Here are my concerns/thoughts so far:

-The description of the activities listed in the “Required Service Components” seem like they overlap with Case Management, ES, and Skill Building.

-RSB activities listed (section 3.3) include on site and off site support at a community business worksite, and then later in the document it says that “staff presence in the workplace  to assist with supervision or teaching of routine work duties is not reimbursed". This seems contradictory

-The note requirements seem to be more in line with the way Residential/skill building does the notes, which will be a big change from how they are now, where we write monthly progress notes that are more generalized on how they are making progress

- Very concerned about not being able to serve clients who also have ACT. Sometimes they need both. ACT is therapeutic, and clubhouse is not intended to be so. 

-With the requirements dictated by this and the CPST, the intake assessments must be way more thorough than they are right now. If we have to create authorizations within one day (currently we have a week window), and have the assessments completed prior to enrollment, rather than as part of our enrollment process, we will need them to be incredibly detailed. This also puts a higher burden on the intake therapists to have detailed knowledge of the clubhouse program in order to understand how to word the assessments.

-“Any observation without an intervention is not a billable activity” Does this mean that we cannot bill for someone who comes to the program and doesn’t interact directly with staff? Sometimes, when dealing with SMI, a person is making progress just by showing up. Currently our program has 85 members, running around 30 ish people a day. How are we supposed to fit two specific billable activities in for every person in 8 hours? Clubhouses are supposed to be member run. Does this mean that if a member is doing things on their own without staff support that we cannot bill?

-Maximum member to staff ratio of one staff for 15 members- we are already pushing it with 7 staff and 85 members. We would not be able to increase our membership without increasing staff. However, these policies seem to be pushing for a smaller program in general. It would be very difficult to bill for all 30 ish people in one day if we can only bill for direct interactions, not just observations.

- Diagnostic Criteria: What are “related disorders”? Does that include Anxiety, Depression, and PTSD? Requiring the extra physician documentation to be included in the authorization seems excessive.

- The included chart on page 7 is confusing. Is this just an example? Right now we can bill max 360 units per six month period, but the example shows only 240 units a year.

- Section 9: It states that one unit of service is one day. Currently we get 3 units per one day per person.

- The very first clubhouse standard is that membership is without time limits, and yet it appears that the MCO’s want to limit the time a person is enrolled. This is contradictory.

-There is a standard ( standard 25) that supports in house education opportunities, and yet that is on the list of non- billable activities.

• Prohibiting clubhouse participation for individuals who are also enrolled in ACT is a major concern since it excludes a population that currently benefits from clubhouse involvement.
• The statement that “observation without intervention is not billable” would prevent billing for members who attend but do not interact—such as those who rest, keep to themselves, or have low-engagement days—potentially excluding individuals who rely on the clubhouse as a safe, therapeutic environment.
• The policy appears to conflict with the foundational clubhouse principle that membership is without time limits, while MCOs seem to push for time-limited enrollment.

• Several Required Service Components appear to duplicate activities already covered under Case Management, Employment Services, or Skill Building, creating ambiguity about what is distinct or reimbursable within the clubhouse model.
• RSB activity descriptions are inconsistent: the policy lists on-site and off-site support at community business worksites, but later states that staff presence at workplaces to supervise or teach routine duties is not reimbursable.

• The proposed note-taking requirements resemble those used in residential or skill-building services, representing a major shift in how clubhouse documentation is currently done.
• Intake and assessment expectations under both this policy and CPST requirements would require far more comprehensive assessments completed before enrollment and authorizations created within a single day—shorter than the current one-week window.
• Requiring additional physician documentation for diagnoses (including unclear “related disorders”) to be included in authorizations is viewed as excessive.

• The maximum staff-to-member ratio of 1:15 is unrealistic for programs already operating near capacity (e.g., 7 staff for 85 members) and would limit growth unless staffing expands—an expensive and impractical requirement.
• If billing is allowed only for direct intervention rather than general presence or support, it would be very difficult to meet billing expectations for large daily attendance (e.g., 30 members present).
• Non-billable categories include in-house educational opportunities, despite clubhouse standards (e.g., Standard 25) explicitly supporting such programming.

• The chart on page 7 is unclear: current policy allows 360 units per six-month period, but the example shows only 240 units for an entire year, creating uncertainty about intended limits.
• Section 9 defines one unit as one day, while current billing allows three units per day, suggesting a major reduction in reimbursable service.

Comparing the DMAS manual and the Clubhouse model, there is major Incongruence, one of which is that MCOs dictate the length of stay, which directly conflicts with the requirements of this "evidence based" model.   Please follow through on the feedback from Clubhouse International, so they will be a model that is effective for members. 

I have been with the ACT team for 7 years and have seen the importance and progress of some of our folks who do not like to interact with us, let alone others in the community.  ACT and Clubhouse staff coordinate and I have personally seen HUGE growth in reducing psychiatric symptoms.   I have also observed individuals who isolate, be able to slowly open up to other members and staff at the Clubhouse.   I read that observing individuals without actually providing an intervention is not billable and I understand that to give money for something that does not seem anything is happening seems wasteful.   I am not about wasting funding, however I will say that often times, an individual with a SMI often has difficulty with interacting with others.   Sometimes just them coming to the clubhouse is a win.  It is an intervention to leave someone alone and just observe them in this social environment, especially if you are aware of their difficulty in interacting with others.  I think that not allowing ACT individuals to participate in Clubhouse would be counterproductive, causing an increase in psychiatric symptoms for many of our individuals, costing even more for possible hospitalizations.  

Summary of Concerns Regarding Proposed Clubhouse Service Requirements

Exclusion of Members Who Receive ACT Services

•  Clubhouse participation is being restricted for individuals who also receive ACT services. 
• This is highly concerning, as many members benefit from both supports simultaneously.
• ACT is explicitly therapeutic and clinical, while Clubhouse is non-clinical and rehabilitative; the two services are fundamentally different and often complementary.
• Excluding ACT recipients removes access for a population already thriving in the Clubhouse setting.

Contradiction Regarding On-Site/Off-Site Support at Community Business Worksites

• The document states that Clubhouses may provide on-site and off-site support at community business worksites.
• However, it later states that "staff presence in the workplace to assist with supervision or teaching of routine work duties is not reimbursed."
• These statements conflict: supported employment inherently requires staff presence, guidance, and teaching.
• This contradiction creates uncertainty and makes implementation nearly impossible.

Diagnostic Criteria and "Related Disorders"

• The use of the term "related disorders" is unclear and undefined.
• It is unknown whether this category includes common and highly prevalent conditions such as Anxiety Disorders, Depression or PTSD.
• Requiring additional physician documentation for authorization - especially when diagnoses are already established - seems excessive and may delay access to needed services.

Contradiction with Clubhouse Standard: Membership Without Time Limits

• The foundational Clubhouse standard states that membership is voluntary and without time limits.
• However, MCO requirements appear to impose time-limited enrollment or periodic reauthorization expectations.
• This conflicts with the international Clubhouse model and undermines core principles of continuity, belonging, and long-term community support.

Non-Billable Time and "Observation Without Intervention"

• The rule that "observation without intervention is not billable" would prevent billing for members who:
  • attend but do not actively engage,
  • rest,
  • keep to themselves,
  • have days of low energy or low participation.
• Many members rely on the Clubhouse as a safe, stabilizing, therapeutic (though non-clinical) environment, even when not actively producing work.
• This requirement would unintentionally exclude the very individuals who need the Clubhouse most.

Non-Billable In-House Educational Opportunities

• The proposed guidelines categorize in-house educational programming as non-billable.
• This contradicts official Clubhouse standards (e.g., Standard 25), which emphasize member access to in-house and community-based educational opportunities.
• Education is a key component of rehabilitation and recovery within the Clubhouse model.

Restriction on Concurrent Clubhouse and Community Stabilization Services

• Members are prohibited from receiving both Clubhouse and Community Stabilization services.
• This exclusion may prevent individual from receiving stabilizing supports that help them recover from crises and transition back into routine participation.

1. Exclusion of Members Who Receive ACT Services

• Clubhouse participation is being restricted for individuals who also receive ACT services.
• This is highly concerning, as many members benefit from both supports simultaneously.
• ACT is explicitly therapeutic and clinical, while Clubhouse is non-clinical and rehabilitative; the two services are fundamentally different and often complementary.
• Excluding ACT recipients removes access for a population already thriving in the Clubhouse setting.

2. Contradiction Regarding On-Site/Off-Site Support at Community Business Worksites

• The document states that Clubhouses may provide on-site and off-site support at community business worksites.
• However, it later states that “staff presence in the workplace to assist with supervision or teaching of routine work duties is not reimbursed.”
• These statements conflict: supported employment inherently requires staff presence, guidance, and teaching.
• This contradiction creates uncertainty and makes implementation nearly impossible.

3. Diagnostic Criteria and “Related Disorders”

• The use of the term “related disorders” is unclear and undefined.
• It is unknown whether this category includes common and highly prevalent conditions such as Anxiety Disorders, Depression, or PTSD.
• Requiring additional physician documentation for authorization—especially when diagnoses are already established—seems excessive and may delay access to needed services.

4. Contradiction with Clubhouse Standard: Membership Without Time Limits

• The foundational Clubhouse standard states that membership is voluntary and without time limits.
• However, MCO requirements appear to impose time-limited enrollment or periodic reauthorization expectations.
• This conflicts with the international Clubhouse model and undermines core principles of continuity, belonging, and long-term community support.

5. Non-Billable Time and “Observation Without Intervention”

• The rule that “observation without intervention is not billable” would prevent billing for members who:
• attend but do not actively engage,
• rest,
• keep to themselves, or
• have days of low energy or low participation.
• Many members rely on the Clubhouse as a safe, stabilizing, therapeutic (though non-clinical) environment, even when not actively producing work.
• This requirement would unintentionally exclude the very individuals who need the Clubhouse most.

6. Non-Billable In-House Educational Opportunities

• The proposed guidelines categorize in-house educational programming as non-billable.
• This contradicts official Clubhouse standards (e.g., Standard 25), which emphasize member access to in-house and community-based educational opportunities.
• Education is a key component of rehabilitation and recovery within the Clubhouse model.

7. Restriction on Concurrent Clubhouse and Community Stabilization Services

• Members are prohibited from receiving both Clubhouse and Community Stabilization services.
• This exclusion may prevent individuals from receiving stabilizing supports that help them recover from crises and transition back into routine participation.
• For many, Clubhouse involvement is itself a stabilizing factor; restricting access during or after crises is counterproductive.

Overall Impact

Collectively, these proposed requirements risk narrowing access, contradicting established Clubhouse standards, and creating barriers for members who depend on flexible, recovery-oriented supports. They may inadvertently exclude individuals with the highest needs—those who benefit from the combination of community, structure, education, and rehabilitative engagement that Clubhouses provide.

It is concerning that the draft Clubhouse regulations exclude Assertive Community Treatment for individuals receiving Clubhouse services. SAMHSA's National Outcome Measures (NOMs) include social connectedness as a key indicator of recovery, assessing how individuals are connected to their communities. Many individuals who meet criteria for ACT services require intensive case management support precisely because they struggle with community integration and social isolation—the very issues that Clubhouse is designed to address. For these individuals, the structured social environment of Clubhouse provides essential opportunities to build meaningful connections and develop recovery-supporting relationships. Excluding ACT recipients from Clubhouse services removes a critical recovery support for some of the most vulnerable individuals in the system.

