attend appointments, advocate for themselves, and access community resources. Assisting our clients with these complex case management needs are an integral part of Intensive In-Home Services and treatment planning. We would not like to see the response to families fractured by having two providers present what should be a seamless response.  .

I agree with each of the previous posts from my colleagues and other mental health professionals.  Further limiting the availabilty and services to the population that qualify for IIH services would be a detriment and disservice. The availability and flexibility of IIH workers provides accessible mental health care to many families who do not have access or funds to pay for transportation. This population already bears challenges and obstacles qualifying for and receiving care in the home and to implement additional obstacles would be unjust. 

I strongly disagree with the proposed changes to Crisis Services. These changes will have a huge impact on service delivery to clients. When referring clients to community services such as CSB there is already a huge burden on them to provide adequate services. Leaving the option open for other mental heatlh agencies will only ensure all eligible clients needs will be met.  

I agree with all of the comments that eliminating casemanagement from service delivery is not providing full systems approach.  Even an outpatient therapist provides some resource managment, linkage and referrals when providing a service.  IIHS has been through many changes, separating out services will only confuse, hinder the clients and limit services.  It could also lead to fruadulent services by new vendor trying to capture and take advantage of the, unprivilaged families and seriously mentally ill population forcing them into a new category of serivces which they may not required.  

As as provider of community based services, formerly an employee of a company, and now an owner, I would like to add my concerns about the proposed changes.  Since my colleagues have been very articulate and I support their commentary I would like to make a general comment regarding Intensive In-Home services.  The goal of IIH is to support individuals and their families with managing challenges related to mental health diagnoses.  I believe our goal is to keep the client and family at the center of the picture while the language of the regulations, in my opinion, presents an effort to control outcomes rather than to guide the process. 

If we are serving the best interests of the client and continuity of care is an objective, it would seem in the best interest of the client to collaborate with the entities that the client and family wish to have as part of their support system or with whom they need to relate to and avoid fragmentation of services. 

Regarding repeated interventions, the clients that we serve have often escalated, sometimes gradually, to behavior that is of significant concern.  If families cannot receive services prior to "hospitalization, incarceration, multiple suspensions/interventions, it is often at such a clinically critical point that IIH intervention can be like a bandaid effect.  The children in our community need and deserve service intervention at a much earlier juncture, not after multiple failed attempts in out-patient therapy, etc. 

ISP signatures:  once again, if the client and family are at the center of the picture, this should be a matter of clinical concern for the client, family, and team, an indication that possibly goals and objectives need to be revised.....this is clinical information and a working document for the client.

I have worked with families where identified individuals have had the opportunity to visit with a grandparent or other relative as a break from the conflictual relationships.  Once again, if the individual and family are at the center of the picture, the concern should be focused on the effectiveness of the interventions - there are no hard and fast rules about families.  And, where continuity of care is concerned and individuals are transitioning from a facility/hospital to home I believe IIH counselors need to begin services where the clients are, at least one to two weeks prior to discharge.  Individuals and families are desperate at this point - they need supportive intervention and to know and begin to build a relationship with their counselor.  Anticipation, preparation, and prevention and safety are very important components in the initial stages, especially, in the provision of services. 

Finally, regarding the 24 hour signature on the intake asessment. This is unrealistic given the expectations and documentation requirements at the present time.  In my agency there are certainly verbal and consultative exchanges that begin with referral and I would like to think this is a common practice in many agencies. 

Finally, in the revision of regulations I hope the committee will be focused on what is in the best interest of the individual and family.  Each situation is unique and requires significant clinical insight and ongoing evaluation to effect interventions that are going to lead toward accomplishing the goals of each individual ISP.

I am strongly opposed to your changes regarding Crisis Intervention Services. Specifically, the proposal to limit services to only be provided by LMHP's and License Elligible individuals will significantly hinder our ability to provide services to all individuals in need crisis intervention. This change will be detrimental to current clients and future clients who are in need of our services. Furthermore, this change is a discredit to all the QMHP's currently providing outstanding crisis intervention services and could potentially damage their job standing. I urge you to reconsider these proposed changes for the sake of both clients and providers. Thank you for your consideration.

I feel that changing the current regulations to Crisis Intervention Services, specifically services only being "rendered by an LMHP, LMHP-supervisee, or certified prescreener" will have an adverse affect on the individuals who need these services.  The demand for Crisis Intervention services places significant strain on many CSB's.  Currently private providers can off set some of this demand while maintaining appropriate care for individuals in crisis.  Should the proposed changes go through, many private providers would not be able to meet the new requirements, thus returning the demand exclusively to an already overburdened CSB/BHA system.  This would in turn adversely affect the care provided to individuals in crisis as they would have to wait longer for some type of response rather than an immediate one, which is needed in most cases.  Additionally, these changes are contradictory to statements made by public officials over the past few years who have publicly committed to increasing access to needed mental health care. 

