The Rappahannock Area Community Services Board would like to express gratitude to DMAS for incorporating some of the input from the previous comment period into this new draft.  Further, we are grateful for the opportunity to provide comments to address our outstanding concerns.

• Not allowing participants of CPST to utilize crisis services (appendix G services) if provided by an affiliated business creates a disruption in care.  If individuals must go out of the region to receive crisis interventions like 23-hour, residential crisis stabilization, the continuity of care is compromised.  This approach creates barriers for individuals at significant risk for getting timely and accurate care.  Individuals will spend more time in emergency rooms waiting for CSU/CRC availability outside of the area.  Transportation to crisis services poses another barrier and safety risk.  Will require more traumatizing response to receive treatment to include ECO and police transport that will likely include restraints.  This is a tremendous liability for very vulnerable populations experiencing acute psychiatric crises.  This restriction remains unchanged in the current version and will restrict CSBs from being able to provide CPST so that they can still ethically serve individuals in crisis in their own community.
• A crisis or safety plan that does not include access or referral to more intensive level of care is misleading and dangerous.  Safety plans are intended to mitigate a crisis when possible but also include numbers and references to resources that may include seeking more intensive support.  Thank you for updating the wording to reflect potential inclusion of and access to the full continuum of crisis services as appropriate.  However, we remain concerned that, as a community services board, any individuals we serve would not have access to the crisis continuum of services based on the restriction outlined in the bullet above. 
• The reimbursement rate and any potential service unit limitations are not fiscally feasible to support the cost of 24/7 availability of F:F crisis supports by the CPST provider.  Moreover, there is a requirement that if referred to a higher level of crisis services in appendix g, the CPST provider must remain involved in the services.  It is unknown if concurrent billing of these separate services will be allowed. What potential risk is there to the crisis services provider (i.e. a CRC) to be denied payment due to the billing of CPST and/or the CPST providers failure to remain involved in the care.  What responsibility do crisis service providers have to verify if there is a CPST provider involved with the individual and attempt to reach them and include them in the crisis interventions?
• The restrictive caseload, staffing requirements, reduced units, barriers to access services and complex matrices of requirements paired with the sharp increased requirement for Licensed staff are major barriers to many organizations to consider providing CPST.  We appreciate the relaxation of some of the requirements included in this draft.  However, the rates which have been presented paired with the requirements of the current draft policy still make it fiscally improbable that agencies will be prepared to provide this service.
• CPST guidelines acknowledge this service is for those with chronic mental health issues, but establishes services that do not address the lifelong nature of many individuals' challenges.  By not acknowledging the chronic nature of SMI, CPST creates barriers to true stability and recovery.  SMI by definition is an acute, persistent, and chronic mental illness.   The additional administrative efforts, decreased authorization timeframes after 18 months, and authority designated to managed care organizations to essentially be able to over-ride clinical, person-centered, team decisions still do not address the chronic and persistent nature of Serious Mental Illness.
• Currently an individual receiving psychosocial rehab, skill building, and therapy (2x month) at most receives 162 hours of support a month.  By new unit maximums the most acute individual will receive just 28 hours a month.  The reduction in resources equates to a loss of nearly 87% or 134 hours of care.  Such a drastic cut in services will create undue hardships and significantly increase risks for hospitalizations.  Current services divert individuals from hospitalization and incarceration.  We anticipate an uptick in psychiatric crises.  The new draft eliminates the grid which reflect authorization unit limits.  However, there is no guarantee that these limits will not be imposed in practice.

Point of Clarification:

Throughout the policy, the word “must” was consistently replaced with “shall”.  Can clarification be provided on the intended difference between the two words?