I would like to bring attention to numerous comments that have been on-going for many months at this location:

http://townhall.virginia.gov/L/ViewComments.cfm?stageid=6034s

To restrict access to MHSS services by increasing t he criteria for admissions to such a level that 65% of the MHSs clients will not qualify is to destroy anyone and chance that those serviced (at risk individuals and impacting families/children) of every getting out of their circumstances, becoming stable, obtaining or holding a job by increasing their stability and having supports to maintain jobs by continuing to work on coping skills and to change the quality of their lives. They will not be able to integrate into a different community due to being kept in their same circumstances.

To require psychotropic medications of a population that is fearful of telling psychiatrist the truth, and others in traditional settings, the truth based on a long history of having their children removed, being investigated by CPS, being institutionalized into hospitals or incarcerated makes this population often skeptical and fearful to tell the full truth of their circumstances. Many clients come to MHSS and their psychiatric visits do not reflect what they have shared during the MHSS assessment or with the QMHP worker. Upon inquiry they state they were fearful to tell those in traditional settings as they felt they had the power to “lock them up”, label them as “crazy”, and to “take my children”.  So now there will not be any place for them to share the truth in order to get the help they sorely need in order to change their lives and ultimately another generation.

The new reg’s are now more focused on skill building and that is great yet removing the support element is removing what they need for reinforcement of functional skills.  There is also a hyper focus on psychotropic meds and they must have been on them or had them prescribed in the last 12 months. Many clients are also fearful of meds, been told by their communities you are crazy for taking them, their diagnosis make them paranoid of such, or other issues connected to their MH and w/o services they cannot overcome these obstacles. Without MHSS and assistance to overcome resistances they will remain at peril to themselves and their families and children as well as ultimately to being cared for by the state in numerous forms of assistance, hospitalization, incarceration, etc.  Also to regulate only certain diagnosis obtaining services or having a psychiatric document why someone w/o those diagnosis needs services is to, as explained above, to keep many from services.

This a population that cannot just go see a therapist due to location and lack of transportation, lack of Care Vans that show up let alone get them there on time. They lose doctors and therapist due to being late, no shows, etc., and excuses are not accepted as to why they missed the sessions for the 1^st or 2^nd time and they are refused services. This population is often unable to maintain housing and will present the State and this City with more homelessness of families and children.

How can psychiatrist approve of services when they do not know that the client has ADL’s issues yet gives the appearance of not having any issues or fears telling the truth. They psychiatrist is not in their home to see the environment, that health and safety issues are a concern and that nutritional standards are not met, the refrig and cabinets are empty and that they cannot pay their bills on time.  There are current reports by psychiatrist stating the client has no ADL issues but they have a host of them documented repeatedly by actually being in the home. Client may even want to tell the MHSS assessor that they are fine in all those areas but the home tells the truth and with some prodding and assistance the client does come around to admission of the full extend of the issues.  Yet this is based on relationship of seeing the person time and time again in intensive forms and not just .5 or 1.0 a month. What a person says in an assessment or in one appointment is just the tip of the iceberg. Being more involved in their lives gives access to critical information that most of those with MH issues feel they must hide but once exposed, and not judged, they realize they can admit it and get help. The issues these client have is based on keeping secrets, being paranoid, fear that is realistic as well as unrealistic fears, being too depressed to remember in an hour or half hour what is going on and all they are experiencing. 

There are also no references to LMHP-E’s in the new regulations leading one to believe that they are not considered as viable options in providing services at a reduced cost operating under a LMHP. This is an increased cost while admissions shrink by 65-70%, rates decrease, and changing regulations take additional staff and admin time to uphold the changes, the increased cost for getting clients approved upfront, etc. The reg;s requested input on how this will impact small business/agencies in Virginia. This is a huge impact. Not only will clients be impacted and families but small business, that make up most of MHSS services, in Virginia. Thereby impacting employees with loss of jobs, loss of benefits for any agencies that can currently provide such, loss of agencies, loss of state revenue, etc. 

