Sections 3.1, 8.1, and 8.3 (pages 8–9 and 22–26) tie admission criteria and levels of need heavily to CANS Lifetime scores. Adults living with chronic schizophrenia, bipolar disorder, psychotic disorders, severe depression, and other serious mental illnesses often experience fluctuations in functioning that may affect scoring without reflecting meaningful changes in their need for support. As written, the draft risks creating situations where individuals lose access to services due to minor changes in assessment scores rather than true clinical improvement.
On page 5, the draft states that the Clinical Director must be available to provide in-person support at the individual's location when clinically indicated. This expectation appears difficult to operationalize in practice. The draft does not address whether this responsibility may be delegated to another licensed mental health professional when the Clinical Director is unavailable. Additionally, each service tier already includes licensed clinical staff as part of the treatment team. It is therefore unclear why the Clinical Director would be expected to personally provide in-person intervention when other qualified licensed clinicians are already available to meet the individual's clinical needs. Clarification regarding delegation authority and the intended role of the Clinical Director in direct field-based intervention would be helpful.
On page 8, it is unclear whether the CANS Lifetime is intended to replace the Comprehensive Needs Assessment (CNA) or be used in addition to it. If it is intended as a replacement, clarification is needed regarding whether it satisfies existing licensing requirements for a comprehensive assessment. If it is intended to supplement the CNA, providers may be required to complete multiple overlapping assessments, significantly increasing administrative burden without necessarily improving clinical decision-making.
On page 12, providers are also instructed to utilize a CANS Lifetime completed by another DMAS provider within the previous twelve months. However, current licensing requirements generally require an initial and comprehensive assessment upon admission to a service. It is unclear whether reliance on a previously completed CANS Lifetime would satisfy licensing requirements or whether providers will be required to complete both assessments. Furthermore, the draft repeatedly references the CANS Lifetime as a critical component of admission, service authorization, treatment planning, level-of-care determinations, and step-down decisions, yet many stakeholders have not had the opportunity to review the actual assessment tool. Before implementation, providers should have access to the CANS Lifetime instrument itself in order to evaluate its content, clinical applicability, and operational impact.
Page 13 references training requirements, but no information is provided regarding the length of training, certification standards, recertification requirements, or associated costs. Given the substantial workforce challenges currently facing Virginia's behavioral health system, additional training requirements may have significant staffing and financial implications. Providers need a clear understanding of these expectations before implementation.
Pages 30 and 31 require a CANS Lifetime assessment to support movement from Tier 1 to Tier 2 services and reference monitoring individuals for ninety days following a step-down to identify worsening CANS scores. These provisions raise important questions regarding how frequently the CANS Lifetime must be completed. The answer has significant implications for administrative burden, staffing, training costs, and service delivery. If the assessment is lengthy or requires extensive training, repeated administration may divert resources away from direct clinical services.
Page 10… If the CSB doesn't provide and/or does not have availability for admission to Assertive Community Treatment, Coordinated Specialty Care, Functional Family Therapy, or Multisystemic Therapy and the service is indicated then the CSB must refer out. Will there be private providers for all these services? Are CSBs going to accept and serve out-of-catchment referrals? This might overburden larger CSBs.
The draft creates potential duplication regarding care coordination services. Page 18 requires care coordination activities as part of CPST, yet many of these responsibilities already fall within the scope of Mental Health Case Management. Qualified mental health case managers routinely coordinate appointments, facilitate access to services, connect individuals with community resources, and support continuity of care. Requiring CPST team members to perform these same activities may create duplication of effort and inefficient use of limited workforce resources. Consideration should be given to allowing qualified mental health case managers to fulfill care coordination functions where appropriate.
page 21… providers report DBHDS Corrective Action Plans (CAPs) to Managed Care Organizations. This requirement appears unique to CPST and does not appear to exist for other behavioral health services. Additional explanation regarding the rationale for this requirement and its intended use by MCOs would be beneficial.
Section 9.2(4) on page 32 appears to prohibit concurrent authorization of CPST and Psychosocial Rehabilitation services. As psychosocial rehabilitation transitions toward the International Clubhouse model, clarification is needed regarding whether individuals receiving CPST will be eligible to participate in clubhouse services. CPST and psychosocial rehabilitation serve distinct but complementary functions. CPST focuses on symptom management, treatment coordination, crisis prevention, and stabilization, while psychosocial rehabilitation emphasizes community integration, social connection, employment readiness, and functional skill development. Restricting access to both services may increase social isolation, reduce community participation, and ultimately contribute to higher-cost interventions such as crisis services, emergency department utilization, and psychiatric hospitalization.