The following comments are being submitted on behalf of the County of Henrico in relationship to the proposed changes to the Mental Health Services Provider Manual.  Our comments focus on what we view as “loopholes” in the current regulations that govern Crisis Stabilization services. 

These loopholes have unfortunately created an environment where the service is being abused by certain providers looking for a quick profit, while putting individuals in crisis and the broader community at risk. Henrico County is compiling evidence that demonstrates certain organizations are representing themselves as Crisis Stabilization providers in order to use the service to provide inappropriate short-term rentals in hotels to people who are in crisis and who have complex problems, without providing the necessary supports – only to bill Medicaid before cutting the client loose.  There are numerous instances where individuals in crisis are being manipulated in this manner, and in large concentrations, at low-budget hotels in Henrico County, with inadequate follow-up services. 

These “providers” reserve blocks of rooms, sometimes hiding their identity by using third-party entities such as Travelocity, in order to cycle people in and out of multiple different rooms and/or hotels.  They transfer clients to other similar “providers” in order to extend their stay and eligibility to participate in the service.  The current practice has allowed providers to essentially turn entire hotels into a would-be “treatment facilities” housing 50-100 people in crisis under one roof, without adequate services or supports to meet the individuals’ needs and without sufficient oversight and accountability.  One hotel in our jurisdiction reported to the Henrico County Police Division in August 2021, that approximately 80 – 85% of their rooms remain booked by such organizations for crisis clients. Hotels are not designed to operate as crisis stabilization facilities in this manner.

The concentration of people enrolled using this approach, using a collection of hotels located near one another, has totally overwhelmed our public safety divisions.  Henrico Police, Fire, and EMS agencies are responding to multiple calls at these facilities for such issues as mental health emergencies, drug overdoses, domestic violence, homicides, prostitution, medical emergencies, loitering, and so on.  During the twelve months of 2020 the Henrico County Police Division responded to over 600 calls for service at one 140-room hotel.  The most common denominator of these 600+ calls was a crisis services client who had been placed at the hotel and then left to fend for themselves without receiving the promised services.    

Based on these experiences, Henrico County recommends that the concept of crisis stabilization in a residential environment needs additional oversight and regulation over the Managed Care Organizations and the Fee-for Service contractors.  We encourage DMAS to consider changes to the manual to address the concerns outlined above, and we respectfully offer the following suggested edits/additions for consideration:  

• There should be a process to verify and validate that community stabilization providers who receive Medicaid reimbursement funding for community-based crisis services are staffed with appropriately trained and certified counselors.

• These appropriately trained and certified Community Stabilization providers should be required to make in-person visits to the client’s home or short-term rental at regular intervals and for sufficient length of time, consistent with the patient’s diagnosis and needs.  For crisis patients staying at hotels, these types of visits should occur at least once per day. 

• Treatment should be provided in the individual’s home whenever possible, as opposed to moving a person out of their community to a short-term rental or hotel.  If the service is to be provided in any a short term stay, hotel, or other temporary setting, the provider should be required to receive advanced authorization from DMAS prior to initiating this short term housing option.  It should be required that the location in which the service is being provided be noted at the time of authorization or registration.  If the location is any type of short term rental, such as a hotel or a motel, DMAS should require approval for the that short-term setting prior to authorizing Medicaid reimbursement.  DMAS should track this type of location information and monitor for compliance with the following requirements.  

• Providers should be discouraged from concentrating Community Stabilization patients into a single short term rental location (e.g., hotel or motel) at the same time.  Multi-family housing and other settings that are zoned appropriately may be appropriate if the individual resided in that setting prior to the need for crisis services or has recently moved to the location via under a permanent lease or mortgage. 

• The number of providers allowed to provide crisis services in any one single short term rental location (e.g., one specific hotel or motel) should be limited to avoid allowing a hotel or motel from becoming concentrated with crisis patients.  

• We suggest that the term “other convenient and appropriate setting” should be more clearly defined (Page 15- Critical Features and Service Components).

• We believe the regulations should allow DMAS to fully ensure that providers are linking and referring people to appropriate supports (Page 16- Critical Features and Service Components).

• If the Community Stabilization service is to be provided to an individual outside of their community of permanent residence, or in the case of a homeless client requiring transportation outside of the locality in which they had their most recent permanent housing, the crisis service should require pre-authorization prior to the Community Stabilization start date and the service authorization request should include a justification as to why the service cannot be provided in the individual’s home and/or community of origin. 

• We suggest consecutive registrations be more fully defined (page 22 - Service Authorization). We recommend a break in service of at least 30 days.