The new reg’s will cause escalating expenses as well for hospitalizations, increased crime, incarceration, recidivism, and disenfranchising those with the greatest risk (the poor) and those with out a voice that have extremely limited to no resources.  (Many of our clients do not even know about the limited free community resources.) This will relegate them to be pushed further out of sight and relegate them to the outskirts of society and our communities. This feels like a direct affront to the poor and to the small business owners that will incur higher costs. Yes, some agencies need to be audited for income while providing no benefits for employees, and for fraud, and for a host of things that do not meet the regulations. However it is my experience that the majority of small agencies want to be in compliance and are working hard to deliver the best of services in the most cost efficient manner and provide a living wage and benefits or working toward such.

It is unconscionable that Virginia has now made accessing basic mental health services more difficult for our most severely and chronically mentally ill patients.   There are numerous details that have not been acknowledged from these new regulations that will make receiving basic outpatient treatment without mental health support interventions extremely difficult if not impossible to obtain.  Mental health support is the only form of “direct service” available to those who are not capable of accessing outpatient treatment services on their own.  From our 18-21 year olds living with parents who escalate (or neglect) their symptoms without mental health support interventions, to our mentally ill adults who are afraid of medications and present themselves well to the psychiatrist without any mental health support interventions, the outcome of this will be catastrophic.  In addition, many patients have been in the mental health system their entire lives due to the chronic and persistent nature of their illness.  Withdrawing mental health support services due to their lack of progress, or for any other reasons of the new regulations, will result in these patients quickly decompensating and result in increased hospitalizations and/or incarcerations.  This is not cost effective nor is it reasonable humane and ethical treatment.  Our state should be ashamed.

Further clarification of the MHSS service definition is needed to identify specific training that is allowed to build functional skills. Currently, the definition of MHSS includes training in “functional skills and appropriate behavior related to the individual’s health and safety; activities of daily living, and use of community resources; assistance with medication management; and monitoring health, nutrition and physical condition.” The service definition should identify all areas of need for functional living skills if those same areas are included in the eligibility criteria. Currently there is no mention of “appropriate use of social skills and personal support system” or “money management” in the service definition, although those statements are specifically included in eligibility criteria for services. Individuals with Axis I serious mental illness will have the need for more functional skill development than that which is included in the current service definition. The service definition, which will guide how providers design ISPs and treatment goals, is limited to very few areas of need that do not encapsulate all areas of need that MHSS clients will have.

I recommend that the service definition be expanded to include provision of training in social skills, community integration, development of support systems, and development of basic living skills that promote the maintenance of stable housing (i.e., money management, complying with community rules/landlord requirements that prevent eviction or homelessness). These skills, in addition to those already included in the service definition, will more completely represent the needs of clients who meet the new MHSS eligibility criteria. 

The statute that DMAS cites to as authority for these emergency regulations was enacted on June 11, 2012. The relevant part of the statute reads: “DMAS shall promulgate regulations to implement these changes within 280 days or less from the enactment date of this Act.”

Despite this, these emergency regulations were not submitted to the Attorney Genera'sl(AG) office for AG review until 8/14/13 and the Governor did not approve of them until 10/10/13. Therefore, these regulations were not properly submitted as emergency regulations. They were not submitted timely. Theyshouldt be withdrawn.

I receive MHS from my local community services office. I was diagnosed with schizophrenia when I was 15 and spent several years in and out of hospitals. I just turned 20 and I have been told that my services will stop because I want to continue to live with my parents. Once I'm 21, I can get the service again. I have no clue how this makes any difference. I have learned that I cannot live on my own and need the support my parents offer, but they don't do for me what my MHS person does for me. They don't know the things they know and they don't have the patience when I get to worrying about bad things happening. I thought about moving out so I could keep the service, but that doesn't seem fair. Last time I moved out even with the service, I ended up in a state hospital for months. So, tell me you people who make these decisions- should I move out and end up in the hospital again (which I understand is expensive) or do you respect my decision to live where I want and let me have a service that has helped me?