Recommendation: Retain the current structure that allows individuals to receive ACT and PSR/Clubhouse concurrently, with strict guidance to avoid overlapping billing.

Section 4.3 states that CARF-accredited Community Integration programs (accredited before 1/1/2026) are not required to obtain Clubhouse International Accreditation but are encouraged to complete trainings.

Provide clarity: Does this language mean that while these programs are exempt from obtaining Clubhouse International Accreditation, they are still required to align their service delivery and program design with Clubhouse International standards?

I appreciate DMAS’ continued efforts through Right Help, Right Now to expand recovery focused, evidence based behavioral health services across Virginia. The development of Medicaid-funded Mental Health Clubhouses represents a meaningful step toward social connection, vocational skill building, and long-term community integration for individuals living with serious mental illness.

However, I am deeply concerned about the proposed exclusion of individuals receiving Assertive Community Treatment (ACT) from Clubhouse eligibility. This limitation is not aligned with clinical reality, community need, or the goals of the redesign initiative.

ACT serves Virginians with the highest level of psychiatric, medical, social, and functional impairment, often those most isolated, unemployed, unstably housed, or disconnected from supportive community roles. These are precisely the individuals who would benefit most from the structured work-ordered day, peer relationships, empowerment model, and vocational pathways that Clubhouses provide.

Excluding ACT members creates several unintended yet predictable consequences:

• It restricts access to rehabilitation and recovery, keeping ACT clients clinically stable but socially and vocationally stagnant.
• It increases long-term system costs, as individuals remain dependent on intensive services without opportunities to step down successfully.
• It undermines continuity of care, forcing ACT teams to choose between medical stabilization and psychosocial rehabilitation rather than integrating both.
• It places cities and local safety-net systems at risk, as lack of community connection increases risk for homelessness, incarceration, crisis utilization, and emergency service spending.
• It contradicts recovery-oriented treatment models, which prioritize autonomy, identity, purpose, and meaningful roles—core goals shared by both ACT and Clubhouse services.

Clubhouses are not duplicative of ACT, they are complementary. ACT is clinical, mobile, and medically focused. Clubhouses are member-driven, community based, and vocationally oriented. Together, they create a full continuum that increases the likelihood of sustainable independence, employment, and reduced reliance on publicly funded systems.

If the goal of Right Help, Right Now is not only stabilization but transformation, then Virginia should incentivize, not prohibit the pairing of ACT and Clubhouse participation for those who would benefit.

I respectfully urge DMAS to remove the categorical exclusion of ACT participants and allow clinical discretion, person centered planning, and managed care oversight to determine appropriateness. Doing so supports clients, strengthens communities, and represents a fiscally responsible investment in long-term recovery.

Thank you for the opportunity to comment and for your ongoing commitment to improving behavioral health services across the Commonwealth.

If the Clubhouse International model is intended to be a long-term maintenance service and set to be in line with a lifetime member why then is there focus on  ‘expectations of improvement’ to move towards discharge?  Often, what appears outwardly to be stagnation or ‘lack of progress’ is actually just a normal manifestation of their recovery and maintenance. Sometimes the recovery is linear and steady, and other times the recovery has setbacks etc. As we saw with Covid, without those ongoing daily and long term supports for our members, they experienced serious setbacks and were unable to maintain previously held gains.  With serious mental illness we know that progress is made in the long term, supported by daily interventions and repetition of skills, knowledge or practice that take years to achieve.  As has been shared previously, sometimes just the member’s act of showing up to the program is a marker of progress. Other times a significant marker of progress is that they have not had an inpatient psychiatric hospitalization in years.  We need this service to acknowledge the long term, persistent, functional deficits that our members face and to provide a service that dedicates itself to the slow and steady battle of recovery and maintenance.

Please clarify “The assessment shall be conducted by a LMHP, LMHP-R, LMHP-RP, or LMHP-S in person with the member, in the member’s home or another location of the member’s/family’s choice.” Must the assessments (initial/renewal) be completed off site of the Clubhouse?

This part of the draft states, “Members with diagnoses that fall outside of these categories may be eligible depending on the level of associated long-term disability; in these cases, a physician letter (documentation from a physician) justifying this exception should accompany the service authorization request.”  This is an unnecessary request. The state of Virginia authorizes and grants trust and autonomy to LMHP’s to make quality decisions regarding a member’s diagnosis as well as the associated level of disability and functional impairment stemming from their SMI. Additionally,  DMAS requirement to have the LMHP trained in Clubhouse International would further exemplify the LMHP’s expertise and knowledge of who is  and who is not appropriate for the service. Asking for a doctor who is completely removed from the ideology of the Clubhouse and who may or may not know the member well (if at all)  and having them make a recommendation for specific service is unnecessary and will only result in delayed  access to services. 

Please clarify diagnoses eligible for the service or specify which ones do not qualify.

I urge you to reconsider some of these non-authorized concurrent services, specifically but not limited to Coordinated Specialty Care. I understand that some of the CSC members are under 18, so developing a caveat that CSC members 18 and older would be eligible is a reasonable request. I believe  (and have seen in many member cases) that the CSC population is an exceptional category of individuals who benefit from the various Clubhouse (as it stands) programming. The CSC population in general present with difficulty in educational and vocational arenas including disruptions in school, dropouts,  as well as issues establishing and maintaining employment. Clubhouse International standards indicate supports and services for not only a work- ordered -day that would allow these young members to learn how to build a routine but also gain access to employment and educational supports all within house. Many of the CSC population are socially isolated, having withdrawn from many previous social life aspects because of their symptoms. Having access to a supported environment such as  a Clubhouse that offers social opportunities for reestablishing or forming new natural supports would only strengthen member recovery. Having both services (CI and CSC) would be a substantial support to aid our struggling youth in their long road of recovery.  Additionally, the disallowance of the other services such as ABA, ARTS, COMM STAB, FFT, MST, etc… , does not support the idea of long- term recovery and maintenance of serious mental illness. Many of our members will likely need and benefit from these types of service episodes throughout their lives.  It would be better for the members and payors to allow these services as needed in order to keep the member in a lower level of care, with the goal being to reduce the burden on hospitalizations and crisis services.  These services need to be on a continuum of care- ongoing, as needed and throughout the duration of the illness and not as separate isolated services. We know our members often need a variety of wrap around services to maintain community tenure, out of a hospital level of care.

Also, I believe in the CPST draft, it excluded Clubhouse programs. This would certainly be a disservice considering how little of actual face- to -face billable time a recipient of CPST will be receiving.  A member would likely have a great routine with a combination of both CPST and Clubhouse. Currently, there are many members who benefit from the group aspect of Clubhouse and the individual aspect of MHSS. These programs have worked extremely well for years together, and we’ve seen the things a member is attempting to learn in one service, they are able to then practice that skill in the other service until they can generalize it to their everyday life. This allows for opportunities for normalization of skill sets in variable environments.

Please clarify the statement “any observation without an intervention is not a billable activity”.

This part states that ‘skills training related to a specific job and staff presence in the workplace to assist with supervision or teaching of routine work duties’ is excluded. This is contradictory to the Clubhouse International Standards and school of thought around Transitional Employment (TE) where the staff are expected to teach side by side how to do specific tasks within the TE placement. While this may not be consistently needed as the member learns the job task,  it is at least initially required.  Please review specifications of Transitional employment vs supported employment.

“Onsite educational support” is listed as a non-reimbursable activity. This seems confusing since a core focus of a Clubhouse International is Educational Opportunities. If the Educational piece is listed as active on the member ISP and the member is making attempts to progress on this goal, why then would their actually receiving the onsite support not be billable?

This part states, “…members are assured that their participation is fully voluntary.” Please clarify this statement. Does this mean members who are NGRI or MOT, for example, cannot be mandated to participate in this service? There are currently many members who are on a conditional release or MOT plan whose participation is court -ordered, or is this referring to voluntary participation in offered aspects of the clubhouse, such as which units they want to participate in for the day? If their participation is voluntary, then one assumes they can come to the program and choose not to participate in any activity. Perhaps they are symptomatic and unable to do so. If so, would just their presence at the program be billable?

The reimbursement rate for the Clubhouse programs is too low. The result will be that Clubhouses will not be able to sustain themselves. Many of the programs in the rural communities of Virginia with limited benefactors and donor pools will not be able to market and fundraise effectively enough to maintain operation costs. The outrageous costs of the Clubhouse International trainings is yet another burden that many agencies cannot afford. For example, sending one LMHP, one Program Director and One Member for the two-week training is estimated to cost in the neighborhood of  $5,000-$7,000 and this is not a fully encompassing cost list. Additionally, the staff to be trained are expected to leave their current employment for two full weeks of training. With many programs already struggling with staffing, this would put an excessive burden on remaining staff. What happens if these trained staff no longer work for the program? Is the program then responsible for training another round of staff for thousands of dollars? Would services be considered non-billable until other staff completed training?  Another cost that providers must fund is the annual dues to Clubhouse International.

The burden of having to create an employment program (transitional and supported) in the CI model is out of the scope of and excessive for this program and the population. Many of the members within the program are either not capable due to disability or don’t desire to have full employment but do enjoy and benefit from the side-by-side work ordered-day tasks they are able to complete. Many of the CSB’s already have some type of employment programs that are offered to the members,  and having two separate employment programs within a CSB would create competition issues within already scare community resources. Furthermore, in these rural areas (which is most of Virginia) finding a suitable employer within four years who is willing to establish such a relationship is markedly unobtainable. Additionally, this model does not account for other barriers such as transportation.  As DMAS has repeatedly been made aware, our members’ main complaint is the lack of adequate, affordable, and readily available transportation. These issues are exacerbated in our rural communities. Most areas where Clubhouse’s would serve are rural and do not have access to public transportation that would be available for the hours of which members may be employed and with such limited staffing ratios, Clubhouse staff would be unable to ensure transportation.

I urge DMAS to consider a couple of things.  Please consider allowing more than one option for accreditation beyond Clubhouse International. Current Clubhouse/PSR services are such a vital part of community-based recovery, and they deserve to have a selection of options to choose from that best fits their population and demographics. Clubhouse International may work well for some agencies in more urban and well-funded areas, but CI’s are likely to struggle in rural areas due to the inherent design of the program. Having only one accreditation option for a long-term program is such a disservice and does not align with social work values of service, social justice and dignity and worth of the person.  Please explore other options for PSR programs to serve members long term beyond Clubhouse International as it will not benefit all of our current members as it stands.  Options should be explored that can combine the best aspects of several different services to manufacture a program that delivers psychiatric rehab through a service of excellence and flexible options.  Many current Clubhouses already excel at providing a work ordered day and psychoeducational opportunities that allow members to work on their recovery in a fully holistic manner. These programs additionally offer socialization efforts to combat limited natural supports and isolation, along with community integration opportunities that allow members to live and thrive as an active member of their community, and they do this all without the restraints of CI accreditation. There are other options.  There must be flexibility allowance to these programs so they can grow with and change as needed to serve their members. Many CSB’s already have services in place to combat housing and employment needs. Adding a service that duplicates these aspects while reducing the importance of discussing mental health symptoms/behaviors seems to be a disservice to our members and creates competition for already scare community resources. Members benefit from the insight building they receive from PSR Services to help them understand their mental illness/symptoms/stressors and generally lack services and supports that assists with this. 

