| Action | Mental Health Skill-building Services |
| Stage | Proposed |
| Comment Period | Ended on 10/23/2015 |
 |
85 comments
The following is being entered consistent with a letter being sent by email and U.S. Mail to Ms. McClellan.
August 27, 2015
Ms. Emily McClellan
Regulatory Supervisor
Department of Medical Assistance Services
600 East Broad Street
Richmond, Virginia 23219
Dear Ms. McClellan
Re: Amount, Duration, & Scope of Medical and Remedial Care And
Services [12 VAC 30-50] -- Mental Health Skill-building Services
Dear Ms. McClellan:
I am writing on behalf of the Association of Community Based Service Providers (“ACBSP”). Our Association is comprised of mental health providers ranging in size from mom and pop small family businesses to member companies that have several hundred employees. Members of the Association are actively engaged in the delivery of a variety of mental health services including mental health skill-building services across the Commonwealth in both urban and rural areas.
The purpose of this communication is to oppose on behalf of the Association and our members the changes to the regulations as published in the Virginia Register on August 24, 2015.
In particular, our Association is opposed to the proposed changes that would change the mental health skill-building services (“MHSS”) to mean that a unit of service would be defined as 15 minutes. Further in the regulations, this proposed change was anticipated to take effect on July 1, 2014.
The proposal to change the unit to 15 minutes would be detrimental and harmful to the patients that we serve. Such a proposal does not bear any reasonable relation to the mental health illness or treatment thereof for our patients. Finally, our Association has never supported this aspect of the proposed changes nor do we know of any provider groups who have supported it.
We look forward to working with DMAS as always but would respectfully request that this change be deleted during the public comment period.
Should you have any questions, please do not hesitate to contact me.
Sincerely,
W. Scott Johnson
WSJ/jpr
DM #745274
cc: Ms. Tyler S. Cox
Ms. Molly Cheek
Ms. Teshana Henderson
Mr. Jonathan Coleman
Mr. Dennis Parker
Mr. Matt Marek
To Whom it May Concern,
I was alerted by our MHSS coordinator to a partular excerpt from the proposed changes. It's difficult to reference, but it's #3, towards the bottom. It is the first sentence of a larger paragraph describing the completion of the ISP for MHSS:
"3. The LMHP, LMHP-supervisee, or LMHP-resident shall complete, sign, and date the ISP within 30 days of the admission to this service."
This is the only ISP reference that doesn't include the "QMHP-A, QMHP-E" credentials. Since this was immediately following the regulation for the SSPI, and had the same phrasing, I thought it may be in inadvertant omission. If it isn't, this would be the only service under CMHRS, that would require an LMHP to complete the ISP. I appreciate your time and consideration.
Thank you,
Scott Britton,
Director of Quality Assurance
MPNN CSB
1)In order for providers to have an LMHP/LMHP-like staff member to complete ISP’s, additional staff will need to be hired.
In addition to the comments submitted, please note that the previous changes to the MHSS program have already limited the access to MHSS services for a number of individuals who were using them to remain stable within the community. With the move to more community based treatment for individuals who experience mental health issues and the utilization of hospital treatment as an acute care model, there is need for more, not less, access to services that are recovery based and community based..
The points outlined in the prior comment (prepared by a colleague) were spot on about the effect the proposed changes would have on the availability of services to support those individuals living in the communities in VA with a diagnosis of mental illness. To remove those and make access much more difficult would put them at serious risk of prolonged hospitalization at a cost much greater than the cost of MHSS services, and in direct conflict with the philosophy of person-centered care and least restrictive care which has been adopted nation wide. The history of the struggle of those with mental health diagnoses has led all professionals to adopt a recovery model of care, which is based in the belief that the individual is the expert in what services they need and creates a partnership between the provider and the individual served to best allow the individual to recover from their illness and move on to a more productive, independent life.
The changes to the MHSS and crisis stabilization services remove the individual from that equation and place arbitrary limits and approvals to the amount and types of care they need. These decisions are made by a professional who has never seen the individual. That professional holds within their hands the access to needed, possibly llife saving services, which they make a decision about solely by what they see on a computer screen. The MCO is charged with saving money, not providing the best possible outcome for the individual.
In addition, there is an inherent contradiction in this proposal. Where DMAS has stated that MHSS services are less intensive and can be provided by QPPMH level staff, they are increasing the level of staff who will actually write a treatment plan for the service. The ISP is meant to be the plan the individual develops for their treatment. The consumer movement has adopted as their motto "Nothing about me, Without me". However, the cost (unreimbursed) to the agency to move to an ISP having to be written by an LMHP is exponentially higher. The rate for MHSS services is based upon the service being performed by a QPPMH staff, not a much more expensive LMHP. Agencies will be forced to make this work, and will have to choose to lose revenue or not provide the service. Agencies who provide the service will necessarily have to limit the total amount of time that the LMHP has to spend with the individual in the writing of the ISP due to lack of reimbursement and the consumers input will suffer accordingly.
Being a provider who has worked in two other states and for an agency that provides service in 8 states, this standard of an ISP being written by an LMHP is far above the accepted standard I have experienced, or have knowledge of. Professionally, the standard is for the LMHP to review and sign off on the ISP, but the ISP is written by the non-licensed staff in conjunction with the individual served. VA is the only state that I am aware of that would require a licensed professional to spend their time actually developing and writing the plan.
I implore you to consider the text in my prior comment and to think about those individuals who will suffer due to the lack of the community resources they need to remain in their community of choice. I also implore you to take a closer look as to why the most severe cost savings efforts so often target the mentally ill population. These changes will make services less effective and less available in a time when average people are struggling to understand why the mental health sysytem is ineffective in preventing tragedies.
An overall vision for a system of care needs to be developed and implemented instead of constant changes to a system which inevitably break down the system of care. Cost savings on the back of the mentally ill are short sighted and create even more social injustice for those already suffering from a mental health disorder.
Proposed Language:
d. e. The yearly limit for mental health support skill-building services is 372 units. Only direct face-to-face contacts and services to the individual shall be reimbursable. One unit is at least one hour but less than three hours.
In the Economic Impact Analysis the following is quoted: The proposed regulations would change the unit structure to a 15 minute billing unit and decrease the number of units per day that an individual may receive the service (decreasing from seven hours to up to 5 hours allowable as a maximum of twenty 15 minute billing units per day) to ensure that the service is not over-utilized. The new unit value and new unit allowance would yield a maximum of 5 hours per day, 5 days per week for a total of 5,200 fifteen-minute units per year. The changes in the daily, weekly, and annual limits would stagger services so that they may be provided consistently over the course of a year. The current reimbursement rate is $91 per unit in urban areas and $83 per unit in rural areas. Under the new system, the rate for one 15-munite unit would be $14.77 in urban areas and $13.47 in rural areas. According to DMAS, under the new unit and rate structure, the total expenditures would increase if the maximum limits are billed. However, with the new daily and weekly limits in the unit structure maximum yearly limit would be more difficult to achieve.
Comment:
15 minute units are preferable, but the proposed language for regulations still reflects current unit structure.
Recommendation:
Update to be consistent with EIA report.
Proposed Language (Page 10 of 25):
"Review of ISP" means that the provider evaluates and updates the individual's progress toward meeting the individualized service plan objectives and documents the outcome of this review. For DMAS to determine that these reviews are satisfactory and complete, the reviews shall (i) update the goals, objectives, and strategies of the ISP to reflect any change in the individual's progress and treatment needs as well as any newly identified problems; (ii) be conducted in a manner that enables the individual to participate in the process; and (iii) be documented in the individual's medical record no later than 15 calendar days from the date of the review.
