12VAC30-60-181 D

Requesting alignment regarding CSAC as CATP between 12VAC30-60-181 & ARTS Manual Chapter IV

Regulation 12VAC30-60-181 states that CSACs can complete assessments and lists them as CATP. The ARTS manual, Chapter IV, Appendix 1 only allows for licensed CATPs to complete an assessment

12VAC30-60-181 2(ISP)- Add in CSAC for 3.7, 1.0,2.1- In 3.7, clients must see physician or extender for physical within 24 hours of admission.  There is already ample oversight by LICENSED STAFF (EVEN MORE IN 3.7) This will increase availability as licensed staff are difficult to recruit and not available to work weekends

12VAC30-60-185- Add language re: telehealth can be included which will allow coverage if a client cannot come in person

12VAC30-60-185 CATP definition

Add back CSACs being able to create ISPs with oversight of Licensed Staff.  CSACs provide essential services and should be allowed to create a substance related ISP with oversight from licensed staff.  If this is left in, must address that CSACs can perform ISP’s with oversight.

If CSACs cannot complete an ISP (with sign off by licensed) all “Primary Counselor” staff must be licensed.  This would be cost prohibitive and recruitment would be impossible. Statewide, there is already a shortage of licensed staff.  By adding this requirement, it will make it impossible to recruit and hire essential staff, thus reducing services available during an opioid crisis. At the very least, allow CSACs with sign off by licensed to complete ISP and MDA in 3.1, 3.3, 3.5, 3.7. In these setting, there are other credentialed staff on site an available ensure the client has his/her needs met.

Add in Licensed Nurse practitioner with experience or training in addiction medicine- Across the State, many nurse practitioners (adult or family) have extensive training and experience in addiction medicine.   

Add in LSATP-R who are under supervision  

12VAC30-130-5040

Evidence based approaches ( to include David Mee-Lee/chief editor of the ASAM criteria) acknowledge that individuals with co-occurring disorders can have multiple primary disorders.One is not primary over the other.  Clarify wording to reflect this. The individual must have a primary substance use disorder, but that does not mean he cannot also have another primary disorder.

For some individuals, there are two primary diagnoses that are being treated concurrently

12VAC30-130-5050 (1)

Leave it at 12 months versus one year.  12 months is more definitive than eight times per year  

12VAC30-130-5050(9)

This says to test.  The individual has the right to choose.  This is too prescriptive.  A test can be offered

12VAC30-130-5080 (ASAM Level 1.0) (A)

-Clarification is important regarding who can provide Outpatient Services

12VAC30-130-5140 (A)

3.7 has extensive additional requirements to include expensive medical personnel.  Rates for this service need to be reviewed.

12VAC30-130-5140 (1)- It is not clinically appropriate and may often be contraindicated to begin therapy during acute withdrawal. 

Other areas that need to be changed.

-Take out treatment history/ medication assisted treatment assessment from ISP- It does not belong here.  It is not appropriate to have an assessment in an ISP.ISP is for client goals and must be in client language.  Add treatment history as part of MDA.  Adding in an assessment to ISP is inappropriate.

The assessment should be in the Assessment/ MDA.  The ISP should reflect needs/goals and                preferences as indicated in the assessment.

-ISP requirements for CSACs:

“All ISPs shall be completed and contemporaneously signed and dated by the credentialed addiction treatment professional CATP preparing the ISP. For ASAM Levels 3.1, 3.3, and 3.5, the ISP may be completed by a CSAC if the CATP signs and dates the ISP within one business day.”

Recommendation:

CSACs should be able to prepare ISPs at level 2.1 and 2.5 as well as others listed.

CSACs that meet CATP definition should not need to be signed off by others. Currently, CSACs complete their own ISPs without additional approval signatures. Having a licensed person needing to sign all ISPs would create a lot of additional work for the licensed staff and add to the already large amount of documentation and review needed to admissions. The Code of Virginia § 54.1-3507.1 indicates that CSACs are “qualified to be responsible for client care of persons with a primary diagnosis of substance abuse or dependence. Providing counseling to persons for a mental health diagnosis other than substance abuse or dependency is outside the scope of practice for CSACs.”

-ISP revision timelines

Recommendation: Clarify and require that the ISP be reviewed quarterly, every 90 calendar days, and updated as the member's progress and needs change to recommend changes in the plan as indicated by the member's overall adjustment during the placement.

-Discharge Planning sections for 3.3, 3.5, 3.7 are confusing and unrealistic.  The timeframes, especially for 3.7 is unrealistic and will result in lack on continuity of care.  Programs cannot wait for the MCO to approve a discharge plan before talking to potential future providers in a short term 7 day program.  This needs to be changed.

-Need to change time frame for the MDA in 3.7 programs - it is inappropriate to attempt to conduct a full psychosocial history while the individual is in the acute phases of withdrawal.  While the current regs allow the PDE to be delayed due to individual illness/withdrawal, the service authorization for is still expected in 24 hours but includes information that is gathered in the MDA.  Specify that providers may complete service authorization form dimension 1 and 2 with 24 hours and complete the rest in 72 hours. Otherwise, the provider must take the chance of not being paid or else must require a sick client to participate.   

-A CSAC should be able to review an assessment and update ASAM Levels, as well as complete an ISP under supervision.

-CSAC versus CATP- Confused about the multiple references differentiating CSACs from CATPs (Credentialed Addiction Treatment Professionals).  We have been operating all of the time with the understanding that a CSAC is a CATP based on the definition given in the initial ARTS rollout:

Recommendation: references should be for CATP only, in other words, CSAC should not be       differentiated from CATPs in the document

- Face to face definition:

"Face-to-face" means encounters that occur in person or through telemedicine.

“Individual psychotherapy or substance use disorder counseling between the individual and shall be provided by a credentialed addiction treatment professional shall be provided CATP. Services shall be provided face to face in person or by telemedicine”

"Telemedicine" means the practice of the medical arts via electronic means rather

than face-to-face the real-time, two-way transfer of medical data and information

using an interactive audio-video connection for the purposes of medical diagnosis

and treatment. The member is located at the originating site, while the provider

renders services from a remote location via the audio-video connection.

Equipment utilized for telemedicine shall be of sufficient audio quality and visual

clarity as to be functionally equivalent to a face-to-face encounter for professional

medical services.”

Recommendation: Resolve inconsistencies in the above definitions

Change “telemedicine” to “telehealth” language throughout. Or, change to “video telehealth”.

Recommend deleting the line about originating site. This would allow for members to join services from their homes vs having to come in the clinic due to transportation or childcare barriers. This has proven to recently help with retention and engage rates.  Or, add a client’s home as a viable remote origination site for telehealth.

Highly recommend allowing group counseling options via telehealth.  COVID-19 experiences have resulted in significant increased engagement (50% to 80%) and is ideal for some who have barriers to treatment such as transportation or childcare.

- Maximum Individuals allowed in Group

Recommendation: In addition to the ASAM 1.0 levels of care, have a maximum requirement for number of individuals served in ASAM 2.1 and 2.5 levels of care to be 12