I do not support the change in eligibility criteria.  As a mental health professional who has worked in a state psychiatric facility with adults and with youth and young adults in community based services and in residential treatment, the changes represent a step backward for Virginia, as opposed to a step forward.  Nationally, we see young people in dire need for more intensive community based mental health interventions, and not just brief intensive interventions like crisis stabilization that can only last 15 days.  Most often, school shootings involved someone who is under the age of 21yo with an SED or SMI, but who are also reliant on family members for basic needs, such as shelter and food.  Often times, the mental illness of youth is born from a dysfunctional family system or excaberated by it. State law often forces a young person to remain in the very environment that contributes to his/her psychiatric crisis. It is unreasonable to insist that such a young person would be able and ready to move out of that dysfunctional living environment on his/her 18th birthday (when he/she can lawfully leave a parent's home) without having the support of a mental health professional to be ready for his/her 18th birthday.  It is completely unreasonable to think that this young person is getting any healthy or adaptive lessons at home (in this example, which is our most common) regarding healthy or adaptive skills for living independently (caring for oneself, getting a job, having income, paying bills, not relying on the welfare system, etc...).  Otherwise, we are setting up young people with mental illness to be homeless or stay in the dysfunctional family home.  In other circumstances, when the family is trying their best to protect their child, but often they can't access more intensive services that could keep the youth, the family members (such as our Senator Deeds), and the community safe.  It is unreasonable to expect and assume that a young person with mental illness can live independently,even within 6 months.  Many times, while working at a state hospital, the most difficult phone call I had to make was to confirm for parents that their child in college in his/her freshman or sophomore year, had just had his/her first psychotic episode of Schizophrenia or episode of bipolar disorder.  I hope our legislators will imagine the heart break that this news brings, and then imagine that in order for their child to get an intensive service like MH Supports that will help him/her recover more rapidly, they have to move that child out of their family home within 6 months of having this first break.  Please also imagine that part of the stressors that may have led to the first episode was the stress of living independently in a college dorm, trying to manage school and work and personal care, without the structure and support of his/her family.  How many tragedies does Virginian constituents have to experience before we will stop considering saving money more of a priority than preventing more tragedies?  It is embarrassing that these new regulations that are solely about saving money are under an "emergency order", when the emergency in our state is the mental health of our young people. 

I am a mother of a child with several mental health diagnoses. I am also a social worker and therapist at a community behavioral health agency in another state, however my family lives in Virginia. I have seen how beneficial mental health services and support have been for my daughter and others who have a mental health disorder. So many of those folks want desperately to live indpendently on their own. They can surely do that with the appropriate support services. It's sad to think that funding would be cut for children under the age of 18 (or anyone with a mental illness) because they choose to live with their parents. I suppose one (or possibly both) of those parents are supposed to stop working, caring for themselves, and being productive members of society since the loss of those services would place the burden of care/support directly on their shoulders. Most of these parents would give their lives for their children, for them to be able to live "normal" independent lives. If my daughter were to stop receiving thos services I would have to stop working a full-time job. Yes I would do that but it would bankrupt my family, not to mention the ultimate cost for my daughter--a decline in her mental health and quality of life.

Horrible, poorly thought out decision. At a time when our country and state need to put more into mental health services you want to cut funding? 

Mental Health Services are vital to the overall health of our citizens. Cutting funds to the most vulnerable shows lack of judgement and foresight.  When bad things happen because needs were not met, look back on the decision you made on this bill. 

I will not be typing eloquent words because non are needed.  It seems eloquent words confuse those that are making life changing decisions for the people of VA.  So, here I go.  The state wants to save money?  Mental health services is not where you make cuts.  Mental Health services are where you ADD money.  Still confused?  I'll make it simpler.  Continue to rise restrictions on who obtains mental health services and continue to cut funding, then be prepared to read more stories of mass shoots, suicides, and family violence.  Are you prepared for those stories?  If not, then do not increase restrictions on who can obtain mental health services.  Increase funding to mental health services, increase mental health providers and allow those trained to address mental health illness BEFORE senseless events occur.  If I'm not mistaken the state as a surplus.  USE THAT MONEY FOR MENTAL HEALTH!!!  PLEASE!!!   If anyone read or heard of  the tragic story of Mr. Deeds and his family and are not hit hard by the fact that WE failed to serve an individual with mental health needs which lead to his death and his father being injured....then what will it take for policy makers to understand?  More deaths? More injuries? This to happen to their family?  The quicker we can begin addressing mental health illness the better change we have to ensure a decrease in tragic-horrific deaths/injuries due to mental health illness.  The quicker we can begin addressing mental health illness for individual the more successful WE will be in changing lives for positive daily functioning for individuals and families and for those individuals to become a viable individual for themselves, family, county, state, and country.  I pray that those that are making this decision  to increase criteria for mental health services stop and think of the severity this decision will have on individuals, families, and state.  God Bless.

