For the purpose of this draft review. The focus will be on general CPST service concerns with some additional school CPST considerations in order to give the benefit of the doubt that the upcoming school CPST draft will be more realistic and in addressing the overall concerns and the concerns specific to the school setting. As written, aside from the ongoing concerns, community and school CPST show promise as an additional supportive service, not as adequate replacements for the identified legacy services.

General observations:

Improvements

1. More clarity – supervision, caseload, staff roles, service intensity standards, authorization expectations, scope of roles
2. Flexibility to allow direct Tier 2 admission
3. Step-up and step-down pathways
4. Admission criteria are clearer
5. Tier 1 versus Tier 2 are more distinct
6. Staff role confusion improved significantly- more operational roadmap for QMHPs, BHTs, LMHPs
7. Supervision requirements are defined- definitions, required frequencies, required hours, related activities, caseload oversight standards
8. Allowing LMHP-E staff with over 50% of hours remaining to serve as supervisors

Concerns:

1. Addressed questions of “how” some of the logistics will work but what is not answered is if agencies will have enough staff, training capacity, and infrastructure to operate the model at scale.
2. Time intensity vs staffing reality: requirements assume consistent weekly contact hours, supervision availability, documentation completion time – how is this achievable with turnover and caseload pressure?
3. Caseload formulas vs real case complexity: weighted caseload caps do not reflect travel time in rural areas, crisis-driven interruptions, and multi-system involvement cases.
4. Service fragmentation risk – separates functions across: LMHPs (clinical), QMHPs (skills/care coordination), BHTs (rehabilitation practice) –reduces continuity of care/increase handoffs, dilutes therapeutic alliance
5. The model assumes stable staffing, stable supervision infrastructure, and reliable training access—conditions that are uneven across the state.
6. Workforce – requirements are clearer but no easier to obtain
7. Clinician shortages, supervision burden, training requirements, staffing ratios
8. Administrative burden – expectations clearer but administrative workload increased instead of being reduced
   1. Documentation, audits, authorization requirements, fidelity requirements
   2. Added: LMHP review requirements, formal supervision documentation, weighted caseload tracking, ISP updates tied to reauthorization, objective outcome tracking
9. The model significantly increases structural expectations on staffing mix, productivity, supervision, and training timelines, while simultaneously tightening reimbursement constraints and limiting flexibility in how agencies deploy staff.

Specific questions, concerns, and areas for reconsideration:

1. CANS /additional assessments
   1. CANS Lifetime readiness  - a whole system is being built around a tool that providers still cannot fully train on or operationalize
   2. What is the plan for ensuring that agencies can access a previously completed CANS?
   3. CANS Lifetime = central gatekeeper for admission, continued stay, step-up, and step-down – is this appropriate to truly determine LON?
   4. It is not clear if the CANS is expected in addition to a comprehensive evaluation/needs assessment – are both going to be required?
   5. It is not clear how often the CANS is able to be reimbursed – if one is needed when a LON change occurs – and this is in less than 12 months, will providers be able to be reimbursed?
2. Family engagement requirements
   1. Sends clear message as to what children/adolescents matter and have the ability to access the service- those with guardians willing and able to meet the requirements 
   2. Caregiver requirements for youth – influences admission decisions, ISP requirements, progress notes, discharge planning
   3. Youth eligibility = harder – requires caregiver available/willing/participating- many have disengaged caregivers, grandparents unwilling to participate, parents working multiple jobs, complex custody situations = difficulty meeting admission and reauthorization expectations
   4. Consistent participation expectations = challenges for families who do not have the consistency
3. TDT (Therapeutic Day Treatment) Replacement Concerns
   1. Loss of structured day programming- no consistent daily structure, reduced group-based therapeutic environments, reduced school-linked behavioral supports
   2. Intensity mismatch – max Tier 2 is 5-8 hours per week where TDT provided multi-hour daily services during school days = not functionally equivalent intensity
   3. School integration gap- does not replicate embedded classroom supports, school-wide behavior systems, daily educational environment interventions
4. Reconsider summer programming as an option
   1. TDT has historically provided summer programming that benefits the youth whose families are not willing or able to engage in home/community based services, those lacking supported and structured peer interactions, those who local summer programs are limited in availability/cost prohibitive/ or inaccessible (transportation and/or behavior barriers)
   2. It ensures access to food, monitoring of well-being when families deny all in home services, and reduces losing skills from lack of practice/increased stress/trauma
5. EBP requirements
   1. EBP referrals first creates a delay in service implementation when providers are required to make additional referrals to services before requesting to initiate CPST
   2. How are all providers expected to know the detailed admission criteria for each of the EBPs?  
   3. Additional tasks and documentation requirements surrounding EBP availability/ referrals, MCO coordination, and requirement for plan to refer to an EBP (regardless of what the client wants) in the ISP create additional administrative and time consuming burdens
6. Crisis requirements
   1. If investing so heavily into crisis continuum of services- why are we not using it? The reimbursement rate of CPST does not cover any level of staff being on call 24/7
   2. Crisis response expectations- rapid and real-time de-escalation support may be difficult to maintain in rural and/or under-resourced systems (staffing shortages, travel burdens, limited training access, fewer backup staff for coverage)
7. Caseload issues
   1. Caseload cap for LMHP oversight with mostly QMHP/BHT = impact on staffing models for agencies
   2. Weighted caseload cap of 20 = Ex: 8 tier 2 clients = a full caseload. LON 6 clients get 5-7 hours per week with required crisis support, community integration, skill practice, caregiver involvement, and provider coordination = potential substantial need for more direct-service staff than currently employed which can impact readiness, hiring, implementation timelines.
8. Supervision
   1. Current requirements removes doing what’s best for staff and their needs, documentation of supervision requirements are unclear but removes trust which in turn negatively impacts client care
   2. Supervision is not clearly funded nor time-protected in a way that aligns with productivity expectations.
   3. Supervision is both broader and more frequent with weekly supervision requirements for most staff. Plus “supervision-related activities” including: documentation review, direct observation, co-treatment, and case consultation. These are clinically appropriate—but functionally create a large hidden workload layer
   4. Reviewing documentation at least every 30 days (shown by a progress note) or co-signatures on progress notes – why is this necessary when no other services require it? Supervisors and/or administrative staff review documentation for quality assurance purposes.
9. Clinical Director
   1. Requirements are limiting and difficult - full time, only 1 agency, responsible for EBP/statewide training compliance, responsible for agency policies, documentation compliance, physically in VA, available for in-person support
10. Billing
    1. If the same codes are utilized for multiple types and levels of services- how will it be differentiated to ensure appropriate reimbursement
    2. With units provided staff can plan for consistency and predictability in scheduling sessions but how can they also simultaneously account for unknown units needed for crisis level supports (which can take hours at a time)
11. LMHP requirements
    1. Aside from supervision requirements for those who also serve as clinical supervisors – required tasks and responsibilities of - assessment, treatment planning, psychotherapy components, face to face contacts, crisis consultation/support, care coordination, ISP updates/reviews- create a role that many LMHPs will not be willing to fill
12. Trainings
    1. MAP training is time intensive, expensive (especially for agencies to maintain with staff turnover), openings in trainings are limited
    2. FSC curriculum, CPST intermediate skills curriculum – have these trainings even been created yet? How much additional funding will they require?
    3. EBPs required for adult providers – who is providing and funding these?