I appreciate the opportunity to provide feedback regarding the proposed Community Psychiatric Support and Treatment (CPST) School Setting service. As written, I have significant concerns that this proposal is not an adequate replacement for Therapeutic Day Treatment (TDT) services and will ultimately reduce access to effective behavioral health interventions for youth in Virginia schools.
CPST Is Not a Comparable Replacement for TDT
For many years, TDT provided intensive, flexible, school-based behavioral health intervention for students experiencing emotional and behavioral challenges that directly impacted academic success, peer relationships, and school functioning. The proposed CPST model significantly narrows eligibility, increases administrative requirements, and shifts substantial portions of direct service time toward documentation, coordination, assessments, and compliance activities.
While the proposal appears designed to increase clinical rigor, the result is likely to be fewer students qualifying for services and fewer resources available for direct intervention once services are authorized. The extensive admission requirements, Level of Need determinations, required CANS assessments, mandated evidence-based practice referrals, multi-tier authorization requirements, and ongoing reassessment expectations create barriers that did not previously exist under TDT.
Students who struggle with emotional regulation, behavioral challenges, trauma symptoms, school avoidance, peer conflict, and emerging mental health concerns often require timely intervention. Under the proposed model, agencies may spend considerable time completing assessments, referrals, care coordination activities, obtaining documentation from schools, and meeting authorization requirements before meaningful interventions can begin.
The Proposal Creates Significant Access Barriers
The requirement that youth be assessed and referred to multiple standalone evidence-based practices when clinically appropriate before CPST authorization can be pursued creates an unnecessary barrier to care. The policy requires consideration of services such as Functional Family Therapy and Multisystemic Therapy and extensive documentation when those services are unavailable.
In many Virginia communities, these services have long waitlists or are unavailable. Requiring providers to document unsuccessful attempts to access other services before obtaining authorization for CPST will delay treatment for youth who need immediate support in the school setting. The focus should be on rapidly connecting children with services rather than creating additional procedural hurdles.
The Administrative Burden Is Excessive
The proposed service includes numerous mandatory components that substantially exceed what many community providers can reasonably implement, including:
Annual and admission-related CANS Lifetime assessments.
Extensive ISP requirements tied to evidence-based practices.
Mandatory coordination with IEP and 504 teams.
LMHP participation in IEP or 504 meetings or submission of written clinical input.
Quarterly face-to-face ISP reviews involving multiple stakeholders.
Detailed crisis mitigation plans with school-specific procedures and annual reviews.
Ongoing documentation of EBP referrals, MCO communication, and care coordination activities.
Required 24/7 crisis consultation availability and rapid LMHP response expectations.
These requirements may be achievable for large behavioral health organizations with substantial administrative infrastructure. However, many existing providers, especially those serving rural and underserved communities, do not have the staffing resources necessary to meet these expectations without dramatically increasing costs or reducing service capacity.
The Staffing Requirements Are Unrealistic
The proposed service relies heavily on LMHP involvement, including assessment oversight, treatment planning, psychotherapy, clinical review, crisis consultation, supervisory functions, and participation in educational planning activities. The proposal also requires providers to maintain a full-time Clinical Director and 24/7 LMHP crisis consultation availability.
Virginia already faces significant workforce shortages among licensed clinicians. Requiring this level of LMHP involvement for every CPST program will likely create significant implementation challenges and reduce the number of providers willing or able to offer school-based services.
The expectation that an LMHP be available to respond to consultation requests within fifteen minutes during the instructional day and thirty minutes outside school hours presents additional concerns regarding operational feasibility and staffing sustainability.
School-Based Implementation Is Likely to Be Extremely Difficult
The policy requires annual Memoranda of Understanding with every school division or private school where services are delivered, including extensive requirements related to space, scheduling, data sharing, crisis response coordination, designated liaisons, dispute resolution processes, and continuity planning.
Many school divisions already face staffing constraints and competing priorities. Establishing, maintaining, updating, and coordinating these agreements across multiple schools and divisions will be administratively burdensome for both providers and educational systems.
Furthermore, the proposal assumes consistent participation from school personnel in ISP development, reviews, care coordination, crisis planning, and educational planning processes. While collaboration is important, many schools simply do not have the capacity to engage at the level contemplated by this policy.
Impact on Students
The greatest concern is that the children who were successfully served through TDT may no longer receive services under the proposed structure.
The students most likely to be impacted are often not those with the most severe psychiatric conditions, but rather those with emerging mental health needs, emotional dysregulation, attendance concerns, behavioral difficulties, peer conflicts, trauma-related symptoms, and school adjustment challenges. These students frequently benefit the most from consistent, accessible, school-based intervention before their symptoms escalate.
By increasing clinical thresholds, documentation requirements, staffing expectations, and operational responsibilities, the proposed CPST model risks reducing service availability and creating gaps in care. As a result, many youth may progress to more severe levels of impairment before receiving intervention.
Recommendation
DMAS should reconsider implementation of CPST as the primary replacement for TDT and engage providers, schools, families, and community stakeholders in further discussion regarding a more practical school-based service model.
Specifically, DMAS should:
Reduce administrative and documentation requirements.
Simplify admission and authorization processes.
Eliminate unnecessary barriers related to mandatory EBP referrals.
Reevaluate the 24/7 crisis response expectations.
Reduce LMHP staffing requirements to reflect workforce realities.
Streamline school coordination and MOU requirements.
Preserve a flexible school-based intervention model that mirrors the accessibility and effectiveness previously available through TDT.
Virginia's children need accessible, timely, and practical behavioral health supports in schools. Unfortunately, as currently drafted, the CPST School Setting model appears overly complex, administratively burdensome, clinically restrictive, and operationally unrealistic. Rather than expanding access to behavioral health care, the proposal is likely to reduce provider participation, limit student access to services, and undermine the preventive and early intervention benefits that made TDT successful.
Additional Concerns
I would also like to express concern regarding the apparent decline in stakeholder participation during this public comment period compared to the previous draft.
The prior version of this proposal generated substantial feedback from providers, schools, families, and behavioral health professionals. However, the current comment period appears to have generated significantly fewer responses. While there may be multiple reasons for this, many providers have expressed a growing perception that meaningful stakeholder feedback is not resulting in meaningful policy revisions.
When stakeholders invest considerable time reviewing lengthy policy proposals and submitting detailed recommendations, they expect to see evidence that their concerns were thoughtfully considered. Unfortunately, many of the significant concerns raised during the previous public comment period appear to remain present in this draft, particularly regarding administrative burden, staffing expectations, service accessibility, school implementation challenges, and the replacement of TDT with a far more restrictive service model.
As a result, some providers may now view participation in the comment process as an exercise with limited impact. The sentiment many are expressing is, "Why bother commenting again if the original concerns were not meaningfully addressed?" While this perception may not reflect DMAS's intentions, it is nonetheless becoming a barrier to authentic stakeholder engagement.
Public input should be more than a procedural requirement. It should serve as a mechanism for collaboration between DMAS and the providers responsible for implementing these services. When stakeholders do not see their concerns reflected in subsequent revisions, confidence in the process diminishes and participation declines.
Ultimately, the limited feedback being received on this draft should not be interpreted as broad support for the proposal. It may instead reflect growing frustration and discouragement among stakeholders who devoted significant effort to the previous comment process and feel their concerns were not adequately addressed.