In reviewing the literature on how people end up in acute systems of care, the primary issues that prevent individuals from seeking mental health treatment are uniformly listed as stigma, and access.Why then does it make any sense to put independent assessments in place that increase the stigma of seeking mental health treatment by forcing consumers to go into community service boards while simultaneously decreasing their access to mental health services by only providing specific appointment times and disqualifying more consumers than they approve? It seems at this point in time that Virginia pays four people to assess the needs of one client. The early assessment comes from school personnel, primary care physicians, psychiatrists, and family members who all indicate that there is a problem that needs to be addressed. Then the consumers are forced to go through an independent assessment,with the assumption that they will be accurate reporters, and have procured all of the requisite documentation for service authorization including psychiatric records, school reports, and failed interventions from other mental health providers. Following the independent assessment, the community-based provider has to assess the client to determine service eligibility,collect histories from all respective parties, and accurately diagnose; and then finally provide all of that information to Magellan for a clinical review and service authorization. While I agree with most of the previous comments from my colleagues, and am grateful to count them among the private providers trying to make a difference in Virginia,I think it is also important to pause and re-evaluate how we're are reinforcing the barriers into systems of care.

I have several concerns with the proposed changes:

1. Considering the need for Crisis Intervention services across the state, it seems unrealistic to ONLY have an LMHP, LMHP-supervisee, LMHP-resident, LMHP-RP, or certified prescreener to provide services to individuals that may need Crisis Intervention services. A trained QMHP can provide quality services to an individual and/or family that is need of Crisis Intervention services. Additionally, if the proposed changes are adopted there will not be enough qualified people to meet the needs of the community.

2. Case Management activities are an integral component of IIH services and should not be removed based on the importance of ensuring services are provided from an holistic approach.

3. There seems to be a conflict with the proposed changes for TDT services, on page 603 #4 it states that the intake shall be conducted by the LMHP, however on page 603 #13 it states that the intake can be conducted by an LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP. Please clarify.

4. It is not always possible to have documentation of repeated interventions at the time of assessment.  It is not realistic to expect the provider to obtain documentation of repeated interventions at the of assessment, especially since often times individuals in need of mental health services are poor historians and do not keep accurate records/documentation. If this becomes a requirement, what type of documentation will be acceptable and how should the provider attempt to obtain this document at the time of assessment and remain in compliance with regulations as it pertains to completing the assessment. Will documentation of repeated interventions be required at the time of the VICAP assessment prior to the recommendation of services?

Respectfully Submitted,

Chartrice Thorne  

As Executive Director of the Virginia Association of Community-Based Providers (VACBP), I want to express concerns about the inadequate notificiation of the opportunity to review and comment on these proposed regulatory changes.  If the Department is interested in the advice of highly professional and experienced people who are striving every day to provide life changing services to people in serious need, there should be a direct communication to all providers, notifying them that their advice is needed in order to establish the most effective regulations. 

This evening, I reviewed the comments on the website (it is notable that prior to today, there were only six comments on the site) and there is a remarkable consistency in the concerns expressed about changes to IIH that will make it harder for children and familes to receive the service and harder for providers to successfully provide it.  It appears that the proposed changes are consistent with many other changes to community-based early intervention services over the past several years.  The changes have not improved the efficiency, effectiveness or accountaility in the delivery of services -- that would take cooperation with providers and efforts to innovate -- to do things better.  These proposed changes will likley reduce access to lower cost services and create more demand for higher cost services -- including social services and criminal justice system services.  The roles of public and private providers of services must be leveraged with effective regulation in order for our system to achieve the significant transformation that is necessary. I have included below the comments and questions of a VACBP member who took time with last minute notice today to respond.  I hope these comments and questions are helpful.  I believe more input from more providers would be beneficial and I hope you will create a process where that can happen.

Comments/Concerns Regarding Town Hall Discussion 1/29/15

Under 12VAC30-50-226 Community mental health services

Definitions –

(page 10 0f 41 when printed)Clinical Experience – What clarity can we receive on this section? The manner in which it is written may be interpreted that the only experience that counts as clinical experience is that which is for the provision of mental health day treatment/partial hospitalization, intensive community treatment, psychosocial rehabilitation, mental health supports [skill building], crisis stabilization or crisis intervention. If this is the case, this will significantly limit the number of qualified staff and in particular newly qualified staff, as they can only get “clinical experience” in a field that can only hire them once they have the “clinical experience.”