According to Clubhouse International is a membership organization, and the people who come and participate in a Clubhouse are its members. Membership in a Clubhouse is open to anyone who has a history of mental illness. This is not conducive to a managed care environment or aligned with the policy proposed by DMAS which restricts admission based on severity of illness and functional impairments. 

The proposed DMAS policy's are not aligned with Clubhouse International's philosophy of "It is designed to be a place where a person living with mental illness is not treated as a patient and is not defined by a disability label" and "the design of a Clubhouse is much like a typical work or business environment, relationships develop in much the same way. The role of the staff in a Clubhouse is not to educate or treat the members. The staff are there to engage with members as colleagues in important work and to be encouraging and engaging with people who might not yet believe in themselves. Clubhouse staff are charged with being colleagues, workers, talent scouts and cheerleaders"

Please consider CARF accreditation as an on going alternative. 

When the office hours call ended on November 5^th, it was the first time there was a slight sense of relief about the BH Redesign.  During that call it was announced clubhouse draft policy would be forthcoming but prior to, visits would be made to clubhouse programs around the Commonwealth.  This was seen as an attempt to right a wrong, which was putting the cart before the horse.  However, when the draft policy was posted a week later,  knowing that few, if any, clubhouse visits could have occurred, the initial sense of relief that was felt was lost.   Clubhouse visits should have happened long before now, prior to the initiation of the BH redesign, and certainly before writing policy to redesign and gut the program.   Clubhouse serves members with severe, chronic, and debilitating mental illness.  The mere task of getting out of bed in the morning and going to the clubhouse program is all some can do.  It has taken years for some to regain skills they once had but lost due to service disruption during Covid.   Ending psychosocial rehab on 6.30.2026 would be a tragedy.  Clubhouse offers a very slow chip away at chronic, and in most cases, lifelong psychiatric illness.  Members have a sense of belonging and community because of clubhouse.   After Covid, many members had to relearn skills they once had mastered, due to lack of ongoing education, consistent repetition, and implementation and practice of skills.  Therapy is a wonderful service, but without an environment, such as clubhouse, to try out skills taught in therapy, the intervention falls short.    Members sometimes need years to buy into clubhouse and transition into acceptance of their illness.  Members need a chance to be educated about their illness, symptoms, early warning signs, and this takes time.  Progress is slow BUT it is evident.  Many of our clubhouse members have been able to, with wrap around supportive services, avoid rehospitalization for DECADES.  If this draft policy is implemented there will be many clubhouse programs throughout the Commonwealth that end, and members will be left with no additional wrap around services outside of case management and crisis services.  Case management and crisis services are wonderful services, but members have demonstrated for years they need more intensive services and intervention than what case management and crisis services offer!    Many current clubhouse programs as they are, cannot afford CI training.   In addition to the upfront costs for CI training, and annual CI fees, reimbursement rates for CI are less than current clubhouse reimbursement rates, leaving CI as an unfeasible option.   For current members, whose clubhouses are slated to end 6.30.2025, what options will they be left with?  This feels like we are cutting members loose without appropriate resources to meet their needs, and this is very unsettling.   We do not want to see history repeat itself.   Psych hospitalization rates will certainly be on the rise if clubhouses close.  Psychiatric hospitalizations costs more per day than psychosocial rehab.   I sincerely request another option for clubhouse be considered other than CI.   

• Clubhouse participation is being restricted for individuals who also receive ACT services.
• This is highly concerning, as many members benefit from both supports simultaneously.
• ACT is explicitly therapeutic and clinical, while Clubhouse is non-clinical and rehabilitative; the two services are fundamentally different and often complementary.
• Excluding ACT recipients removes access for a population already thriving in the Clubhouse setting.

• The document states that Clubhouses may provide on-site and off-site support at community business worksites.
• However, it later states that “staff presence in the workplace to assist with supervision or teaching of routine work duties is not reimbursed.”
• These statements conflict: supported employment inherently requires staff presence, guidance, and teaching.
• This contradiction creates uncertainty and makes implementation nearly impossible.

• The use of the term “related disorders” is unclear and undefined.
• It is unknown whether this category includes common and highly prevalent conditions such as Anxiety Disorders, Depression, or PTSD.
• Requiring additional physician documentation for authorization—especially when diagnoses are already established—seems excessive and may delay access to needed services.

• The foundational Clubhouse standard states that membership is voluntary and without time limits.
• However, MCO requirements appear to impose time-limited enrollment or periodic reauthorization expectations.
• This conflicts with the international Clubhouse model and undermines core principles of continuity, belonging, and long-term community support.

• The rule that “observation without intervention is not billable” would prevent billing for members who:
  • attend but do not actively engage,
  • rest,
  • keep to themselves, or
  • have days of low energy or low participation.
• Many members rely on the Clubhouse as a safe, stabilizing, therapeutic (though non-clinical) environment, even when not actively producing work.
• This requirement would unintentionally exclude the very individuals who need the Clubhouse most.

• The proposed guidelines categorize in-house educational programming as non-billable.
• This contradicts official Clubhouse standards (e.g., Standard 25), which emphasize member access to in-house and community-based educational opportunities.
• Education is a key component of rehabilitation and recovery within the Clubhouse model.

• Members are prohibited from receiving both Clubhouse and Community Stabilization services.
• This exclusion may prevent individuals from receiving stabilizing supports that help them recover from crises and transition back into routine participation.
• For many, Clubhouse involvement is itself a stabilizing factor; restricting access during or after crises is counterproductive.

I question the adoption of the Clubhouse model for all PSR programs.  As stated in “A Systematic Review of Evidence for the Clubhouse Model of Psychosocial Rehabilitation”  Administration and Policy in  Mental Health and Mental Health Research,  2016 Aug 31;45(1):28–47.

 “Clubhouses are a promising practice and the research supporting Clubhouses is growing, but additional studies are necessary to provide a clearer and more contemporary basis for evaluating the Clubhouse Model.”

Further; “Many of the existing services or programs have yet to be thoroughly investigated making it impossible to know which have the best outcomes. Unless these programs are included in research, stakeholders have no scientific way of knowing how these programs compare to existing EBPs. These models may risk elimination because of a lack of empirical research as opposed to a lack of effectiveness.”

Simply because a few studies have been published does not make Clubhouse evidence the premier evidence based program;  especially since other PSR models in the state have not been assessed for overall effectiveness.  It may very well be that existing PSR programs are as good as or better than Clubhouse.

The Clubhouse model offers a significantly lower reimbursement rate than current PSR services. Furthermore, it requires significant investment from the CSB - staff have to be trained (and trained again when staff leave and new ones are hires), program must be accredited, a medical director has to be identified as part of the model at a time where psychiatric availability is already extremely limited. In addition to all that, there is no easy way to participate in this long-term training while the same staff still have to tend to current clients. It would be great to know about some viable alternatives to this model - what else was considered and why was it not chosen? If not Clubhouse or PSR, are there other services that can be considered as an alternative?

Please find our concerns and needed clarifications on the Mental Health Clubhouse Services (Clubhouse). Thank you.

Concerns:

-Limits on certain service lines and housing situations impacting qualification to participate with the service when The Clubhouse Model is defined as open to any person experiencing mental illness (Assertive Community Treatment and Sponsored Residential limits will impact approximately 1/3 of those currently attending.) These individuals will lose social supports currently in place.

-Limits on qualifying diagnoses without letter from physician could potentially impact approximately ½ of those currently attending. Would it be possible to consider expanding eligible diagnoses to those listed in definition of serious mental illness as well as those with significant trauma history without requiring documentation from physician?

-Navigating various regulations/requirements (DMAS, CCBHC, Licensure, Agency, Authorizations, etc.) in addition to International Clubhouse accreditation standards when regulations don’t fully align.

-Barriers with developing supported/independent employment and housing resources in a rural area with limited funding and transportation.

-International Clubhouse training requirements and how this relates to staff position changes (turnover, transitioning positions, etc.). If there are turnovers, is the expectation that new staff get the training. This is very costly ongoing.

-Staffing concerns related to acquiring/retaining employees with the additional expectation of weekend/holiday/evening program, disruptions to routine to accommodate additional programming, and how this will impact the budget (for example compensating for holiday pay, having on-call staffing if needed, facility expenses for additional days)

-Concerns regarding when consensus-based decision may not be appropriate and may require alternative decisional making processes (such as behavioral issues, following program rules/expectations, functional/cognitive limitations); how to navigate consensus-based decision if no agreement and this results in conflict.

-Privacy concerns related to outreach and discussing other client concerns in a group setting.

-Shifting focus to employment/housing will impact those who currently access the program for additional wellness skill development. This shift in focus will change the current structure and focuses on what may be important for an individual when other skill development may be more important to the individual.

Clarification:

-More information related to separate advisory board and expectations for this.

-What qualifies as the at least 2 required activities that allows for billing (for example: access to community/employment/educational resources, educational groups on psychosocial topics-interpersonal skill development, individual interventions, mental health management, physical health/wellness education, assisting with tasks at center, art activities, volunteerism related to special events/activities)

-Information related to frequency of holiday, evening, and weekend programming. Capacity limits for special programs and how to determine who is able to attend.

-Social activities outside of work ordered day will impact those who are not able to attend on weekends/evenings/holidays and would like to participate in social aspects of the program to further develop interpersonal skills as part of the daily program structure. Are social activities not allowed to be counted outside of weekend and evening hours?

-What is the expectation as far as housing needs in comparison to what would typically be coordinated with other service providers?

-How much focus is being placed on employment/housing versus additional mental health management aspects.

-Is there specific curriculum to support with guiding RSB activities or is this developed by the program members/staff?

-What is the expectation for employment outcomes and does skill development at the program meet this criterion (such as volunteering for tasks, assisting with food preparation/clean-up, etc.).

-What is considered reimbursable as far as off-site employment skills training at community business worksites?

-Can a staff who didn’t perform a specific intervention still document in a group program where multiple staff are interacting with members throughout the day if the staff documenting is on-site.

-Crisis plans-will this need to be specific to the program, or can this be developed with the treatment team and applied at the program?

2. Service Definition/critical features

• “The Clubhouse has its own physical space that is observervably separate from mental health center/institutional settings and does not include ‘staff only’ spaces”. While all other areas of the clubhouse building can easily remain open to both members and staff, the removal of staff offices would extremely hinder staff’s ability to complete many of the requirements outlined in this draft. The completion of daily documentation, authorizations, ISPs, CNA’s, etc, requires a designated space in order to be completed in a timely manner and in a manner that is compliant with HIPAA.
• “… including holding clubhouse meetings that are open to members and staff.” While our clubhouse currently holds several daily meetings that are co-run by members and staff, our staff do need to be allowed space and time to discuss the milieu and any concerns that may be protected by HIPAA. Being collectively aware of any changes to a members behavioral, mental, or medical health is essential to providing competent care and it would not be appropriate for other members to be a part of these conversations.

