Thank you to everyone who has been working so diligently on Medicaid redesign and for allowing ample public comment.  In comparing the first draft of the policy to this draft, it appears that only fairly minor changes have been made.  In reviewing all the comments, the patterns and consistencies are obvious.  I think the comments are fair, comprehensive, and reflect accurately on the services from the perspective of those who provide them.    I will isolate my comments to only three areas.

1.  The overall flavor of the document is overly prescriptive in terms of defining the way that agencies need to manage their staff.  It suggests that DMAS does not trust agencies to train, supervise, and monitor staff appropriately.
2. The focus on the services not being long-term in nature reflects a poor understanding of the nature of the SMI/SED population.  I think that all of those who work with this population and are highly invested in those they serve would be thrilled if natural supports could take the place of professional/paid services.  Sadly, this is not the case for most of those we serve.  Many clients have extensive trauma histories due to abuse suffered in their families of origin, have families with untreated mental health and addiction issues that affect their capacity to provide support, and have financial, transportation, and residual mental health symptoms that are genuine barriers to making and sustaining friendships.  All of this is exists within the context of an epidemic of loneliness and isolation that has been well documented and extends beyond those with SMI.
3. The necessity to provide a face-to-face, in-person response 24/7 continues to be a concern.  While I appreciate that crisis mitigation plans will be an integral part of the treatment model, anyone who has worked extensively with this population knows that these written plans are never 100% effective, especially in the early stages of treatment.  It has been stated that an in-person response should be needed only very rarely due to crisis mitigation plans.  This is simply not true and hints at being out of touch with the realities of providing services to this population.  Additionally, we serve a very large, very rural area.  Cell phone coverage is sketchy or non-existent in many areas we cover.  Expecting staff to respond to crisis events after hours and alone is not reasonable or safe.  This may be the deciding factor in whether or not we can continue to provide what is essentially mental health skill building services.  I  do not exaggerate when I say that this is a life-saving service for some of our individuals.  Details provided upon request.