1. New requirement for ACT teams to directly respond and be the first-line crisis evaluator for PACT clients 24/7. Advocating the current regulation stands for 24/7 response; it allows for coordinating outside the team for coverage. More justification below under crisis response section. 

2. The use of QMHP and LMHP in several places, versus also allowing for LMHP-Es and QMHP-Es. We are advocating that any time an LMHP or QMHP is required, that Es are also eligible considering work force shortages. 

3. Some requirements seem better suited for a fidelity measures versus regulation. This may help smaller CSBs, or those in the highest workforce shortage areas, to still operate ACT to the best of their ability. This would be in line with the new per diem proposals related to fidelity levels.
4. Recommendations for changes under Team Staffing and Service Requirements. See below. 

Crisis Response:

• Concerned some regulations and code need more consistency; will the administrative Code of Virginia also change?

• Recommend keep D. This makes sense and consistent with Virginia Code. The practice has worked well over many years of providing PACT and ICT around the state. 

D. The ICT or PACT ACT team shall make crisis services directly available 24 hours a day but may arrange coverage through another crisis services provider if the team coordinates with the crisis services provider daily.

• Recommend strike changes to E.  As long as clients have access to competent professionals for coverage 24/7, it does not need to be required that ACT team staff are also the 24/7 first line evaluators. Accomplishing this with teams as small as ACT is virtually impossible. This requirement will increase staff turnover which is a detrimental to clients. This will be difficult for many CSBs to make happen. This could be a high fidelity measure versus regulation. 

This can also be construed to mean ACT teams need pre-screeners to do and appropriate crisis evaluation.  Adding a crisis evaluator pre-screeners to ACT, would not cover 24/7 and may result in higher hospitalization rates. New Mobile Crisis services may be better suited to stabilize a crisis without hospitalization and coordinate with ACT.

E. The PACT ACT team shall operate an after-hours on-call system and shall be available to individuals by telephone or in person have 24-hour responsibility for directly responding to psychiatric crises, including meeting the following criteria:

1. The team shall be available to individuals in crisis 24 hours per day, seven days per week, including in person when needed as determined by the team;

2. The team shall be the first-line crisis evaluator and responder for individuals served by the team; and

3. The team shall have access to the practical, individualized crisis plans developed to help them address crises for each individual receiving services.

Treatment Team Staffing:

• Several items seem better suited for a Fidelity Measures versus Regulation. This may make it difficult for some CSBs to offer ACT. Fidelity Measure versus regulation would fit with current proposed Behavioral Health Enhancement rate structure.

• Recommend LMHP-E be allowable anywhere LMHPs are required, for all relevant positions throughout.  These are hard to fill positions due to work force shortages and duties can be successfully completed by LMHP-Es under supervision.  

• Recommend QMHP-Es be allowable anywhere QMHPS are required, for all relevant positions throughout. This will help with workforce shortages and duties can be successfully completed by QMHP-Es under supervision.

• ICT Peer specialist- recommend removing requirement to also be QMHP. The role of peer is more appropriate for peer training than QMHP. This would be an additional set of certifications and cost for the peer. This may also confuse the role of peer.

• Recommend striking F that require a Psychiatrist versus Nurse Practitioner to be more consistent. There are conflicting sections related to “psychiatrist” (f) and “psychiatric provider” (g) –

• Recommend allowing for more general Nurse Practitioner versus “Psychiatric” Nurse Practitioner. Certified “psychiatric” nurse practitioners are very rare. Many Nurse practitioners currently, and successfully, work with mental health patients under more general NP board certifications. Most NPs working in mental health have collaborative agreements with psychiatrists.

• Recommend striking 2. QMHP and mental health standards for ICT teams. This item includes 50% requirement for staff to have Master’s Degrees in the Human Services Field. Due to this regulation, we had to move a great employee with a Master’s Degree in Public Health off our PACT team. This is also a burden to a team in terms of work force issues. In addition, to qualify for QMHP, the Board of Counseling narrowed what qualifies as Human Services Field, for example, a bachelor’s degree in Social Work is also not included.

• Recommend striking requirement related to Full Time Vocation and Substance Use specialist. This amount of time may not be needed for small teams. The amount should be more general and dependent on team size. Also hard to staff these positions due to work force issues.

• Language regarding ACT and ICT is confusing. Example: 3. Staffing for ICT teams, includes several items about ACT.

• Concerned the code may not allow for anything other than high fidelity which may be difficult for some teams. Confusing understanding what is required by “code” and what may be considered “high fidelity” for licensing and reimbursement purposes.

• Recommend striking item 3.H – Generalists. Does not seem to be needed as other required staffing requirements are noted in detail. If included, allow LMHP-E.

• Daily Meeting Times inconsistency.  Recommend keep B. that notes “at least four days per week” to review and plan routine services and to address or prevent emergency and crisis situations. And amend/deleted  A. ICT teams and PACT ACT teams shall conduct daily organizational meetings Monday through Friday at a regularly scheduled time to review the status of all individuals and the outcome of the most recent employee or contractor contact, assign daily and weekly tasks to employees and contractors, revise treatment plans as needed, plan for emergency and crisis situations, and to add service contacts that are identified as needed. 

Service Requirements:

• Recommend deleting service requirement 11 related to services provided to non-clients. Will this be added to an allowable reimbursement under ACT? Not currently a billable service for non-clients.

11. Support, education, consultation, and skill-teaching to family members, and significant others, and broader natural support systems, which shall be directed exclusively to the well-being and benefit of the individual;

• Recommend delete item 15 related to mobile crisis and the ACT team documenting that the services are provided consistent with the individual's assessment and ISP. This is not a PACT service. Mobile Crisis teams would document their services in the record. If the intervention is emergent, do not believe it needs to be on the ISP.