3. Required Service Components

• 2. “Assessments shall be conducted… in person with the member in the member’s home or another location of the member’s/family’s choice”. We are not a home-based program like ACT. We provide services within our program’s building, and the members would be receiving those services within the program’s building. It would not be appropriate or viable to send staff to clients’ homes to complete an assessment for a service that would only be provided at a designated location. Our staff are not trained to complete in-home care and our current staff shortages would not be able to accommodate this.  

4. Provider Qualifications Requirements

• “The maximum staff-to-member ratio shall be one staff to 15 members”.  A ratio of 1 staff to 15 members would not be viable to run our program. I truly believe this would result in the closing of our program, and likely many others. This number does not reflect or consider the number of staff needed to maintain a reasonable workload and keep the program running as the program/building is separate from other services, as it is required to be by these standards.  A program/building must be adequately staffed to ensure coverage for staff who are on lunch break, out sick, on vacation, in the process of being hired or trained, etc. With a membership of around 45, we would be allowed 3 staff members max. This would not be an adequate number to complete daily tasks, even with member participation. It definitively would not be an adequate number of staff to complete the clinical daily tasks, which members cannot complete on behalf of staff (ISP, ASSESSMENTS, SKILL BUILDING, CARE COORDINATION, CRISIS SUPPORT, ETC) or to safely address any mental health crisis concerns as they arise, which they frequently do with the population we serve.
  • In the event that one staff member quits (which is an inevitable part of any program or agency), how will two staff members run a program in the meantime? They would not be able to have vacation days, sick days, or breaks. Furthermore, the basic operations of the program would simply not be manageable, even with equal participation from members.
  • Under these requirements, to be a billable service, each member must receive at least two billable interventions and have detailed documentation on both. At a ratio of 1 to 15, a single staff member would be responsible for providing at least 30 billable interventions within a day and complete documentation on those 30 interventions. In a 5-hour period (which DMAS has set as the daily requirement), that staff member would need to provide 3 billable interventions in each 30-minute period. This is without factoring in staff and member co-meetings, lunch periods in which members are provided a meal, or the unique circumstances that arise within the milieu setting (addressing conflict between members, assisting in task completion, managing mental health concerns as they arise, etc) This would have to be completed on top of any assessments, ISP’s, daily operations such as maintaining the building, etc). It would not be viable for the program to continue operating with a 1 to 15 ratio, even with equal member participation.

I believe every program should be able to decide how many staff is needed for their program, as the needs for each will inevitably be unique and only the organization is able to accurately determine what those needs are. If DMAS insists that a limit be set, I would suggest a foundational limit with additional incremental limits as needed. An example, for a client membership of 50 and below, 5 staff are allowed. For every additional 10 members after 50, 1 additional staff can be hired. That way if we are a smaller program or experience a smaller membership, we still have enough staff to keep the program open.

4.3 Provider Accreditation

• “Clubhouses must acquire and maintain clubhouse international accreditation”. Several of the DMAS requirements under this draft are in direct opposition to the standards outlined by Clubhouse International (CI). Fidelity to BOTH would pose an impossibility.

6. Exclusions and Service Limitations

• 9. Employment supports listed are not reimbursed

Again, these are requirements of the CI standards, and the CI standards highlight the “work-ordered day” and focus on employment as a main service offered by PSR. This would mean that the majority of our day-to-day operations would not be billable. How can a staff member offer 3 separate billable services, per 30-minute period, while also offering job-related skills training and job development to members AND provide community participation/presence with community employers?

• 10. Members receiving Clubhouse may not be authorized to receive the following services: Assertive Community Treatment.

We have several members that attend our program and receive ACT services. We often work collaboratively to help a mutual client receive care. It would be a disservice to require these high-need individuals to choose between two programs that benefit them differently.

8. Additional Documentation Requirements and Utilization Review

• 1 & 2: See concerns under 4 listed above. Unmanageable workload in consideration of the listed client to worker ratio, billable services requirement, and services required outlined by CI that are not reimbursable.
• 4: “An LMHP must review documentation of non-license staff at least every 30 calendar days…”. None of our direct staff are LMHP. Would this require our offsite program director to review at least one progress note per member or per staff each? If this is per member, that would require our program director to review over 40 progress notes every 30 days, which is excessive.

While the concerns noted are extensive, we as a program are excited for further investment in our PSR program and our continued growth toward expanding the quality of services we provide. I sincerely hope DMAS will carefully consider and respond accordingly to the concerns of the staff that have current and ongoing experience serving these communities and providing PSR. The current draft regulations combined with Clubhouse International Standards are unclear, incohesive, and in some areas not viable. We look forward to continuing to grow as a program to meet the growing needs of our community and we hope DMAS takes this unique opportunity to collaborate with PSR workers to enhance the services provided rather than hinder our ability to serve our communities.

-We have concerns regarding the transportation of individuals. We do not offer daily  transportation over holidays, weekends, etc. and we do not have readily available public transportation in our area. 

-The requirement to submit authorizations within one business day is an extremely tight turn around time, especially when we do not hear back from some MCO companies regarding an approval or denial in the 14 days that they currently have to respond. 

-The 24/7 crisis coverage that does not extend to our CSB emergency services program. The idea that QMHP staff will have to provide crisis response to members as opposed to deferring to the internal emergency services staff is an added layer that complicates the role of the QMHP within Clubhouse. We should be able to use internal supports like our emergency services staff in these situations. If we are not able to do this, we should be able to utilize peer support, with established guardrails in place. 

-The accreditation and training piece that is required is going to take time and money, which is going to be challenging considering how the billable rate for Clubhouse is being directly affected. 

-The revised hours of operation (including holidays) is unreasonable. We are limited from a staffing perspective and to expect staff to take time away from their families to provide Clubhouse services when historically we have been closed does not support good employee care or work/life balance. 

-The requirement to have a licensed staff review all notes monthly is an added administrative burden. 

-We would like clarity on what additional information will be required to submit from a physician when submitting authorizations? This will lead to additional time, making the one day turn around submission time extremely challenging.  

The following suggestions are based on how we operate as a CARF Accredited program that uses the tenants of the Clubhouse Model to lend structure to our services which are provided through evidenced -based practices. 

2. Service Definition/Critical Features

The Clubhouse has its own physical space that is observably separate from mental health center/institutional settings and does not include “staff only” spaces.

While our program has its dedicated space as defined, there are “staff only” spaces and locked parts of the building for privacy, security, and risk management purposes. 

3. Required Service Components

3.2 Service Planning

4. The ISP may be developed through a team approach and must be authorized and overseen by either the Clinical Director or Program Director.

Please remove “Clinical Director or Program Director”.  Allowing a LMHP, LMHP-R, LMHP-RP, LMHP-S to authorize and oversee the ISP is clinically appropriate.  This aligns with who may complete the assessment as well as the Board of Counseling regulations for QMHPs.  Many CSBs, including ours, already have an intermediate supervisory level with these credentials that do not require the clinical or program director to provide this oversight. 

3.3 Rehabilitative Skill Building (RSB)

2. RSB shall be provided in-person.

 Please consider use of telehealth as an exception and the following statement:   “RSB shall be provided in-person unless conditions for use of telehealth are met in Section 9.2 below”.

4. RSB in the context of short-term, transitional employment opportunities through relationships between the Clubhouse and local businesses

5. RSB that provides supported employment, including on-site and off-site support at a community business worksite.

Many CSBs offer specific supported employment services and are funded by DARs, not Medicaid; these services do not permit transitional employment as described in the Clubhouse model. The intent of the standard is to offer employment opportunities which can be accomplished through providing transitional employment opportunities or referral for supported employment services. Please consider the following statement to replace 4. And 5. : “4. RSB in the context of short-term, transitional employment opportunities through relationships between the Clubhouse and local businesses

OR coordination with, or referral to, supported employment services.

7. Social skill development activities assist in communication-skill restoration and community integration. These activities occur during evening, weekend, and holiday programming organized by members and staff outside of the work-ordered day.

 It is burdensome for CSBs, which are government agencies, to offer this schedule for clients if not already budgeted for such coverage. Our staff job descriptions do not include evening, weekend, or government holiday program coverage.  We are also sensitive to offering any holiday programming due to the diversity of the program clients (ie non-American, a variety of religious practices).  Please consider the following statement: “These activities may occur during evening, weekend, and holiday programming organized by members and staff outside of the work-ordered day.”

3.4 Crisis Support    

5. In person support must be offered and available.

Crisis support as described is a reasonable expectation as the services are provided in person and they are not expected 24/7. In the event of after-programming crisis, other CS Crisis Resources are already available.  

4 Provider Qualification Requirements

4.1 Clubhouse Staff Requirements

1. Licensed Mental Health Professional who holds a current, active and unrestricted, Virginia license from the Department of Health Professions that qualifies them as a LMHP with Clubhouse International training.

Please remove the training requirement as it suggests comprehensive Clubhouse International training would be expected even for those with CARF Accreditation.   This draft policy (4.3) already encourages training for CARF Accredited programs which can be met through Clubhouse International  (including development, comprehensive, specialized track, and webinars).  Those programs seeking Clubhouse International Accreditation would already be required to have this training.    

4.3 Provider Accreditation

Programs providing Clubhouse services who were Commission on Accreditation of Rehabilitation Facilities (CARF) accredited for the program “Community Integration” prior to 1/1/2026, are not required to obtain Clubhouse International Accreditation but are encouraged to complete trainings.

Thank you for recognizing CARF Accreditation! Rather than only “grandfathering in” those with a current CARF Accreditation, consider allowing CSBs to OPT IN to seek CARF Accreditation for “Community Integration”, using the same timeline as noted for other Redesign services.  This option will allow CSBs to choose the accreditation that best aligns with their operations while still following the tenets of the clubhouse model as listed in this draft policy.

4.4 Clubhouse Operation Requirements

1. Clubhouse providers shall follow all Clubhouse International Accreditation standards.

Please consider the following statement :  “Clubhouse providers shall follow all Clubhouse International Accreditation requirements unless they are CARF-Accredited”.   This will allow the CARF-Accredited programs to align with the model but follow their CARF accredited standards. 

2. The Clubhouse shall have an independent board of directors, or if it is affiliated with a sponsoring agency, it has a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support and advocacy for the Clubhouse.

Clarification: Consider allowing either an independent board of directors OR CSB Board of Directors to meet this requirement. We frequently share information with our CSB Board about the program, especially with regard to finances, accreditation surveys, audits, health department inspections, etc. To have another board would be a duplication of this work and potentially compromise or put in conflict the advisory process.

6. Exclusions and Service Limitations

9b. Staff presence in the workplace to assist with supervision or teaching of routine work duties.

This statement contradicts the Transitional Employment activities for the Clubhouse Model. As part of the chosen Clubhouse model, transitional employment services should be billable.  Clarifying that Supported Employment is not a reimbursable service, if it is receiving other forms of reimbursement (such as DARS) is acceptable here.

10. Members receiving Clubhouse may not be authorized to receive the following services: a. Individuals receiving Clubhouse may not receive the following services:

iii. Assertive Community Treatment,

iv. Coordinated Specialty Care,

Please consider whether disallowing authorization for ACT and Coordinated Specialty Care benefits the client; from a tiered- payment system this limit is understandable, however many programs concurrently serve these clients as part of supporting overall community stability.

