I would like to speak to the regulation change requiring for Assertive Community Treatment (ACT) Team Lead to be LMHP.  My programs are in a rural area in Southwest Virginia.  We have extreme difficulty in hiring LMHP's in our area.  I would ask that either a waiver process be put in place, for areas such as ours, to allow LMHP-E's to be considered for ACT Team Leads and other positions.  In order to draw the LMHP pool of applicants to our rural area, it is often necessary to open our positions for LMHP-E's with supervision for licensure provided.

Could we consider including LMHP-E's within this requirement or having a waiver process for situations such as we may face in rural areas?

Thank you for your consideration.

General, Top Three Concerns:

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

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.

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. T

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.

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.

1. New requirements related to after hours and the requirement that PACT teams directly respond for clients 24/7 places additional burden on small teams and will likely increase staff turnover which has negative impacts on the program, agency, and most importantly individuals being served.  We would like for the requirement of 24/7 response to be left as is which allows for additional flexibility for PACT to coordinate with other providers to ensure client needs are met. Current regulation: “D. The ICT or 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.”

2. Please consider allowing LMHP-Es and QMHP-Es under supervision in the program in regulation where requirement is specified for LMHPs and QMHPs. We have faced challenges recruiting for PACT programs as it is. CSBs face workforce shortages and LMHP-Es and QMHP-Es should also be considered eligible for work in the program.

3. Request that the QMHP requirement for ICT Peer Specialist be removed. Peer training is a more appropriate skill set for this staff member.

4. Recommend allowing for general Nurse Practitioner be considered as eligible to provide psychiatric medication management services to the program instead of “Psychiatric Nurse Practitioner.” Psychiatric nurse practitioners are rare.

5. Will Code of Virginia also be updated to be consistent with new regulations?

6. The language surrounding ACT and ICT is confusing and does not appear to be consistent throughout the regulation.

7. Many of the regulation requirements would impact the ability of smaller CSBs to effectively implement ACT program. Some requirements seem to fit in best with fidelity measures rather than a requirement in regulation.

I agree with all other comments to date.  I would add for the Peer, to remove the requirement to be QMHP as peer now has a registration/certification.  Also I would recommend not limiting this to a peer with SMI history as the peer movement now trains peers to help cross disability so someone with SUD background could be effective with those with mental health challenges as well as the opposite.  It should not be based on disability but their ability to use their peer experience within their work on the team and with consumers.

Fidelity standards and Licensure regulations

• Some requirements seem better suited for fidelity measures versus the regulation. Aligning regulations to the base level of compliance with TMACT standards may help smaller CSBs, or those in the highest workforce shortage areas, to still operate ACT to the best of their ability.
• The proposed changes to the Code that exceed fidelity requirements handicaps programs that can provide based on TMACT standards, but for myriad reasons, cannot attain the additional DBHDS licensure requirements.
• Confusion about the difference between base TMACT fidelity, Licensing regulations, and medical necessity criteria could result in MCOs denying payment to teams providing services based on TMACT fidelity.

Staffing

• The requirement to hire additional personnel to be compliant with new ACT requirements penalizes boards that have been providing services that meet TMACT fidelity standards but lack resources to fund additional positions. A team in compliance with the current ICT licensing guidelines will have to reduce its census, resulting in a loss of revenue that is essential to operate the program.
• Licensed practitioners - LMHP-Es are essential to our workforce. As a smaller locality, we have difficulty recruiting LMHPs (salary competitiveness and many licensed staff exiting the CSB system).
• ICT Peer specialist- recommend removing the requirement to be a QMHP. Requiring that the ICT Peer specialist earn the CPRS credential is more in line with the expectations and the professional path DBHDS has established for Peers.
• Nursing staff - Do not regulate 2 FTE nursing positions (1 RN and 1 LPN) for a medium-sized ACT team. Let the nursing FTE ratio be measured in fidelity reviews rather than mandated by regulations. Hiring additional nursing staff may not be fiscally feasible for smaller boards.

