I agree with some of the regulatory changes for MHSS for the purpose of creating a more clinically effective service.  Although the changes are quite significant with regards to the new eligibility criteria in addition to other restrictions on providers (i.e. weekly service limits, not being able to bill over hours allotted on the ISP, necessary documentation in individuals' charts, etc), it has been my hope that the service will still enable many of those with serious mental illness to access and benefit from Mental Health Skill-Building.

I am very concerned, however, in what some providers have reported and am afraid that our agency will soon experience as well.  It seems that many providers are being told that although the individuals they submit for MHSS authorization  meet the new eligibility criteria, that those individuals are being denied services because the focus on the authorization was not pertaining to "hands-on skills training" rather the focus was on social skills and/or coping skills training.  It has been stated on more than one occasion that this type of training should take place in an outpatient therapy setting.  The new regulations state, "The individual shall require individualized training in acquiring basic living skills such as symptom management; adherence to psychiatric and medication treatment plans; development and appropriate use of social skills and personal support system; personal hygiene; food preparation; or money management."  I would argue that symptom management is accomplished through the use of coping skill training.  Additionally, social skill training is specifically listed as a need of these individuals per the new eligibility criteria.  Research has shown that for this population, traditional outpatient therapy is not typically beneficial for a number of reasons: difficulty with insight, difficulty with effective communication, difficulty with follow through of what is learn during the outpatient session, difficulty applying what is learn during therapy to personal living situation, difficulty in physically accessing an outpatient therapy office, etc).  Additionally, studies indicate that SMI population benefits most significantly from continued and repeated rehearsal and practice of skills over time within their own environment and often in the moment when the issues arise.  It would not be clinically beneficial to work on an IADL such as budgeting, for example, while not also working with the individual to cope with their paranoia when out in the community due to their Axis I diagnosis while you practice the budgeting skills.  Likewise, it would not be beneficial to help teach the individual to access community resources without working with them on appropriate social skills while accessing these resources.  These are just two of many examples.  For individuals involved in MHSS, these issues do not occur by themselves in a vacuum and cannot be treated as such.  If we take these crucial elements out of the service, I believe we are actually weakening the service rather than strengthening it, which was the intended purpose of the regulatory changes to begin with.

I am also concerned about the proposed regulation stating that an ISP has to indicate both the amount of days in addition to the amount of hours a provider works with an individual and therefore not bill any time that is over this indicated amount on the ISP.  It makes sense to indicate the amount of hours on an ISP and to stay within that pre-allotment and therefore not bill over that amount.  However, the number of days in which the total amount of service hours are provided to an individual should not matter as there is no therapeutic benefit of service hours being done only within a certain amount of allotted days.  There are situations when this could vary based on client need.  I see this regulation as actually being counter therapeutic in that an individual may be struggling a particular week and would benefit from service hours being provided with more frequency, but shorter duration, than what may have been allotted on the ISP.  It has also been proposed that providers will have to submit billing by indicating the amount of units/hours provided per day rather than, at present, being able to bill a total amount of units over a given period.  This places an undue burden on many providers' present billing systems.  If this is being proposed for the purpose of ensuring that providers are remaining within the ISP and regulatory daily/weekly allotments, I feel this can and should be captured during the audit process.

There has also been some indication that in the future, a signed ISP will be required as part of the authorization process.  From a clinical standpoint, this seems counterintuitive.  Presently, one would want to perform the assessment prior to the development of the ISP so that the ISP accurately captures all of the current issues that a client may be experiencing.  The LMHP assessor would then provide the information from the assessment to the QMHP who works with the client on developing the ISP.  The LMHP uses the information from the assessment to submit the authorization request.  The LMHP cannot do this more than 30 days prior to the individual's authorization end date per regulations, but should do this at least 2 weeks prior to the current authorization end date due to a possible denial or due to a request for more information.  This timeframe helps to ensure no lapse in services or the clinical time needed to appropriately terminate services with the individual.  Consequently, there is very little time to orchestrate both of these pieces of documentation together since an assessment and authorization have to be done prior to the completion of an ISP. Furthermore, for new clients, a general preliminary ISP would only be available at the time of the authorization request.