(page 11 of 41 when printed) LMHP-Resident – This section specifies that an individual “cannot perform the functions of an LMHP-R or be considered a “resident” until the supervision for specific clinical duties at a specific site has been preapproved in writing by the Virginia Board of Counseling.” This significantly burdens employers, as they would be required to recruit and hire individuals that may take months to be preapproved by the VA Board of Counseling before they are able to perform their specific job duties. Our specific experience has been with LMHP-R’s, as we have dealt directly with the VA Board of Counseling. As the regulations require provider specific intakes completed by LMHPs, LMHP-Rs, LMHP-RP, or LMHP-S, for MHSS and now Crisis Stabilization, this significantly limits providers’ abilities to provide services. In some areas of Southwest Virginia there are significantly limited numbers of LMHPs, which forces employers to hire Residents or Supervisees, but there are also limited Licensed Supervisors that can act in a supervisory capacity to oversee an individual’s residency.  Additionally, since the regulation states that it must be the specific site that is approved, any new employee would have to go through the registration of a supervisor process regardless if they are already approved to be a resident by the Board of Counseling. We have gone through registering our LMHP-R’s and have been notified by the Board that there is a backlog of sometimes 50 applicants and that approval from the Board of Counseling will take up to and maybe more than three months. Furthermore, the Board of Counseling will not approve Resident status for individual working only as MHSS Assessors/LMHP-Rs as the Board of Counseling reports this does not provide the Resident with the depth of clinical experience needed to prepare them for working independently as a counselor. The Board of Counseling has also questioned and reported concerns about LMHP-R’s providing supervision to other staff as a part of the Residency, as the Board views this as outside the purpose of a Residency, which in the Board’s opinion should be focused on Residents providing direct service. The Board of Counseling does not recognize MHSS as a direct service that qualifies as Residency experience. Nor does PSR qualify for Residency experience. Crisis Stabilization Services may count toward a residency. This creates a situation where these regulations and the Board of Counseling come into direct conflict, effectively limiting providers ability to provide these services. While the regulations suggest that and LMHP-R could supervise QMHP-As, QMHP-Es, and QMHPPs, the Board of Counseling does not approve of this as a main job duty. Additionally, the Board of Counseling does not approve of LMHP-Rs only conducting assessments/intakes.

7.            Crisis Stabilization Services (page 16 of 41 when printed) – The intake must be completed by and LMHP, LMHP-Resident, LMHP-Supervisee, LMHP –RP. This again creates a situation where individuals may not be served due to the limited availability of these types of qualified staff.

               f. 3 – (page 17 of 41 when printed) “Exhibit such inappropriate behavior that immediate interventions documented by the mental health, social services, or judicial system are or have been necessary.” Does “documented” mean separate documentation from the specific mental health, social services, or judicial system provider? If so this creates an even more burdensome intake process that requires providers to get even more outside documentation such as police records, CPS investigations (which may not be released), etc.

8.            Mental Health Support Services (MHSS) (page 18 of 41 when printed) – Please note that this should be Mental Health Skills Building Services. If providers are required to implement changes in the title of a service set forth by DMAS, it seems a fair expectation that DMAS and the regulations set forth would also be required to implement this change in title.

               a.3 – same as above regarding the need to document outside interventions.

 

12VAC30-60-5 Applicability of utilization review requirements (page 19 of 41 when printed)

F. 3 – “Payments shall not be permitted to healthcare entities that either hold provisional license or fail to enter into a Medicaid Provider Enrollment Agreement for a service prior to rendering that service” – This suggests an extremely punitive review of providers by DBHDS and would effectively shut down any provider that is on a provisional license.  Also, when a provider is first licensed to provide a service, they are under a provisional license.  Would they not get paid?  What is the objective of a provisional license at this point, if the provider can no longer receive payment?

12VAC30-60-143 Mental Health Service utilization criteria; definitions

B.4 (page 28 of 41 when printed) – This section identifies that providers violating the marketing requirements and regulations “shall be terminated as a Medicaid provider.” The marketing guidelines have been in place with the previous consequence involving fines. However, these regulations were not enforced. Rather than making a more severe regulation, why not enforce the regulation that was already in place?

B. 6 – Regarding informing an individual’s PCP – What about Clients who do not have a PCP? Additionally, if a client does not want a provider to communicate with a PCP, they may refuse to sign a release of information. To then communicate with the PCP would violate the Client’s Human Rights.

