As a Provider/Director of various psychiatric and substance abuse services in diverse contexts for over 20-years, I am again concerned that the Department may be short-sighted and has not fully evaluated  the impact that such a change may have on IIH Clients, their Families and the Community-At-large. I believe that it is prudent that the Department engage Key Stakeholders, such as Private Providers, Clients, their Families and the host of private physicians, psychiatrist, educatiors, etc. that provide these services.

It is well known and documented that our CSB's have been overwhelmed for 10+ years and have not been able to provide timely services for consumers. Their "Waiting List" have grown to at least 4-6 months in the past few years, which poses a health risk for the public. Additionally, it is well known and documented by public and private provider alike that CSB's "Case Management" is not sufficient for the IIH population, which requires intensive services BEYOND 10-hours weekly to stabilize the family system and prevent an out-of-home placements. Case Management is usually one (1) time monthly and their caseloads are very high. Conversely, PACT MAY only provide as similar service at 1-3x weekly. 

Ms. Youmell, (License Eligible) from our Agency, succinctly provides River City's concerns regarding this matter:

12VAC30-50-130 - The addition of language "Care coordination" and elimination of “case management activities”)

This change in semantics aims to restrict the covered activities performed by In-Home workers which provide family and individual stabilization and support. The change in semantics also purposes to eliminate support by IIH workers being provided in environments that are “non-medical,” but are nevertheless often contribute to the individuals eligibility for IIH services in the first place (i.e., judicial involvement under eligibility criteria 2). Since the CSB's are currently the only providers allowed to bill for case management, eliminating case management from Intensive In Home would require the family to additionally seek out the CSB for Case Management. As evidenced by the challenges experienced by CSB’s in the wake of the initial implementation of the VICAP assessments (for which they eventually had to contract out to private providers (e.g., United Methodist Family Services) for assistance), the CSB’s do not have the capacity to handle the volume/influx of clients that will require case management and it will result in disruption in the continuum of care, gaps in services, and functional regression of the clients and their families. The CSB case managers already have caseloads of upwards of 40-50 that they are unable to serve within the confines of a regular work week (i.e., a case manager with 50 clients would be unable to devote even 1 hour per client per week and I can assure you that most court proceedings exceed that. Because of their high caseloads, it is impossible for these professionals to be as knowledgeable about the client’s needs and strengths as the in-home workers with a caseload of 4 or less. In court, our in-home workers have been able to testify on behalf of the clients’ strengths, goals and interventions, and treatment outcomes, which in some cases has decreased the level of the clients’ judicial involvement. This would be unlikely if a case manager just dropped the client off at the court house because they did not have time to adequately address the client’s needs or worse, have to detract from another client’s treatment.

I agree with Ms. Cheek that case management has been a part of Intensive In-Home since it’s conception; the families we serve present with exceedingly complex needs that directly affect, often negatively when we first encounter them, the emotional stability of the identified client.  

12VAC30-50-226 – The addition of language, “The documentation shall describe how the alternative community service location supports the identified clinical needs of the individual and describe how it facilitates the implementation of the ISP” and removal of the language, “In some circumstances, such as lack of privacy or unsafe conditions, services may be provided in the community instead of the home.”

Here I agree with Mr. Slabaugh:  "The new language creates an unnecessary and subjective burden by requiring documentation of a correlation that may not exist.” 

 12VAC30-60-61 - The addition of the language “documented” in the follow policy:

b. Exhibit such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary.

The addition of this language will create an unnecessary barrier to obtaining necessary that, when properly executed, will prevent clients and families for having to seek more costly services such as hospitalization, inpatient services, and residential care. This is a direct attempt to prevent needy families from obtaining these services as it has with its implementation for Mental Health Skill Building Services. This puts the burden on medical providers to provide this information in an expedient manner and in our experience since the implementation of these criteria for adults, the medical providers have been unable to keep up with the demand. HCA hospitals have had to contract out and it can take up to a month, with daily follow ups by the workers, for private providers to receive these records. The clients we serve are often poor historians and cannot remember timeframes of treatment, which at most medical providers is a requirement for them to furnish the records (we have been told that the request with the clients’ demographic information is insufficient for them to provide records) or at a cost to private providers of upwards of $60 per page for records (yes, this is illegal as the law states that you can only change up to $15 for documents that are under 50 pages, but we have addressed it with the provider, Panic, Anxiety & Depression Center, and nothing has been done to change their practices).

Instead of introducing language meant to, I support Ms. Cheek’s call to action to introduce interpretive guidelines to the DBHDS service regulations, rather than semantics to limit access and further dilute IIH services as opposed to improving them. I agree that there seems to be no data driven information to support neither the proposed changes nor the CSB’s ability to functionally manage the influx of clients as well or better than private providers have been.  This seems simply an attempt to reduce utilization by introducing additional hoops for private providers to jump through and further punishing and discouraging the families who desperately need intervention.

Sincerely, Jimmy Christmas, LCSW, ADS, RYT