Thank you for providing us with the opportunity to make comments and to seek clarification of the proposed Clubhouse model. The key themes of concern are centered around fiscal impact and administrative burden. The proposed plan for requiring Clubhouse International as the sole accreditation source has resulted in at least 3 Virginia PSR programs closing or with formal plans to close, while several more agencies have considered closing in the Virginia Leadership network. The consequence of PSR programs closing in the state is decreased access to valuable service and potential disruption in the recovery efforts of individuals who attended the programs that are now closed. The lack of access to care may contribute to the need for higher intensity services and a significant increase in cost to Medicaid.
We currently operate a psycho-social program that mimics a clubhouse program in many facets. Participants within our program obtain tangible outcomes that promote independent functioning and decrease the need for more intensive levels of service. The current draft eliminates the ability for programs to have other effective evidenced based practices like CBSST (Cognitive Behavioral Social Skills Training) integrated into psychosocial groups and IPS (Individual Placement and Support) within the same physical space, amongst others. Being 1 of 2 localities in the state who have achieved good fidelity to IPS, the integration of Clubhouse’s transitional employment within the same agency appears in conflict. We understand that there are ongoing conversations with IPS and Clubhouse regarding the two services working together, but that is not addressed in the current draft of regulations.
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Guidance Category |
Draft Language |
Comments |
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Section 1. Definitions |
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No comments |
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Section 2. Service Definitions and Critical Features |
The Clubhouse has its own physical space that is observably separate from mental health center/institutional settings and does not include “staff only” spaces
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HAMHDS’ Lakeside Center currently houses staff from three different collaborative mental health programs. We respectfully request reconsideration of this requirement, as it would pose a significant financial burden due to necessary structural changes. Additionally, eliminating all “staff-only” spaces create confidentiality concerns, as clinically driven activities—including reviewing treatment plans, developing crisis plans, and completing progress notes—require privacy to maintain professional standards and protect member confidentiality.
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Section 3. Provider Qualification Requirements |
3.1 Clubhouse Staff Requirements |
No comments |
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3.2 Staff Supervision Requirements |
Clarification is requested regarding the elimination of staff?only spaces (as referenced in Section 2) while also requiring monthly supervision for all Clubhouse staff. We ask that staff?only areas be permitted to allow for private supervision and completion of administrative responsibilities.
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3.3 Staff Training Requirements
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The extensive training requirements would create a significant fiscal impact that is not supported by the proposed reimbursement rate. We request reconsideration of the training expectations for a nonclinical service or, alternatively, the establishment of supplemental funding to offset associated costs. |
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3.4 Licensing and Enrollment Requirements |
We request clarification on how a nonclinical service will be implemented while maintaining clinical licensing requirements. Alignment between DBHDS and DMAS requirements is recommended to reduce the clinical administrative burden and better reflect Clubhouse International standards. |
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3.5 Provider Accreditation 3.5.1 Previous Psychosocial Rehabilitation Providers with Commission on Accreditation of Rehabilitation Facilities (CARF) accreditation for the program “Community Integration” |
We request reconsideration of CARF accreditation as a long?term alternative should DBHDS licensing requirements remain unchanged, to reduce overly clinical requirements.
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3.6 Clubhouse Operation Requirements 3.6.2. The Clubhouse shall have an independent board of directors, or if affiliated with a sponsoring agency, shall have a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support and advocacy for the Clubhouse. |
CSBs already maintain a Board consisting in part of individuals and family members of individuals who receive services through the agency. Clarification is requested regarding whether a separate board is required. We recommend allowing the existing CSB Board of Directors to be paired with an advisory board composed of Clubhouse members and staff. |
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Section 4 Required Service Components |
4.1 Assessments 4.1.4. The assessments shall be provided on a one-to-one basis with the member. |
We request reconsideration of the requirement prohibiting staff?designated spaces, as private settings are essential for one?to?one assessments. |
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4.2 Service Planning
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We respectfully request reconsideration of requiring the Program Director or an LMHP to sign the ISP. If Clubhouse International is not considered a clinical service, clarification is needed regarding the necessity of an LMHP signature. |
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4.3 Rehabilitative Skills Building (RSB) 4.3.10. RSB in the context of short-term, transitional employment opportunities through relationships between the Clubhouse and local businesses. |
We request reconsideration of the transitional employment requirement for agencies that have achieved good fidelity to the IPS model. IPS, an evidence?based practice, strongly discourages transitional employment, creating a conflict with this requirement. |
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4.4 Crisis Support |
We seek confirmation that “crisis support” may be provided in conjunction with a CSB’s Emergency Services department for after?hours and holiday coverage. |
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4.5 Care Coordination |
No comments |
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Section 5. Clubhouse Medical Necessity Criteria |
5.1 Admission Criteria |
No comments |
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5.1.1. Comprehensive Needs Assessment Requirements |
No comments |
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5.1.2. Age Requirements |
No comments |
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5.1.3. Diagnostic Criteria
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We request consideration allowing the Program Director or LMHP to determine eligibility for individuals with diagnoses outside the listed categories in 5.1.3.1, based on their clinical judgment and expertise. |
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5.1.4. Functional Impairment Criteria |
No comments |
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5.2 Continued Stay Criteria |
No comments |
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5.3.1-6. Discharge Criteria The member shall be discharged when they meet one of the following… |
Clubhouse International Accreditation standards specify that membership is voluntary and without time limits. We request alignment between discharge criteria and these standards to avoid negative fiscal and ethical impacts on both programs and members. |
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Section 6. Exclusions and Service Limitations |
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No comments |
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Section 7. Service Authorizations (SA) |
7.1 General Requirements
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We request consideration for a registration?based authorization model, like case management’s 12?month timeframe, to reduce administrative burden for a nonclinical service with expanded eligibility. |
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7.2 Service Authorization Period and Unit Allocation |
We request consideration for a registration?based authorization model, like case management’s 12?month timeframe, to reduce administrative burden for a nonclinical service with expanded eligibility. |
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7.2.3 Minimum Service Requirement |
We request consideration for a registration?based authorization model, like case management’s 12?month timeframe, to reduce administrative burden for a nonclinical service with expanded eligibility. |
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7.3 Preservice Authorization Request |
No comment |
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7.4 Concurrent Authorization Request |
No comment |
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Section 8. Additional documentation requirements and Utilization review |
8.1 Daily Log of Attendance |
The administrative requirements for this nonclinical service exceed those for clinical psychosocial rehabilitation. We request reconsideration of the ISP goal requirement to reduce unnecessary administrative burden. |
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8.2 Weekly Progress Note |
The weekly documentation requirement for a nonclinical service exceeds that of clinical psychosocial rehabilitation. We request reducing the requirement from weekly to monthly progress notes. Additionally, Sections 8.2.3 C and D appear duplicative; we request that one of the two be eliminated. |
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8.3 LMHP Review |
The LMHP documentation requirements do not align with Clubhouse International standards and add unnecessary administrative burden. We request reconsideration of these requirements. |
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Section 9. Billing requirements and Information |
9.1 Mental Health Clubhouse Services Billing Code |
The proposed reimbursement rate does not sufficiently support the financial demands associated with training, accreditation, facility modifications, expanded staffing needs, and administrative responsibilities required of Program Directors and LMHPs. We request revisiting the proposed rate. |
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9.2 General Billing Requirements |
No comment |
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9.3 Assessments and Annual Reassessments |
No comment |