B.7 – “An ISP that is not updated either annually or as the treatment interventions based on the needs and progress of the individual change shall be considered outdated.” Other language in the document reports that providers will not receive reimbursement for services conducted under an outdated ISP. What guidance is offered on determining when the needs and progress of an individual require a change to the ISP?  Individuals are dynamic in nature and theoretically, the ISP may be updated daily under this requirement. Who will be interpreting when the needs and progress of a client require an ISP update?

D.1 – (page 29 of 41 when printed) – PSR intakes must be completed by an LMHP, LMHP-R, LMHP-S, LMHP-RP. This again creates a barrier to individuals receiving services in parts of Southwest Virginia where LMHPs, residents, supervisees, etc. are extremely limited.

H.1- (page 32 of 41 when printed) – Crisis Stabilization intakes must be completed by an LMHP, LMHP-R, LMHP-S, LMHP-RP. This again creates a barrier to individuals receiving services in parts of Southwest Virginia where LMHPs, residents, supervisees, etc. are extremely limited.

12VAc30-130-2000

Part XVII – Marketing of Provider Services

D.1 – (page 35 of 41 when printed) Discusses providers not offering “non-cash incentives” for rewarding behavioral changes and “compliance with goals and objectives staged in beneficiaries’ ISP.” This seems very open to interpretation. Does this include praising a client for achieving an identified objective or offering a small token of recognition when a client achieves specific goals and objectives and is ready to be discharged to a less intense level of care? Recognizing, validating, and honoring a client’s growth is an important part of any treatment process.

D.2.f – (page 36 of 41 when printed) Providers shall not collect or use PHI provided by another entity to identify and market services to prospective beneficiaries.  This suggests that providers may not take referrals from other providers and that only individuals calling directly for services may receive information from providers. Clients with SMI often struggle with accessing appropriate services. If a client is struggling with accessing services, what recourse does a referral source such as a psychiatrist, CM, outpatient counseling, etc. have?

12VAC30-130-3010

Independent Clinical Assessments are required for individuals under the age of 21 for MHSS. There are a host of issues related to this that have already been discussed.

 12VAc30-130-3020  - Independent Clinical Assessment Requirements

D. – “DMAS may apply the independent clinical assessment requirement to any of the other Medicaid-covered community mental health services set out in 12VAC30-50-130 and 12VAC30-50-226 with appropriate and timely notice to providers.” Who determines what is appropriate and timely? The ICA process has been extremely challenging in areas where the CSB was ill prepared. Additionally, there is a conflict of interest for CSB’s to conduct ICA’s when they offer the services. How is it independent in these cases, if the assessors work for an agency that provides the services recommended by the ICA ? Finally, the collaboration required to ensure individuals receive services in a timely and appropriate manner require cooperation from the CSB, which in some areas has been significantly lacking. What recourse do individuals have who are not served appropriately by their local CSB, and what recourse to private providers have when individuals report significant barriers to services due to CSB practices?

I agree with all comments that have been posted prior to mine pertaining to the many irregularities in the proposed regulations. 

However, as a Human Resources Director, many of the proposed regulations have a tremendously adverse impact on employees and the clients we service.  In efforts to develop compassionate, caring, and clinical staff, the regulations continue to make it virtually impossible to identify and employ qualified mental health professionals.  Many candidates invest in their education with degrees that "qualify" them as a QMHP, IF they have 1 year clinical experience.  Many programs do not require internships or practicuums as a part of completion of the program.  Therefore, many candidates seek out their own clinical experiences in hopes of becoming a qualified mental health professional.  The language in the proposed regulations indicates that "unsupervised" internships, practicums, or field experiences do not meet the requirements.  This industry overall is extremely competitive.  Since the regulation changes in 2010, it has become even more challenging to hire and retain quality staff.  Often, there are compassionate, caring, and knowledgeable staff who are unable to succeed in the industry due to strict regulations.  Unfortunately, the industry is also saturated with many "qualified" professionals who do not provide quality service and still make it through the doors of many agencies that are desparately plagued with vacancies.  With millenials entering the workforce, it is unfair to disqualify an individual who took a risk and creatively sought opportunities to develop their clinical experience  on the premise that the experience was not "supervised."  Supervising interns is a hardship on any behavioral health services agency.  We must comply with supervision requirements for our paid employees while "contemporaneously" providing gainful clinical experience to our interns.  What documentation is available or expected of the employer to determine if clinical experience was supervised vs. unsupervised if the potential employees' educational program does not require it for the degree completion?  Why would DBHDS list certain degrees as acceptable in the document entitled Human Services and Related Fields Approved Degrees/Experience if the degree program does not require supervised practicums, internships, or field experiences?  This seems like a flawed regulation that should be revisited to realistically classify an individual as QMHP-A, QMHP-C, or QMHP-E based on education and experience of programs that are REQUIRED to have clinical experiences as a graduation requirement. Human capital is the essence of service provision, so hiring people who fit the culture of the agency and the clients we serve will only become more challenging with the current and proposed regulations.  Hiring a QMHP-E is often a hardship for many agencies if they do not have a triennial license or DMAS-approved Supervision Training Program.  How would a newer agency meet compliance with trying to develop a workforce? 

