Thank you for the opportunity to respond to the latest draft of CPST regulations. We appreciate the changes you have made in response to our voices. Here are additional thoughts relating to the latest draft:
1. - Page 6. 3.2
“Individuals shall be referred to and their needs assessed for any clinically appropriate standalone EBPs of which they may meet admission criteria, prior to the authorization of CPST services, regardless of whether the agency completing the CANS Lifetime offers the EBP.”
How will this be monitored?
Will CPST providers be held accountable for providing CPST, in good faith, when a referral to EBPs was not made, unbeknownst to the CPST Provider?
2. - Page 10. 4.3(7)
“A single LMHP is prohibited from providing supervision/oversight of more than 120 cases in a calendar month. The total number of cases a single LMHP provides oversight to, shall take into consideration the other staff involved in the care of cases, for example, if supervising a number of LMHP-types who are completing the assessment, treatment planning, and psychotherapy components of CPST, 100 cases may be appropriate. If the LMHP is supervising primarily paraprofessionals and providing the assessment and treatment planning components of the service directly, oversight of 120 cases would not be appropriate.”
We appreciate the change in supervision requirements allowing LMHPs to oversee max case loads instead of numbers of staff. We still believe, however, that there will be predictable gaps in accessing sufficient licensed people for this purpose.
The new regs allow for LMHPs to supervise a staff over a max case load of 100-120. If the case loads are smaller (eg. 8), the number of staff an LMHP may supervise can be as high as 15. This is an improvement from the max of 9 in the previous regs. However, if the case loads reach 20 as allowed, the number of staff an LMHP may supervise may be as low as 5 (100/20). There simply aren't enough fully licensed individuals interested in this work to allow for a sustainable service model. Providers will enter into a bidding war for LMHPs leading to a large-scale consolidation of the providers with the deepest pockets. Access will diminish significantly.
Additionally, there is no practical allowance or accommodation provided for losing an LMHP supervisor. Are services expected to precipitously stop? What will this accomplish other than to hurt the client and create instability? The regs state that the Clinical Program Director may assist in this case, but what will this mean for their other duties? What if a larger provider loses more than one LMHP, especially when they are lured away by another provider who needs them?
We believe that LMHP-Es should be allowed to operate in these roles as they do today. This solution is pragmatic and will allow for a sustainable and functional system.
Furthermore, we would ask that providers are allowed more than one clinical director (regional clinical directors)so that we may fill the gaps should we lose more than one LMHP at the same time.
Lastly, in the event that more LMHPs or LMHP-Es depart than may be backfilled by a clinical director, we ask that a window of time be granted to rehire (eg. 2 months)
LMHPE-s being allowed to act as clinical supervisors will alleviate much of this need.
3. - Page 12. 5.3.(4-5)
“In-person crisis support shall be offered and available 24 hours per day, seven days per week, 365 days per year. The individual’s needs, preferences and specific crisis mitigation plan shall be the determining factor regarding whether crisis supports are provided in-person, face-to-face (telemedicine), or audio-only.”
"In-person crisis support shall be provided by the CPST provider prior to any referral to a Comprehensive Crisis and Transition Services (Mental Health Services Manual, Appendix G) unless the referral to Comprehensive Crisis and Transition Services or other emergency service is due to an acute crisis situation with safety concerns. If a referral to another type of service to assist with the acute crisis situation (911, 988, Emergency Room, CSB Emergency Services, 23-Hour Crisis Stabilization, Residential Crisis Stabilization Unit) is made by the CPST provider, the CPST provider shall remain engaged in the situation and with other service providers that are involved."
Must we respond to every crisis in some manner?
What if the client calls 988 on their own, unbeknownst to the provider? Will the provider be held accountable?
4. - Page 21.- 9.1.(C)
“Phone contacts including attempts to reach the individual by telephone to schedule, confirm, or cancel appointments are not reimbursable.”
It appears that phone contacts are acceptable for crisis management but not reimbursable for other CPST services. Is that the case?
Ref: page 12 - 5.3.(4-5):The individual’s needs, preferences and specific crisis mitigation plan shall be the determining factor regarding whether crisis supports are provided in-person, face-to-face (telemedicine), or audio-only.”
5. - Page 21 - 9.2(d)
“Individuals receiving CPST may not be simultaneously serviced authorized to receive the following services:
i. Applied Behavior Analysis with a primary diagnosis of Autism Spectrum Disorder,
ii. Assertive Community Treatment,
iii. Coordinated Specialty Care,
iv. Community Stabilization,
v. Functional Family Therapy,
vi. Mental Health Intensive Outpatient,
vii. Multisystemic Therapy,
viii. Psychiatric Residential Treatment Facility (PRTF) or
ix. Therapeutic Group Home (TGH) services.”
How will this be monitored? How will CPST providers know if the client is receiving community stab, or other services?
6.
We would like a better understanding of how telehealth may be used. We ask that this be spelled out directly with a simple explanation of who is eligible for telehealth, when they are eligible, and in what capacity. It appears that telehealth may allow for all services to include crisis management, but not for Rehabilitative Skills Practice.
Thank you again for your hard work and willingness to collaborate.