Comment:
This definition conflicts with:
b. Documentation of this review shall be added to the individual's medical record no later than the last day of the month in which this review is conducted, as evidenced by the dated signatures of the LMHP, LMHP-supervisee, LMHP-resident, QMHP-A, QMHP-C, or QMHP-E and the individual.
Definition of a Review and Description of Review not consistent across regs.
Recommendation:
Consistent language of 15 calendar days from the date of the review through-out the regulations.
Proposed Language:
Page 12 of 25
5. Crisis intervention shall provide immediate mental health care, available 24 hours a day, seven days per week, to assist individuals who are experiencing acute psychiatric dysfunction requiring immediate clinical attention. This service's objectives shall be to prevent exacerbation of a condition, to prevent injury to the client or others, and to provide treatment in the context of the least restrictive setting. Crisis intervention activities shall include assessing the crisis situation, providing short-term counseling designed to stabilize the individual, providing access to further immediate assessment and follow-up, and linking the individual and family with ongoing care to prevent future crises. Crisis intervention services may include office visits, home visits, preadmission screenings, telephone contacts, and other client-related activities for the prevention of institutionalization. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. The provision of this service to an individual shall be registered with either DMAS or the BHSA within one business day or the completion of the service-specific provider intake to avoid duplication of services and to ensure informed care coordination. Authorization shall be required for Medicaid reimbursement.
And (page 13 of 25)
7. Crisis stabilization services for nonhospitalized individuals shall provide direct mental health care to individuals experiencing an acute psychiatric crisis which may jeopardize their current community living situation. Authorization shall be required for Medicaid reimbursement. Services may be authorized for up to a 15-day period per crisis episode following a face-to-face service-specific provider intake by an LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP. Only one unit of service shall be reimbursed for this intake. The provision of this service to an individual shall be registered with either DMAS or the BHSA within one calendar day of the completion of the service-specific provider intake to avoid duplication of services and to ensure informed care coordination. See 12VAC30-50-226 B for registration requirements.
Comment:
Per the proposed regulations, Crisis Intervention and Crisis Stabilization would require an authorization. Currently, they require a registration. Because these services are short term and meant to address time sensitive mental health needs, waiting on an authorization is not in the best interest of an individual waiting on CI services. Not consistent immediacy and need for service. The authorization requirement is inconsistent with proposed regs, discusses authorization, but also speaks to about registration process.
Recommendation:
Continue registration requirement for Crisis Intervention and Crisis Stabilization.
Proposed Language:
8. Mental health support skill-building services (MHSS) shall be defined as goal-directed training and supports to enable individuals to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. Authorization is required for Medicaid reimbursement. Services that are rendered before the date of service authorization shall not be reimbursed. These services may be authorized up to six consecutive months as long as the individual meets the coverage criteria for this service. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. This program These services shall provide goal-directed training in the following services areas in order to be reimbursed by Medicaid or the BHSA: training in or reinforcement of (i) functional skills and appropriate behavior related to the individual's health and safety, instrumental activities of daily living, and use of community resources; (ii) assistance with medication management; and (iii) monitoring of health, nutrition, and physical condition with goals towards self-monitoring and self-regulation of all of these activities. Providers shall be reimbursed only for training activities defined in the ISP and only where services meet the service definition, eligibility, and service provision criteria and this section. Service-specific provider intakes shall be repeated for all individuals who have received at least six months of MHSS to determine the continued need for this service.
Comment:
This reads as if a full SSPI is required at 6 months. This is an additional burden on consumers. It is felt that a comprehensive assessment, or the original SSPI, reviewed by an LMHP, instead of redoing an SSPI is preferred.
Recommendation:
Review of SSPI at 6 months by the LMHP
Proposed Language:
3. The LMHP, LMHP-supervisee, or LMHP-resident shall complete, sign, and date the ISP within 30 days of the admission to this service. The ISP shall include documentation of how many days per week and how many hours per week are required to carry out the goals in the ISP. The total time billed for the week shall not exceed the frequency established in the individual's ISP. The ISP shall indicate the dated signature of the LMHP, LMHP-supervisee, or LMHP-resident and the individual. The ISP shall indicate the specific training and services to be provided, the goals and objectives to be accomplished, and criteria for discharge as part of a discharge plan that includes the projected length of service. If the individual refuses to sign the ISP, this shall be noted in the individual's medical record documentation.
Comment/Recommendation:
QMHPs should be able to complete and sign the ISP, and not just LMHPs. At least, QMHPs should be able to complete, with LMHP review. In addition, regular provision of care is allowable when completed by QMHPS, as are ISP Reviews.
Proposed Language:
4. Every three months, the LMHP,LMHP-supervisee, LMHP-resident, QMHP-A, of AMHP-E shall review with the individual in a manner in which he may participate with the process, modify as appropriate, and update the ISP. The ISP must be re-written at least annually.
Comment:
Clearer language is needed regarding the quarterly review of the ISP. It can be interpreted that the ISP must be updated every three months.
Recommendation:
Change language to read, modify as appropriate and update the ISP if changes are made.
Proposed Language:
1. Prior to At admission, an appropriate face-to-face service-specific provider intake must be completed, conducted, documented, signed, and dated, and documented by the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP indicating that service needs can best be met through mental health support services. Providers shall be reimbursed one unit for each intake utilizing the appropriate billing code. Service-specific provider intakes shall be repeated when the individual receives six months of continual care and upon any lapse in services of more than 30 calendar days.
Comment:
The regulation reads that the rate for the SSPI assessment is equal to one unit. In these proposed regulations one unit is 15 minutes. Under the new system, the rate for one 15-munite unit would be $14.77 in urban areas and $13.47 in rural areas.
Recommendation:
Its unlikely that an SSPI be completed in a 15 minute unit. Recommend reimbursement for full hour of assessment equal to 4 (15 min ) units.
This creates an unrealistic expectation, particularly in the more rural areas of Virginia where LMHPs are continually in high-demand for a variety of positions. Requiring LMHPs to create all ISPs and QRs for clients remove LMHPs from the clinical work they have trained for and been extensively educated about and transitioning them to a paperwork laden position. This change will require numerous agencies to complete restructure programs and create additional positions to accomodate this change while simultaneously reducing the clinical work provided aas the paperwork burden increases. Finally, this creates an increasedly likelihood of unethical behaviors in order to meet and maintain minimum standards with this new regulation.
In order or providers to have an LMHP/LMHP-like staff member complete ISP's, the provider would be responsible for hiring more staff. LMHP employees cost more, which means the companies are paying more out of pocket to maintain the regulations, and several mental health agencies cannot afford these extra expenses. If they could be afforded, providers would be forced to make cuts in other areas to pay for the LMHP/LMHP-like staff. LMHP staff often do not have as much contact with the clients as the clinicians do, therefore having these individuals create and be responsible for the ISP's means that they would not be as accurate, or detailed about the progress that the client may have made. Mental health has suffered with other regulation changes, and we really hope that this does not pass, as it will only make it more difficult to provide the clients with that they need on a daily basis in order to live the best lives possible.
Region V ES Council have discussed this issue in the past and agree that requiring authorization for Crisis Intervention and Crisis Stabilization is not in the best interest of the individual being served . The proposed change to require authorization rather than the current required registration will create a barrier to immediate access to a level of care that is less restrictive in nature and prevents hospitalization.