7. Service Authorization (SA)

7.1 Preservice Authorization Request states that in order to have a completed authorization at the start of services, the initial assessment and the ISP must be submitted within one business day of admission; yet these documents currently have a 30 day period to be completed. The current manual (Sect IV p.20) notes “the FFS service authorization contractor and the MCOs have the discretion to request that providers submit the Comprehensive Needs Assessment for review”.    “For mental health services requiring service authorization, the medical record content must corroborate information provided to DMAS or its contractor” (Sect IV p. 25) .  Please keep this policy consistent with the current language in the manual (or new versions)  as we must follow the individual MCOs’ direction for submitting the authorization for PreService and Concurrent Requests. 

8. Additional Documentation Requirements and Utilization Review

1. The progress note must clearly document that the services provided are related to the members’ goals, objectives and interventions in the treatment plan, and are medically necessary and clinically appropriate.

Monthly progress notes, when written to include the necessary elements noted here are sufficient to demonstrate medical necessity and clinical appropriateness. Please do not require this documentation to occur more frequently than monthly.

2.e. The only staff who may complete a progress note is the staff who delivered the service. It is not permitted for a staff to deliver the service and another staff to document and/or sign the progress notes.

 As most programs provide multiple activities in a milieu/ team approach within the month the progress note covers, this requirement is confusing. Currently, we have each staff write the monthly progress note for their assigned clients with input from the team.  Please delete this requirement or clarify further.

4. An LMHP must review documentation of non-licensed staff at least every 30 calendar days as evidenced by a progress note in the member’s chart written by the LMHP or a co-signature on the non-licensed staff’s progress notes. Non-licensed staff include LMHP-Rs, LMHP-RPs, LMHP-Ss, QMHPs, QMHP-Ts ,RPRSS and BHTs.

This will be a burden for those programs who have few LMHPs on staff. Our ISPs are cosigned by an LMHP at least q 90 days with the review, this seems sufficient to review the non-licensed staff documentation.

9. Clubhouse Billing Requirements and Information

1. One unit of service is one day.

This is one of the best parts of this draft policy! Thank you- this will save countless hours of double- checking billing practices.

2. To bill the per diem unit, members must receive a minimum of two required activities on the day of service. At least one of the required activities shall be in-person.

Please consider a Telehealth option when the program is experiencing unusual circumstances. This is supported by the Clubhouse International Model.   We have found during inclement weather, pandemic, etc the use of Telehealth services promoted client engagement when the physical space was temporarily unavailable.  Please consider the following statement:  “ To bill the per diem unit, members must receive a minimum of two required activities on the day of service. At least one of the required activities shall be in-person. 

In extenuating and time-limited circumstances (inclement weather, building power outages, risk for health-related outbreak, etc)  telehealth services may be provided temporarily but require at least one face- to- face activity in order to bill the per diem unit.”

Thank you for considering these comments/suggestions.

At the October VACSB meeting, it was stated that CSBs would have the option to choose between CARF accreditation OR Clubhouse International given the costly nature of training and accreditation for CI. The email sent following one of the provider calls, at the request of DMAS, which detailed the required training was the impetus for making the decision to provide choice to CSBs.  This provided great relief!  Upon publishing of the draft regulations, the option for CSBs to choose between CARF or CI is no longer made clear but, rather, only CARF is an option if the CSB is already CARF accredited.  CSBs need to have the option to pursue the path that best fits their program philosophy and budget needs. 

Section 2

The Clubhouse has its own physical space that is observably separate from mental health center/institutional settings and does not include “staff only” spaces.

While all other areas of the clubhouse building can easily remain open to both members and staff, the removal of staff offices would extremely hinder staff’s ability to complete many of the requirements outlined in this draft. The completion of daily documentation, authorizations, ISPs, CNA’s, etc, requires a designated space in order to be completed in a timely manner and in a manner that is compliant with HIPAA.

Individual choice is emphasized in Clubhouse policies and procedures and members are assured that their participation is fully voluntary.

              Many individuals that are adjudicated NGRI have a conditional release plan that includes PSR for structured supports.  These individuals, along with those on an MOT, are not technically voluntary.  Would they no longer be able to attend clubhouse?  Clubhouses provide the appropriate structured daily activity and monitoring to ensure everyone’s safety and compliance with the CRP and individualized goals.   Please continue to allow for these individuals to attend even if not considered to be “fully” voluntary.

Section 3.2 Service planning

3.2.4. The ISP may be developed through a team approach and must be authorized and overseen by either the Clinical Director or Program Director.

              Please remove “Clinical Director or Program Director”.  Allowing a LMHP, LMHP-R, LMHP-RP, LMHP-S to authorize and oversee the ISP is clinically appropriate.  This aligns with who may complete the assessment as well as the Board of Counseling regulations for QMHPs.  Many CSBs, including ours, already have an intermediate supervisory level with these credentials that do not require the clinical or program director to provide this oversight. A clinical or program director would not have the time to monitor every member’s individual treatment plans or know the individualized needs.

3.3 Rehabilitative Skill Building (RSB)

3.3.3. RSB that assists members with learning the skills necessary to seek, obtain, and maintain independent employment.

              Not all of our members want to or are able to maintain independent employment.  Many see clubhouse as their employment thru their daily task completion at the program (clerical, maintenance, business, and kitchen unit tasks). Can attending a clubhouse program be considered employment and be worked into their ISP goals (as we do currently)?

3.3.8. RSB to achieve independent living includes development of skills to find housing opportunities, communicate with landlord, apartment maintenance, and other tenancy sustaining skill development needed to live independently.

              These are community mental health skill building tasks and asking staff working in a PSR/Clubhouse program to do this level of skill building would be difficult to manage.  PSR focuses on day to day needs and collaborates/monitors/refers individuals to other resources/supports when these concerns are noted by members of the program.

3.4 Crisis Support (entire section)

To provide therapeutic and effective crisis intervention strategies, an employee must have specific training to provide crisis planning, crisis avoidance and crisis intervention. Once again this provides another requirement and layer of training which will be timely and costly to the CSB and staff.  Additionally, these regulations are not at all consistent with Clubhouse International model of care and are eerily similar to the CPST Tier I and Tier II models of care which are also introduced within this Redesign. 

4.4 Clubhouse Operation Requirements

2. The Clubhouse shall have an independent board of directors, or if it is affiliated with a sponsoring agency, it has a separate advisory board comprised of individuals uniquely positioned to provide financial, legal, legislative, employment development, consumer and community support and advocacy for the Clubhouse. Clubhouse holds open forums and has procedures which enable members and staff to actively participate in decision making, generally by consensus, regarding governance, policy making, and the future direction and development of the Clubhouse.

In consultation with Clubhouse International, this board must be distinctly different from an existing board of directors over a CSB.  Appointing additional oversight would pose an additional burden to the program/agency.  What if this additional oversight completely differs from current board of directors, how could this be managed. 

5.1 Clubhouse Admission Criteria

a. Completion of an in-person Comprehensive Needs Assessment by a LMHP, LMHP-R, LMHP-S, or LMHP-RP within 30 days prior to admission.

              This needs clarification and could result in delayed billing and services to those referred to our program.

Part 5.1.2 Diagnostic Criteria

Emphasizing this comment from another individual on the forum:

“This part of the draft states, “Members with diagnoses that fall outside of these categories may be eligible depending on the level of associated long-term disability; in these cases, a physician letter (documentation from a physician) justifying this exception should accompany the service authorization request.”  This is an unnecessary request. The state of Virginia authorizes and grants trust and autonomy to LMHP’s to make quality decisions regarding a member’s diagnosis as well as the associated level of disability and functional impairment stemming from their SMI. Additionally, DMAS requirement to have the LMHP trained in Clubhouse International would further exemplify the LMHP’s expertise and knowledge of who is and who is not appropriate for the service. Asking for a doctor who is completely removed from the ideology of the Clubhouse and who may or may not know the member well (if at all) and having them make a recommendation for specific service is unnecessary and will only result in delayed access to services.” 

This is a great comment…It shows how far out of scope these proposed regulations are. 

Added, are additional burden and time to our psychiatrists and NPs who we/CSBs are already known to have shortages for and who are our most expensive providers.  This does NOT fit with clubhouse model either.

5.2 Continued Stay Criteria

4. There is a reasonable likelihood of continued substantial benefit from active continuation of the services, as demonstrated by objective behavioral/functional measurements of improvement.

a. The member must be expected to improve at this current level of service.

              This is not CI model.  CSBs could be at risk of losing CI accreditation based on these very stringent DMAS regulations interspersed not only here, but throughout the regulations.

6. Exclusions and Service Limitations

10. Members receiving Clubhouse may not be authorized to receive the following services:

i. Addiction and Recovery and Treatment Services (ARTS) Levels: ASAM 2.1-3.7

iii. Assertive Community Treatment

PSR programs regularly serve individuals at varying co-occurring levels of care as well those receiving ACT services. Rehab and treatment are not one in the same and should not be treated as such. 

8. Additional Documentation Requirements and Utilization Review

e. The only staff who may complete a progress note is the staff who delivered the service. It is not permitted for a staff to deliver the service and another staff to document and/or sign the progress notes.

Clubhouse works in a group dynamic.  What if a staff member becomes ill, leaves for an emergency, or is terminated? Can another staff member complete a note with these circumstances? If so, how much time is allotted for notes to be submitted to remain in compliance?

Excluding Members Who Receive ACT Services: Restricting Clubhouse access for ACT recipients is concerning. ACT is clinical and therapeutic, while Clubhouse services are non-clinical and rehabilitative. They serve different purposes and often complement each other. Exclusion removes essential support for members who benefit from both.

Conflicting Guidance on On-Site/Off-Site Support at Worksites: The document permits on-site/off-site support at community worksites but later states that staff presence for supervision or teaching is not reimbursable. Supported employment requires staff presence; this contradiction creates implementation barriers.

Undefined “Related Disorders” and Excessive Documentation: “Related disorders” is not defined, leaving unclear whether common conditions (e.g., anxiety, depression, PTSD) qualify. Requiring additional physician documentation despite established diagnoses is burdensome and may delay services.

Conflict with Clubhouse Standard of Membership Without Time Limits: Clubhouse standards require voluntary, time-unlimited membership. MCO expectations for time-limited enrollment or repeated reauthorization conflict with the international model and undermine continuity and long-term support.

Non-Billable “Observation Without Intervention”: Prohibiting billing for observation without intervention excludes members who attend quietly, rest, or have low-energy days. Clubhouse is a safe, stabilizing, non-clinical environment even when participation varies; this rule risks excluding those who need it most.

Non-Billable In-House Educational Activities: Making in-house education non-billable contradicts Clubhouse standards, which prioritize access to both in-house and community-based educational opportunities—central components of rehabilitation and recovery.

Restriction on Clubhouse + Community Stabilization: Prohibiting concurrent Clubhouse and Community Stabilization services prevents members from receiving critical supports during crises or transitions. Clubhouse participation itself is often stabilizing; restricting it is counterproductive.

The overall impact to these requirements narrows the access, contradicts established Clubhouse standards, and creates barriers for individuals with significant needs—those who rely on flexible, recovery-oriented, community-based supports.

