On page 6 of the manual, under Case Management Agency requirements, it states that the provider agency must "Guarantee that individuals have access to emergency assistance either directly or on call 24 hours per day, seven days per week and holidays. This may be done via telephone and face to face contact and/or coordination with other providers and DBHDS administered crisis services."

This is a requirement that has changed over the course of the TCM development process, and one that we have received conflicting guidance on. We have been told that it is somehow related to a specific CMS and/or Medicaid requirement, that all Medicaid providers are required to meet it, and that smaller providers should investigate how "mom & pop" organizations in other Medicaid support areas meet it.

On it's face, it places a particularly harsh burden on smaller providers who have less staff available to "share the wealth" of being on call 24/7 including holidays. It is a truism that human services staff are already underpaid and overworked and requiring providers to require this from our staff is a huge barrier to our ability to continue to support this population, as we have done for decades without being on call at all times.

Initially we were told that this requirement could be met without having a live person available. We could, for example, have a 24 hour answering machine (as even doctor's offices do!) that states our operating hours and directs individuals to call 911 for medical emergencies and the local 24 hour CSB crisis intervention line for behavioral &/or mental health crises. That would make sense.

What doesn't make sense is having an already underpaid & overstretched employee being woken up in the middle of the night or interrupted in the middle of their holiday celebrations to take "emergency assistance" calls.

It is not clear if the emergency assistance is merely verbal - where the staff takes down info, offers advice/direction, & addresses it as soon as possible during normal business hours - or if this requirement means that staff must be prepared to leave their homes and travel to offer assistance. If it is the former, it can be accomplished via a voicemail system. If it is the latter, it is an undue burden that will erode staff morale and increase employee turnover/vacancies. On the rural Eastern Shore, for example, we employ 1 case manager. Even if the advent of TCM meant we could hire a PT case manager to work with him this would still require that these staff basically devote their lives to support provision, decreasing their availability for needed work during regular hours, and increasing their motivation to go work at Wal-Mart instead, where sometimes their life is their own.

Please consider sharing with stakeholders the specific language behind DMAS' need for this requirement and consider working with stakeholders to find workable solutions to meet the intent of that language without creating barriers to support provision.