G. Intensive community treatment (ICT).
1. A service-specific provider intake that documents eligibility and the need for this service shall be completed by either the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP prior to the initiation of services. This intake documentation shall be maintained in the individual's records. Proper completion of the service-specific provider intake shall comport with the requirements of 12VAC30-50-130.
The aformentioned paragraph
SSPI cannot be completed by LMHP-RP as the changes in January 2015 do not apply to case management
"LMHP-supervisee in social work," "LMHP-supervisee," or "LMHP-S" means the same as "supervisee" is defined in 18VAC140-20-10 for licensed clinical social workers. An LMHP-supervisee in social work shall be in continuous compliance with the regulatory requirements for supervised practice as found in 18VAC140-20-50 and shall not perform the functions of the LMHP-S or be considered a "supervisee" until the supervision for specific clinical duties at a specific site is preapproved in writing by the Virginia Board of Social Work. For purposes of Medicaid reimbursement to their supervisors for services provided by supervisees, these persons shall use the title "Supervisee in Social Work" after their signatures to indicate such status.
What are the purposes for 18VAC125-20-65 and 18VAC140-20-50 generally in reference to LMHP
I digress
Continued the quote below
"LMHP-resident in psychology" or "LMHP-RP" means the same as an individual in a residency, as that term is defined in 18VAC125-20-10, program for clinical psychologists.
seemly contradicts and pre-emempts the following paragraph below
18VAC140-20-10
Clinical social work services" include the application of social work principles and methods in performing assessments and diagnoses based on a recognized manual of mental and emotional disorders or recognized system of problem definition, preventive and early intervention services and treatment services, including but not limited to psychotherapy and counseling for mental disorders, substance abuse, marriage and family dysfunction, and problems caused by social and psychological stress or health impairment.
because again 18VAC125-20-10
is too broad definitions and does not reference anything such as other parts of Virignia Administrative Code
Title 18 and subsquent chapters
Licensed Mental Health Professional (LMHP)
– means a physician, licensed clinical psychologist, licensed professional
counselor, licensed clinical social worker, licensed substance abuse
treatment practitioner, licensed marriage and family therapist, or
certified psychiatric clinical nurse specialist.
• LMHP Supervisee or Resident (LMHP-S; LMHP-R; LMHP-RP)
– LMHP-R means the same as "resident" as defined in (i) 18VAC115-20-
10 for licensed professional counselors; (ii) 18 VAC115-50-10 for
licensed marriage and family therapists; or (iii) 18 VAC115-60-10 for
licensed substance abuse treatment practitioners;
– LMHP-RP means the same as an individual in a residency program as
defined in 18VAC125-20-10 for clinical psychologists.
– LMHP-S means the same as "supervisee" as defined in 18 VAC140-20-
10 for licensed clinical social workers
An LMHP-Supervisee or Resident in any of the above definitions shall
be in continuous compliance with the regulatory requirements for
supervised practice and shall not perform the functions of the LMHP-S,
LMHP-R, or LMHP-RP or be considered a "supervisee" or “resident”
until the supervision for specific clinical duties at a specific site is pre-
approved in writing by the appropriate Virginia Board.
Concerning the regulation change in which Non-Residental Crisis Stabilization may be used as a higher level of care in the consideration of MHSS eligibility criteria:---We support the addition of this service as a higher level of care, as the services provided in non-residential are the same as in residential CSS, they are just provided in a different setting.
The proposed regulations which state that LMHP, LMHP-Supervisee, or LMHP-residents must complete, sign, and date ISPs does not make logical sense to provide effective MHSS to clients. There is already a shortage of licensed or licensed eligible individuals in many areas, therefore many agencies will not be able to fill these positions. Also, for a licensed eligible resident, these hours do not count toward licensure and therefore it would decrease or eliminate those individuals from applying for such positions.
On behalf of the Virginia Association of Community-Based Providers (VACBP), thank you for the opportunity to comment on the latest proposed changes to Mental Health Skill-building Services, Crisis Stabilization Services and Crisis Intervention Services.
VACBP Comments on Proposed Regulations:
Regarding the proposed regulation which states that LMHP, LMHP- Supervisee, or LMHP- resident shall complete, sign and date an ISP:
In order for providers to have an LMHP/LMHP-like staff member to complete ISP’s, additional staff will need to be hired.
In many parts of the state, there is a severe shortage of licensed or licensed eligible individuals to fill these positions. If this change is approved, MHSS providers will likely not be able to fill the needed number of positions, resulting in a reduction or elimination of the service.
It is our experience as private providers that those licensed or licensed eligible staff who are available are not apt to take jobs such as these because they are paperwork intensive and their training causes a desire to work with people, not just fill out papers. In addition, the work that would be required of these positions does not meet the requirement for hours toward licensure and as such does not make these jobs attractive to licensed eligible individuals, making it even more difficult to find staff to fill these roles.
If this change is adopted for this service, it may be the only service that does not permit QMHP-A or QMHP-E credentialed professionals to complete an ISP.
This approach to writing the ISP’s seems contrary to current trends.
The definition, scope of service and intent of MHSS has been modified to the point that regulatory bodies state that a QMHPP can provide the service, implying that the service is less intensive than others, yet it now requires and LMHP to write the ISP.
To the extent these ISP’s could be written, they would be written by staff who have very little contact with the client.
Approving this change will reduce access to services that are needed by Virginians who suffer from serious mental illness.
Regarding the proposed regulation requiring an authorization for Crisis Intervention and Crisis Stabilization:
Currently, registration is required and can be done expeditiously.The timeframe for receiving an authorization for other services is anywhere from 2-5 days. Considering that a client is in a crisis situation when they come into this service, it does not seem feasible to wait for an authorization to be approved to begin services. An authorization requires a large amount of paperwork and this would further delay the beginning of actual services during a critical time.
If the intention is for providers to begin services without an authorization, are providers guaranteed payment if the authorization is eventually denied?
Delays in the beginning of the provision of these services could lead to clients seeking more expensive and intrusive higher levels of care.
Regarding the proposed regulation that Service Specific Provider Intakes (SSPI’s) shall be “repeated” for all individuals who have received at least six months of MHSS to determine the continued need for the service:
Does this mean that the SSPI must be re-done after six months?If so, this would be an unnecessary burden and distraction from delivering care for providers and consumers.We support appropriate review of the original SSPI.
Regarding the proposed regulation on the number of days per week and hours per week required to carry out the goals in the ISP:
Will providers be reimbursed if they provide services outside of these prescribed levels set forth in the ISP? Client’s needs fluctuate greatly over the course of time and issues that arise may require additional hours/days of services. Will these either be denied or reclaimed in an audit?
Approving this proposed change diminishes a person-centered approach and the ability to meet a client’s specific needs as they arise.
Regarding the deletion of the change in the billing unit structure that was formerly mentioned in the proposed regulations:
This change would have resulted in a reduction in the quality and access to services and we wholeheartedly support the wise decision not to pursue it.
While the Department of Planning and Budget’s (DBP’s) Economic Impact Analysis states that the proposed changes to the billing unit and rate structure may be budget neutral, providers estimate a reimbursement reduction of 10-25% if this change were approved. This would seriously impact the ability to continue to provide services as well as have the quality assurance and supervisory measures in place to make sure the services that are provided are of high quality.
Regarding the proposed change in which Non-Residential Crisis Stabilization may be used as a higher level of care in the consideration of MHSS eligibility criteria:
We support the addition of this service as a higher level of care, as the services provided in non-residential are the same as in residential CSS, they are just provided in a different setting.
Thank you for considering our comments and concerns.
