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

1. Definitions

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

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

Early Serious Mental Illness (Adults):

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

3. Required Service Components:

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

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

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

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

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

3.2 Treatment Planning

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

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

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

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

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

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

3.3 Psychiatric Services

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

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

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

3.6 Health Literacy Counseling

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

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

3.7 Rehabilitation Skill-Building

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

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

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

Comment -- Consider adding LPN

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

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

3.8 Care Coordination

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

Comment -- Add LPN for care coordination

3.9 Crisis Support

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

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

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

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

3.10 Peer Recovery Support Services

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

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

4 Provider Qualification Requirements

4.1.1 Required team members

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

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

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

5. Medical Necessity Criteria

5.1 Admission Criteria

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

Comment -- What does this stand for? EPSDT

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

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

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

6. Exclusions and Service Limitations

7. Other Limitations:

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

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