3.1 Clubhouse Staff Requirements-

LMHP-R, LMHP-RP, or LMHP-S with Clubhouse International training — expanding eligible credential types and removing the "Clinical Director" title. Is the LMHP expected to be available on call 24/7? Is there flexibility between the program leadership and Director?

• Staff-to-member ratio changed: Old draft set ratio at 1:15; new draft raises it to 1:20 members during program hours. Ratio 1:20 is significant and poses a safety concern for emergency situations and day-to-day management. In addition, there should be a lesser ratio on community outings such as 1:10 ratio for safety in the community.

3.2 Staff Supervision Requirements (New Section)

• New section added requiring all Clubhouse staff to receive at least 1 hour of supervision per calendar month from the Program Director or LMHP. This is contradictory to the QMHP requirement to run the clubhouse. What is the training frequency after initial training?

3.3 Staff Training Requirements (New Section) This is a significant cost to CSB’s to transition to a new service that is extremely similar to current PSR services. Several CSB’s have already closed due to the anticipation that the costs of the transition are too great. This will have an impact on the PSR clubhouse population. It is highly likely that there will be an increase in decompensation and crisis situations as these members will no longer be receiving services or proper supports. It is also highly likely that there will be an increase in in-patient hospitalizations and incarcerations. Current daily costs for PSR services are $89.97 for 3 units and $59.98 for 2 units per day as opposed to the cost of a hospital emergency room visit and daily cost of a state hospital. An average emergency room visit is $520-$800 per day. Sometimes a mental health patient can stay in the emergency room for several days waiting for bed placement at a behavioral health unit. The average cost of an inpatient hospital stay is $1000 per day, with the average stay of 3-5 days. PSR services are evidenced based and have a demonstrated success rate to reduce the recidivism rate and inpatient hospital stays. I beg the argument that the costs of current PSR compared to emergency room visits and behavioral health units be considered and that the evidenced based practice of PSR services be reconsidered as an effective service.

• New section added requiring all staff to receive training as required by Clubhouse International. Will there be supplemental funding provided to support training? Is there a timeframe for when staff must be trained? Does everyone need to be trained or just the program director? How long is training good for?

• Newly enrolled Clubhouses must send a team (including at least one member) to an authorized Clubhouse International training base within the first 12–18 months of operation.  The newly proposed rate will not sustain the PSR program during the training process, nor will it cover the cost of training.

3.4 Licensing and Enrollment Requirements (Renumbered from 4.2)

If the service requires external accreditation for ‘clubhouse international”, there should be consideration for alignment with DBHDS licensing requirements to reduce administration burden for annual reviews.

? New draft: Application must be submitted within 18 months of DMAS enrollment; full accreditation within 3 years of DMAS enrollment. It has been stated that Clubhouse International is currently backlogged for years. How will they keep up with the demand of several new applicants?

• CARF exemption changed: New draft creates subsection 3.5.1 giving those providers an extended transition timeline (application within 36 months; full accreditation within 5 years), with a requirement to comply with all Clubhouse International Standards during the transition. Is there an option between Clubhouse international or CARF accreditation? If not, can CARF be reexamined as an option?

Governance/open meeting requirement made more specific: Old draft stated the Clubhouse "holds open forums." New draft requires meetings to be regularly scheduled, posted, and accessible, and that member participation in governance shall not be contingent on clinical status or participation level.

What holidays are accepted by the Clubhouse International model, please clarify.

An Independent board of directors’ requirement is a difficult requirement for CSB’s who have an existing board of directors. Please consider an advisory council comprised of program leadership and members.

Prior assessment acceptance added: New draft allows use of an assessment completed within 12 months prior to admission, updated in person, rather than always requiring a new full assessment — reducing administrative burden. What type of assessment needs to be completed? Does an assessment need to be conducted for each department and are they interchangeable among the different services within one CSB?

Service authorization sub-provision removed: Old draft required service authorization for any reassessment beyond the annual one; this was deleted. Is this stating that we just need one authorization from the MCO?

4.2 Service Planning

• ISP signing deadlines added: ISP must be signed within 30 days of admission and 15 days of an ISP review by both the member/legal representative and the Program Director or LMHP/LMHP-type. Consider staff completing the service plan and signing it rather than the Director/LMHP. If the clubhouse international model is not a clinical service, what is the rationale for an LHMP signature?

