Thank you for the opportunity to comment on the most recent version of possible regulation changes for MHSS. 

This version of regulation changes has some very positive improvements included such as adding folks with certain credentials back into the regulations as being able to provide MHSS, such as QMHP-E's, which we had been told was an oversight.  The addition of counting non-residential crisis stabilization as a higher level of care for eligibility criteria is also a positive change.

The concerning portion of this version of changes is the cap on the number of units MHSS can be provided in a day.  While I certainly agree that serving clients for 3 units (more than 5 hours) a day should not be necessary on a frequent basis, there are some very real and legitimate times in which  spending that much time with a client is not only necessary, but to do otherwise could be neglectful and/or limit the client's access to care.  A new client who comes into services frequently comes in with nothing.  No housing, no resources, no medications, etc.  It is imperative during that first week to see to the needs of that client so that their risk of hospitalization and other higher forms of care are decreased.  It would be very difficult in this situation to limit the services given to the client just based on regulation as opposed to the client's need.  This is especially true in rural areas where resources are spread out across a large geographical area.  In rural areas, clients are forced to go long distances just to get their basic needs met and to see service providers, including psychiatric care.  Limiting the client's access and not basing the services on the client's needs is not person-centered and, depending on the client's need, could be considered neglectful.  This will either force clinicians to provide services for free or the client's needs will not be met.  This type of choice will encourage less ethical individuals to engage in fraudulant activities.  For those providers who choose to continue to see the client, providing the services for free, it will significantly impact their revenue as they will continue to pay staff, but receive no reimbursement for the additional hours. 

Another instance would be when a client is having difficulty with heightened symptoms and the clinician is able to talk the client into going to the hospital for evaluation with them.  The waiting times for these evaluations can be extremely long and can quickly add up to more than a 5 hour visit with the client.

In the new regulations, DMAS has lifted the cap of 8 hours per day for Crisis Stabilization and Magellan has stated that appointments longer than 8 hours will face more auditing and/or scrutiny.  This is the standard that should apply to MHSS as well.  Those clients that are consistently seen for 3 units a day should be examined to make sure there is appropriate supporting documentation to justify the more lengthy provision of services.  
Another option would be to audit more closely those providers who consistently provide services for longer than 3 units a day for many of their clients. 

It would appear that this change in regulation is in response to providers who are not good stewards of the service.  A change like this would only limit a client's access to care and make it difficult to meet their needs.

Although the total units per six month period increased to allow 10 units per week, there is an issue with the maximum amount of units billed per day being capped at 2. This restriction is especially an issue when it comes to servicing individuals both in their home and in the community who live in rural and remote areas. Often individuals do not have access to providers who 1) are located in the area because it is expansive and there is no public transportation option and/or 2)  accept Medicaid insurance in the area. While 5 hour sessions are rare, extenuating circumstances do arise to address immediate medical and psychiatric needs. Some individuals are in need of training during emergency room visits and multiple appointments with providers in the same day. 

Please reconsider capping the daily unit limit to 2 and allow 5 hour sessions if training services provided are justified. 

In addition, I think it is important for MHSS to focus on basic life skills instead of activities of daily living considering that much of what is defined as ADLs requires specialized training outside of the scope of being a mental health professional. Basic ADLs: eating, bathing, dressing, toileting, transferring (walking) and continence. While some basic life skills overlap with ADLs, both concepts are different and widely subjective. Please provide a breakdown of what exactly constitutes as ADLs cited in the changes so that there is a clear centralized base for all providers to work from.  

 

While the test of the regulation does not specificlly state this, it has been verbally indicated that SSPI evaluations will have to be conducted every 7 days while a person is enrolled in Crisis Intervention/Stabilization Services.  If it is true, this would be an onerous and clinically unnecessary burden to place on providers.  While we do not believe that persons in immediate ECO/TDO-level  crisis will be affected by this regulation, it is possible that some providers may reconsider opening come consumers to these services, thus delaying interventions until such times as hospitalization becomes necessary.  I do not believe that it is anyone's intent to inhibit access to these services, so I offer this caution against unintended consequences.

There are often incidents that require you to spend more that a 2 unit time frame with client's, such as when you intially assume the case.  The client requires an increases amount of attention when being connected to different resources in order to assist them with becoming more independent.  

Also, seeing an individual this many times a week decreases their ability to gain independence as oppose to increasing their independence.  

I feel that times should be allotted basesd off of a particular situation.  

The information about having a new SSPI required after 7 days for crisis intervention services is not written explicitly in the Town Hall proposal.  However, Magellan is verbally training providers that this will be instituted as a business rule.  Can the ACO institute requirements that are not covered in the regulations?  

I would express deep concern about the potential to reduce access to needed and critical crisis services by adding a burdensome requirement that could prevent or reduce access to crisis intervention services.