I am very concerned about the new regulations for clubhouse services that have recently been released.   For years, members have attended clubhouse in a safe, secure, non-judgemental environment where they have learned skills to help them in whatever their definition of recovery is.  For many, simply getting out of bed and walking through the door is what they can accomplish that day.  Many take years to show progress, and for some this progress may be minor, but to them it is huge.  Education about mental health symptoms, coping skills, and stressors are an essential piece in the overall recovery process.  The Clubhouse International model does not place focus on this, which is an essential piece in helping members learn and grow.  Financially, the cost of Clubhouse International is unrealistic for many programs, already struggling with low reimbursement rates and increasing expenses.  Over the years, many programs have already closed due to this.  The expense of the training, along with annual fees, is more than some programs can manage.  Employment opportunities are already limited in rural areas and transportation issues are a major barrier for individuals being able to get to and from work.   Having several different accreditation options would be helpful in programs deciding on if services were feasible and help with maintaining members in the community.  Clubhouse services are a lifeline to an already vulnerable population and losing these services would be a detriment to many.  For many individuals, clubhouse is their major support and peers are their supports and for many the most stable relationships they have. 

After reading the new regulations for clubhouse services there are several areas of concern. 

-According to Clubhouse International it is once a member always a member.  This does not align with MCO’s that have already been denying services stating that Clubhouse is not a lifelong services.

-CI puts an emphasis on Employment and training/support opportunities for employment, yet one of the non-reimbursable activities is Staff presence in the workplace to assist with supervision or teaching of routine work duties.  How is that not reimbursable if that is the primary focus of CI?

-CI also puts an emphasis on Education, but onsite Education support is not a reimbursable activity.  This seems to contradict one of CI’s basic foundations. 

-“Any observation without an intervention is not a billable activity.  Sometimes observing and allowing the individual to problem solve themselves is the intervention.  How is that not reimbursable?

-CI does not focus on symptom management/education but this would be essential for members wanting to gain employment as managing symptoms would be a key component of maintaining the employment.    

CIBH’s public comment response to DMAS Clubhouse Draft Policies due 12/3/25

Thank you for the opportunity to review and provide feedback on the draft DMAS policies relative to behavioral health redesign and its impact on clubhouse/PSR services.  Following are our suggestions or concerns as they relate to the draft policies:

Financial Burden of Clubhouse International Alignment

• Significant cost implications: Aligning with Clubhouse International standards requires substantial investment in accreditation, staff training, overtime hours to meet expanded schedule, travel, and restructuring to meet staffing and operational expectations. These costs are not currently reimbursed or subsidized by DMAS.
• Infeasibility under current reimbursement models: Many CSBs and community-based programs operate within tight budgets. If proposed billing reductions and unit limitations are implemented, programs will not have the financial capacity to meet Clubhouse standards.
• Unfunded mandates threaten program viability: Without additional funding or reimbursement adjustments, requiring Clubhouse-level standards is unrealistic and places programs at risk of downsizing or closure, ultimately reducing access to care for vulnerable populations.

Client Impact and Program Effectiveness

• Loss of structure may harm client outcomes: Our current PSR model emphasizes structured, therapeutic engagement throughout the day. Members thrive under this model, and loosening participation requirements could lead to disengagement, reduced progress, and poorer outcomes.
• Risk of losing satisfied members: Members who have found stability and success in our structured environment may leave if the program shifts toward a less structured, less engaging model. This would be a disservice to individuals who rely on consistency and accountability.
• Exclusion of ACT and Sponsored Residential clients is harmful: The proposed exclusion of individuals receiving ACT or living in sponsored residential settings would disqualify approximately one-third of our current participants. These individuals would lose critical social supports and community integration opportunities.
• Shifting focus to employment/housing may exclude others: While employment and housing are important, many members attend for wellness, socialization, and skill development. A narrow focus could alienate individuals whose primary goals are not vocational, but rather emotional regulation, community inclusion, social skills, or daily living skills.

Physical Space and Facility Requirements

• “Staff-only” space restrictions are impractical: While our program has a dedicated space separate from institutional settings, we maintain “staff-only” areas for privacy, safety, and administrative purposes. Requiring fully open spaces without exceptions is not feasible for CSBs and may compromise safety and confidentiality.
• Facility costs for extended hours: Expanding programming to evenings, weekends, and holidays would increase utility, maintenance, and security costs. These expenses are not currently budgeted and would require additional funding.

Service Planning, Documentation, and Staffing

• Restrictive ISP oversight language: Limiting ISP authorization to Clinical or Program Directors excludes qualified licensed professionals (LMHP, LMHP-R, LMHP-RP, LMHP-S) who are already permitted to complete assessments. This change would reduce flexibility and efficiency in clinical oversight.
• Progress note authorship requirement is overly rigid: The policy stating that only the staff who delivered the service may write the progress note does not reflect the team-based, milieu approach used in many programs. Staff often collaborate to document client progress, and this policy would reduce efficiency and documentation quality.
• Monthly documentation should remain sufficient: Requiring documentation more frequently than monthly would create unnecessary administrative burden. Monthly progress notes, when written to include goals, interventions, and clinical relevance, are sufficient to demonstrate medical necessity and appropriateness.
• LMHP review frequency is excessive: Requiring LMHPs to review non-licensed staff documentation every 30 days is burdensome, especially for programs with limited LMHP availability. Suggest allowing an LMHP review and co-signature every 90 days is clinically sound  and in alignment with other services and should be maintained.

Authorization and Intake Timeline Concerns

• One-day turnaround for assessments and ISPs is unrealistic: The proposed requirement to submit both the assessment and ISP within one business day of admission is a drastic shift from the current 30-day window. This would require significant operational changes and may delay access to services.
• Inconsistency with current manual guidance: The current DMAS manual allows for discretion by MCOs and the FFS contractor regarding documentation submission. The proposed policy should align with this existing flexibility to avoid confusion and ensure compliance with varying MCO requirements.

Governance and Oversight Requirements

• Advisory board requirement is duplicative for CSBs: CSBs already report to a Board of Directors that oversees financial, legal, and operational matters. Requiring a separate advisory board for the Clubhouse program would duplicate efforts and potentially create conflicting guidance. Flexibility should be granted to allow existing governance structures (i.e. CSB Board of Directors) to fulfill this role.

Evening, Weekend, and Holiday Programming

• Unfunded expectations for extended hours: Requiring evening, weekend, and holiday programming is burdensome for CSBs, many of which are government agencies with fixed staffing models and budgets. Staff job descriptions do not include coverage during these times, and adding such requirements would necessitate new funding and staffing plans.
• Staffing and retention challenges: Recruiting and retaining staff willing to work nontraditional hours is already difficult. Adding these expectations without increased compensation or staffing support will likely lead to vacancies, burnout an/or higher turnover.
• Holiday pay and on-call coverage: Additional programming would require compensating staff for holiday pay, arranging on-call coverage, and potentially increasing facility expenses—none of which are currently accounted for in program budgets.
• Cultural and religious sensitivity concerns: Mandating holiday programming may conflict with the diverse cultural and religious practices of our members. A more inclusive and flexible approach would be to state: “These activities may occur during evening, weekend, and holiday programming organized by members and staff outside of the work-ordered day.”

Eligibility and Diagnostic Criteria

• Limits on qualifying diagnoses are too restrictive: Requiring a physician’s letter for certain diagnoses could exclude approximately half of our current members. Many individuals with serious mental illness or trauma histories may not have recent documentation or access to a physician for verification.
• Recommendation to expand eligibility: Consider aligning eligibility with the broader definition of serious mental illness, including individuals with significant trauma histories, without requiring additional physician documentation.

Consensus-Based Decision-Making Concerns

• Consensus may not be appropriate in all situations: While member input is valuable, there are situations—such as behavioral issues, safety concerns, or cognitive limitations—where consensus-based decision-making may not be feasible or appropriate.
• Need for alternative decision-making processes: Programs must retain the ability to make timely, staff-led decisions when consensus cannot be reached or when member safety and program integrity are at risk. Clear guidance is needed on how to navigate these situations.

Privacy and Confidentiality Concerns

• Outreach and group discussions may compromise privacy: Discussing individual member concerns in group settings or during outreach efforts raises confidentiality issues. Programs must be allowed to maintain HIPAA-compliant practices that protect member privacy.

Regulatory Alignment Challenges

• Conflicting standards across systems: Programs are already navigating complex and sometimes conflicting requirements from DMAS, CCBHC, Licensure, MCOs, and internal agency policies. Adding Clubhouse International accreditation standards—especially when they don’t align with state or federal regulations—creates confusion and administrative burden.
• Need for regulatory harmonization: DMAS should work to align expectations across systems and provide clear guidance on how to prioritize or reconcile conflicting requirements.

Thank you for the opportunity to provide public comment regarding the proposed changes to Psychosocial Rehabilitation Services and related service requirements. As an established Psychosocial Rehabilitation Services (PSR) program, we are deeply concerned about the significant negative impact these changes will have on our ability to serve members—many of whom have been stable and successful in our current model of care.

1. Excluding ACT and Coordinated Specialty Care clients is harmful.
Many of our members are ACT clients, and the proposed prohibition on serving ACT-enrolled individuals will not be beneficial in any way. This change would greatly reduce access to needed services and will likely result in members losing support they rely on. We are already seeing insurance denials stemming from this shift. Removing ACT clients from eligibility puts some of our most vulnerable members at risk of losing essential PSR services.

2. Our members are satisfied with our program and may be forced to leave, or may not fully participate in this new model.
As an existing PSR program, we have built a strong, supportive environment where members consistently report positive experiences. These proposed changes jeopardize that stability. Some members may no longer qualify under the new rules, despite benefiting significantly from the services they currently receive. We are concerned that this proposed model allows more opportunity for members to be present without engaging or participating. Under our current structure, we see meaningful progress because we actively and consistently encourage participation, offer structured activities, and engage members throughout the day.
If members are permitted to enroll but not participate, their outcomes will suffer, and programs like ours may appear ineffective despite our best efforts. We may also lose members who have thrived under the expectations and structure we currently provide. 

3. Overlap and contradictions within the Required Service Components.
The activities listed under “Required Service Components” closely resemble Case Management, Emergency Services, and Skill Building functions, raising concerns about role clarity and reimbursement.
Additionally, Section 3.3 states that RSB activities include onsite and off-site support at a community business worksite, yet later indicates that staff presence in the workplace for supervision or teaching routine job duties is not reimbursable. This contradiction creates confusion about what is allowed.

4. Documentation expectations appear misaligned with current PSR practice.
The proposed note requirements resemble Residential or Skill Building documentation standards. This represents a major shift from PSR documentation and will require considerable workflow changes.

5. Increased intake and authorization demands are unrealistic.
Requiring full assessments prior to enrollment and authorizations completed within one day is not feasible without added staff. Currently, we have a week to submit authorizations, and assessments are completed as part of enrollment. The proposed changes would require far more intensive assessments upfront, placing strain on both staff and members.

6. “Observation without intervention” being non-billable is concerning.
Many PSR members attend for therapeutic structure and a safe space, even when they are not actively interacting. Some may spend time resting or stabilizing. If these quiet or observational periods are not billable, PSR programs will struggle to support individuals who benefit from a supportive milieu rather than constant engagement.

7. Member-to-staff ratio and billing limitations are unrealistic.
A 1:15 ratio is challenging in practice. These policies seem to push programs toward much smaller membership, reducing access.
If billing is limited only to direct interventions and not therapeutic presence, it becomes even more difficult to meet daily billing expectations.

