GENERAL
Overall I appreciate the efforts to incorporate the Clubhouse International standards into the regulations.
It is requested that updated regulations address how Clubhouses can bill for evening/weekend/holiday hours, which are a required component of Clubhouse per Clubhouse Int’l standards. This is not currently addressed at all in the DMAS regulations. If this is a required component, it must be an allowable billable activity with guidance.
FEEDBACK BY SECTION
3.1 Assessment- the old CNA Is referenced in this section instead of the new CANS-Lifetime. Will the CANS-Lifetime be used as an assessment for Clubhouse, or will Clubhouse members need the old CNA?
Recommendation: At the very least, I would suggest that the CANS-Lifetime be one of the acceptable assessments for Clubhouse members along with the CNA, given that all of the other new services will be using the CANS.
5.1.2 Diagnostic criteria- Clarification is requested on language surrounding the SMI diagnosis requirement- specifically that MDD is not listed, but this is typically considered one of the SMIs.
5.1.2 Diagnostic criteria- Recommend reconsideration for the requirement that other mental illness diagnoses outside of those listed require a physician's note for participation. This is stricter than the current PSR medical necessity criteria, which do not specify which mental illnesses are allowable. It is also stricter than the CPST diagnostic criteria, which allow any DSM-5 diagnosis, even though Clubhouse is considered a less clinical service than CPST. There are many other mental illnesses for which Clubhouse services would be clinically appropriate, such as MDD, OCD, personality disorders, agoraphobia and other specific phobias, anxiety disorders, and more. The assessing clinician will be licensed (or license-eligible) by the state, and should not need a physician to speak for them about whether or not an individual is appropriate for the service. In my organization’s experience, when we need to request a physician's letter to permit individuals to receive MHSS services, this results in a delayed process and physicians often complete the note inaccurately as they don’t know what is expected of them. The doctor’s note requirement will do nothing but delay access to services and prevent individuals from getting services who need them.
My recommendation is that this requirement to be updated to include a DSM diagnosis of any mental illness, same as in the CPST diagnostic criteria, paired with demonstrated functional impairment as currently described in the Clubhouse regulations.
5 and 6 Continued Stay and Discharge Criteria- The discharge and continued stay criteria contradict the Clubhouse Int’l tenet of “members for life”, specifically Clubhouse Standards #1 and #6 (“Participation is voluntary and without time limits,” and “Members have a right to immediate re-entry into the Clubhouse community after any length of absence, unless their return poses a significant and current threat to the Clubhouse community”). While I appreciate that no length of stay has been established, requiring discharge if a client is not making progress or if the client has met treatment goals contradicts the “member for life” concept. If programs are required to follow these standards and receive accreditation, then the DMAS regulations must be consistent with the standards.
My recommendation is that regulations be updated to remove requirements for discharge that would violate the “member for life” tenet.
6.9 Non-reimbursable supports- The categorization of in-house educational programming as non-billable contradicts the Clubhouse Int’l standards, specifically Standard 25, which requires Clubhouses to offer either in-house education supports, or support with accessing education opportunities in the community. Again- if Clubhouse accreditation is required, and adherence to all of the standards and tenets is a requirement for accreditation, then DMAS cannot impose requirements that contradict Clubhouse standards such that programs that follow the DMAS requirement would be ineligible for CI accreditation.
My recommendation is that this aspect of the regulations be updated to allow in-house education activities, in compliance with Clubhouse Int’l standards.
6.10 Concurrent Services- Recommend reconsideration of the requirement that Clubhouse is not available to individuals receiving ACT or CSC. These services do not provide center-based daytime structured activities and therefore Clubhouse is not a duplicative service to either of these. We currently have many clients who receive both PSR and ACT or CSC and being able to access both services aids in their recovery.
9.2 Billing Requirements- It is requested that updated regulations better clarify what elements of participation are required to bill the per diem rate. Currently it is unclear how an individual could participate in “two elements” of the Clubhouse service per day. For example, if a member is present and participating in the work-ordered day for the entirety of the program’s day (for example, working in the program’s kitchen), this would just count as 1 element, but as the regs are written, we could not bill the per diem rate. This makes no sense. Additionally, a requirement of participation in any specific Clubhouse activities is in contradiction to the Clubhouse standards, specifically Standard #3, which states, “Members choose the way they utilize the Clubhouse, and the staff with whom they work. There are no agreements, contracts, schedules, or rules intended to enforce participation of members.” If we must require certain types of participation from members in order to bill Medicaid, we will not be in compliance with the Clubhouse International standards and will be unable to receive the required accreditation.
My recommendation is that instead of requiring activities, which is in contrast with the Clubhouse Int’l tenets, that a minimum timeframe for attendance be established in order to bill the per diem rate, such as 1 hour.