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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.