Michael Carlin
Executive Director
Virginia Association of Community-Based Providers
WRT billing units of 15 minutes: This is the model currently used in the medical community. This method has resulted in depersonalization of the patient/client. While it seems efficient, this is not a valuable system to accomplish mental health goals and treatments, especially the skill-building therapies conductd by private corporations. The client with mental health diagnoses already feels marginalized, and being seen on 15-minute increments does not afford the clinician the opportunity to form a working relationship with the client. If you want qualified people to treat those with mental health issues, the price must be paid. These clinicians frequently hold masters or doctoral degrees and work in smaller corporations because they want more face-to-face time with their clients. And this method works.
WRT changes in urban rates and rural rates, why? Because clinicians who live in rural areas deserve less pay than urban clinicians? Rural clinicians can see fewer clients daily because of the distance between homes/facilities. By reducing the pay, you are reducing the household income of a hard-working individual. Why? Who profits here?
WRT removal of the requirement for hospitalization prior to receipt of MHSS, I completely support this. Hospitalization for mental health issues can be restrictive and dehumanizing. Not every client in need of MHSS needs hospitalization first. This goes against the ADA of least-restrictive environment and denies services to those who have mental health disabilities.
WRT persons uner the age of 21 years who live with parents or guardians. With whom one lives and one's chronological age are NOT factors determining the need of MHSS. Additionally, most care givers of persons with chronic, life-long mental health disorders need the support of the MHSS teams to reinforce the skills they teach their dependent.
Lastly, the idea that these services can be provided by the local community service boards is laughable! The CSBs are overworked and understaffed already, having waiting times of up to a month in many locales. So, one might hypothesize that saving money from individual corporations and giving it to the CSBs would allow the CSBs to accomodate the increased need. HA! Anyone who has studied government understands that, when a government entity is given an increase in budget for a program, the first thing that happens is a new level of middle management is created, and few of the dollars fund the issues for which the program was created. In a private corporation, the buismess is in business - they have to make a profit to stay in business, so they manage their time and funds more effectively.
If there are problems with private companies failing to provide proper services or misusing funds, take them down! Don't throw out all of the companies because of a few bad ones. Seriously.
Chesapeake Integrated Behavioral Healthcare---Our responses to the proposed changes are as below.
1) In reference to the following passage:
8. Mental health support skill-building services (MHSS) shall be defined as goal-directed training and supports to enable individuals to achieve and maintain community stability and independence in the most appropriate, least restrictive environment. Authorization is required for Medicaid reimbursement. Services that are rendered before the date of service authorization shall not be reimbursed. These services may be authorized up to six consecutive months as long as the individual meets the coverage criteria for this service. The service-specific provider intake, as defined at 12VAC30-50-130, shall document the individual's behavior and describe how the individual meets criteria for this service. This program These services shall provide goal-directed training in the following services areas in order to be reimbursed by Medicaid or the BHSA: training in or reinforcement of (i) functional skills and appropriate behavior related to the individual's health and safety, instrumental activities of daily living, and use of community resources; (ii) assistance with medication management; and (iii) monitoring of health, nutrition, and physical condition with goals towards self-monitoring and self-regulation of all of these activities. Providers shall be reimbursed only for training activities defined in the ISP and only where services meet the service definition, eligibility, and service provision criteria and this section. Service-specific provider intakes shall be repeated for all individuals who have received at least six months of MHSS to determine the continued need for this service.
Chesapeake Integrated Behavioral Healthcare believes completing an SSPI every six months is not practical and no other service reimbursed by DMAS has this requirement. Additionally, completing an SSPI every six months creates an additional burden on the individual receiving the service while yielding very little, if any, additional information that could not be obtained by a review of individuals record and consultation with clinicians providing the service.
2) In reference to the following passage:
3. The LMHP, LMHP-supervisee, or LMHP-resident shall complete, sign, and date the ISP within 30 days of the admission to this service. The ISP shall include documentation of how many days per week and how many hours per week are required to carry out the goals in the ISP. The total time billed for the week shall not exceed the frequency established in the individual's ISP. The ISP shall indicate the dated signature of the LMHP, LMHP-supervisee, or LMHP-resident and the individual. The ISP shall indicate the specific training and services to be provided, the goals and objectives to be accomplished, and criteria for discharge as part of a discharge plan that includes the projected length of service. If the individual refuses to sign the ISP, this shall be noted in the individual's medical record documentation.
Chesapeake Integrated Behavioral Healthcare (CIBH) believes that QMHPs should be able to complete and sign the ISP with a review by an LMHP. The QMHP is the clinician who is going to work directly with the individual receiving services. The QMHP will also meets with the individual to revise the ISP when changes occur. The LMHP assesses and provides oversight to the development of the ISP, including signing each Quarterly Review, so completing the ISP by the LMHP appears to be unnecessary.
3) The proposed changes include changes to units. For example:
d. e. The yearly limit for mental health support skill-building services is 372 units. Only direct face-to-face contacts and services to the individual shall be reimbursable. One unit is at least one hour but less than three hours.
In the Economic Impact Analysis the following is quoted: The proposed regulations would change the unit structure to a 15 minute billing unit and decrease the number of units per day that an individual may receive the service (decreasing from seven hours to up to 5 hours allowable as a maximum of twenty 15 minute billing units per day) to ensure that the service is not over-utilized. The new unit value and new unit allowance would yield a maximum of 5 hours per day, 5 days per week for a total of 5,200 fifteen-minute units per year. The changes in the daily, weekly, and annual limits would stagger services so that they may be provided consistently over the course of a year. The current reimbursement rate is $91 per unit in urban areas and $83 per unit in rural areas. Under the new system, the rate for one 15-munite unit would be $14.77 in urban areas and $13.47 in rural areas. According to DMAS, under the new unit and rate structure, the total expenditures would increase if the maximum limits are billed. However, with the new daily and weekly limits in the unit structure maximum yearly limit would be more difficult to achieve.
Chesapeake Integrated Behavioral Healthcare supports the 15 minute unit.
This subject is of great concern to me as a provider as the proposal requiring LMHP/LMHP-like staff is contrary to current trends in the mental health field and requires that additional staff must be hired at higher salaries which will hinder us providers to provide services because of budgeting concerns. This will have a direct impact on the consumer. The documentation turn around time will be longer thus creating a possible crisis for the consumer by heightening his/her psychiatric symptoms while awaiting documentation to provide services.Many of these consumers are already having to be put on a waiting list to receive services and community service boards are overwhelmed and understaffed. LMHP/LMHP-like staff are in short supply and these hours required to write ISPs which could be accomplished by lesser qualified staff do not count toward licensure supervision hours that are required to obtain LMHP status.
The proposed regulation for requiring authorization for Crisis Stabilization Services seems counterproductive for the consumer in many ways. The time-frame for those in Crisis is paramount. Any regulations that delay the process of a consumer receiving crisis services in a timely manner puts that consumer in an unnecessary at-risk situation. In the advent of delay the consumer may be forced to have to access higly expensive and often unwarranted intrusive higher levels of care thus creating apprehension for the consumer to seek such care and could put his/her life in jeopardy or someone else's. As we have seen in far too many tragedies in the news media consumers need speedy and less cost preventive intervention. In addition, I wholeheartedly support the deletion of the language that may have led to a change in the unit structure or the reimbursement rate as crisis intervention is far less costly than higher level care intervention and is able to respond in a more timely and thorough manner spending time with the consumer until the crisis is abated without involving more costly and overwhelmed inpatient services. Making Non-Residential Crisis Stabilization services an eligibility criteria for follow-up MHSS services is a more cost effective and less cumbersome process without overwhelming the already overburdened healthcare residential system and greatly increases the consumer's access to needed mental health skills building follow-up care.
