Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
Amount, Duration, and Scope of Medical and Remedial Care and Services [12 VAC 30 ‑ 50]
Action Mental Health Skill-building Services
Stage Proposed
Comment Period Ended on 10/23/2015
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10/20/15  4:26 pm
Commenter: Bob Deisch, LCSW, Adult Clinical Services Director/Hampton-Newport News CSB

Response to Proposed Changes to Mental Health Skill Building

1. Proposed Language:  1. Prior to At admission, an appropriate face-to-face service-specific provider intake must be completed, conducted, documented, signed, and dated, and documented by the LMHP, LMHP-supervisee, LMHP-resident, or LMHP-RP indicating that service needs can best be met through mental health support services. Providers shall be reimbursed one unit for each intake utilizing the appropriate billing code. Service-specific provider intakes shall be repeated when the individual receives six months of continual care and upon any lapse in services of more than 30 calendar days.

The requirement of a six-month administration of the Service-Specific Provider Intake (SSPI) is not required by DMAS of any other Community Mental Health Rehabilitative Service (CMHRS). The Department of Behavioral Health and Developmental Services (DBHDS) mandates reassessments be completed at least annually, or when a need presents, which offers consumers and service providers greater flexibility in adapting services to fit the actual needs.. For the typical consumer receiving MHSB services, the factors being addressed through treatment are chronic in nature and are generally better assessed over longer periods of time, such as during an annual review. Again, the DBHDS licensure standard provides direction to reassess as significant change occurs. A requirement of a six-month reassessment is superfluous and unnecessary given the licensure provision. In addition, a six-month reassessment requirement could result in consumers becoming frustrated, anticipating change within an unrealistic timeframe. The ongoing review of the Individual Service Plan (ISP) serves as a sufficient component of a continuity of care review between the initial intake and annual review. The structure of the SSPI and the included 15 elements do not serve as the most effective tool to assess a consumer’s progress in an enrolled service.

The SSPI, as it is defined by DMAS, was not designed to specifically assess progress of a specific service, such as MHSB, over time (per the definition of the SSPI), but to serve as a tool to determine the ongoing needs and preferences of an individual. Meeting with the individual, reviewing the ISP, quarterlies, progress notes, and obtaining feedback from the QMHP, provides the LMHP with the clinical information needed to determine if the individual will continue to need and benefit from MHSB.  The LMHP can use the combined measures of progress noted above to document a continued need for services. The LMHP can also determine along with the QMHP if there are any other training needs identified in the past six months. Given the current methods employed to assess progress throughout a consumer’s enrollment (e.g., ISP and quarterly reviews), an annual update of the SSPI by the LMHP is sufficient.

 2. Proposed Language: 3. The LMHP, LMHP-supervisee, or LMHP-resident shall complete, sign, and date the ISP within 30 days of the admission to this service. The ISP shall include documentation of how many days per week and how many hours per week are required to carry out the goals in the ISP. The total time billed for the week shall not exceed the frequency established in the individual's ISP. The ISP shall indicate the dated signature of the LMHP, LMHP-supervisee, or LMHP-resident and the individual. The ISP shall indicate the specific training and services to be provided, the goals and objectives to be accomplished, and criteria for discharge as part of a discharge plan that includes the projected length of service. If the individual refuses to sign the ISP, this shall be noted in the individual's medical record documentation.

Currently, there are no other CMHR services that require the LMHP to complete the ISP. Even a program such as Intensive Community Treatment (ICT), which is a more intensive program than MHSB, allows for a QMHP-A or QMHP-C to develop the ISP. In order to complete a comprehensive and thorough assessment of the client’s needs, the LMHP would have to meet with the individual several times during the 30 day period prior to developing the ISP. Once the assessment is completed and the ISP developed, the LMHP might have met with the individual up to five times, depending on the individual. The LMHP will then share the ISP with a QMHP to provide the training listed in the ISP.  As this could be the first interaction the QMHP has with the client, there has not yet been an opportunity to build a therapeutic rapport with the client and their major service provider despite the client having been enrolled in a program for 30 days. This is not best practice and could result in a delay of service initiation. Typically, during the period used to assess a client, the QMHP is developing a therapeutic relationship with the client. The ISP developed by the QMHP and client is a contract between the two, establishing responsibilities and steps to achieve the client’s goals. In regards to having a highly qualified individual engaged in this process, QMHPs are required to have a Bachelor’s degree in a human services field and one year experience with the identified population. Based on these requirements, they are more than qualified to develop the ISP.

Additionally, the proposed regulations do not indicate a rate increase or provision of administrative funding to offset the cost of increased utilization of LMHPs. Currently, the demands for and on LMHPs are increasing and are often in excess of the pool of qualified professionals, as this proposed regulation would further exacerbate. As such, it is imperative to ensure program requirements reflect a use of all adequately qualified personnel to meet the service needs of consumers. Our QMHPs are valuable resources who have admirably and adequately completed the ISP development mandate in the past and continue to be reasonable and cost effective resources moving forward.

CommentID: 42246