The biggest concern regarding CPST is that there is no feasible way that the system will be ready to begin providing the new CPST services or other redesigned services on 7/1/2026. Given the policies & documents that will need to be created and the coordination between DMAS, DBHDS, and the MCOs before providers can begin to have a full understanding of what it will take in terms of staffing and training to achieve what is required to deliver the service, this plan is unattainable in this timeframe. Also, the education of members and community stakeholders in unachievable by this date. Listed below are many other concerns with the CPST paradigm.

1. CPST Teams: - Team definitions represent an extensive increase in reliance on Licensed staff. This will greatly increase the cost to provide the service as well as impact the ability of agencies to be able to offer this service due to the severe workforce shortage already evident for licensed-type providers.  The requirement for 24-hour service availability necessitates on-call staffing and compensation. Can you please explain how these rates will allow for this added staffing? The staffing expectations, and supervision requirements, seem to require a significant increase in licensed staff. Workforce shortages will make this difficult and provide additional barriers. The new section in this draft requiring case coordination is totally duplicative of Targeted Case Management.
2. Measurement Based Care: The CANS is an issue as it is an untested and not validated assessment. Also, there is an excessive amount of "recommended" assessments. Will all of these assessments become required?
3. Required Oversight & Supervision: Clarification of the word "direct" is needed. Does this mean within the same agency? On-site? Certain level of hours of supervision? The requirement for the licensed provider to provide in-person services every 90 days further increases the cost to provide services which is exacerbated by workforce storages. Management of providing this level of direct service as well as the required hours of supervision based on the provider type of staff decrease the feasibility of managing the multiple, increased requirements. The following describe the increased burden on LMHP staff:  minimum face-to-face team meetings weekly; weekly supervision for all non-licensed staff; supervision documentation maintained in employee records; LMHPs to write progress notes reviewing non-licensed team members every 30 days; DHP just create a pathway for QMHP-Ts to be supervised by experienced QMHPs. Because agencies worked together in forming the BH Redesign, why are QMHPs not allowed to supervise under CPST?
4. Crisis Support: CPST 24/7 crisis services are unnecessary due to the already established Emergency Services, Mobile Crisis Response, Regional Crisis Hubs, and 988 programs. Why are crisis services being limited for this program but not for other programs?
5. Psychotherapy: Why is Psychotherapy being provided under the CPST code at a lower rate than under outpatient?
6. Continued Stay Criteria: How is "not making sufficient progress" measured to trigger the need for an alternative service plan within 90 days? Nitey days is NOT sufficient time to make "sufficient progress."
7. Discharge Criteria: Four to twelve months is very limiting as it can take months to build therapeutic rapport with a client. Duration of services from 4-12 months is unrealistic, as is looking for improvement within 90 days from the start of services. These timelines need to be increased or removed. 
8. Exclusions & Service Limitations: The regulations state that members may not participate in both CPST and Clubhouse services. These are two very different programs that complement each other, and members should be able to participate in both. The regulations state that the provider shall not provide Mobile Crisis Response, 23-hour Crisis Stabilization, or Residential Crisis Stabilization to any individual receiving CPST. This will be a barrier to CSBs ability to provide CPST services. 
9. Summary: The BH Redesign needs to be responsive to the needs of Virginians with Serious Mental Illness. Currently CPST does not achieve this.