We greatly appreciate being able to provide comment and feedback to the current iteration of the CPST model and framework. We applaud the tremendous amount of thoughtful work that went into this document, and its intention to increase the quality and standards of service delivery and the goal to effectively help members who are engaged in these services. We especially appreciate the focus on trauma-informed care and evidence-based practices as we think these will benefit Medicaid members substantially. Our intention with this feedback is to ensure that quality care and standards are in place and that they are done in a feasible and practical way that won’t limit network providers being able to comply with some of these requirements.
This feedback on the CPST policies and procedures contains several key concerns and requests for clarification regarding provider requirements, evidence-based principles and policies, training mandates, position titles, and documentation standards within a behavioral health services framework. It highlights ambiguity in terminology and implementation expectations, extensive training requirements, and addresses administrative burdens related to supervision and recordkeeping. Recommendations are provided to ensure clearer definitions, practical guidance for providers, and adjustments to policy language for improved feasibility and compliance across different provider types.
Page 5, Sub-heading 3, Number 1: There is uncertainty regarding the meaning of ‘evidence-based principles’. Specifically, clarification is needed on what this term entails and how it should be implemented by providers in a practical sense. The phrase ‘modular activities’ also requires a clearer definition, as does the concept of these being ‘dynamically applied’. The current language directs providers that they shall implement these items, but it is not clear what this refers to in practical terms.
Page 5, Sub-heading 3, Number 3: The requirement for providers to have evidence-based policies covering mandates, differential reimbursement, or development of core competencies needs elaboration. Examples of such policies in these three areas would be helpful for providers to better understand expectations.
Page 7: 3.3.1 Service Delivery- Specific to Youth:
For youth presenting with a mental health disorder, that aligns with an evidence-based treatment approach, that cannot be provided directly through the CPST service structure, CPST providers shall ensure that the EBP options are coordinated through the care coordination component of the service. Application and education on clinical best practice guidelines and evidence-based approaches shall be a priority focus in supervision and other reflective and professional development opportunities offered by the agency to support staff.
This is vague and unclear in terms of what is expected of the provider, specifically around the care coordination if an EBP is not available.
A more precise definition of the requirements in this section would be beneficial.
Page 6, Section 3.3.1: The mandate that all providers—including multiple provider types—must be trained in Managing and Adapting Practice (MAP) raises questions about reimbursement. It is unclear whether this training will be financially supported or if it is an unfunded requirement for providers. When considering MAP, CANS Lifetime, and statewide foundational training, the extensive amount of required training should either be reimbursed or factored into the provider rate and this clearly shown in the rate breakdown for transparency. There is also a question as to whether these additional training requirements were considered in the original rate study as much of these requirements have come out after the initial rate study.
Page 7: Additional foundational training is required. It would help if would be further clarified- is this in addition to MAP, CANS Lifetime, and specific evidence-based practice (EBP) training? The volume of required training appears burdensome, especially for smaller providers, and may limit the availability of a sufficient provider network statewide.
Page 8, Section 4.1: The requirement for agencies to designate a “CPST Clinical Director,” defined as a full-time LMHP with an active Virginia license providing oversight for the CPST program, may create complications related to position titles and pay structures. This title is commonly used in various ways and often carries responsibilities outside the scope of DMAS, falling under agency-specific business decisions. It is recommended that the title requirement be removed, as the position expectations can be maintained by referencing “LMHP” alone.
Page 9, Section 4.2: The stipulation for weekly face-to-face supervision is viewed as overly prescriptive and may not be suitable in all cases, depending on individual needs, caseloads, and the LMHP’s responsibilities. While general supervision requirements are important, it is suggested to set broader guidelines (e.g., supervision at least monthly) rather than detailed specifics, such as required documentation in employee HR files. Supervising staff typically do not have access to HR files, which could make compliance difficult and increase administrative burden. A more general requirement—that documentation be maintained and provided upon request—would be preferable.
Page 13, Section 5.3.10: Clarification is requested regarding whether every individual receiving CPST services must have a crisis mitigation plan, regardless of their history of crisis.
Page 13, Section 5.4: It is important to clarify whether Restorative Life Skills Training applies to all individuals receiving services or only to those identified as needing it based on assessments. Additionally, further explanation is needed on how this relates specifically to youth services.
Page 20 8.4 Additional Tier Two CPST criteria for youth states: There shall be an identified caregiver or legally authorized representative available and willing to participate. a. The caregiver shall be a responsible adult who lives in the same household as the youth and is responsible for engaging in family/caregiver psychotherapy and service-related activities to benefit the youth. b. The family/caregiver(s) shall commit to participating in ≥ two hours of CPST covered service components a week. c. The family/caregiver(s) shall attend treatment planning meetings quarterly. d. The family/caregiver(s) shall be available for crisis consultation within two hours during business days.
If the designated caregiver does not participate as required, it is important to clarify the provider's responsibility in these cases. Specifically, guidance is needed on whether services must be discontinued or if documenting attempts to engage the caregiver would allow the youth to continue receiving some level of intervention. This is particularly relevant if the specified response timeframe cannot be consistently met. It is recommended that the strict timeframe requirement for crisis consultation be reconsidered or removed, as it may not be feasible in all situations and there may be valid reasons for non-compliance by the caregiver that shouldn’t negate the child’s need for treatment.