Public comment notes:
Mobile Crisis Response
Crisis Hotline Requirement:
The requirement to receive the referral from the Crisis Hotline to obtain payment for work performed is a concern. Referrals for crisis services come from various avenues (law enforcement/emergency room/private providers/self-referrals, 24 hour emergency services line, etc.). Self-referrals are received from individuals showing up at the door indicating a crisis. It seems that the requirement for a referral to come from the crisis hotline is an added step that hinders positive customer service and hinders the staff by taking away from the customer who needs the service immediately. There are organically occurring referrals in crisis.
Questions: The crisis services and the crisis transformation relies heavily on the positive interaction among community partners. When law enforcement or other community partners must go through a regional crisis hotline in order to access a service, it is concerning that these relationships will be burdened with a third party contact. Who is responsible for making these calls to the crisis hotline? What is the purpose of calling the hotline to utilize a service that the CSB has always performed/provided? In addition, the Code of Virginia states that law enforcement agencies are to notify the CSB of an executed Emergency Custody Order. It is concerning that the requirement to receive a referral from the crisis hotline would create room for error and delayed time. These calls should come directly to the CSB. If the purpose of the requirement is to collect data, the regulations should spell out the expectation is to contact the crisis hotline to log a contact, not receive a referral and payment for a service.
Mobile Crisis Response Assessment:
The draft of the Medicaid manual does not clarify what kind of assessment is acceptable. Since a preadmission screening is a service that can be provided under the mobile crisis service, it would be suggested that the prescreen be a tool to use for the mobile crisis assessment. A determination would need to be made as to whether or not an individual needed involuntary psychiatric hospitalization or not in the midst of the crisis. When the individual does not meet involuntary hospitalization criteria, then the prescreen could be used as a mechanism to begin for mobile crisis response/services.
Staff requirements to complete a pre-admission screening:
The requirement of an LMHP or LMHP eligible staff person to complete the pre-screening will have a negative impact on the workforce in some areas of the state. Requiring a LMHP to be available in real time with a QMHP to complete a prescreening is a waste of resources. Prescreeners were grandfathered or have been conducting pre-admission screenings for many years. To say that they are no longer able to bill for a service that has been performed for years by a particular staff solely based on their credentials effective December 1 does not make sense and will be detrimental to the community due to reduced workforce staffing. A staff person certified by DBHDS should have the ability to bill for the service. The CSB is the backbone of crisis services in the community and employs good clinicians to provide the services. There is no reason why a DBHDS prescreener could not provide preadmission screening or mobile crisis services. In fact, a prescreener would have more clinical training than a CSAC or QMHP would have to respond to crisis situations. The prescreening service should be pulled out from mobile crisis and billed as a separate service item to reduce confusion.
Community Crisis Stabilization
Requirement of crisis hotline referral as a condition of billing does not allow for consumers to transition between levels of crisis care smoothly based on need – for example it is not reasonable for a consumer served in 23 hour crisis observation to require a separate crisis hotline call to be referred for community crisis stabilization
The assessment for Crisis Stabilization is not defined as to what would be acceptable as the third option to enter the service.
If it is expected that a CEPP be used for the crisis services, what does this look like? REACH has a CEPP and it is lengthy. This is a concern as to time spent documenting when essential services can be provided to the individual who is in crisis.
23- Hour Crisis Stabilization
Psychiatric evaluation requirement:
Regulations states psychiatric evaluation must be available at the time of admission which is inappropriate clinically and should only be required when assessed by the LMHP type to be necessary. Not all consumers will require psychiatric evaluation and prescribing of medication during this service.
Unable to occur due to workforce shortages there are simply not funds to pay for nor psychiatrist/ psychiatric nurse practitioners available to provide this service 24 hours per day
24/7 Registered Nurse Requirement:
The U.S. is in the midst of a pandemic and well documented nursing crisis. The requirement for 24 Registered Nurse (RN) coverage is unnecessary and staffing to support this is unavailable in the current workforce.
The allowance for use of a Licensed Practical Nurse is unhelpful because it requires an RN to be at the facility.
If nursing is a required component it should be on an as needed basis- available to respond to the location OR allow for LPN level nursing with access to an RN by phone for oversight/ supervision.
This requirement is cost prohibitive and cannot be accomplished by providers with a December 1, 2021 implementation date.
Earlier draft of regulations did not require 24/7 RN staffing, including those draft regulations circulated by DMAS in August 2021.
There is contradictory language about who can provide assessment: In some sections it indicates Physician Assistants can provide care and then later allows only psychiatrist or psychiatric Nurse Practitioner to provide care.
Assessment- 23 hour & CSU level
References to multiple assessments that may be used/ required. Assessment should be consistent with other services and utilize the Comprehensive Needs Assessment for this purpose without creating additional assessments that will require consumers to repeat their stories and are redundant.
Assessment should align with the CNA requirements for ARTS so that two separate assessments are not required.
Crisis Education and Prevention Plan
Required for multiple services. This is unnecessary, particularly in more acute, shorter term services such as stabilization and 23 hour observation- Current CEPP used by REACH is excessively cumbersome.