Another HR concern with the proposed regulations is the shift in requiring that Crisis Intervention services are provided by LMHP, LMHP-Supervisee, LMHP-Resident, or LMHP-RP.  Implementation of this regulation would pose hardship and loss of employment to many QMHPs who are currently providing the service.  This could potentially create a negative impact on service provision (meaning clients without a much needed service) and gainful employment (similar to what  the 2010 regulations did on for so many). 

Respectfully Submitted

 

Ryshonna Stith, MA

On behalf of private providers, I would like to thank you for the opportunity to comment on the proposed changes to behavioral health services.  It should be noted, however, that up until today, no provider that I know of knew about these proposed changes or the opportunity to comment in the Town Hall format.  I encourage those that use this forum as a way of gathering input on proposed changes to be more pro-active in publicizing these opportunities.  Because providers are not notified of these opportunities, it appears as though nobody objects to the changes and that the agencies involved in making these changes have been transparent in their desire to gather input from stakeholders.  This is blatantly untrue.  As there have been very few comments and in networking throughout our area today there have been no providers who were aware of this posting, I also encourage that the timeframe for public comment for this particular Town Hall be extended.

There seems to be a general tightening of regulations and a general disregard for the provision of services to individuals who so desperately need assistance.  There seems to be little regard for businesses who are attempting to provide good services to the citizens of the commonwealth. 

Specifically, many of the changes affect services through the ability of providers to hire staff.  There is language in the proposals related to clinical experience that appears to state that the "Clinical Experience" of a QMHP can only be gained by working in the very programs in which their lack of experience disallows them from working.  Exactly how would someone gain experience in MHSS, ICT, PSR, etc. if they cannot be hired to work in those setting without the experience?  In addition, there is tightening of the qualifications in positions that require a licensed or licensed eligible individual.  The proposals state that a resident may only provide services if they are registered with the Board of Counseling with that specific site for licensure supervision.  The Board of Counseling sometimes runs 3 months or more behind in approving registrations.  What would a provider do with that employee while they wait for the Board to approve the individual?  In many parts of the state, there are an extremely limited number of licensed individuals and when providers are able to find licensed eligible, it takes time to register them. 

There is language in the proposals that seems to suggest the independent clinical assessments will be required in much broader fashion than was previously required, specifically for all age groups in MHSS.  Even if there is not a specific proposal for this at this time, there is a proposal that these types of assessments could be applied to any behavioral health service and that the only requirement is that DMAS give appropriate and timely notice to providers.  I am very concerned about what DMAS would deem appropriate and timely notice.  Also, the fact that CSB’s perform these assessments does not make them an “independent” clinical assessment, as the very services that these assessments recommend are provided by the CSB themselves.  In addition, many CSB’s only recommend their own services once the assessment is done and bar providers in certain services with assisting consumers to the assessment appointments stating that the provider has a financial interest in the client completing the assessment.  As a provider, we have seen case after case of delayed VICAP assessments due to this narrow vision on the part of CSB’s.  Clients who would otherwise complete the assessment with the support of a Crisis Stabilization worker, refuse to go back in the assessment for less intensive services due to severe anxiety and the CSB will then not complete the VICAP.  The thought that this could become the process for more behavioral health services is very alarming to consumers and providers alike.

Another concern is the wording that the criteria for services includes documented interventions related to previous mental health, social service, or judicial services.  This requirement added to the already burdensome documentation that is required for services, will once again make it much more difficult for consumers to receive services. 

My last comment relates to the language concerning violations to the marketing guidelines set forth by DMAS and also found in guidelines published by Magellan.  At this time providers are governed by a memo that states that the first violation of a marketing guideline will result in a $1,000 fine.  The second offense would result in a $2,000 fine and then the third offense would result in the provider losing their license.  These consequences have never been imposed on any providers in our area, even though we are aware of consistent violations to the current regulations.  Increasing the consequences will not matter if the consequences are not imposed when violations occur. 

Again, thank you for the opportunity to comment, I only wish that more stakeholders had been aware of this opportunity so that those gathering these opinions could have more input.

 

As a Community Based Provider, I disagree with the IIHS Proposed Changed. I believe Case Management should not be removed as one of the duties and responsibilities of IIHS workers; they are more than capable and qualified to render this service effectively.