I echo the concerns of many others who have commented about the burden that will be created by the requirement for PSR programs to switch to the Clubhouse International model. The proposed CPST rates and limits are simply not tenable to sustain a PSR program; therefore, the only option many PSR programs will have in the redesign structure is to transition to the Clubhouse model. In addition, with all the other changes that are going on both at the state and federal levels, this appears to be a rushed process that could have unintended consequences for the people who need the service.

There are several concerns about what will happen on July 1, 2026, when the current PSR billing code is no longer available. Will the programs that attested to their plans to transition to the Clubhouse model be allowed to bill for it at that time? If not, what billable service will there be? What is the interim plan for billing for services for programs working toward attaining Clubhouse International accreditation?

More clarity is needed on the space/location requirements for a “clubhouse.” For some current PSR programs, the program site is located near the main CSB offices. In the case of our PSR program, this allows members to see their doctors without there being a transportation barrier. It also allows quick access to medical personnel if there is an emergency in the program. Will Clubhouse programs be able to continue to be located on the grounds of or in close proximity to CSBs? It is not easy or affordable, in many cases, to find a space for such a program, whereas CSBs have designed spaces for PSR programs that have proven to be successful in supporting individuals with mental illness in their communities. These programs were acceptable as we worked through the implementation of STEP-VA including making modifications to programs to increase the services that PSR programs can provide; but these sites in which we have invested might not be acceptable under the Clubhouse International model.

For CSBs that choose to pursue Clubhouse International accreditation and whose program sites do not meet the separation of space requirements, will there be funds available to support relocation? CSBs do not have the funds to be able to purchase or lease new space and will likely be unable to find such space quickly. If this is to be a successful system-wide transition, there has to be funding to acquire the needed space and/or make the necessary renovations.

If CSBs are unable to meet these location requirements, it might mean the dissolution of several PSR programs. What will happen to the individuals who have come to rely on their PSR program for a safe place to be during the day, an opportunity to socialize with a network of peers, a connection to people who can support them in their recovery and help keep them stable in the community, and a place where they can have nutritious meals during the day? Disbanding these programs will increase crises— an area in which the state has finally begun to build out a comprehensive system— thereby negating some of the important work that has been done. It can also exacerbate issues that we are currently facing such as individuals with mental illness wandering the streets or not having a place to go during the day so that their loved ones can maintain employment.

Is it necessary to change the current PSR program structure? If the issue is demonstrating that the funds provided for the service are being utilized appropriately, there are other means to address this without having to jeopardize and/or uproot the stability of the individuals within the PSR programs. We have been working on incorporating options such as supported employment and housing supports. If there are missing elements from the current PSR model that make it a more holistic approach, can those just be added in as requirements under our STEP-VA metrics?

More clarity is needed around the timeline for implementation. Although we are told there is consideration of the length of time it takes to become accredited, there is no guidance on the timeline within which CSBs are expected to meet various milestones to demonstrate progress toward accreditation. There also needs to be training and guidance related to Clubhouse International accreditation to ensure that all CSBs resources and supports that they can go to for guidance. Without these things in place, we run the risk of creating a fragmented set of programs based on individual interpretation rather than having a roadmap that depicts a common goal and how to achieve it as a statewide behavioral healthcare system. 

Please consider the totality of this shift and weigh out whether these changes we are being required to make will result in improvements in the lives of the people we serve. The CPST services impose rate and time limits that do not meet the needs of people who need these programs daily. The Clubhouse International model requires lengthy planning and culture shifts that do not happen quickly in addition to financial investments for which resources are not available. Please also consider how this change will potentially negatively impact the work that is being done in areas such as expanding crisis services and enhancing the availability of other community-based services. I would like to be clear, there is room for the Clubhouse International model in the continuum of services provided in Virginia, but it should be left to providers to decide whether the Clubhouse model is something that can be done within the scope of their resources and whether it adequately meets the needs of the people they serve. It is not something that can be seamlessly imposed over an existing program. At a minimum, any changes should allow for time and adequate planning so that such a shift does not end up negatively affecting the people we are here to support.