The proposed DMAS draft continues to highlight significant discrepancies between the regulatory framework and the standards required for certification by Clubhouse International. These discrepancies suggest that the proposed rules are more appropriately aligned with clinically driven service models rather than the clubhouse model, and therefore warrant clarification and expansion of allowable service model options.

While the clubhouse model is a well-established, recovery-oriented approach emphasizing member choice, peer support, and a work-ordered day, it is not inherently structured to meet the level of clinical specificity, medical necessity criteria, and staff-directed intervention requirements outlined in the proposed regulations. Attempting to impose these requirements onto clubhouse programs risks creating documentation and practice inconsistencies that could compromise both regulatory compliance and model fidelity.

Key Observations:

1. Alignment with a Clinical Framework
   The proposed regulations strongly reflect a medical and clinical model of care, including individualized treatment planning, staff-led interventions, and measurable, goal-oriented service delivery. These elements are foundational to clinical service models but are not naturally congruent with the clubhouse approach, which is intentionally non-clinical and member-directed.
2. Documentation and Medical Necessity Standards
   Requirements for detailed, intervention-specific documentation tied to clinical goals are consistent with therapeutic and rehabilitative service models. In contrast, clubhouse services are structured around participation and engagement rather than discrete, billable clinical interventions, making alignment challenging without fundamentally altering the model.
3. Service Delivery Expectations
   The emphasis on staff-to-client service provision, clinical oversight, and defined therapeutic interventions suggests that DMAS is conceptualizing psychosocial rehabilitation as a structured clinical service. This differs significantly from the clubhouse model’s emphasis on shared responsibility and non-hierarchical relationships.
4. Additionally, the client to staff ratio is concerning. The current draft indicates an increase to 1:20. Given the complexity and needs of the individuals served in PSR programs, lower staff to individual ratios are needed to ensure safety and quality of care, especially with the documentation requirements in the current draft.  

Financial and Ethical Considerations:

The current misalignment also raises important financial and ethical concerns:

• Requiring clubhouse programs to document services as individualized, staff-directed clinical interventions may inadvertently lead to documentation that does not accurately reflect the service delivered. 
• Forcing a non-clinical model to conform to clinical billing structures may result in administrative inefficiencies, increased overhead, and reduced time spent on meaningful member engagement. This undermines cost-effectiveness and may divert resources away from direct service delivery.
• Equity and Access Concerns
  If clubhouse programs are unable to comply with clinical requirements, they may reduce services or close, limiting access to recovery-oriented supports. Conversely, maintaining reimbursement for services that do not meet clinical intent may create inconsistency in service quality across providers.
• Ethical Tension in Service Representation
  There is an inherent ethical concern in requiring providers to frame member-driven, voluntary activities as clinician-directed interventions to meet billing standards. This may compromise transparency, professional integrity, and person-centered care principles.
• Program Integrity and Accountability
  Aligning reimbursement with clearly defined clinical models supports stronger accountability, clearer outcome measurement, and more defensible use of public funds.

Implications:

Given these discrepancies, it may not be appropriate to expect clubhouse programs to conform to the proposed regulatory structure. Instead, the regulations appear better suited to service models that are inherently clinical, intervention-based, and documentation-driven.

Recommendations:

1. Clarify Service Model Intent
   DMAS should explicitly define whether psychosocial rehabilitation services are intended to operate within a clinical framework. If so, regulations should acknowledge that this framework differs from the clubhouse model and may not be compatible with Clubhouse International certification standards.
2. Establish Distinct Service Tracks or Model Options
   Consider creating separate regulatory pathways, such as:
• A clinically oriented psychosocial rehabilitation model aligned with medical necessity and therapeutic interventions
• Reconsider allowing for CARF certification
• A clubhouse or recovery-based model with alternative documentation and service structure requirements
3. Recognize Clinically Aligned Evidence-Based Models
   Several established models are more consistent with the proposed DMAS framework, including:
• Psychiatric Rehabilitation (clinical PRS model) focused on skill-building, functional assessment, and individualized goals
• Cognitive Behavioral Therapy (CBT)-informed skills groups, which align with goal-oriented, measurable treatment interventions
• Illness Management and Recovery (IMR), which integrates recovery principles within a structured clinical framework

These models inherently support the types of documentation, service definitions, and staff roles described in the proposed regulations.

4. Ensure Regulatory-Model Fit
   Aligning regulations with clinically oriented models would reduce administrative burden, improve documentation integrity, strengthen ethical compliance, and ensure that services delivered are consistent with both regulatory expectations and evidence-based practices.

In summary, the proposed DMAS regulations appear to be thoughtfully designed for clinically structured psychosocial rehabilitation services. However, they are not well aligned with the clubhouse model as defined by Clubhouse International. Rather than attempting to adapt clubhouse programs to fit a clinical framework, it would be more effective to either (1) establish distinct regulatory pathways or (2) prioritize models that are inherently compatible with the clinical expectations outlined.

Thank you for your consideration and for the opportunity to provide input on these important regulations.