Just wanted to share a recent attempt on my part to advocate for my clients.  I wrote the following letter at my outrage about the mental health care in our state and how it impacts the clients I serve.  I was interviewedlast week by two news channels based on my letter.  The letter and links are below.

In hearing about the report released yesterday on the Sandy Hook shooting, (prior to the shooting) Adam Lanza would have met current criteria for an intensive mental health service in Virginia called Mental Health Supports.  As of Dec 1., someone like him in VA will not meet the new criteria because he had not been hospitalized in the past 12 months, and was not living independently and probably could not realistically move out of his mother's home within 6 months.  Mental Health Services and providers CAN make a difference and do make a difference. This criteria in VA for this intensive and very effective service is being changed to mainly save money and to make it nearly impossible for young adults to access the service (also to save money.) Please change the criteria in order to allow more young people access to this much needed service.   

Just want to go on record saying that as an Agency providing housing and supportive services for homeless female-headed households, mental health support is a vital part or their successful transition to both wholeness & healing. 

To assign a finanicial value to the difference that Mental Health support has made in both the lives of the families and the NATASHA House's HomeMakers Program would be an injustice.  I'm asking you to reconsider this decision and continue allowing families who would not otherwise recieve the "help" they need to begin again. 

Just want to go on record saying that as an Agency providing housing and supportive services for homeless female-headed households, mental health support is a vital part or their successful transition to both wholeness & healing. 

To assign a finanicial value to the difference that Mental Health support has made in both the lives of the families and the NATASHA House's HomeMakers Program would be an injustice.  I'm asking you to reconsider this decision and continue allowing families who would not otherwise recieve the "help" they need to begin again. 

As a professional in the human services field for over 25 years, I have observed many community services that offer “quick-fixes” and do not result in sustained change. Yet, MHSS is in a unique position to be able to work with seriously mentally ill individuals in their homes and community to truly “build skills” to promote lasting independence and autonomy.

These regulation changes will remove least-restrictive community-based service options for the most vulnerable of the mentally ill population—those who have not had previous access to treatment or cannot report treatment history.  Their access to treatment may have been limited by the very illness that led to their need for services.  For an individual experiencing the onset of mental illness, they will not have a "treatment history," yet could be in serious need of skills training and services in order to remain independent in the community.  If an individual does have a treatment history, the very nature of serious mental illness often means difficulty in accurately recalling details of treatment, or in some cases even acknowledgement by the individual that they have a treatment history.  Some individuals have not been prescribed medications because they have had no access to medical care.  As numerous studies support, a large percentage of those incarcerated, and an even larger percentage of the chronically homeless suffer from serious mental illness, but do not necessarily have a history of "treatment" as defined in these regulations.

Changes to regulations in 2010 required intensive involvement and oversight in treatment planning by Licensed Mental Health Professionals.  LMHP’s complete assessments for admission to services and are licensed by the State of Virginia.  These professionals are highly trained specifically in regard to mental health and are more than qualified to make the determinations outlined in these regulations. How can a physician accurately and fully determine a patient’s “functional limitations” when there is no access to the patient’s home and they are completely dependent on patient report, or the report of others? 