Crisis plan integration added: New draft requires all ISPs to incorporate a crisis plan per section 4.4. During the clubhouse international training process, will crisis training be provided considering QMHP’s are not clinical staff and do not have the proper credentials to mitigate in a crisis situation? Asking for QMHP’s to assess and intervene in cris situations appears to be an unethical practice.

5.1 Admission Criteria

In comparison research shows that PSR population differ from Clubhouse International population whereas CI clients are higher functioning and are more capable of vocational skills whereas PSR clients require an individualized recovery plan to reduce mental health symptoms, increase ADL skills, and restore skills.

The Clubhouse model thrives on a non-clinical environment, proving that clients are more capable of manging skills at a higher level.

 PSR offers a more structured, clinical, and goal oriented approach compared to clubhouse international. CI focuses on a voluntary community and work ordered day. PSR caters more to individuals needing more intensive skill building such as ADL’s and IADL’s therefore needing more clinical oversight. 

The skill levels should be considered before forcing PSR members into a new model that they may not be capable of performing within the parameters of a work ordered day.

Continued stay standard changed: Old draft required "objective behavioral/functional measurements of improvement." New draft recognizes that maintenance of skills, community integration, employment, social connections, or prevention of deterioration/higher-level-of-care utilization also justifies continued stay — reflecting the long-term nature of the Clubhouse model. Thank you for changing this standard.

Non-engagement discharge threshold established: New draft requires at least 120 days of nonattendance and at least three documented outreach attempts using varied modalities (phone, letter, peer outreach) before discharge for non-engagement. Old draft had no defined threshold. Current DMAS requirements state that an ISP be reviewed every 90 days. Changing the discharge requirement to 120 days will cause the ISP to be delayed and therefore out of compliance.

• Member choice of discharge added: New draft adds "the member chooses to discharge" as an explicit discharge criterion. Is this the only option for discharge?

• New general requirements subsection added (7.1): Includes a standard 6-calendar-month authorization timeframe, a provision allowing MCOs to waive SA if providers are within permissible limits and members are progressing, and the MCO/FFS contractor's ability to recommend alternative services. This is contradictory to section 4.1 Assessment section which states that the authorization period is every 6 months.

Minimum service requirement added (7.2.3): New draft requires a minimum of 24 consecutive months of service, with authorizations issued in 6-month increments. This concept was not present in the old draft. This section needs clarification. This appears to read that a client must that it is a requirement for a client to receive services for a minimum of 24 consecutive months.

• Member return rights added: New draft explicitly states the Clubhouse retains the right of all members to return after any absence without re-authorization or re-assessment, unless formally discharged per Section 5.3. If members were discharged then reassessment should be in order to determine if clints meet criteria regardless of whether they were a pervious member. There are sometimes stipulations that a client has to be discharged against their will non-compliance of behavioral guidelines and an inability to thrive in a clubhouse environment.

New draft — 8.2 Weekly Progress Note: A weekly narrative note replacing the daily narrative note, with required elements including an attendance table, narrative covering services, member engagement, behaviors, progress, and plan for the coming week. Notes may be co-written, collaboratively written, or drafted by the member — a significant change from the old draft's restriction that only the delivering staff could complete notes.

Is there a choice between daily logs or weekly notes or are both required? Is this suggesting that members write their own notes? Additionally, It is not feasible for the best use of time for an LMHP requirement to complete or sign off on clinical notes every 30 days for each member’s clinical documentation. This is not feasible or the best use of time for the LHMP skillset and contradictory for a non-clinical service. It appears that the documentation requirements for CI are excessive and do not adequately reflect the clinical level of service for reimbursement rate. Consider consolidation. 

H2031 per diem requirements restructured: Old draft required "a minimum of two required service components on the day of service, with at least one in-person." New draft requires RSB shall be provided in-person on each day billed, with documented exceptions permitted when at least two other service components are provided in-person, or when an initial or annual reassessment is the primary service on that day.

Rate does not support the accreditation, staff training, and construction costs requirements. Who is expected to become the funding source for members who want to continue who are not covered by Medicaid or are not authorized for the service but have Medicaid? The requested details for a concurrent authorization in the first 24 mos of services is overly burdensome. Consider consolidation of requirements to a specified form or inclusion of most recent ISP review instead during the first 4 continued stay requests.