For the co-occurring disorder specialist the qualifications are LMHP, QMHP, or CSAC. I thought I recalled during the workshops that LMHP types (LMHP-E, RIC) would also be allowable in this position. Not all LMHP types maintain their QMHP registration. I can't imagine why if a QMHP would be qualified an LMHP type would not qualify as well. 

The crisis coverage language contradicts itself. Under D it says an ACT team may arrange coverage through another crisis provider to make coverage available 24/7 but E2 says the team shall be the first line crisis evaluator. Requiring the team to be the first line crisis evaluator is going to result in significant increase in staffing resource need. Given the fact that the grant allocation is not increasing this would be a significant burden that I am not sure we could meet with our current financial resources. We currently arrange coverage with our emergency services department after hours and that staff has the number for the team on-call. This has worked well and ES routinely calls our on-call. 

I agree with all other comments listed.  Specifically:

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

Requiring the team to be the first line crisis evaluator is going to result in potential staff turnover. I would recommend allowing teams to triage with Emergency Services for crisis contacts.

For staff requirements, we have some staff that are LMHP-E, but are not registered as a QMHP.  I would recommend allowing LMHP-E staff to fill these positions in addition to QMHP.

VB DHS has concerns regarding the addition of an expectation that ACT teams “shall be the first-line crisis evaluator and responder”.  Although ACT teams are expected to have staff members available for assistance in crises at all times, this on-call access is best suited to help with de-escalation and connection to crisis evaluators when de-escalation is unsuccessful.  ACT staff are also available to Emergency Services pre-screeners to help coordinate care.  Inclusions of a requirement for a first-line crisis evaluator blurs the boundary between two Licensed services – ACT and Emergency Services.  Per state legislation, Emergency Services evaluations must be provided by Community Services Boards and those staff members must have specific training.  Therefore, it falls beyond the purview of any ACT provider to assume this role.  The current language of making crisis services directly available 24 hours a day sufficiently articulates that a high level of responsiveness is expected.  Removal of the option to coordinate coverage via another crisis provider may make it challenging to provide this level of responsiveness is rural localities, ultimately having a negative impact on the availability of this service.  In addition to the role-diffusion, there are concerns regarding the impact of additional requirements to members of ACT teams.  Requirements to provide a higher level frequency and intensity of crisis services will contribute staffing shortages, both in the short-term (as staff members can only work a certain number of hours safety) and in the long-run (due to increased staff turnover), again detracting from the overall ability to provide this valuable service.

We also advocate to have LMHP-Es specifically referenced as being able to provide ACT services.  Although Residents in Psychology, Residents in Counseling, and Social Work Supervisees inherently meet the requirements of being a QMHP, omission of this qualification will result in increased, unnecessary financial and administrative burdens – applicants will need to register with their Licensing Board for their supervision and with the Board of Counseling as a QMHP-A; the Board of Counseling will have to process these duplicative applications. 

Please consider allowing LMHP-Es and QMHP-Es., we are asking that any time an LMHP or QMHP is required, that Es are also eligible considering workforce shortages.

Please consider allowing for a Nurse Practitioner be considered as eligible to provide psychiatric medication management services to the program instead of “Psychiatric Nurse Practitioner.” Psychiatric nurse practitioners are rare and result in variances being asked for with this credential. 

I recommend that the following revisions are made to draft regulations for ACT services:

1.  The ACT team shall have 24-hour responsibility for directly responding to psychiatric crises...the team shall be the first-line crisis evaluator and responder for individuals served by the team.  1) This regulation would force PACT teams to respond in person around the clock which would have a negative impact on staff retention; 2) ACT services are heavily based upon rapport with the individual.  Having the ACT worker serve as the prescreener and evaluator will potentially impair relationships built with individuals served; 3) Many ACT team workers are not prescreeners and doing so would force clinicians to focus on crisis management as primary role on the team.