The emphasis of these emergency regulations on documentation both for psychiatric treatment and prescription of psychotropic medications creates bureaucracy with the sole purpose to stop access to services. The lack of documentation of treatment or medication as a reason to deny someone who is seriously mentally ill the services they are assessed as needing raises not only serious ethical questions, but human rights questions as well.  Virginia DBHDS Human Rights Rules and Regulations state that “Providers shall ensure that all services…are at all times delivered in accordance with sound therapeutic practice.”  If an individual meets the clinical standard established for a service and other criteria, such as a history of treatment, HOW can services be denied simply because there is not supporting documentation (that may not be available)?  If providers are held to a standard to ensure clinically indicated services are not denied to qualifying individuals, it seems only fitting that the agencies overseeing those providers be held to the same standards.  Accessing treatment records presents other challenges. There are state facilities that closed and records are not available.  There are also clients who have received treatment, but because of their mental illness, cannot or will not provide information that allows records to be obtained.  New regulations require that at a minimum, a phone call be made to verify services—yet this action is a violation of HIPAA.

If regulators are concerned that providers are misrepresenting the services they are providing, or are misrepresenting the seriousness of a person’s illness, there are already regulations in place to deal with those individuals/providers.  Providers are licensed by the State of Virginia, and are subject to auditing by DMAS, yet there are providers out there who have NEVER been audited, and who have never received more than a cursory licensing review. There are well established agencies that have been repeatedly audited with limited corrective actions and few sanctions because they DO operate ethically and honestly.  New regulations will not control unethical or dishonest providers—they will serve only to prevent services from being provided to people who need these services.  It is shameful that the state’s failure to adequately oversee services and regulate growth will result in a denial of services to the seriously mentally ill who have no voice.

DMAS’ Agency Statement in the regulatory documents states “MHSS is being inappropriately utilized as evidenced by reports from DBHDS' licensing specialists and DMAS' auditors. Individuals who have been receiving the services are not measurably improving and this service is costing the Commonwealth millions of dollars.” This begs the question, WHY was this not dealt with on an individual basis with those providers?? The report also states “Imprecise Medicaid eligibility criteria and service definitions have allowed individuals who do not have a serious mental illness or a serious emotional disturbance to access Medicaid's MHSS.”  Yet current regulations DO state that MHSS is to provide training to individuals with “significant psychiatric functional limitations” and additionally outlines very specific criteria that an individual must demonstrate to be eligible. Existing regulations ALSO require that measurable improvement be documented on a quarterly basis and that changes be made to service plans to reflect the progress of the individual.

DMAS and DBHDS have the ability to fine, demand corrective action, or close programs under current regulations.  Yet, even while costs were increasing, new programs have continued to be licensed by the State of Virginia, and credentialed by Department of Medical Assistance Services. A failure to regulate this growth, using tools already available to those agencies, should not result in the loss of services for seriously mentally ill individuals who demonstrate a sound clinical need for services. 

  I am in favor of using regulations already in place to make sure that clients are getting services that they need. If there is a concern that some clients are getting services that they do not need because of organizations misrepresentations of client's needs, there are already regulations to take care of that.

  I am disappointed that while the old regulations would have covered the Sandy Hook shooter and found him eligible for services, the new regulations would NOT perform that function. 

Thank-you.

I am a concerned mental health professional. Over the past several years there have been multiple changes made to the regulations of providers and consumers. I'm afraid that the upcoming regulations will drastically effect many mentally disabled individuals that will lose services. As Virginians, we have recently had cases that due to lack of mental health services has caused horrific incidents that potentially could have been avoided. I hear from consumers on a daily basis that their services has assisted them hugely with becoming more independent in our society. I'm worried that there will be enormous repercussions to our society as a whole if/when these individuals are discharged from services.  Please, Lets not put a budget before the people we serve.

Having been a Social Worker for 10 years and as someone who closely follows these specific topics through the media, fellow co-workers  and having spent countless hours with the individuals who will be directly effected by these decisions, I can say that to ignore the results of recent events and then make even more changes that would further restrict access to the needs of those who need the services the most  is madness itself. Something else comes to mind in comparison. That of gun control. The decisions we make today effect so many lives. As with both things, there are regulations  and laws already in place. Let us simply enforce them and give it time to work.  Are Virginia's prisons and hospitals not already full enough? Let us professionals do or work. How many more school shootings, stabbings, suicides and other  tragic events have to happen before someone realizes these issues can no longer be ignored?