Propsed changes that require LMHPs to wirte ISPs for client's they have little contact with is not in the best intrest of the client. The clinicain (QMHP) knows the client best and can offer more insight into thier specfic needs. The QMHPs are very qualified to continue completing these douments.
Medicaid is proposing language that would require “pre-authorization” of Crisis Intervention and Crisis Stabilization services. ChildSavers provides Crisis Intervention as part of our Immediate Response program. The proposal to require service pre-authorization is not client centered and does not support the service requirement that the provider be available 24/7 to provide Crisis services. The change is akin to telling emergency rooms that they need to treat the clients, but you will tell them later if they will be reimbursed or not. We recommend continuing with the current process of requiring a service registration as a child in crisis cannot wait 3-5 days for a determination of covered services.
Concerning the regulation change allowing non-residential crisis stabilization to be considered as a higher level of care in consideration of MHSS eligibility criteria, I wholeheartedly support this change. Most individuals are unaware that the services provided in a non-residential CSS program are significantly the same as the services provided in a residential CSS.program. Also, non-residential CSS is much more available and attainable for clients in our area, due to only having one residential CSS that they can access. Criteria to be admitted into that specific residential CSS is also strict due to the program being voluntary and screening for a client's risk of flight. Also, clients with substantial medical problems are denied admission to residential CSS. As a result, the client has to access non-residential CSS to stabilize. These clients that are denied admission to residential CSS, due to circumstances beyond their control, should not be excluded from being able to access MHSS. Especially when it is the same service being provided, just in a different setting.
As an LPC working in community based mental health services, I have the following comments related to the various proposed regulatory changes:
1. Regarding the proposed regulation which states that LMHP, LMHP- Supervisee, or LMHP- resident shall complete, sign and date an ISP:
With a shortage of LMHPs, especially in the rural areas of Virginia, I am concerned that this requirement will significantly limit mental health services to clients in these areas. In addition, LMHP-types will not be able to count writing ISPs for MHSS as a part of the direct clinical services they need in order to meet requirements for their Residencies, as MHSS is not recognized as "clinical" experience by the governing boards for these health professionals. Furthermore, often LMHPs will not take these positions due to the intense paperwork requirements involved, when most have entered the field to work with people, not push paper. I am not clear why MHSS will be the only service that is provided by QMHPs and/or QMHP-Es but also requires a LMHP/LMHP-type to complete the ISP. If the clinicians working directly with the client day in and day out are qualified to provide community based interventions with appropriate support and clinical supervision, then why can they not work collaboratively with their clients to craft a treatment plan with the same support and supervision? Finally, due to the higher cost of LMHP/LMHP-types, companies will be forced to find ways to make this regulation work through increased "efficiency" and "productivity" of the LMHPs, which translates in the ISPs being completed with minimal input from the client. This is not person centered.
2. Regarding the proposed regulation requiring an authorization for Crisis Intervention and Crisis Stabilization:
The very nature of these services indicates that an individual is in need of timely intervention to prevent higher level of care, which is also more costly. The current registration process allows communication and timely oversight of individuals receiving this service, without delaying the services. With a minimum of 2 day waiting periods for authorizations for other mental health services, I am very concerned that requiring an authorization for these crisis services will significantly and negatively impact individuals suffering from acute mental health crises. If this regulation does go through, please provide clarification on how this will be implemented without causing harm to residents of Virginia. Will there be a separate authorization line to get authorization for these time sensitive services in real time? Will providers have a certain grace period where services can be rendered with reimbursement prior to the authorization being approved? If these clarifications are not provided and considered and these authorizations are completed as they are for the other mental health services, I am concerned that more individuals will be forced to enter more costly, higher level of care options, and/or individuals will decompensate in the community leading to increased risk of harm toward self and/or others.
3. Regarding the proposed regulation that Service Specific Provider Intakes (SSPI’s) shall be “repeated” for all individuals who have received at least six months of MHSS to determine the continued need for the service:
Forcing clients to undergo a full SSPI every six months seems unnecessary, when LMHPs could complete an appropriate review of the original SSPI to determine any updates to the client's diagnosis, treatment needs, and appropriateness for services. Focus should be on review of services, treatment recommendations, and determination of appropriate services for the client, rather than on completing a more lengthy, paperwork intensive SSPI.
4. Regarding the proposed regulation on the number of days per week and hours per week required to carry out the goals in the ISP:
Will there be any flexibility to this, if there is documented need in the client's medical record? Clients' needs vary over the course of treatment and services should be provided based on need versus a pre-prescribed number of days and hours per week.
5. Regarding the deletion of the change in the billing unit structure that was formerly mentioned in the proposed regulations:
I support removing this revision from the regulations. The unit structure and rate reimbursement outlined in the Economic Impact Analysis would significantly impact providers being able to continue this service, which would again lead to Virginian residents not receiving needed care.
6. Regarding the proposed change in which Non-Residential Crisis Stabilization may be used as a higher level of care in the consideration of MHSS eligibility criteria:
I also support this change in the regulations, as it will allow individuals receiving this higher level of care to be eligible for MHSS as a step down in services, providing more continuity of care and greater community support for individuals suffering from severe mental illness.
Thank you for your time and consideration in reviewing my thoughts and concerns.
Sincerely,
Zizi LoFaro, LPC
Psychological problems can increase the likelihood that people will make poor behavioral choices which can contribute to medical problems. I suggest you think about those individuals who will suffer due to the lack of the community resources they need to remain in their community of choice. I also advise you to take a closer look as to why the most severe cost savings efforts so often target the mentally ill population. The changes proposed will hinder more than just the private sectors staff and owners, it will also affect the client ultimately in the end.
I am client that is benefiting from private sectors more than bigger city owned companies that I've used in the past. The private company I use is thoughtful, resourceful and very helpful in providing me the necessary tools I need to live a more independent life.
I am concerned as to the proposed regulations requiring an authorization for Crisis Stabilization. Currently, receiving an approval for other services has a timeframe anywhere from 2 to 5 days; however, taking into consideration that a client has a crisis situation and is in need of immediate service, it does not appear to be conducive to the client's treatment if that client is having to wait for an authorization to be approved in order to have assignment of a trained provider to begin working with the client. This would delay beginning the crisis service and potentially contribute to the client's increased symptoms, thus placing the client in the hospital. An authorization for Crisis Stabilization requires an extensive amount of paperwork; therefore, this proposed regulation does not appear to have stability in meeting the client's needs effectively. Also, as a valued member of the agency in which I am employed, if the intention is for the providers to begin services with the client in crisis without the approval, does or would this be a guarantee that the payment for the service is rendered if the authorization is eventually denied? All in all, this would delay the beginning of services, which is instrumental to the client and could lead the client to seek other expensive avenues for services and intrusive higher levels of care.
Thank you for your consideration in this matter,
Jenny Brummitt, BS,QMHP-A
Changes should not be made that will jeopardize the mental health needs of clients. Cutting any pay to those that provide services will cause many qualified professionals to seek other employment. The only positive change would be eliminating the hospitalization requirement to receive services. Being hospitalized carries a stigma that many are not willing to carry. We need to reach potential clients before they have a break and are required to be hospitalized. We need to reach clients before they hurt themselves or innocent people. Instead of finding ways to cut services we should be finding ways to increase services and make services readily available for more people are there that have not sought help.
I have worked in the mental health field for six years and have volunteer experience prior to paid work experience and have experience in a variety of scenarios and programs.
