Thank you for the opportunity to review the proposed revisions to the Community Psychiatric Support and Treatment (CPST) service model. We appreciate the intent of the redesign to improve clinical structure, accountability, and consistency of care. However, significant concerns continue with the current draft revision.
The model assumes a workforce capacity that does not currently exist in most parts of Virginia, particularly rural and high-need regions. This creates an underlying structural concern when the system shifts more responsibility to teams, but does not meaningfully expand the available clinical workforce to support that shift.
The model as written assumes a workforce structure that is not stable enough to support it. Required LMHP involvement in assessment, treatment planning, supervision, and oversight creates a structural dependency on clinicians who are already in short supply. LMHP caps (75–120 cases depending on structure) still require enough licensed staff to supervise increasingly structured teams. That means LMHPs are no longer just clinical providers—they become the rate-limiting step for entire program capacity. In practice, this will likely lead to agencies capping enrollment not based on need, but based on LMHP availability, longer waitlists for Tier 2 entry, and LMHP burnout due to dual clinical + administrative oversight roles.
The model increases reliance on QMHPs and BHTs for direct service delivery, but recruitment and retention for these roles is already unstable. Turnover rates are high in many provider agencies and agencies may further struggle to maintain stable staffing ratios required for Tier 2 intensity. Tier 2 depends heavily on QMHP/QMHP-T/BHT delivery of: crisis support, rehab skills practice, care coordination, and community-based implementation. But pay levels remain relatively low, expectations are significantly higher (real-time crisis intervention, environmental structuring, frequent community work), and billing caps (750 units/month per non-licensed staff) limit flexibility. This creates a high-demand / high-burnout role with limited sustainability.
An LMHP supervisor is simultaneously responsible for: clinical oversight, documentation quality control, crisis consultation availability, and treatment planning approval workflows. This creates a system where LMHPs function as: clinician + supervisor + compliance officer + utilization reviewer. That combination is not realistically sustainable at scale without increasing administrative staff support (which is not clearly funded in the model).
Training requirements are significantly expanded and formalized, which maintains the previous concern that implementation timelines are not realistic. Training expectations are clinically coherent but operationally heavy, with unclear statewide capacity to deliver training at scale before rollout deadlines.
MAP training requirement adds a delayed workforce pipeline problem. For youth services, MAP credentialing is required. This creates a 12–18 month training lag before full compliance, productivity loss during training period, and higher turnover risk for newly trained staff (poached by higher-paying systems). Smaller agencies will struggle to maintain enough “fully credentialed” staff to scale services.
Multiple layered training systems (Foundational Skills Curriculum, Intermediate Skills Curriculum, BHT Academy, EBP-specific training requirements (CBT variants, trauma-informed modalities, etc.)disadvantage smaller agencies, staff without formal psychotherapy training pipelines, and highlight training infrastructure limitations
Supervision is expanded in a way that is clinically reasonable and geared towards best practice but is operationally underestimated. Supervision is no longer “one meeting a week”, it now includes: weekly sessions, documentation review requirements, case consultation, co-treatment, direct observation expectations, and crisis oversight responsibilities. This effectively creates a second full workload layer that is not directly tied to billable production.
The model as written introduces layered documentation requirements that go beyond typical service authorization systems. CPST shifts toward a highly structured, compliance-heavy model that increases administrative workload significantly without proportional increases in billable efficiency, creating concern about “paper compliance vs clinical time”. The integration of Level of Need (LON), CANS Lifetime assessments, domain-specific impairment thresholds, and tiered eligibility criteria introduce a high level of documentation complexity. This raises concerns that: documentation requirements may reduce time available for direct care, providers may experience increased audit risk due to layered eligibility criteria, and administrative burden may disproportionately impact smaller and rural agencies.
CANS Lifetime dependency (required for admission, LON, continued stay, step-down decisions) creates heavy reliance on standardized assessments that require training and time to administer. Layered documentation requirements with frequent ISP updates require frequent formal updates even in more stable cases. Outcome tracking mandates place a burden on providers to demonstrate symptom reduction, crisis reduction, functional improvement, and rationale for lack of improvement with expected trajectory. This does not account for “real life” where there are frequent changes in client needs and symptoms based on unpredictable circumstances. Supervision documentation requirements expand significantly with required tracking, related activities, case oversight logs, and caseload monitoring. With the heavy increase in documentation requirements and increased billing constraints (tight rules on face to face requirements, simultaneous billing, individual versus group time, and nonbillable activities) the time required to meet administrative requirements makes CPST as written a financial risk for agencies.
Rural CSBs face unique structural constraints that are not fully accounted for in the current model design, including: significant travel time between clients limiting billable efficiency, LMHP recruitment and retention challenges, smaller supervisory staffing pools, higher per-client administrative overhead, and limited funding for training and infrastructure costs.
CPST assumes frequent community-based services, but rural providers have long drive times between clients, low client density per geographic area, and high cancellation impact on scheduling. The result is significant non-billable travel time that is not offset in reimbursement structure.
The CPST model assumes a level of staffing density and service clustering that does not exist in rural regions. As a result, there is concern that rural providers may experience: reduced service capacity, increased per-client cost of delivery, difficulty maintaining compliance with supervision and documentation requirements, and potential service withdrawal from low-density areas.
Fixed supervision burden hits rural agencies harder with requirements for weekly supervision, documentation review, case tracking logs, and caseload management systems are the same regardless of agency size. But rural CSBs have fewer supervisors, fewer administrative support staff, and smaller workforce pools to distribute workload This means fixed overhead becomes disproportionately expensive per client served.
LMHP recruitment problem becomes service capacity ceiling. Rural areas already struggle with LMHP shortages and now LMHPs are required for: nearly all core service components, high-frequency supervision, and oversight caps. This will likely result in capped enrollment regardless of demand, inability to expand CPST coverage geographically, and increased reliance on crisis services instead of preventative care.