We have recently received notice from Magellan that even though crisis intervention services can be provide for up to 30 days from the initial crisis intervention service that in addition to registering the initial crisis intervention service within 24 business hours, starting August 1, 2016, we need to re-register for crisis intervention services every 7 days. In trainings that have been provided by Magellan, we have been instructed that along with this re-certification we have to conduct a new or revised SSPI and a revised ISP.

It has been burdensome and counter-productive to providing quality clinical services to require a SSPI at the initial point of providing a crisis intervention service. There is much that a clinician needs to do when assessing and assisting an individual who is experiencing a behavioral health crisis that is clinically necessary. While some of the elements of the SSPI are important to know, there are many elements that are not necessary to gather in the midst of a crisis. More importantly, there is other information that is essential to know. For example, a glaring omission in the elements of the SSPI is the provision of a risk assessment regarding harm to self or others. If we are to avoid a hospitalization, yet safely manage risk, immediate clinical action is needed. Clinical documentation requirements should be kept to a minimum. It is my contention that the identified service specific elements of an SSPI are not service specific to the provision of quality crisis intervention services. Requiring another SSPI every 7 days compounds the issue.

Lastly, the regulations say that an ISP for crisis intervention services is not needed until the 4th crisis intervention session. I am therefore puzzled by the Magellan training where it was stated that a revised ISP has to be submitted every 7 days as well.

We are trying to utilize crisis intervention as a more appropriate, least restrictive, best practice alternative to hospitalization, especially given that our hospitals are struggling with census management for those who are more acutely in need. Additional requirements such as these present unnecessary barriers to stabilizing individuals in need and successfully diverting them from inpatient treatment.

 

I do not support limiting the daily Mental Health Skill Building Services (H0046) cap to 4.99 hours, 2 units. I believe that a compromise can be made with the existing MHSS unit structure by dissolving 7+hours, 4 units but the State should strongly consider keeping the 3 unit option of providing greater than 5 hours of service. The probability and the necessity of greater than 5 hours service is very likely in rural parts of the state. Access to resources and the coordination of care can be made more timely within a Medicaid determined "Urban" rate demographic location, but this isn't the case in the "Rural" rate demographic, Virginian outlying regions. Aside from the fact that rural rates are already paid at a lower rate than Urban, the Rural demographic's timely access to resources/care exists within a larger geographical area so clearly this service will take additional time by proximity. 

I fear that adopting this regulatory proposal as it is currently written will likely dissolve the presence of Rural providers in the outlying areas of the Commonwealth leading to no access to care.  

 

 

Regarding the new regulation changes that Department of Medical Assistance Services (DMAS) has considered to Mental Health Skill Building Services (MHSS), by decreasing the cap of daily units that an agency may provide is a major concern. Every fiscal year the General Assembly in coordination with DMAS, make drastic changes to mental health services that individuals receive. This is very unfortunate and unfair to the consumer and the agencies that provide these services to the community. MHSS is a training service, which cannot be as effective or realistically accomplished, especially in rural areas with the new proposed DMAS policy, of 2 units per day at maximum of 10 units per week. MHSS are trainings and supports that assist individuals with major documented emotional and behavioral disabilities, in achieving and maintaining community stability through teachings and reinforcements of independent livings skills. Ultimately the agency, which I am employed, and others will be forced to provide

Pro-bono services to their consumers, which is also a major conflict, due to our employees will be financially reimbursed for providing a much needed service, although the agency would loose revenue.

As previously mentioned this is especially true in rural areas where resources are spread out across a large geographical area. (e.g. South Hill, Hanover, New Kent, Boynton). Eventually this will cause all community base private providers and others, to decrease their staff and loose consumers. Currently many consumers clinically diagnosed and meet the criteria to receive MHSS services often require more that 10 units per week, due to the unfortunate crisis that many experience weekly. MHSS services are also a safe and reliable avenue for the consumer to utilize and access needed services and remain in the community.

 It is imperative that the DMAS do not decide to finalize a decrease in the number of units per day and/or per week, with the population clinically eligible to receive these services. The local, regional and state Department of Human Rights is very clear in their policy, that no agency or individual has the right to limit an individual’s access to fair treatment and/or restrict them from receiving the best, most appropriate services available if needed, that meet the consumers emotional and behavioral needs. Treatment must be person-centered, without bias, prejudice or neglect.