I feel that if an LMHP or LMHP-like staff is required to complete ISP's, there will be more cost incurred by companies to pay staff with such credentials, which may in turn, decrease care in other areas of services. The worrk involved in creating an ISP does not contribute to hours needed to obtain licensure and therefore would make obtaining LMHP staff more difficult due to already limited access to such individuals. ISP's are designed to be person centered, which also makes it more difficult for an LMHP staff to complete as the LMHP is currently only present with the individual for a limited amount of time and cannot ensure that upon creation of the ISP, the client will be willing to participate in all areas of the ISP, which places the ISP at risk of taking longer to be approved and signed upon by both the client and the LMHP staff.
I feel that requiring an authorization for Crisis Stabilization Services is counterintuitive to the work that is to be provided by Crisis Stabilization clinicians as the point of providing such services is to assist the individual in decreasing costly hospitalizations or risk of harm to self or others. If the Crisis Stabilization Service requires an authorization, the individuals will not receive prompt care and could be placed in a more restricted environment, such as hospitalization, which would increase the crisis upon discharge from hospitalization. For a person in a crisis situation, a 2-5 day wait for authorization for Crisis Stabilization Services could be the difference between life or death.
I support the addition of Non-Residential Crisis Stabilization Services as a higher level of care in the consideration of MHSS eligibility criteria. In order to be admitted to Non-Residential Crisis Stabilization Services, an individual must be approved through an assessment process by an LMHP or LMHP-like staff member. Non-Residential Crisis Stabilization Services provide the same services as Residential Crisis Stabilization Services. However, residential facilities are limited in our area. There are benefits to receiving Non-Residential Crisis Stabilization Services that are not present in Residential Crisis Stabilization Services as the individual is learnign how to manage triggers to heightened symptoms in their live environment so that they are more capable of managing such stressors independently upon completion of the program. The individual is receiving one-on-one training and linking to needed resources to decrease the risk of more costly alternatives, such as hospitalization, and are able to access such resources with the support of the clinician to create more comfortability in utilizing such resources upon the completion of the crisis program.
I appreciate your consideration in these matters and would like to request that the well-being of those that suffer with mental illness be considered in implementing proposed changes so as to not create an environment with decreased supports to those individuals, which can create the presence of increased social situations by individuals who are unable to receive needed care to learn mental health symptom management techniques.
Thank you.
I want to voice concerns primarily in reference to the hospitalization requirement. This impacts the access to those in need of services for a variety of reasons. Mental health challenges, often go unaddressed and increase harmful risk of family instability, elevated rates of homelessness, and joblessness. More people suffer from mental health issues than the number of individuals serviced. Without supports those who suffer from Mental Health issues are twice as likely as other Americans to become chronically homeless and unemployed. Also the lack of education and limited functional skills are significant causes of these problems. Mental health problems and lack of care for those problems create numerous factors to consider such as substance abuse disorders and problematic alcohol use. For some the stigma of being hospitalized is embarrassing. Barriers to care can also breed increased levels of violent behaviors related to mental health. We need to create easier access for people suffering from Mental Health disorders.
Requiring LMHP or LMHP-like staff to complete ISP's will not only encourage unethical behavior, but will hinder agencies that strive to provide high quality, ethical mental health services as the cost incurred to pay staff with such credentials will increase, which may in turn, decrease care in other areas of services. The work involved in creating an ISP does not contribute to hours needed to obtain licensure and therefore would make obtaining LMHP staff more difficult due to already limited access to such individuals. ISP's are designed to be person centered, which also makes it more difficult for an LMHP staff to complete as the LMHP is currently only present with the individual for a limited amount of time and cannot ensure that upon creation of the ISP, the client will be willing to participate in all areas of the ISP, which places the ISP at risk of taking longer to be approved and signed upon by both the client and the LMHP staff.
In regard to requiring an authorization for Crisis Stabilization Services, I believe that this change would limit individuals with serious needs from accessing services in order to avoid hospitalization. If the Crisis Stabilization Service requires an authorization, the individuals will not receive prompt care and could be placed in a more restricted environment, such as hospitalization, which would increase the crisis upon discharge from hospitalization. For a person in a crisis situation, a 2-5 day wait for authorization for Crisis Stabilization Services could be the difference between life or death.
Thank you for your time and consideration.
The proposed changes to Mental Health Skills Building would drastically affect the clients and staff that we serve. Licensed and Licensed Eligible employees are currently taking care of all assessments and all re-authorizations for Mental Health Skills Building which is a difficult job. Adding the creation of ISP’s to their duties would not only be a disservice to the clients, but would make the job of Licensed and Licensed Eligible individuals even that more difficult. The clients are an important part of creating their ISP and feel the most comfortable discussing their goals with the clinician that is qualified and present in their lives. QMHP-A Clinicians are qualified to create and implement ISP’s and should be able to continue to do so, as they have successfully up to this point.
The proposed changes to Crisis Stabilization regarding authorizations that could take between 2-5 days to be approved is setting individuals with severe heightened symptoms up for failure. The goal and purpose of having Crisis Stabilization is to meet the client’s needs immediately and to avoid having the individual go into the hospital, jail, or worse- acting on potential suicidal or homicidal thoughts/plans. Having someone wait for an authorization to be approved is not only endangering that person or others, but it’s also going to lead to an increase in hospitalizations which takes “beds” from other individuals that could need that placement and increases the cost that Virginia is paying for Medicaid funded mental health services. The Creigh Deeds situation is a perfect but very sad example of what could occur if there are no beds available in a psychiatric hospital. By providing immediate crisis stabilization services to clients, we can attempt to avoid the hospitalization and save that bed for someone that may need a higher level of service.
Please consider not making the proposed changes. Please help us continue to be successful with our clients and allow us to provide sound therapeutic services without increased barriers.
Thank you,
Stevie N. Phillips, BS, QMHP-A
EVERYONE MUST READ
I recognize as a private provider and someone who has been in the mental health field for over 12 years that costs affect the nature of business in VA.
However, I believe that we have lost site of the true nature of our business and that is helping those with mental illness. We are out here in the trenches supporting those that have been left behind in almost every other aspect of their life. We are in a position where we can change the course of their direction and guide them to their ultimate destination and ultimate potential.
The more recent changes requiring hospitalization from adults with mental illness has made it nearly impossible to provide proactive assistance to individuals. All we can do is provide reactive assistance to these individuals after they have decompensated and are in crisis. Making not only our job 10 x’s harder but also making it even more difficult for the client to get back on their feet, when we could have just assisted with stabilization from the beginning with or without the hospitalization requirement.
The pattern for VA funding has been to make these regulations more and more stringent over the last few years.
What I find hard to believe is that instead of taking a hard look at private sector companies who abuse the privilege of billing for Medicaid funded services and stopping them, or demanding re payment, the decisions made by our government penalize all private providers!
There are horrible unethical private providers!!! There are also outstanding private providers out here doing things ethically and with purpose!!!
Shut down or penalize the providers who are fraudulently billing for services or not providing quality care. I used to worked for an agency that committed millions of dollars’ worth of fraud. I did everything I was supposed to when I discovered fraud within the company. I reported it to Licensure and the Medicaid Fraud Unit with a heavy heart. From there an investigation ensued for over 2 years, part of it under seal. The government then chose not to intervene, and passed the buck to my attorneys. There were not enough people within the company to back the story (hence why they call it a whistleblower suit, qui tam litigation, aka no one else knows because it’s only at the top).