8. Diagnostic criteria and required documentation need clarification.
The term “related disorders” is unclear—does it include Anxiety, Depression, or PTSD?
Requiring additional physician documentation for every authorization seems excessive and may delay or disrupt continuity of care.

9. Concerns about the financial burden associated with Clubhouse International.
If programs are expected to transition toward or align more closely with Clubhouse International standards, it is important to acknowledge the significant cost this places on agencies. Clubhouse International accreditation, training, travel, and required staffing structures can be expensive.
For many CSBs and community programs, these costs are not feasible within current reimbursement structures—especially if proposed billing reductions and unit limitations take effect. Expecting Clubhouse-level standards without providing the financial support to meet them is unrealistic and places programs at risk of losing sustainability.

10. The chart on page 7 and unit definitions are confusing and inconsistent.
Currently, we can bill up to 360 units per six-month period, but the example chart shows only 240 units per year. Section 9 also states that one unit equals one day, whereas we currently receive three units per day. These significant reductions would undermine program stability.

11. Time limits contradict foundational Clubhouse standards.
The first Clubhouse standard states that membership is without time limits, yet the proposed changes appear to move toward limiting a person’s length of enrollment. This contradicts the evidence-based model.

12. Education activities labeled as non-billable conflict with established standards.
Standard 25 supports in-house educational opportunities, yet these are listed as non-billable activities. This restriction would limit meaningful programming that supports recovery and skill development.

Conclusion
Overall, these proposed changes would reduce access to services, destabilize current members who are succeeding in our PSR program, introduce significant financial burdens, and contradict both the clinical needs of the population and the established Clubhouse model. We respectfully request reconsideration of these changes and clearer alignment with current PSR standards, funding realities, and the needs of the individuals we serve.

Thank you for the opportunity to provide comment regarding Sections 3.2 and 4 of the proposed guidance, specifically the requirement that the Individualized Service Plan (ISP) be authorized and overseen by either the Clinical Director or Program Director.

ISP Oversight Requirement (Sections 3.2, 4):
Requiring the Clinical Director or Program Director to oversee and authorize all ISPs will create a significant burden on our system and is not feasible with our current staffing structure. In most community-based programs, Clinical Directors and Program Directors are removed from direct service delivery and primarily focus on administrative, operational, and compliance responsibilities. They are not the individuals most familiar with the day-to-day needs, progress, and challenges of each member.

Qualified Mental Health Professionals (QMHPs) are the appropriate staff to oversee ISPs.
QMHPs have the practical, hands-on knowledge required to develop and oversee service plans. They work directly with members, understand their needs, and are best positioned to ensure that ISPs are accurate, person-centered, and clinically appropriate. Restricting this responsibility to high-level administrative staff will slow down workflow, create bottlenecks, and increase the risk of delays in service delivery.

This requirement will ultimately reduce efficiency, limit responsiveness, and place strain on programs that already operate with tight staffing ratios. Allowing QMHPs to continue overseeing and updating ISPs is essential for maintaining timely, high-quality care.

We respectfully request reconsideration of this requirement and recommend reinstating QMHP responsibility for ISP oversight to reflect the operational realities and best practices of community-based mental health services.

Thank you for the opportunity to comment on the draft Clubhouse regulations. Southside Behavioral Health (SBH) supports the goal of strengthening rehabilitative services for adults with serious mental illness, but we have significant concerns about areas where the proposed policy conflicts with the Clubhouse model, creates barriers to access, or imposes administrative and staffing requirements that will be difficult to implement in rural communities.

Below are the key issues we would like the Department to consider.

1. Exclusion of ACT Recipients From Clubhouse Services

The proposed rule prohibiting individuals enrolled in ACT from participating in Clubhouse services will remove a stabilizing support for some of the most vulnerable people we serve. Many ACT recipients struggle with social isolation and have limited opportunities for safe, non-clinical community engagement. Clubhouse offers a structured setting that supports social connectedness, an outcome directly aligned with SAMHSA’s National Outcome Measures.

We strongly recommend that ACT and Clubhouse remain concurrent services, with clear billing safeguards.

2. “Observation Without Intervention” as Non-Billable

The policy states that observation alone is not billable. This conflicts with how members with SMI often engage. Some individuals attend Clubhouse precisely because it offers a safe place where they can be present, even on days when active participation is not possible. Allowing members to rest, sit quietly, or remain low-engagement is not passive care; it is a clinically meaningful part of recovery for those with severe symptoms, anxiety, or social avoidance.

A strict ban on billing for these situations would unintentionally exclude members who rely on Clubhouse the most.

3. Restrictions That May Limit Member Participation

The draft imposes several new barriers that are inconsistent with the model:

• Prohibiting members from receiving Community Stabilization while also participating in Clubhouse

• Requiring comprehensive assessments and service authorizations within a single day

• Requiring additional physician documentation for diagnoses already established

• Time-limited enrollment expectations from MCOs that conflict with the Clubhouse standard of “membership without time limits”

These restrictions undermine core Clubhouse principles and reduce flexibility for members whose participation fluctuates due to symptoms.

4. Non-Billable In-House Educational Opportunities

The draft excludes in-house educational programming from reimbursement, even though Clubhouse International Standard 25 explicitly includes access to both in-house and community-based educational opportunities.

Education is central to recovery and should remain reimbursable when provided within the work-ordered day framework.

5. Billing Structure Is Unclear and Appears More Restrictive

The proposed shift from three units per day to one per diem unit represents a significant reduction in allowable billing. The manual also lists 240 units per year, which conflicts with the current 360-unit allowance. This reduction will limit program hours and weaken sustainability, especially for programs that already operate with low reimbursement rates and limited funding sources.

We request clarification of the intended annual unit cap and unit structure.

6. Risk of Excluding Members With Instability or Higher Needs

The Clubhouse model is intentionally inclusive of individuals whose mental health fluctuates. Several proposed rules unintentionally push out individuals with:

• Active symptoms

• Limited social capacity

• Low motivation

• Difficulty engaging at a clinical pace

These individuals are among the most likely to benefit from the psychosocial, non-clinical support of Clubhouse.

The policy should avoid inadvertently creating a “most stable members only” program.

7. Impact on Rural and Low-Resource Areas

Rural programs already face challenges with transportation, stigma, staffing shortages, and low funding. The draft regulations increase administrative expectations, limit who can participate, and narrow reimbursable activities. These changes could reduce access in communities where psychosocial rehabilitation options are limited or nonexistent.

We urge DMAS to consider rural barriers and avoid requirements that unintentionally restrict access.

8. Board of Directors Requirement Is Difficult to Maintain in Rural Areas

We operate in a rural, economically depressed region. Recruiting and maintaining a board with this level of specialized expertise is far more challenging than in urban centers. Community leaders are limited in number and often already spread across multiple nonprofit boards. Continuously maintaining a board at this level will be burdensome and may jeopardize accreditation or compliance solely due to geographic limitations—not quality of service.

A more flexible governance model is needed for rural localities.

9. Dedicated Facility Requirement Creates Significant Financial Barriers

SBH currently operates our Psychosocial Rehabilitation Program out of an older building that requires ongoing maintenance. Purchasing or constructing a new dedicated Clubhouse facility would cost hundreds of thousands of dollars in capital. Upkeep, utilities, insurance, ADA compliance, and staffing add additional annual costs.

Yet the draft limits reimbursable services to 5 hours per day, 5 days per week.

This means SBH would be expected to secure, upgrade, and maintain a dedicated building while only being able to bill for a fraction of the daily operational hours. The mismatch between capital investment and billable hours is not financially sustainable.

10. Required Staff Training Costs Are Unrealistic Without Additional Funding

The draft references Clubhouse International training expectations. These trainings typically require 2–3 weeks of onsite participation and cost between $5,000–$7,000 per person, not including travel.

If SBH were to train a minimum of 4–6 staff (consistent with our current staffing), the cost would range from $20,000–$42,000, plus travel and lodging.
There is no dedicated funding stream to offset training costs, nor any reimbursement mechanism built into the rate structure. For small and rural CSBs, this is prohibitive.

Without state-supported funding for required accreditation and training, providers may be unable to meet these requirements.

SBH supports building a strong Clubhouse service system and welcomes continued collaboration to ensure the final regulations reflect the evidence-based model while remaining practical for providers across Virginia.

Thank you for allowing a comment period for the Clubhouse regulations.

AHCS is concerned with the draft regulations. Clubhouse members have attended a safe, secure, non-judgemental environment in obtaining skills for their mental health. Sometimes progress is slow however this program is vital to not only assist individuals in their recovery but to keep individuals out of hospitals. Education, coping skills, and overall health are vital to maintain recovery. The CI model does not place focus on the above. The financially burden and administrative overhead is another concern for the Clubhouse operations. Many Clubhouse programs have closed and I fear many more will follow suit. Clubhouse is a major support for many to remain stable within the community and in relationships. 

Thank you for the opportunity to comment on the draft Clubhouse regulations. Alleghany Highlands supports the goal of strengthening rehabilitative services for adults with SMI, however we have concerns about areas that will create barriers to access or imposes administrative and staffing requirements that will be difficult to achieve in rural communities. 

Below are the concerns AHCS would like the Department to consider:

1. Observation without Intervention as Non-Billable: The policy states that observation alone is not billable. This conflicts with how adults with SMI often engage. Some adults attend Clubhouse programs because it offers a safe place where they can be present, even on days were active participation is minimal. Allowing adults with SMI to have a safe, quiet place with minimal participation is part of their recovery. 
2. Restrictions that may limit Participation: The draft regulations imposes new barriers that are inconsistent with the model. 1. Prohibiting members from receiving Community Stabilization while also participating in Clubhouse. 2. Requiring comprehensive assessments and authorizations within a single day. 3. Requiring additional physician documentation for diagnoses already established. 4. Time -limited enrollment expectations from MCOs that conflict with the Clubhouse Model standard of "membership without time limits". The will reduce adults flexibility whose participations fluctuates due to symptoms. 
3. Non-Billable In-House Educational Opportunities: The draft regulations excludes in-house educational programming from reimbursement, even thought CI standard 25 explicitly includes excess to both in-house and community-based educational opportunities. Education is vital to recovery and should remain reimbursable. 
4. Billing Structure is unclear: The proposed change from three units to one diem unit presents a significant reduction in allowable billing. The manual also lists 240 units per year which conflicts with the current 360 unit allowance. This reduction will limit program hours and weaken sustainability in programs that already operate within low reimbursement rates and limited funding sources. 
5. Risk of Excluding Adults: The CI model is inclusive of adults whose mental health fluctuates. Several proposed changes will exclude adults: 1. active symptoms, 2. limited social capacity. 3. low motivation. 4. difficulty engaging at a clinical pace. These adults are among the most likely to benefit from the psychosocial, non-clinical supports.
6. Impact on Rural Areas: Rural areas already face challenges with transportation, staff shortages, lack of private providers, stigma, and low funding. The draft regulations increase administrative expectations, limit who can participate, and reduction in reimbursement. We urge DMAS to consider rural barriers and avoid requirements that unintentionally restrict access. 
7. Board of Directors requirement: AHCS operates in a rural, economically challenged region. Recruiting and maintaining a board with the level of specialized expertise would be extremely challenging. Community leaders are limited in numbers and are often already spread across multiple nonprofit boards. Continuously maintaining a board at this level will be burdensome and may jeopardize accreditation or compliance solely due to geographic limitations and not quality of service. A more flexible governance is needed in rural areas. 
8. Dedicated Facility Requirements: AHCS currently operates our Clubhouse program out of an older house that requires ongoing maintenance. Purchasing or constructing a new dedicated facility would be a financial burden and unrealistic. 
9. Required Staff Training Costs: CI model training expectations references in the draft regulations, are costly without a funding stream. The trainings typically require 2-3 weeks of onsite participation and cost between $5,000-47,000 per staff, not including travel and lodging. For small, rural, CSBs, this is prohibitive. 