Thank You

The proposed changes in the crisis intervention regs would effectively eliminate the availability of Crisis Intervention services for many people who may be hospitalized due to the lack of these less restrictive services. It places an undue burden on clinicians who provide both these crisis intervention services and emergency services without adding to the quality or effectiveness of the services provided. The additional and unnecessary workload presented by completing weekly treatment plans and intakes creates a staffing demand that is unable to be met by many local agencies. Not only will these regulations make crisis intervention services unavailable in many areas, it is counterproductive to the provision of quality therapeutic treatment for individuals in crisis. The completion of a full bio/psycho/social/legal assessment, such as the SSPI, every 7 days is not only unnecessary but it would also serve to discourage individuals in crisis from continuing in services. It is unnecessary because during crisis intervention services a clinician is meeting regularly and frequently with the individual in crisis. The discouragement is born from the mere size of this battery of questions, the repetition of static factors, and its interference with addressing the issues that brought the person into crisis in the first place. The existing 30-day period for crisis intervention services is appropriate for the treatment of individuals experiencing crises that may escalate to the point of hospitalization without this type of intervention. In 30 days the crisis can be identified, triggers/barriers can be addressed, referrals can be made and completed, and treatment plans can be put in place. A shortening of this authorization period would do a disservice to the individuals in our communities who are in the most immediate need.

I feel that these changes will require a clinician to choose between working in the best interest of the client and the time alloted. The client should always come first. There are emergencies and distance to community providers that are factors. Clinicians will not be able to explain to a client who may be in crisis or have travel difficulties that their situation is limited on time and therefore will not be addressed.

Clients seen in this part of the state are limited to psychiatric, primary care and especially specilist providers and accessing larger communities takes excessive amounts of time often requiring 5 hours or more. For this reason many times it is difficult for clients to obtain reilable Medicaid transportation and the client who may have disabilities or other limiting factors are forced to spend entire days accessing needed provider services. In addition this lack of primary support and extended stressful time can heighten client's psychiatric symptoms and cause them to avoid recieving necessary care.

There are times, when a client initially comes into services, that a client requires more time as there are significant needs that may take longer than 3 hours to address. Especially living in a rural areas where medicaid transportation is not reliable and resulting in clients losing established providers. 

• From experience, it has been observed that seeing clients on frequent occasions creates increased dependency on services.
• Clinician providing services in rural areas with limited accessibility to resources may require more than five hours to ensure that their needs are met.
• There are times that appointments often exceed three hours due the nature of the appointments and clients often exhibit increased symptoms due to long waits and often decide to discontinue services is there is no source of support or reinforcement available.   

The clinician may be assisting a client through a three (3) hour session and during the session,  the client may experience heightened metal health symptoms. Although the clinician may attempt to decrease symptoms or de-escalate the situation that creates the heightened symptoms, it is determined that the client should be assessed at the hospital. The clinician convinces the client that an assessment is needed at the emergency room and they go to the hospital and experiences a lengthy waiting period. This session would easily be beyond the five (5) hours allowed for two (2) units.

I feel that this new regulation will be detrimental to my clients and ultimately cause them to deteriorate. I am in a rural area so provider appointments often take 5 hours and yes, I could assist my clients with arranging Medicaid transportation, but there are many issues with this. First- Medicaid transportation is unreliable, at least in my area, and sometimes doesn't show up or arrives late, which causes untold complications including losing providers which causes clients to deteriorate. Second- if I am not with my client at a provider appointment, I am not able to provide optimal services such as facilitating communication, making sure they address all concerns, and de-escalating clients should something unforseen cause them to experience heightened symptoms.

A client may agree to meet with a specialist, due to their mental health needs. due to experiencing heightened levels of social anxiety or pranoia, of  meeting with a large group of people or someone new, clinician will need to provide skills training in role-playing with the client to decrease their heightened symptoms and how to interact appropriatley with the service providers.  Clinician will also need to facilitate the communication between the service provder and the client to ensure that all information is being informed correctly and for the cleint to be able to follow appropriate medical orders to help maintain stability into the community without hospitalization.  Following the appointments , the clinician will need to help the client obtain appropriate community resources by obtaining refills on medicaitons and this will defenitely take the hours of 5 hours sessions.

 

A clincian may be working with a client through a 3- hour session and during the appointment, the client may be having difficulty with heightened symptoms. In spite of the clinician's attemps to de-escalate whatever situation has caused, this tey determine the client shoud be assessed at the hosptial. The clinciian talks the client into going with them to the emergency room and they go to the hospital where thee is typically a long wait time.  This appoinment could easily stretch beyone the 5 hours allowed for 2 units. 

A client may come into services without any supports. There may be situationsin which clients require linkage to several different community agencies.  They may need assistance accessing those resources, completing applications, etc, that may take an extendeed amount of time.

 

 

 

 

 

 

 

 

 

 

 

As a Clinician, there are times when working with a client through a 3 hour session and during the appointment the client may be having difficulty with heightened symptoms. Certainly it would not be a good idea to just leave the client due to a cap on the units. Many clients come into services without any supports and rely on their clinician for support as they also don't have family support either. Some doctor appointments for our clients are not local therefore requiring travel and we all know a doctor's appointment is not a place where you can walk in and out of quickly.  Our main focus for our clients is to keep them stable in the community even if it from time to time take 5 hours to do so.

