Thank you for the opportunity to bring up questions regarding the manual. We appreciate the opportunity to provide feedback and address direct concerns from the provider’s perspective and implementation of the CPST program.

While we appreciate the detail that is being put into the roll out of this program, our primary concern remains the overabundance of tasks placed on an LMHP. May of the tasks could be facilitated by an LMHP-E. The rigid numbers (monthly limits, supervision requirements, direct care requirements, in-person requirements, increased assessments, implementation of EBP, tracking and audit increases) also make it challenging and do not account for potential turnover, staff out on leave and overall are very restrictive. If an LMHP leaves, there is no flexibility to cover for students in services which causes clinical and ethical issues. It is important to broaden the role of the LMHP-E to give providers flexibility to not only build but maintain a successful program. The LMHP shortage and high turnover for agencies has been well documented across the state.  

Additional questions include the following:

3.2 Many of the services are not available in the area. If CPST starts, and then another service becomes available, it should be up to the provider and client if both (new service and CPST) services are appropriate. Many families can benefit from both services as they target several different areas (MST and CPST/MAP can be used simultaneously per the training). In addition, it is not person centered to discharge from one program solely due to enrollment in another.

3.3 The cost or details of the QMHP training has not been disclosed. Agencies cannot set long term planning goals without knowing costs without these long term projections.  

3.4 Oversight to ensure ethical work is important. However, there is no reimbursement for agencies that are now accountable to insurance companies, licensure and VCU as well as the agency. This is an abundance of reporting when already adding case management, team meeting and LMHP responsibilities. What is reported to each agency is also not clear.  

4.1 Thank you for adding details to the crisis section. However, please describe how billing (as there are limits on QMHPS, LMHPS and hours for clients) works. Please also describe a plan for agencies when this service is not available. Agencies are already short-staffed, what happens when staff leave unexpectedly?  

4.2 Increased coordination and no reimbursement.

4.3 Caseloads are very rigid and do not allow for flexibility if staff resign, are out on leave, etc. which leaves the agency out of compliance or at risk for allegations of abandonment from the board.

5. What does the first sentence mean? It is not clear what CPST offices are considered and is not realistic that they only utilize a CPST room twice a week. Especially given the curriculum for EBT which often involves a lot of office time. The state mandated program requires ongoing tracking, implementation of therapeutic interventions that will need to take place in the office.

5.1 CANS is not required to be facilitated in person for social services; it is overly cumbersome to add this responsibility without increased reimbursement. This will hinder clients in rural areas from accessing services especially those with transportation issues.  

5.3 Crisis services remain a duplication of programs that have already been put in place. There is no clear reimbursement description for this service. There is no explanation of how this is billed given the strict caps and restrictions on hours and caseloads for staff. The addition of crisis services seems to be trying to combine two services/jobs into one with minimal pay. Staffing this will be impossible for smaller agencies. It is also not ethical for many EBPs that the ongoing therapist is the crisis response therapist (ex. DBT). The push for EBPs and combining crisis response is actually counterintuitive.

5.5. It is not clear if employment exploration is covered. One section states that it can be billed under Restorative Life Skills but the other section indicates it is not billable under CPST. Case management services through the MCO should be the responsibility of the MCO. Responding should be the responsibility of the CPST counselor but we cannot be responsible for insurance companies not appointing workers or those workers not communicating with staff. This has been an ongoing issue with MCOs.

6.0 The team approach to assure ethical services is a great idea. However, the CPST worker, supervisor providing services and the client being enrolled in outpatient (and case management) creates a duplication of some services or possibly different therapeutic approaches/styles being applied at the same time. Outpatient (and coordination with the outpatient counselor) should count as the meeting with LMHP staff.

8.1 Clarification question: Staff are completing an agency assessment, SDQ, CANS Lifetime, an initial SRA, ISP and complying with EBP. We were under the impression CANS Lifetime would reduce some of the cumbersome enrollment process to focus more on treatment. This is more responsibility, limiting staff who can perform the tasks and the reimbursement is not clear as far as the assessments. Will insurance companies be able to deny and reduce units (like they do now) with the additional information. It is an ongoing concern that the information is not reviewed (we will be filing two complaints this week alone addressing this concern). We were not able to access this form.

As an agency, we have appreciated the request for feedback, questions and concerns. When the program was presented, it was expressed that it was to help children access services. This program, by setting so many limitations and expectations on LMHPs will make it challenging for kids in rural areas to access the services. It also places an abundance of responsibilities on LMHPs who will likely seek employment in higher paying, less responsibilities positions. As it is now, it appears to be moving away from client centered and more towards limiting services.

We do find it helpful that authorizations are 6 months. And we really appreciate the state providing free MAP training (which our staff have enjoyed) to get the program going. We have also appreciated the opportunities to share our concerns prior to the rollout.