Thank you for the opportunity to make comments on the proposed changes affecting members of our communities across the state with serious mental illnesses.

My question first of all is - "What is broken"?  And therefore, what are we trying to fix?

In the work that I do in the psychosocial rehabilitation program for our CSB, I see first hand, everyday, the evidence based on the small and incremental progress that attendance and participation in the program makes for our members.  They love this program and have a huge part in what makes it work!

We operate on a "hybrid" model - blending components of the traditional clubhouse model with individualized goal-oriented psychosocial rehabilitation principles.  This has proven effective over the years.

My greatest concern of transitioning to Clubhouse International is the heavy financial barriers associated with accreditation , trainings, etc.  I don't know how this is going to be possible for our CSB which serves 7 financially strapped rural counties.

I am also concerned with the employment component as our area already has such competition for entry-level type jobs.  

Maybe trying to fit this service (PSR/clubhouse) into a medical model is what needs to be examined?  We know that it greatly benefits the quality of life for those with serious mental illness.  Possibly there are block grant funds that the state can earmark for clubhouse/PSR for its public mental health services ?

Thank you for considering my comments.

1. Section 2: Clubhouse Service as described in this draft is not consistent with Clubhouse International standards in several significant ways which would make achieving and maintaining accreditation difficult if not impossible. Specifically, one of the foundational Clubhouse International standards states that membership, “is open to anyone with a history of mental illness.” This standard is incompatible with the expectations specified in Medical Necessity Criteria in the current document, including requirements that members must have a serious and persistent mental illness demonstrated by continued functional impairment. In addition, , the current document focuses on specific reimbursable supports that are provided by professional staff on behalf of members with debilitating mental illness instead of on the empowerment of the members to engage in all areas of the work of the Clubhouse, including providing supports to one another, as is the intent of the Clubhouse model. We are also concerned about the time and expense required to achieve and maintain accreditation.
2. Section 3.1: Regarding Item 2, it is not practical for an Assessment to be conducted in the consumer’s home or off-site as a part of a service that is provided in-person in a group setting. Group services require as many staff members be present with the group as possible in order for services to be safe, particularly when working with individuals with debilitating SMI.
3. Section 3.3, Item 1: Required activities should be reimbursable. For example, a foundational value of Clubhouse International is the inclusion of members in all aspects of programming and program functioning and professional staff are needed to empower members to this level of participation yet these activities are excluded from reimbursement. Item 5: it is not practical for staff in a Clubhouse model to provide job support at the job-site. Safe group work requires as many staff members as possible be present with the large group, not with individuals off-site. Additionally, if this is not a reimbursable service (as specified in 6.9.b), it is not appropriate or financially feasible to require this RSB.
4. Regarding Item 7, social skills development occurs within a normalizing social environment at all times, and does not require additional events. Expectations around evening, weekend, and holiday social events are not made clear in this document overall. If these are required, additional staff will also be required.
5. Please note that if any RSBs are listed as required, they must be reimbursable. Sufficient staff (and resulting funding) must be added to complete any off-site work and holiday/ evening/ weekend work.
6. Section 3.4: Regarding Items 3 and 5, if immediate, in-person support for crisis management must be offered and available outside the work-ordered day and outside the Clubhouse site, by Clubhouse staff, funding must be provided for individual staff to be trained in how to provide these supports safely, particularly in high-acuity and off-site locations. Staff who are on-call and who provide crisis response must be specifically reimbursed for these services. Additional staff must be added in order to provide these services. It is of note that this portion requires yet another duplication of the crisis continuum services much like the draft CPST regulations. Requiring crisis services to be provided by Emergency Services, Clubhouse and CPST teams is not only redundant but also impractical given hiring challenges in 24/7 services.
7. Diagnostic Criteria is unclear specifically what is meant by “related disorders?” Will common and highly prevalent diagnoses such as Anxiety Disorders, Depression and PTSD be authorized? Narrowing medical necessity to a small portion of diagnoses also runs counter to the inclusive focus of Clubhouse International which is to be open to anyone with a history of mental illness. Also, requiring a note from a physician is expensive, stigmatizing, and redundant when a Comprehensive Needs Assessment conducted by a medical provider licensed in mental health treatment and assessment has already been required.
8. Regarding Item 3, the Functional Impairment Criteria are inconsistent with the values and Quality Standards of Clubhouse International. Requiring members to meet these impairment criteria in order to become members will not allow for the level of inclusivity valued by Clubhouse International. Requiring members to continue to meet functional impairment criteria in order to maintain membership will not allow members to achieve the level of independence and functionality envisioned by Clubhouse International. 
9. Section 5.2: Regarding Item 1, the admission criteria required for Continued Stay are not consistent with the values and Quality Standards of Clubhouse International.
10. Section 5.3: Regarding Item 1, the admission criteria required to avoid Discharge (if desired) are not consistent with the values and Quality Standards of Clubhouse International.
11. Regarding Item 10.a.iii, excluding ACT would restrict members with SMI from receiving essential services. ACT and Clubhouse model PSR provide services that meet different needs. While ACT services may provide 1:1 work toward rehabilitation and maintaining tenure in the community, many ACT recipients also require Clubhouse PSR services to develop social skills in a normalizing social environment and to maintain a daily routine that is an essential part of sleep hygiene, personal empowerment, and symptom management. For many of those in PSR programs, the intensive nature of ACT services is required for engaging in mental health services (including medication management and OPT), as these individuals have been unable to participate in traditional office-based services in the past without this intensive level of support. As an example, some current consumers who have NGRI conditional release plans rely on both PSR and ACT to meet the requirements of the court and to maintain within the community. For many consumers, both services are required in order to work toward recovery, avoid symptom relapse, and maintain in the community.
12. Requiring assessment and ISP completion on day one of membership is not feasible or clinical best practice. The current 30 day requirement allows for time for members to learn about the service and develop relevant individual goals.

Club House International standards focus heavily on preparing people for competitive work.  The work requirements are overly burdensome in rural areas where jobs are few, even for those without disabilities.  Additionally, the lack of transportation creates another barrier that is REAL.  We do not have bus service (with the exception of limited  bus service within the city limits of Farmville) within our 7 rural counties.  Finally, many of the members of our current psychosocial program are simply to symptomatic or cognitively involved, whether the model acknowledges this reality or not,  to make competitive employment an option.  I am also very concerned about the cost of transitioning to this program.  We will likely need to hire an employment specialist, which is not a billable service, maintaining clubhouse accredidation is costly, and the reimbursement rates are insufficient to support the program.  Fundraising in poor rural communities is not a reasonable way to sustain a program like this without sufficient reimbursement from Medicaid.  Please reconsider requiring club house international as the only model for those CSB's who are not CARF accredited.

I echo the concerns of many others who have commented about the burden that will be created by the requirement for PSR programs to switch to the Clubhouse International model. The proposed CPST rates and limits are simply not tenable to sustain a PSR program; therefore, the only option many PSR programs will have in the redesign structure is to transition to the Clubhouse model. In addition, with all the other changes that are going on both at the state and federal levels, this appears to be a rushed process that could have unintended consequences for the people who need the service.

There are several concerns about what will happen on July 1, 2026, when the current PSR billing code is no longer available. Will the programs that attested to their plans to transition to the Clubhouse model be allowed to bill for it at that time? If not, what billable service will there be? What is the interim plan for billing for services for programs working toward attaining Clubhouse International accreditation?

More clarity is needed on the space/location requirements for a “clubhouse.” For some current PSR programs, the program site is located near the main CSB offices. In the case of our PSR program, this allows members to see their doctors without there being a transportation barrier. It also allows quick access to medical personnel if there is an emergency in the program. Will Clubhouse programs be able to continue to be located on the grounds of or in close proximity to CSBs? It is not easy or affordable, in many cases, to find a space for such a program, whereas CSBs have designed spaces for PSR programs that have proven to be successful in supporting individuals with mental illness in their communities. These programs were acceptable as we worked through the implementation of STEP-VA including making modifications to programs to increase the services that PSR programs can provide; but these sites in which we have invested might not be acceptable under the Clubhouse International model.

For CSBs that choose to pursue Clubhouse International accreditation and whose program sites do not meet the separation of space requirements, will there be funds available to support relocation? CSBs do not have the funds to be able to purchase or lease new space and will likely be unable to find such space quickly. If this is to be a successful system-wide transition, there has to be funding to acquire the needed space and/or make the necessary renovations.

If CSBs are unable to meet these location requirements, it might mean the dissolution of several PSR programs. What will happen to the individuals who have come to rely on their PSR program for a safe place to be during the day, an opportunity to socialize with a network of peers, a connection to people who can support them in their recovery and help keep them stable in the community, and a place where they can have nutritious meals during the day? Disbanding these programs will increase crises— an area in which the state has finally begun to build out a comprehensive system— thereby negating some of the important work that has been done. It can also exacerbate issues that we are currently facing such as individuals with mental illness wandering the streets or not having a place to go during the day so that their loved ones can maintain employment.

Is it necessary to change the current PSR program structure? If the issue is demonstrating that the funds provided for the service are being utilized appropriately, there are other means to address this without having to jeopardize and/or uproot the stability of the individuals within the PSR programs. We have been working on incorporating options such as supported employment and housing supports. If there are missing elements from the current PSR model that make it a more holistic approach, can those just be added in as requirements under our STEP-VA metrics?

More clarity is needed around the timeline for implementation. Although we are told there is consideration of the length of time it takes to become accredited, there is no guidance on the timeline within which CSBs are expected to meet various milestones to demonstrate progress toward accreditation. There also needs to be training and guidance related to Clubhouse International accreditation to ensure that all CSBs resources and supports that they can go to for guidance. Without these things in place, we run the risk of creating a fragmented set of programs based on individual interpretation rather than having a roadmap that depicts a common goal and how to achieve it as a statewide behavioral healthcare system. 

Please consider the totality of this shift and weigh out whether these changes we are being required to make will result in improvements in the lives of the people we serve. The CPST services impose rate and time limits that do not meet the needs of people who need these programs daily. The Clubhouse International model requires lengthy planning and culture shifts that do not happen quickly in addition to financial investments for which resources are not available. Please also consider how this change will potentially negatively impact the work that is being done in areas such as expanding crisis services and enhancing the availability of other community-based services. I would like to be clear, there is room for the Clubhouse International model in the continuum of services provided in Virginia, but it should be left to providers to decide whether the Clubhouse model is something that can be done within the scope of their resources and whether it adequately meets the needs of the people they serve. It is not something that can be seamlessly imposed over an existing program. At a minimum, any changes should allow for time and adequate planning so that such a shift does not end up negatively affecting the people we are here to support.