Section 2: Clubhouse Service as described in this draft is not consistent with Clubhouse International standards in several significant ways which would make achieving and maintaining accreditation difficult if not impossible. Specifically, one of the foundational Clubhouse International standards states that membership, “is open to anyone with a history of mental illness.” This standard is incompatible with the expectations specified in Medical Necessity Criteria in the current document, including requirements that members must have a serious and persistent mental illness demonstrated by continued functional impairment. In addition, , the current document focuses on specific reimbursable supports that are provided by professional staff on behalf of members with debilitating mental illness instead of on the empowerment of the members to engage in all areas of the work of the Clubhouse, including providing supports to one another, as is the intent of the Clubhouse model. We are also concerned about the time and expense required to achieve and maintain accreditation.
Section 3.1: Regarding Item 2, it is not practical for an Assessment to be conducted in the consumer’s home or off-site as a part of a service that is provided in-person in a group setting. Group services require as many staff members be present with the group as possible in order for services to be safe, particularly when working with individuals with debilitating SMI.
Section 3.3, Item 1: Required activities should be reimbursable. For example, a foundational value of Clubhouse International is the inclusion of members in all aspects of programming and program functioning and professional staff are needed to empower members to this level of participation yet these activities are excluded from reimbursement. Item 5: it is not practical for staff in a Clubhouse model to provide job support at the job-site. Safe group work requires as many staff members as possible be present with the large group, not with individuals off-site. Additionally, if this is not a reimbursable service (as specified in 6.9.b), it is not appropriate or financially feasible to require this RSB.
Regarding Item 7, social skills development occurs within a normalizing social environment at all times, and does not require additional events. Expectations around evening, weekend, and holiday social events are not made clear in this document overall. If these are required, additional staff will also be required.
Please note that if any RSBs are listed as required, they must be reimbursable. Sufficient staff (and resulting funding) must be added to complete any off-site work and holiday/ evening/ weekend work.
Section 3.4: Regarding Items 3 and 5, if immediate, in-person support for crisis management must be offered and available outside the work-ordered day and outside the Clubhouse site, by Clubhouse staff, funding must be provided for individual staff to be trained in how to provide these supports safely, particularly in high-acuity and off-site locations. Staff who are on-call and who provide crisis response must be specifically reimbursed for these services. Additional staff must be added in order to provide these services. It is of note that this portion requires yet another duplication of the crisis continuum services much like the draft CPST regulations. Requiring crisis services to be provided by Emergency Services, Clubhouse and CPST teams is not only redundant but also impractical given hiring challenges in 24/7 services.
Diagnostic Criteria is unclear specifically what is meant by “related disorders?” Will common and highly prevalent diagnoses such as Anxiety Disorders, Depression and PTSD be authorized? Narrowing medical necessity to a small portion of diagnoses also runs counter to the inclusive focus of Clubhouse International which is to be open to anyone with a history of mental illness. Also, requiring a note from a physician is expensive, stigmatizing, and redundant when a Comprehensive Needs Assessment conducted by a medical provider licensed in mental health treatment and assessment has already been required.
Regarding Item 3, the Functional Impairment Criteria are inconsistent with the values and Quality Standards of Clubhouse International. Requiring members to meet these impairment criteria in order to become members will not allow for the level of inclusivity valued by Clubhouse International. Requiring members to continue to meet functional impairment criteria in order to maintain membership will not allow members to achieve the level of independence and functionality envisioned by Clubhouse International.
Section 5.2: Regarding Item 1, the admission criteria required for Continued Stay are not consistent with the values and Quality Standards of Clubhouse International.
Section 5.3: Regarding Item 1, the admission criteria required to avoid Discharge (if desired) are not consistent with the values and Quality Standards of Clubhouse International.
Regarding Item 10.a.iii, excluding ACT would restrict members with SMI from receiving essential services. ACT and Clubhouse model PSR provide services that meet different needs. While ACT services may provide 1:1 work toward rehabilitation and maintaining tenure in the community, many ACT recipients also require Clubhouse PSR services to develop social skills in a normalizing social environment and to maintain a daily routine that is an essential part of sleep hygiene, personal empowerment, and symptom management. For many of those in PSR programs, the intensive nature of ACT services is required for engaging in mental health services (including medication management and OPT), as these individuals have been unable to participate in traditional office-based services in the past without this intensive level of support. As an example, some current consumers who have NGRI conditional release plans rely on both PSR and ACT to meet the requirements of the court and to maintain within the community. For many consumers, both services are required in order to work toward recovery, avoid symptom relapse, and maintain in the community.
Requiring assessment and ISP completion on day one of membership is not feasible or clinical best practice. The current 30 day requirement allows for time for members to learn about the service and develop relevant individual goals.