It was explained that basically this wasn’t a case with a large company, more of a mom and pop, so therefore it just wasn’t worth their time anymore. After another almost year of attorney’s stepping into the governments’ shoes to continue to pursue qui tam litigation the case was all of a sudden dismissed sighting because the disclosure statement did not contain enough detail. This was after setting trial dates, and preparing to attend a trial date to compel the other company to produce evidence within a couple of weeks. While a very detailed disclosure statement was provided, the THOUSANDS of documents were not able to be presented at that point in litigation. Therefore, millions of dollars walked out the door. I used the system provided to me. I did what was ethically sound.
And for that I am repaid by now worrying that my now business will be greatly affected by rate cuts, qualification changes, and more upheaval to the delivery of Mental Health Skills Building Services.
In addition, let's have Licensure regulations and expectations that are the same across the board for ALL private providers. On paper it may appear that way, but each Licensure Specialist has their own requests and requirements and each private provider is at their beck and call in order to continue to receive a license in good standing.
It is inconceivable that the Community Service Boards can provide the needed services at the rate and frequencies needed by these mentally ill individuals. I have spoken to clients who have utilized CSB services and the response is always the same. The staff come once a week to check on them, they don’t know who their Case Manager is because they haven’t seen or heard from them in so long, the waiting list is over a month long, they are not accepting new patients for psychotropic medications, and on and on. They mean well, but it's just inconceivable to expect them to be able to manage it all.
A man called my company on the phone in crisis and I was able to verify his insurance, verify he met all the Medicaid criteria for services, and then send an Intake Specialist and Staff member out to the house to conduct the intake assessment, staying on the phone with him until they arrived. Then from there he was able to receive 1:1 direct care from a qualified staff member 3-4 times per week.
We are the ones who provide the reports to the CSB for their files and to count as their contact. We do all the ground work and keep these individuals afloat.
Virginia we have to do better!!!! Stop this madness!!! Please think about who you will effect before making more changes!! Address the real problems!!!
I also support the VACBP comments to the proposed Mental Health Skill Building Changes:
Regarding the proposed regulation which states that LMHP, LMHP- Supervisee, or LMHP- resident shall complete, sign and date an ISP:
In order for providers to have an LMHP/LMHP-like staff member to complete ISP’s, additional staff will need to be hired.
This approach to writing the ISP’s seems contrary to current trends.
Regarding the proposed regulation requiring an authorization for Crisis Intervention and Crisis Stabilization:
Regarding the proposed regulation that Service Specific Provider Intakes (SSPI’s) shall be “repeated” for all individuals who have received at least six months of MHSS to determine the continued need for the service:
Regarding the proposed regulation on the number of days per week and hours per week required to carry out the goals in the ISP:
Regarding the deletion of the change in the billing unit structure that was formerly mentioned in the proposed regulations:
Regarding the proposed change in which Non-Residential Crisis Stabilization may be used as a higher level of care in the consideration of MHSS eligibility criteria:
Thank you for your consideration and I hope that you are able to support our desires for the mentally ill in VA.
1. Proposed Language: 1. Prior to At admission, an appropriate face-to-face service-specific provider intake must be completed, conducted, documented, signed, and dated, and documented by the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP indicating that service needs can best be met through mental health support services. Providers shall be reimbursed one unit for each intake utilizing the appropriate billing code. Service-specific provider intakes shall be repeated when the individual receives six months of continual care and upon any lapse in services of more than 30 calendar days.
The requirement of a six-month administration of the Service-Specific Provider Intake (SSPI) is not required by DMAS of any other Community Mental Health Rehabilitative Service (CMHRS). The Department of Behavioral Health and Developmental Services (DBHDS) mandates reassessments be completed at least annually, or when a need presents, which offers consumers and service providers greater flexibility in adapting services to fit the actual needs.. For the typical consumer receiving MHSB services, the factors being addressed through treatment are chronic in nature and are generally better assessed over longer periods of time, such as during an annual review. Again, the DBHDS licensure standard provides direction to reassess as significant change occurs. A requirement of a six-month reassessment is superfluous and unnecessary given the licensure provision. In addition, a six-month reassessment requirement could result in consumers becoming frustrated, anticipating change within an unrealistic timeframe. The ongoing review of the Individual Service Plan (ISP) serves as a sufficient component of a continuity of care review between the initial intake and annual review. The structure of the SSPI and the included 15 elements do not serve as the most effective tool to assess a consumer’s progress in an enrolled service.
The SSPI, as it is defined by DMAS, was not designed to specifically assess progress of a specific service, such as MHSB, over time (per the definition of the SSPI), but to serve as a tool to determine the ongoing needs and preferences of an individual. Meeting with the individual, reviewing the ISP, quarterlies, progress notes, and obtaining feedback from the QMHP, provides the LMHP with the clinical information needed to determine if the individual will continue to need and benefit from MHSB. The LMHP can use the combined measures of progress noted above to document a continued need for services. The LMHP can also determine along with the QMHP if there are any other training needs identified in the past six months. Given the current methods employed to assess progress throughout a consumer’s enrollment (e.g., ISP and quarterly reviews), an annual update of the SSPI by the LMHP is sufficient.
2. Proposed Language: 3. The LMHP, LMHP-supervisee, or LMHP-resident shall complete, sign, and date the ISP within 30 days of the admission to this service. The ISP shall include documentation of how many days per week and how many hours per week are required to carry out the goals in the ISP. The total time billed for the week shall not exceed the frequency established in the individual's ISP. The ISP shall indicate the dated signature of the LMHP, LMHP-supervisee, or LMHP-resident and the individual. The ISP shall indicate the specific training and services to be provided, the goals and objectives to be accomplished, and criteria for discharge as part of a discharge plan that includes the projected length of service. If the individual refuses to sign the ISP, this shall be noted in the individual's medical record documentation.
Currently, there are no other CMHR services that require the LMHP to complete the ISP. Even a program such as Intensive Community Treatment (ICT), which is a more intensive program than MHSB, allows for a QMHP-A or QMHP-C to develop the ISP. In order to complete a comprehensive and thorough assessment of the client’s needs, the LMHP would have to meet with the individual several times during the 30 day period prior to developing the ISP. Once the assessment is completed and the ISP developed, the LMHP might have met with the individual up to five times, depending on the individual. The LMHP will then share the ISP with a QMHP to provide the training listed in the ISP. As this could be the first interaction the QMHP has with the client, there has not yet been an opportunity to build a therapeutic rapport with the client and their major service provider despite the client having been enrolled in a program for 30 days. This is not best practice and could result in a delay of service initiation. Typically, during the period used to assess a client, the QMHP is developing a therapeutic relationship with the client. The ISP developed by the QMHP and client is a contract between the two, establishing responsibilities and steps to achieve the client’s goals. In regards to having a highly qualified individual engaged in this process, QMHPs are required to have a Bachelor’s degree in a human services field and one year experience with the identified population. Based on these requirements, they are more than qualified to develop the ISP.
Additionally, the proposed regulations do not indicate a rate increase or provision of administrative funding to offset the cost of increased utilization of LMHPs. Currently, the demands for and on LMHPs are increasing and are often in excess of the pool of qualified professionals, as this proposed regulation would further exacerbate. As such, it is imperative to ensure program requirements reflect a use of all adequately qualified personnel to meet the service needs of consumers. Our QMHPs are valuable resources who have admirably and adequately completed the ISP development mandate in the past and continue to be reasonable and cost effective resources moving forward.
The proposed changes that require LMHPs to wirte ISPs for client's LMHP's have little contact with client's and QMHP A, sees client 3 -5 days a week it is not in the best intreast of the client. The clinicain (QMHP) knows the client,s needs and can offer more insight into thier specfic needs,plus allowing client's to have an imput in treatment plan. The QMHPs are very qualified to continue completing these douments.