2.  DMAS considers LMHP and LMHP-E to be equivalent in terms of allowances related to service provision.  Please change language to allow LMHP and LMHP-E to be used interchangeably.  

I agree with the comments as stated. I do think that QMHP-E and LMHP-E should be allowed in their respective capacity to provide client services. I am also in agreeance with removing the requirement of ACT being first line of response for Crisis. I believe most CSB's are providing this service thru Emergency Services and Prescreen processing, while implementing needed coordination of care to ensure client is taken care of. Our agency works very close with our Emergency Services Program to ensure client safety and to promote client's positive mental health. Please consider all (demographics, location of services, access of professionals to provide said services, etc) when final decision is made. Please also consider how client services/ outcome may be impacted by proposed changes. Please consider how proposed changes may have the potential to decrease availability of qualified providers to provide the said service.

Definition section:

“ a team of medical, behavioral health , and rehabilitations professionals….”

Comment—seems like we could just say a team of behavioral health professionals..

“to meet the needs of an individuals with severe and persistent…

1. “Provide person-centered services addressing the breadth of an individual’s needs, helping him the individual achieve his personal identified goals.”
2. “serve as the primary provider of all the behavioral health services that an individual …..

10.  “promote self-determination, respect for…, and engage peers in promoting recovery….

Comment—does this use of “peers” refer to the individual being served, Peer Recovery Specialists, other professionals…?

Treatment team and staffing plan:

1d.  QPPMH or QMHP-A—the language from the Department of Health Professions is “Registered Peer Recovery Specialist”. It would be helpful to use the same language.

4b. Nurses—ACT nurses shall be full-time employees or contractors….

Comment:  Does this exclude the use of permanent part-time nursing staff?  The requirement that medium and large ACT teams can only hire full-time nurses limits flexibility in a very competitive job market for nurses. 

4f. Program Assistant—"one full time…”

Comment: Is this indicating that even a small ACT team would need a full-time program assistant? This standard is also very specific about job functions.  In large boards some of these functions like “maintain accounts and budget records” are farmed out to other parts of the agency—not totally sure what “budget records” is referring to.

4g. Psychiatric Care Provider: “…The psychiatric care provider shall be a fully integrated team member who attends team meetings and actively participates in developing and implementing each ISP.” 

Comment:  regulations like this often prompt licensure specialists to ask how we can document the psychiatric care provider’s development and implementation of each ISP?  Would this require the Psychiatric Care Provider’s signature on the ISP?

5.  Staff to individual ratios for ACT Teams:

There is labeling error in this section—it goes from a,b,c, to B, C, D

D-E.  5D states that an ACT team may arrange coverage through another crisis services provider. 5E 1-2 indicates that the “team shall be available to individuals in crisis 24 hours per day…” and “the team shall be the first-line crisis evaluator….”  Section D and E seem to be in conflict with each other.

Contacts:

 Section A.  –It is unclear how  the aggregate average will be determined.  Will this be based on one week randomly selected by the licensure specialist, a span of time, etc?  This appears to be more of a fidelity measure than a licensure regulation. 

ICT and ACT service daily operation and progress notes:

Section A indicates that ICT and ACT teams “shall conduct daily organizational meetings Monday through Friday…”  Section 5B indicates that teams “shall meet daily Monday through Friday or at least four days per week…”  These two sections are in conflict with one another.

Service requirements

11.  “which shall be directed exclusively to the well-being and benefit of the individual…”  This requirement seems unnecessary and very subjective. For example, if we are teaching parents appropriate limit setting skills, the individual being served may not think this is beneficial.

I agree with all of the comments posted.  In particular, not allowing for QMHP-E's and other licensed eligible clinicians to work in these programs.  Workforce shortage issues are real and exist across programs.  "Growing our own" is one way many CSB's have successfully mitigated this problem.  I also strongly agree that utilizing staff from these intensive services to provide on site responses to crises 24/7 will place undue burden on these staff, which may well result in high turnover and the destabilization of the team approch.

