Southside Behavioral Health (SBH) supports expanding access to community-based behavioral health services that promote recovery, strengthen natural supports, and help individuals function successfully in their homes and communities. The proposed Community Psychiatric Support and Treatment (CPST) model offers opportunities to provide individualized treatment and rehabilitation to adults, children, and families.

SBH serves Halifax, Mecklenburg, and Brunswick counties in rural Virginia. Our agency provides outpatient treatment, psychiatric services, case management, psychosocial rehabilitation, and crisis services, among other programs. Implementation of CPST must account for the circumstances of rural communities, including travel distances, transportation barriers, limited workforce availability, and uneven access to reliable internet and cellular service.

We respectfully request revisions and coordinated implementation guidance to ensure that the new requirements expand access without making services financially or operationally unsustainable for rural providers.

1. Establish a coordinated and realistic implementation process

The licensing requirements must align with final DMAS coverage and reimbursement policies. This licensing proposal does not itself resolve questions about payment rates, billing units, authorization, allowable service combinations, documentation, or reimbursement for travel and after-hours responsibilities.

SBH requests that DBHDS and DMAS issue a coordinated implementation package that clearly explains these requirements, identifies the responsibilities of managed care organizations, and resolves differences between licensing and payment standards. Providers should have at least 12 months after publication of final coordinated requirements to complete required implementation activities.

Implementation requires more than hiring direct service staff. Agencies must revise policies, configure electronic health records, establish billing procedures, train employees, develop supervision and crisis coverage arrangements, and prepare quality monitoring processes. These activities place substantial demands on the same small administrative and clinical teams that maintain existing services.

The six-month startup transition plan permitted under 12VAC35-105-1423 should also allow extensions based on documented recruitment efforts, training availability, and progress toward compliance, with appropriate safeguards for individuals receiving services.

2. Allow staffing arrangements that are sustainable in rural communities

Under 12VAC35-105-1423, providers must have a full-time LMHP clinical director, an experienced LMHP available for consultation at all times, an LMHP supervising each team, and direct LMHP supervision of all CPST staff.

SBH supports qualified clinical leadership and meaningful supervision. However, these combined requirements may be difficult to sustain where the available clinical workforce is limited and enrollment is dispersed across several counties. Drawing clinicians away from existing outpatient and crisis programs could reduce access elsewhere in the service system.

We request explicit permission for qualified clinical leadership to be shared across compatible agency programs or regional partnerships when workload, availability, and clinical oversight remain sufficient. The final requirements should clarify whether one qualified LMHP may fulfill more than one required role.

DBHDS should also define “direct supervision,” including required frequency, documentation, availability, and whether remote supervision is permitted. The regulation should distinguish clinical supervision from continuous physical presence and allow supervision arrangements appropriate to community-based work.

3. Integrate CPST crisis support with existing crisis services

The combined requirements in 12VAC35-105-1423 and 12VAC35-105-1424 establish continuous LMHP consultation and 24-hour crisis support. The draft also requires providers to attempt internal crisis support before referring to an external crisis resource.

SBH supports timely crisis intervention. However, requiring a separate CPST crisis structure could duplicate existing CSB and regional crisis resources while drawing from the same limited workforce.

The regulation should explicitly permit established agency crisis departments, regional partnerships, and formal agreements with qualified crisis providers to satisfy these requirements when responsibilities, access to relevant information, coverage, and handoffs are clearly established.

Please define what constitutes an internal crisis support attempt and identify expectations for response times, documentation, escalation, and responsibility when another service assumes care. The regulation should expressly allow immediate access to emergency medical services or the appropriate crisis response when clinically necessary, without requiring a preliminary internal intervention that could delay care.

DMAS payment policies should account for the cost of maintaining coverage, consultation, and coordination outside scheduled service hours.

4. Make service location requirements responsive to individual needs

SBH supports delivering services in homes and natural community settings. However, the weekly limit on office-based services in 12VAC35-105-1424 may create barriers when applied without exceptions.

In rural communities, a missed home visit, severe weather, long travel distances, an unsafe home environment, or the lack of a private meeting space could affect an individual’s service schedule. A rigid weekly percentage could discourage an otherwise appropriate office appointment or create a compliance issue despite reasonable clinical decisions.

We request documented exceptions based on clinical need, individual preference, privacy, safety, weather, and access barriers. DBHDS should also consider measuring the service location percentage over a longer period rather than each week.

The final guidance should explain how telephone and telemedicine contacts count toward service location requirements and identify which CPST components may be delivered remotely. Remote services should remain an option when clinically appropriate and accessible to the individual, while recognizing that some rural residents cannot reliably use them.

Reimbursement should reflect rural travel time, mileage, missed visits, and circumstances requiring two staff members for safety. Productivity assumptions should account for the distance between individuals served.

5. Strengthen safeguards for discharge based on limited progress or disengagement

Under 12VAC35-105-1421, discharge may occur when an individual has not made progress, is not expected to progress, or remains disengaged despite outreach.

SBH requests safeguards to prevent discharge before providers assess the reasons for limited progress or participation. Transportation problems, unstable housing, communication barriers, caregiver limitations, disability-related needs, and changes in symptoms may affect engagement without eliminating the need for treatment.

Before discharge on these grounds, providers should assess barriers, consider reasonable accommodations, review the treatment approach and service intensity, document appropriate engagement efforts, and determine whether another service would better meet the individual’s needs.

The final language should recognize maintenance of functioning and prevention of deterioration as meaningful clinical benefits when supported by assessment. Lack of measurable improvement over a short period should not, by itself, establish that continued care has no value.

Discharge procedures should include appropriate notice, transition planning, and a warm handoff when another service is needed.

6. Protect current psychosocial rehabilitation participants

SBH is concerned about continuity for individuals who rely on existing PSR services for structured rehabilitation, social connection, and ongoing support.

CPST includes a different combination of services and requires Tier 2 rehabilitation skills practice to occur individually. It should not be assumed that this model will meet every current PSR participant’s needs or preserve the benefits of an established group setting.

We request that the Commonwealth preserve access to reimbursable PSR or a comparably accessible group rehabilitation option. If existing services are phased out, the transition must include individual reassessment, informed choice, and confirmation that an appropriate replacement is actually available.

No individual should lose needed services solely because of a system conversion, provider licensing delay, or the absence of a replacement program in the individual’s community. Clinically necessary transition overlap should be permitted, with clear billing rules that prevent duplicate payment for the same activity.

7. Provide clear training and documentation standards without unnecessary duplication

The evidence-based practice training requirements in 12VAC35-105-1423 should identify accepted training, applicable staff roles, completion deadlines, competency expectations, and any renewal requirements before implementation. Training should be affordable, available remotely, and accessible to new employees after initial rollout.

DBHDS and DMAS should issue consistent documentation standards that can be incorporated into existing electronic health records. Providers need clear distinctions among restorative therapeutic interventions, rehabilitation skills practice, psychotherapy, and care coordination, including the qualifications required for each activity.

Guidance should also clarify whether every individual must receive every program component or whether the combination and frequency are determined by assessed need and the individualized services plan. Requirements for CPST care coordination should align with case management rules so providers can coordinate care without unnecessary duplication or conflicting billing expectations.

For rural agencies with small quality, information technology, and EHR departments, unclear or changing requirements create significant implementation costs and divert staff from ongoing service oversight.

Southside Behavioral Health supports the goals of CPST and requests a final framework that makes those goals achievable in rural Virginia. Flexible staffing, coordinated crisis coverage, adequate reimbursement, and a protected transition for current participants are necessary to ensure that rural residents can access and continue receiving needed care.