I have a problem with the proposed changes to my field. I am aware that there are not many LMHP's to choose from and this would effect my ability to work. With this change, my company and companies like ours, may not be able to stay in business and our client's will still need the assistance. Now there could be more mental health citizens in need of care.
In regards to proposed changes to Mental Health Skill- Building Services, such changes would create an unethical approach to determining the objectives needing to be met for individuals seeking care as well as create added duties to Lisenced and Licensed Eligible individuals when QMHP-A are qualified to do so. The primary clinician assisting the individual with reaching these objectives has the most awareness of objectives needing to be focused on as well as provides for more personal involvement with the individual in the creation of the ISP. Such changes would create an environment where an individual is creating objectives for a person that they are not involved with on a regular basis, providing for an unethical enviroment for all parties involved.
In regards to proposed regulation changes involving Crisis Stabilization Services, this creates a very dangerous environment for individuals involved in any potential crisis; client, clinician, family, friends, community, etc. Crisis Stabiliation Services provide for immediate action when crisis is present. Requiring authorization for said services that could take days to be approved does not provide for adequate care and could lead to much more potentially harmful consequences as well as increase the need for hospitilzation, when one could have possibly been assisted within their own, less- restrictive, environment before symptoms were heightened to a level that required hospitalization.
As one that works within mental health and strives to provide ethical services instrumental in increasing the well- being of those we serve, I ask that you consider not making these proposed changes.
Thank you,
Brittany Mason, BS, QMHP-A
Mental Health Skill Building Services
Crisis Stabilization
I am a non-clinical, business professional residing in Southwest Virginia. Over approximately the past five years, I have had the opportunity to become a more active member and advocate for the mental health community within the Roanoke Valley and its surrounding areas.
It is my firm belief that any proposed regulation changes should solely be made in the spirit of improving the system with minimal impact to its constituents. I am unsure if this Virginia is practicing this credo.
I have followed regulation proposals for Mental Health legislation in Virginia and I am noticing an alarming trend. There exists countless instances in which reactionary proposals continuously spew out with careless impact analysis for the sole reason to immediately mitigate the financial damages of a broken system. This ideology will not work.
If the primary reason for reactionary regulation proposals is ultimately for financial recapture (as I personally believe it is), then I propose that Virginia end this archaic system of thinking and adopt a proactive approach by implementing a more efficient auditing process with stricter consequences for the agencies and individuals who abuse the system.
That being said and in light of responses I have so far read, this is my feedback concerning this round of regulation proposals.
Proposal - LMHP, LMHP supervised, or LMHP resident completes, signs, and dates ISP
To begin, Southwest Virginia as well as many other parts of Virginia does not have the human capital available to effectively allow this proposal to be passed. Of the little capital that is available, I would highly doubt the individuals who pursued this next-level of licensure had dreams of filling out countless stacks of paperwork. The QMHP individual’s credentials seem more than adequate to fulfill the needs of completing an ISP and this is the individual who is working with the patient on a daily basis. This concept would be similar to a personal trainer to completing a client’s fitness plan, seems appropriate.
Proposal - Crisis services requiring an authorization
The definition of a crisis is “a time of intense difficulty, trouble, or danger.” I do not support the requirement of an authorization for crisis services. The very nature of a crisis situation elicits an immediate response. This service cannot be effectively administered with the delay of big brother approval.
Proposal – Non-Residential Crisis Stabilization as qualifying higher level care criteria for MHSS eligibility
I support this proposal to regulation. As current legislation allows Residential Crisis Stabilization as a higher level of care criteria, I believe that Non-Residential Crisis Stabilization should apply as higher level of care criteria as well.
Proposal - LMHP, LMHP supervised, or LMHP resident completes, signs, and dates ISP
1. This is an unreasonable burden on these clinicians.
2.It doesn't make sense and it will take the LMHP forever to get these completed.
3. LMHP's are needed to conduct more supervisory tasks.
Proposal - Crisis services requiring an authorization
Again this doesn't make sense. Clients who need the service don't need another senseless delay before they can receive help. Why is it a consideration to add more red tape?
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Now more than ever, we need to be doing all we can to see that those among us that need services can get them in a timely manner. The proposed changes will make it more difficult to do so.
The clients feel the most comfortable discussing their goals with the clinician that is qualified and present in their lives. QMHP-A Clinicians are qualified to create and implement ISP’s and should be able to continue to do so, as they have successfully up to this point.
As a mental health professional who has only recently obtained licensure in the Commonwealth of Virginia, I find the proposed regulation changes concerning ISPs being completed by a licensed professional and Crisis Stabilization requiring prior-authorization to be deeply concerning. These proposed changes will severely limit the ability of trained QMHP clinicians to effectively serve their clients and meet the needs of both the client and the community we all serve. Additionally, it will significantly increase the workload on an already overtaxed and numerically limited Licensed Professional population. In order to provide appropriate clinical guidance and maximize the money spent on services, it is imperative that QMHPs who have been properly trained and supervised be utilized to provide these services. In addition, proposing an additional 2-5 day wait on a service that by design is intended to meet an immediate crisis needI can only compound an already critical situation, potentially resulting in a more costly service and a higher level of care needed for the client. These proposed changes, as far as I can see, offer little to no benefit to either the professionals providing service or the clients which we serve. Please do not limit us further by implementing these changes.
Thank you for your consideration.
Julia Johnson MA, LPC
Good Afternoon,
I am voicing my opinion on the proposed rate changes for MHSS. It has been noted that there has been a significant rate change proposed which would greatly affect clinicians who work very very hard in this field on a daily basis. There are a lot of things that need to be changed in society but making it harder for hard working professionals who are qualified to provide a much needed service is not a place to start. Reducing the rate per unit that is reimbursed would lead to companies looking to reduce the hourly rate, or salaries paid to individuals who go out in the community daily to assist individuals who have mental health issues. Individuals go into this field to make a difference in the lives of others, and to be the ones behind the scenes to provide consistency and stability to other individuals who may have never had this in their own lives. As a professional who has been in the field for the past 7 years I have seen how the demand of the job can lead to burnout, or how lack of raises for hardworking clinicians have lead to them looking to change career paths. In order to keep dedicated and hardworking professional gainfully employed it is imperative that these regulation changes do not occur. The heart to serve others should not go forgotten, or left behind simply because other individuals who do not sacrifice their own time, and energy feel that they can make a decision that would greatly impact so many hardworking professionals.
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The proposed changes to mental health skills building services are concerning for a number of reasons. The more restrictions to community based services impact the clients who are in need across the state. As a LPC, I understand the difficulty that up and coming professionals are facing when trying to meet the requirements of the Counseling Board as well as DMAS and the state regulations. This poses a serious disadvantage to agencies that will not be able to hire the staff needed to comply with these proposals. Also, living and working in more rural areas, there are significantly less licensed individuals to fill the required positions, which would negatively impact client’s ability to access services.
As part of my responsibilities I currently provide crisis stabilization assessment services. It is inconceivable to be able to place a client who is currently on hold while we request approval. The current timeline for receiving authorizations for other services is up to 5 days. There are times clients are at risk of harming themselves or others and it would be unethical to postpone services in order to receive an authorizations.
There has been a significant trend of encouraging community based services and use of community service board over residential treatment facilities. Therefore many clients have received outpatient crisis stabilization services rather than inpatient services. Clients should be able to count outpatient crisis stabilization services since the services is the same, just provided in a different setting.