I do not support the daily Mental Health Skills Building Services cap to 2 units. There are several instances where a client may need extra attention and a longer session. An example of this would be when a client is having difficulty with heightened symptoms and the clinician is able to talk the client into going to the hospital for evaluation. The hospital may have lengthy wait times and the client may need the clinician's assistance with facilitating conversation with providers. Placing a daily cap on the units may compromise the level of care received by the clients and may cause difficulty in establishing healthy relationships with providers.

There are times, that a client requires more time as there are significant needs that may take longer than 3 hours to address.  For instance, a client that has 2 doctor appointments and there is  a wait and then have to puchase medications at the pharmacy and again have to wait, so this can be a form of neglect for clients if the appointment can only be 3-4.99 hours.   Client's do need the services to become more indpendent in the community and the new regulations can cause the client more harm than good.  .

the proposed changed to the srisis intervention progam are completely unnecessary and would decrease the quality of treatment that individual are able to recieve. SSPIs do not change in 7 day. Infact, most information gathered in an SSPI, besides the current presenting problem, does not change at all and is demographic and background history. By adding this additional burden to clinical staff, it will decrease the amount of time clinical staff can devote to treatment.

I believe seeing clients more frequently, for shorter periods of time, creates more of a dependency on the services... but I also believe that serving clients for more than 5 hours a day would not be necessary on a frequent basis.  Clinicians providing services in rural areas may need 5 or more hours to help clients meet all of their needs.  For example, resources in rural areas are more spread out.  There are a lot of clients who set up Medicaid Transportation for scheduled appointments, but have been discharged from their providers due to Medicaid Transportation not being reliable and the client not being able to make it to their appointment.     

 As a clinician working with the clients in the community we are subject to run over times. A majority of the clients have socialization issues that makes it difficultly to engage within the community by themselves and the clinician is there to help assist them. A majority of the clients don't have family members that they are dealing with due to the heightened mental issuers so this limits them.

I currently work with clients that are living in rural areas making it impossible to get to appointments without going over time.

I have a concern that working with my clients that may have times when they have great difficulty with heightened symptoms and are isolated in the home and the clinician are having to take the clients to the doctor or hospital for evaluation to make sure that they are okay and the waiting time may be extremely long and they are unable to be left alone. 

 

A client may come into services without any supports. There may be situations in which clients require linkage to several different communtiy agencies. They may need assistance accessing those resources, completing applications, etc that take much more time. To help clients meet their needs extra time has to allotted.

I am very concerned at to the unit cap requirement for MHSS and how this will significant impact the treatment and care for the clients we serve.  My office is based out of Martinsville where there is very limited resources for the client's we serve.  Most of our clients come into our services with absolutely nothing, no primary care physician, no case manager, no psychiatrist to assist with their mental illness and no knowledge of needed resources.  Our staff ensures those clients are linked to the various services they need to live more freely, live more independently and manage the symptoms of their mental illness.  However, in my location, being linked to those services require going outside of our location to get the care they require.  While I agree that serving clients for more than 5 hours a day (3 units) should not be necessary on a frequent basis, it is extremely difficult to establish the resources they need by taking them from Martinsville, VA to Roanoke, VA or Troutville, VA and to manage this in 3 hours proves quite difficult.  Those clients will not receive the quality care that we value in our community.  Those clients will not receive the prompt resources that is available if we only give them a short amount of time to achieve this.  Limiting the client's access and not basing their services on the client's needs does not define "Person-Centered" and depending on the client's need, this could be considered very neglectful!  Please reconsider this unit cap by keeping in mind the need for the clients we serve.  Each person deserves a fulfilled quality of life. 

By providing a 2-unit cap daily per person, DMAS recipients will not always receive appropriate care in regards to needs.  Due to limited availability of specialists, medical and mental health, in our rural area, clients may need to travel to outlying areas to receive such care.  Medicaid transportation is available for clients to access such providers; however, due to anxiety, limited ability to self-advocate, difficulty with management of anger and other emotions, and difficulty in remembering and effectively communicating questions and concerns with providers, MHSS providers are often needed to provide real-time training on how to effectively access and utilize such specialist services to ensure that needs are met.  Upon completion of such appointments, medications are often needed to be obtained and this further extends the time needed to be utilized during such sessions. 

In assisting clients in accessing needed resources, the 2-unit daily cap may be detrimental to the clients' mental health as they may be facing eviction, legal interventions, and/or disruption of services (such as electricity) and require assistance in accessing such resources to prevent such crises from occurring.  Due to many such resources being on a first come, first served basis, clients and clinicians may be required to participate in lengthy wait times to receive such assistance in accessing resources. 

