Virginia Regulatory Town Hall
Department of Medical Assistance Services
Board of Medical Assistance Services
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9/29/21  10:17 pm
Commenter: Stefania Fabbri, Licensed Clinical Psychologist, PhD (Compass)

The right thing to do vs the easy thing to do. Sessions in the home vs in clinic.

I appreciate the intention behind these new regulations and I believe some good things will come from them. 


As we take these regulations from paper to implementation in the real world, I can foresee a few issues playing out over time.


Fundamentally I would like to encourage a reflection upon “what do we know will lead to the best outcomes for the children and families we work with and whether these new regulations will make it more or less likely to achieve the best possible outcomes”


The right thing to do vs the easy thing to do. Sessions in the home vs in clinic. On paper having the opportunity to do both is great. Now in practice, we know that working in homes is way harder to do then working in a clinic, you face multiple challenges: more chaotic environment, less structure, less control, multiple people to work with and account for, family dynamics, driving etc.. …BUT we do it because we know it is the “right thing to do” and by that I mean working in the home is where we can have the most impact, it is the place where we can observe how behavior occurs naturally, it’s the environment the child operates in, it is where skills learned need to be generalized, its where we can support the parents at the hardest times.


Now going back to our original question -  Do we think that these new regulations will encourage/reinforce practitioners working in the home? If a practitioner is reimbursed the same for the “easy route” would we predict that, even with the best intentions and greatest intrinsic motivation to do the “right thing”, such practitioner, day after day, will continue to pick the hard road? Probably not. Most likely over time people will gravitate to what is easier and move away from providing services in the home. Companies that require more home based work will have a harder time hiring and retaining staff. 

Maybe these new regulations should find a way to either incentivize work in the home (eg: higher rate?) or somewhat restrict/put parameters around how much time is spent in the clinic and require a specific rationale for that, otherwise it is only a matter of time before witnessing an industry wide change that will no longer include the provision of services in the home.


Intentionality vs reactivity

The current regulation don’t include treatment planning, data review and analysis as its own billable entity. We know that treatment planning, case conceptualization, frequent data review and analysis is foundational to ensure we create plans that lead to the best possible outcomes. Treatment planning takes time and intentionality. It requires the opportunity to take a step back, think, plan vs reacting in the moment or improvising. Prompt and frequent data review and analysis is necessary for making timely and data driven adjustment to any given plan of care. 

Going back to our questions, do we think these regulations that cut down the amount of time that can be devoted to intentional planning and data review will increase or decrease the quality of care our clients receive? In the real world how do we think this will play out? Will it look like “cutting corners”? Using “one size fit all” plans and protocols? Will it look like multitasking and “reactively” adjust protocols or interventions while sitting in a session with a client and a technician? When you are treated by a physician, would you want that physician to spend time reviewing your records, exams, updated labs ahead of time or just try to improvise based on what he/she sees right there and then? 

If intentional and responsive treatment planning is so instrumental to best client outcomes should we not recognized it as its own entity just like face to face time? Should we not incentivize this foundational part of the work we do?


Collaboration vs isolation

Care Coordination and collaboration with other providers does not appear to be a reimbursable category in the current regs. Integrated care is something that our clients deserve and that requires REAL collaboration between professionals. Effective Care coordination is also extremely challenging mostly because it implies the recognition that we are not the experts of everything and that to look at the child as a whole we NEED to collaborate with other professionals.

Do we think that not reimbursing for Care Coordination will lead to better outcomes for our clients? How will this paly out in the real world? Would people mostly defaulted to sending a fax, or a quick email to “collaborate” with another providers/professional vs discussing, brainstorming, supporting eachother's work? Most likely it will lead to ineffective or completely absent collaboration, disjointed treatment efforts, isolation and providers working in their own “professional silos” and will in turn lead to poorer client outcomes.

CommentID: 100869