Fairfax-Falls Church CSB agrees and supports all other comments to the date.

12VAC35-105-1370 Treatment team and staffing plan.

e. ACT Peer specialists - one or more full-time equivalent peer recovery specialists who is or has been a recipient of mental health services for severe and persistent mental illness. The peer specialist shall be a certified peer recovery specialist (CPRS) or shall become certified in the first year of employment. The peer specialist shall be a fully integrated team member who provides peer support directly to individuals and provides leadership to other team members in understanding and supporting individuals' recovery goals.

d. Peer ICT peer specialists - one or more full-time equivalent QPPMH or QMHP-A who is or has been a recipient of mental health services for severe and persistent mental illness. The peer specialist shall be a fully integrated team member who provides peer support directly to individuals and provides leadership to other team members in understanding and supporting individuals' recovery goals.

These regulations require dual credentials as a peer and paraprofessional/professional. The state’s Registered Peer Recovery Specialist (RPRS) Credential is higher than the CPRS.

Comments:

These regulations require dual credentials as a peer and paraprofessional/professional. The state’s Registered Peer Recovery Specialist (RPRS) Credential is higher than the CPRS.

Recommend removing the QPPMH/QMHP, and CPRS requirements. Replace with the RPRS credential only. Recent legislation making its way through the general assembly requires RPRS for peers on mobile crisis teams. It would be inconsistent for PACT teams to require more peer  credentials than those required for peers on Mobile Crisis teams.

In addition, there is an inherent conflict in clinical/peer dual credentialing. One of the defining features of peer support services is they are “non-clinical.” Requiring a clinical credential for a peer specialist implies they are providing clinical rehabilitative services. In addition, due to workforce issues very few peer specialists can obtain both credentials. And, those who can will generally choose to work in a clinical role with higher pay.

Loudoun MHSADS agrees with and supports all comments to date. 

Definitions:

Definition for ACT describes the provider being the primary provider for ALL services. As ACT is not the provider for all medical (e.g., eye, dental, physical) we recommend removing "all" from the definition. 

Definition for ICT no longer is consistent with new criteria within the regulations. 

12VAC35-105-1360 Admission and discharge criteria

Will the admission criteria be consistent with DMAS criteria? 

Discharge

There are also times when the individual disengages and ICT or ACT staff do not know where the individual is, so revising the ISP is n/a if the person is not located.

What is the evidence-based decision for two years? This seems paternalistic in the absence of data indicating two years as the recovery mark. Plus if you add #5 under the heading in B (“discharged for failure to comply or other expectations”), it seems that sustained recovery is considered a failure.  Recommend either remove five or change the header in B.

12VAC35-105-1370 Treatment team and staffing plan

Recommend inserting some language allowing CSBs to hire the most qualified applicant for each position even if the qualifications fall short of licensure requirements if no applicants meet the qualifications set forth in licensure. There is a shortage of professionals especially with this many years of required experience.

For ICT and ACT staffing ratios: we cannot discharge individuals for two years of sustained recovery with minimal contacts, or inpatient treatment for over a year, or incarceration for a year (which means we would have someone being counted as a client who is not receiving the intensive levels of service). Recommend language that allows for additional individuals to be enrolled per individual in monitoring or transitioning status.

Peer Specialists who are certified or become certified within a year of employment as a Peer Specialist. REcommend removing reference to QPPMH or QMHP. Keep this consistent with ACT Peer Specialist. Also, remove the description of what type of mental illness is required for the peer recipient of services for “Severe and Persistent” mental illness.

Recommend LMHP-E anywhere it says LMHP

Recommend ICT and ACT allow a physician and/or advance practice nurse working within the scope of the medical training and license to provide psychiatric medication services.

"2. The team shall be the first-line crisis evaluator and responder for individuals served by the team if clinically appropriate." It would not make sense clinically to make an individual in need of a TDO talk to an ACT therapist first and then repeat the whole evaluation with Emergency Services.