If a client is in need of emergency care, the daily cap could decrease access to such care as many clients will not access such services without the assistance of a clinician.  Due to limited emergency services in rural areas, there is frequently an extensive wait time to be seen when accessing such services and this could place the clinician at risk of exceeding the unit cap.  However, if a clinician is to leave a client waiting for services due to daily unit cap, there is risk that the client may leave the facility and not receive the needed emergency services that they were seeking.

By capping the units in a manner that could decrease the quality of services provided to clients, DMAS is removing the person-centered focus of care and services may be viewed as neglectful and border violation of client rights as their needs may not be fully addressed due to MHSS need to limit services to ensure compliance with DMAS regulations. 

Due to the daily cap, clinicians who work in excess of three hours may not receive adequate compensation as financial reimbursement will not be provided by DMAS, the quality of MHSS clinicians may decrease throughout the field as a whole.  Clinicians enter the workforce to ensure ability to provide for their families and if pay structure is interfered with, clinicians may enter other fields and create a decrease in available MHSS providers, which further decreases the ability to meet the needs of clients seeking MHSS.

I do not support only being able to provide Mental Health Skills Building Services for two units a day.  I believe there can be a compromise made in regards to the unit structure.  The necessity of greater than 5 hours of service is very likely in rural areas of the state in which it takes longer periods of time to reach service providers.  For example, when a client is having difficulty with heightened mental health symptoms, the Clinician is able to talk the client into going to a local hospital for evaluation with them.  The waiting times in rural areas for evaluation can be very long and often ends up being at least 5 hours in duration or longer. 

I believe seeing clients more frequently for shorter periods of time will create a dependence on services.  A Clinician may be unable to assist a client through heightened symptoms due to time restraints.  Many clients often come into services without any supports.  There may be certain situations that require a client to be linked to several different community agencies and may need assistance in accessing all of these resources.  These appointments often take an extended amount of time due to filling out applications, etc.

 

A client may finally agree to see a specialist and have very heightened anxiety surrounding this appointment.  The Clinician will utilize role play to assist client in interacting with the specialist in an appropriate manner prior to the appointment.  Often clients become very overwhelmed with new service providers and may not remember to address all areas of concern without assistance from the Clinician.  Following appointments, Clients may  need to visit local pharmacy to obtain needed medications and the Clinician may need to provide skills training regarding understanding new medication and how to properly take medication.  Appointments such as these may take more than 5 hours. 

Clinician providing services in rural areas may need 5 or more hours to properly help clients meet their needs.  In rural areas in Virginia, resources are often very spread out and require more time.  I fear  that adopting this regulation as it is currently written will likely dissolve the presence of Rural providers in the outlying areas of the Commonwealth leading to no access to care. 

There have been many times where my clients have required more time than the allotted new unit cap due to heightened symptoms during appointments, out in the community, and communicating with others, and dealing with many every day mental health issues. Many of my clients have health and mental heath providers which are located at least 45 minutes or more from their homes, which makes travel a large part of the issue especailly when other transportation will not serve their area due to being so. Clients have reported that they have had difficulty with other transportation being reliable and have suffered a loss of providers due to not being able to attended resulting in discharge. Clients have reported that they experience extreme heightened symptoms related to their mental health while utilizing other transportation and not having support to reduce or minimize these symptoms resulting in negative back slides relating to their ISP. Clients who have heightened symptoms that are unable to be seen more than their 3 hrs will be left to move through these potentually damaging symptoms especially when experinicing heightened suicidal symtpoms. In order to work towards discharge with a client, clinician needs to be spending time with clients during these heightened situations in order to train, model, and role play ways that they could effectively reduce these symtpoms. Clients will possibly feel less supported and vulnerable when they should feel supported and confident when dealing with daily issues connected to their mental health and medical concerns.

Although 5 units are not used often, there continues to be a need.  The unit cap per day can create dependency for the service, making it more difficult to accomplish goals and eventually dischage clients.  Many of our clients have difficulty navagating treatment/medical provider appointments indepenenlty.  Often may of our client's live in rural areas, where much of that time is spent in travel to access areas where treatment can be provided. Please reconsider this change so our community and our client's will continue to prosper. 

I urge the reconsideration of the 2 unit per day cap on MHSS due to the negative impact it will have on clients, especially in rural areas. While 5 + hour sessions should be rare, there are a number of circumstances that would justify working with a client for five hours. Service coordination, heightened client needs, and crisis situations do arise in the populaiton served by MHSS and  may require more than 5 hours of service. Please consider monitoring frequent 3 unit a day billing through targeted audits rather than capping the service at 2 units a day.

In my 2+ years experience of providing MHSS in a rural area, I have found that there have been times when resources are more spread out relative to where clients live which affects the time that we spend together. I have typically used any extra time getting to and from resources to address other objectives that would not have otherwise been addressed. Many of these times, 3-4.99 hours is insufficient to meet all of a client's needs in a day, especially if they live 45 minutes from the closest specialist for a condition or the nearest food pantry that serves them on a particular day.

 

Additionally, seeing clients more frequently for shorter periods of time creates a dependence on the service, which is intended to move a client towards independence. It does not benefit a client to be seen four or five days a week for three hours per day if the goal is independence; especially if the objectives can be met more efficiently in three days if one of those days has more time spent with the client. Additionally, two days of two unit sessions and one day of a three unit session would cost the state less than four days of two unit sessions. This approach allows the client's needs to be met throughout the week without fostering dependence on what is supposed to be a long-term, but temporary, service and can help Virginia spend less money on the service, which I believe is the goal of this regulatory change.

Requiring a renewed registration every seven days, in combination with developing an SSPI and ISP every seven days, is not conducive to timely crisis response or clinical best practices in crisis intervention.  The crisis clinician needs the flexibility to provide rapid response to help ameliorate multi-faceted problems occuring over a short period of time. This should be based on a single assessment and ISP, which is then reviewed throughout the intervention period as a "living" document guiding practice and outcome. Attempting a comprehensive reassessment and full ISP every seven days prevents seamless clinical progress and full attention to intervention during a critical time of change for the individual in need of services.  This is an undue burden on both the clinician and the client, who should be focused on getting better - not getting comprehensive assessment - each visit.

Capping the unit hours for MHSS clients can be detrimental to clients and service providers. Decreasing this would cause unnecessary stress on all sides, especially when clients are experiencing an intense crises, heightened symptoms and more. Decreasing the cap will cause additional stress to service providers that would force them to take on more clients, causing burnout. If it must be done, a past rate increase so be necessary Please do not do this. Thank you.

There are several times when a client needs more time as there are significant needs that may take longer than five hours to address. For example, a client may come into services with no identified supports and require immediate linkage to various community resources to prevent a higher level of care in order to maintain safety or avoid hospitalization. Clients often times need assistance identifying the resources, navigating those resources, completing applications,etc. This would be difficult to accomplish in a 1 or 3 hour session, particularly for clients who live in areas with high volume of traffic or distance between location of home and services. A worker may also be working with a client through a 3-hour session and during the appointment, the client may be having difficulty with heightened symptoms and other safety concerns. In spite of the worker's attempts to de-escalate whatever situation has caused this, they determine the client should be assessed at the hospital. The worker persuades the client go with them to the emergency room which would cause the appointment to exceed 5 hours. Another example would be when a clinician assists a client to a new provider such as a psychiatrist or primary care physician. Many clients struggle with going to new providers due to heightened anxiety. The worker would go to the client’s home prior to the appointment to make sure the client is ready and makes it to the appointment. During the time prior to the appointment, the worker would be preparing the client for the appointment by role playing what the doctor may ask, reminding the client what questions they may have for the doctor and prompting the client to use coping skills to deal with their anxiety leading up to this appointment. During the appointment, the worker is an invaluable resource to the client, reminding the client of questions to ask, assisting them with new patient information, etc. Following the appointment, the worker may have to take the client to the pharmacy to fill or re-fill a prescription and then make sure that any prescriptions are understood, properly stored and/or placed in a medi-set box to insure proper times and dosages. This description does not include any wait time that may be required to see a doctor during which the worker would be assisting the client in managing their anxiety. In rural areas where resources are very limited, clients are required to travel long distances to receive services. For example, a person living in Danville, VA may need assistance attending their first psychiatry appointment. There are currently no psychiatrists accepting Medicaid reimbursement in the Danville area and clients must travel to Roanoke, almost 2 hours away in order to receive psychiatric services. It is easy to see how limiting the number of hours that a client may receive MHSS, could seriously limit their access to care, as it will not be feasible for providers to assist clients to their needed appointments. In addition to the examples above, this limit on daily reimbursement for services encourages seeing clients on a more frequent basis for shorter periods of time which may create more of a dependency on the service as opposed to the independence that is the goal of the service.

The proposed changes requiring updated SSPI and treatment plans for crisis intervention services are not conducive to effective care for individuals in Virginia's communities.  These requirements would create signficant barriers to service.  There is no clinical or treatment value gained from repeated questioning and assessment about known information and the seven day period is often insufficient for resolution of  a psychaitric crisis.  The practice would discourage individuals from participating in services due to the barrage of questions the individual would be repreatedly subjected to, wasting valuable time that could be used for intervention and increasing the likelihood of psychiatric hospitalization.

To require that an individual to state the same informaiton over and over is both inefficient and recognized as poor clinical care.  Given the frequent cooccurrence of trauma and mental illness, most individuals who receive crisis intervention have experienced significant trauma.  To ask these individuals to restate and revisit information about these traumatic experiences requirement borders on unethical and certainly is not in keeping with best practices and national efforts to promote trauma informed care.

 

While a service exceeding five hours in a day is not regularly required to meet the needs of a client, there are instances where this is necessary and appropriate. 

Just one Example: In rural areas where resources are very limited, clients are required to travel long distances to receive services. For example, a person living in Danville, VA may need assistance attending their first psychiatry appointment. There are currently no psychiatrists accepting Medicaid reimbursement in the Danville area and clients must travel to Roanoke, almost 2 hours away in order to receive psychiatric services. It is easy to see how limiting the number of hours that a client may receive MHSS, could seriously limit their access to care, as it will not be feasible for providers to assist clients to their needed appointments. I can provide other examples where limiting acces to care are not beneficial to the client, but I believe this is obvious. Even if limits are imposed there needs to be some some flexibility to serve clients in rural areas and/or clients who are experiencing a moment of crisis and need additional support to avoid hospitilization. 

1. It is so sad that once again bureaucratic practice/insurance regulations are overtaking common sense.  Virginia is trying it's best to protect and help people in mental health crisis yet instead of providing resources and streamlining the emergency intervention  the process gets bogged down by more paperwork/assessments.  We are Master's level clinicians trying to provide vital assistance to an individual in crisis yet we are hindered and unable to use our counseling skills because we are spending the majority of our time making telephone calls seeking placement or completing unnecessary paperwork instead of interacting with the individual in crisis.  This is not person-centered or recovery focused.  Please stop this.

The proposed change to the crisis intervention services would decrease the quantity and quality of treatment for the individual coming in to be seen during a crisis. Having to complete a SSPI weekly would take away from treatment for the crisis. A majority of the SSPI information collected will not change within a week to week's time frame. Continuously asking the individual the same questions every week would discourage the individual to continue with services and possibly increase the likelihood of a possible hospitailzation or residential crisis stabilization.

We have significant concerns relating to recent Magellan notifications about 7-day registration requirements for crisis intervention and MHSS Treatment Plan Reviews being proposed by Magellan. Magellan trainings provided included some verbal indication that providers would not only have to do a 7-day registration update, but it was also verbally stated that providers would also need to do a new SSPI and ISP every seven days for crisis intervention.  This information is not written in any of the official materials being released, nor in the Regulatory Town Hall proposed final regulations. On the most recent Magellan provider call on 7/22/16, it was stated that a new SSPI and ISP would not be required if the registration was not for a new crisis but the provider would need to determine needs and identify barriers to resolving the crisis with an update of the ISP. The latest information given on the provider call is contradictory to the training information provided regarding SSPI and ISP requirements and has caused significant confusion. It was also stated by Magellan providers that this will be instituted as a business rule as there is potential to reduce access to needed and critical crisis services by adding some burdensome requirements that prevent or reduce access to crisis services.In addition to the crisis intervention changes there is also significant confusion surrounding the MHSS requirements regarding treatment plan reviews that are to be documented in the individual's medical record no later than 15 calendar days from the date of the review. In the Magellan training this was discussed as a new requirement for MHSS but on the most recent Magellan provider call it was stated this was for all CMHRS services except for case management services. Again this is contradictory information from the webinar training regarding the upcoming trainings and given the number of CMHRS services, clarification on this requirement is a significant. 

 

To the subject of having to complete an SSPI at the initiation of a crisis. This is not in the regulations  but was part of the Magellan training. That in itself is unclear as we are being trained for something that is not part of regulations. Does this include the prescreening? In Virginia we have 8 hours to complete an assessment, gather all information and find a bed. At times that includes calling up to 26 hospitals and faxing prescreening to each one of them. Our goal should be to provide intervention for a person in crisis. We are already completely overwhelmed by documentation and now Magellan wants a SSPI for a person we may never see again once they are hospitalized or a safety plan has been formulated. I'm sure this is true for the other CSBs/Regions.  If this is not required at prescreening then it should be made clear. We are getting conflicting directives. Our priority is to keep the person in crisis safe not duplicating our justification for providing the service. The prescreening is 10 pages that contains every piece of information needed. An SSPI is not justified in this case.

I have worked with clients who experienced severe anxiety & displayed aggressive behavior when their symptoms escalated. These clients benefited from being connected to an ER with the presence of MHSS worker. These sessions would sometimes exceed 3 hours. When an extended session is justifiable it should be allowed.

I do not support limiting the daily Mental Health Skill Building cap to 2 units. My concerns for the client that is exhibiting heightened symtpoms that may not be ready for Medicaid transportation and have a long appointment for travel/surgery appointments. It is rare that I ever bill for 5 or mre hours but when I do I feel it is always for the best practice for my client's.

The requirement to do an SSPI and ISP every 7 calendar days for crisis intervention is unbelievable.  This will not allow the clinical work regarding the crisis to every get addressed due to the time to do these other paperwork tasks.  Crisis intervention requires immediate interventions for the issue at hand.  If I were the individual coming for services, I would not participate in a long psychosocial history and ISP development for several hours and never get a real chance or time to address the real reason I presented....my crisis....it would throw me into a bigger crisis.  Magellan's constant requirements for more and more paperwork, in all areas, are leading to less treatment time with the client; the time that is left for treatment is resulting in diminished quality of care.  As a taxpayer and a provider, this concerns me for the individuals were are charged with taking care of in a quality, therapeutic way.  The community as a whole should be concerned too due to safety issues if we are not allowed to address behavioral health crisis in a timely, therapeutic manner due to mundane bureaucracy. 

Being required to conduct an SSPI and ISP every seven days for crisis intervention services is overall doing a disservice to our individuals.  Having to complete an SSPI each week and typically only getting to meet with an individual once a week will not be therapeutic for the client. The whole time for each session will be spent working on an SSPI. However, even if a clinician were to be able to conduct the SSPI and schedule the individual within the next seven calendar days, just to turn around and do another SSPI is illogical.   The static information is not going to ever change and the dynamic information in a seven day period is not likely to change as well. The time, effort, transportation, and documentation time involved is ridiculous. The service provider and/or agency is not able to bill for each SSPI, therefore is losing money. The individual will most likely become frustrated and not want to continue brief therapy and may become at higher risk for hospitalization. I have individuals now that get frustrated doing them once a year because of the re-traumatization, much less every seven days.

Martin Luther King Jr. stated that "Violence is the voice of the unheard". What better way to tell someone that you're not listening or don't really care about their issues than spending a significant amount of time completing a SSPI  and various forms instead of listening and helping them with their problems.  Why bother seeking services if you know that you'll be spending the first few hours answering a ton of questions that are not related to your current issues? Most of this information is often already in the person's chart if they have received services in the past. Clients will either avoid services alltogether or act out violently demanding immediate care in order to get their needs met. The community will blame the person with a mental illness for not patient. When will we become patient centered care focused?

Mental health skill building clients are in need of a range of services; basic life skills to independent living coupled with mental health concerns. Diminishing hours spent with these clients is a disservice to the counselor and the client. Treatment takes time, eliminating that time will only cause detriment to the client. People recover with time and patience, so please do not take that time away. 

 

The proposed requirements to make SSPIs and PAs, etc to have to be completed every 7 days is a little ridiculous.  Once an SSPI is completed, the majority of the information in that document does not change.  To me the most important part of crisis intervention is the actual intervention and helping the clients we serve move on to a healthier lifestyle and not bombarding them with the same questions every week.  This has the potential to aggravate clients and discourage them from attending future appointments as they may begin to feel as though they are not getting adequate treatment and therefore the "revolving door" continues.  The focus should be on the wellbeing of the clients we serve, not worrying about having to complete a mound of paperwork, in turn the clients are the ones who continue to suffer.

The proposed changes in the crisis intervention regs may eliminate the availability of Crisis Intervention services for people who may be hospitalized due to the lack of these less restrictive services. . The additional and unnecessary workload presented by completing weekly treatment plans and intakes creates a staffing demand that is unable to be met by many local agencies.

The completion of a full bio/psycho/social/legal assessment, such as the SSPI, every 7 days is unnecessary & it discourages individuals in crisis from continuing in services. During crisis intervention services, a clinician is meeting regularly and frequently with the individual in crisis. The questions are lengthy & repetitive & interfere with issues that brought the person into crisis. The existing 30-day period for crisis intervention services is appropriate for the treatment of individuals experiencing crises that may escalate to the point of hospitalization without this type of intervention. In 30 days, the crisis can be identified, triggers/barriers can be addressed, medications evaluated and adjusted, referrals can be made and completed, and treatment plans can be put in place. A shortening of this authorization period does disservice to the individuals in the most immediate need.

The problem doesn't necessarily lie in the amount of time that is spent with those MHSS clients who NEED it, it might lie with the "gatekeepers" that determine eligibity for medicaid and the persons responsible for allotting the hours. (For example: one MHSS client might need the entire 10+ hours. and then another person will only need a few hours per week). You shouldn't make it hard on those who need it because of the ones that "abuse" the system.    

I am writing to express my concerns about the proposed changes in the crisis intervention regulations that limit (effectively discontinue) Crisis Intervention services for my patients.  My patients will likely end up being hospitalized because they were not given this less restrictive service. I do not see how this new regulation increases quality or effectiveness of the services being provided already. These regulations make crisis intervention services unavailable in many areas, as there will be unnecessary workload added to those who provide emergency services.  I feel that if some of my patients are asked to sit through a full bio/psycho/social/legal assessment, they are likely to discontinue services altogether.