I am a concerned mental health professional.  I find it contradictory that the proposed regulations limit clients who have not had prior history of hospitalization, when they have received support which has prevented them from hospitalization.  Consumers have been maintaining progress in the community with the support of MHSS and now without it are at risk of hospitalization – or jail, causing increased cost to the community.  These proposed changes affect consumers with severe mental illness that have decreased support system.  Now due to the changes they might be losing the only support they have.  One should consider the severity of consequences to the consumer and the likely hood of increased cost and figure another way to manage the regulations that are already in place.

The other concern is that the clients the proposed changes are limiting MHSS are diagnosed with severe mental illness and are not accurate reporters due to severity of mediations, memory issues, and severity of symptoms.  There is decreased likelihood that clients will be able to verbalize dates and locations to obtaining now needed documentation.  Also, with severe Mental Illness there is increased likelihood of increasing symptoms by asking for documentation which might also jeopardize therapeutic relationships.

It seems to me that these regulations impact the ability to provide services to consumers who are reporting increased symptoms and thoughts of self-harm yet have no history of hospitalization.  What kind of ethical implications will this have if we have to discontinue providing services to clients who are at risk?

I am currently receiving services through the local CSB in my community that provide me with the necessary access to appointments/ community supports that allow me to function daily.  I have recently been informed that I will no longer qualify under the newly proposed regulations.  This concerns me due to my need to have these services and support systems offered to me and my family.  Without theses services I will be placed in an emotional, financial, physical, social and intellectual void.  The MHS services that allow me to access these services I will no longer qualify for once the new regulations take effect.  This will put increased stressors on me and my family affecting my ability to function in the least restrictive environment.  This country has seen a recent increase of MH incidents that could have been avoided if support services like the ones I am currently eligible for were offered.  I am dealing with a special needs child that requires support services and places increased stressors on me. With out theses available to me it will be a emotional challenge to provide the support to him as well.  As a recipient of MH services I encourage you to revisit and rethink your decisions to make it more difficult to receive the necessary supports.  I feel the long term benefits will yield better results than addressing the individuals who will fall through the MH support cracks.

Broad sweeping legislation like this seems much to far reaching. Surely some parents can provide appropriate care to their children with mental illness, many cannot. If an individual is at risk of hospitlaization due to their mental illness but has no prior hospitalizations, do we wait until they reach their breaking point, and deal with the collateral damage, or do we serve them because they have very real needs and are at risk so they are not as great a risk to themselves or others. I believe these new policies push reactive intervention which will prove much more constly than these proactive services with their current regulations. As others have stated, if a company is not demonstrating a benefit to their members, address the company, not those who are doing their jobs well.

As a mental health professional, I am appalled that the governing forces in our great Commonwealth of VA find it necessary to further restrict/ or end services for the mentally ill who genuinely need and benefit from skill-building services. As evidenced more and more in VA and nationwide in the past years and months, mental health cannot be an afterthought-it must be a preventative set of services in place so these tragedies don't occur.

With these new regulations, mentally ill clients who are currently receiving skill building services and  living independently while working on bettering their lives, are going to lose the only support that they know, will de-compensate, and will end up in our jails or in our psychiatric hospitals costing the Commonwealth much more than if they continued to receive skill-building services in the first place! We don't need more mentally ill people incarcerated, as our jails are overcrowded now and they cannot receive the help they need there; they will not receive any medications or psychiatric care in jail and when released, will only repeat this pattern over and over because now they are un-medicated, have no place to live, and have no skill-building services. And if they are hospitalized after losing skill building services, the cost to the Commonwealth for that individual's psychiatric hospital for just one day alone is astronomical!

The bottom line is that VA needs to enforce the policies that are already in place and crack down on providers that aren't already following the set guidelines. The mentally ill population of Virginia depends on these services and shouldn't be treated like second-class citizens. Stand up Virginia-we ARE better than being 48th in the nation for mental health care!

As a professional in the human services field for over 25 years, I have observed many community services that offer “quick-fixes” and do not result in sustained change. Yet, MHSS is in a unique position to be able to work with seriously mentally ill individuals in their homes and community to truly “build skills” to promote lasting independence and autonomy.

These regulation changes will remove least-restrictive community-based service options for the most vulnerable of the mentally ill population—those who have not had previous access to treatment or cannot report treatment history. Their access to treatment may have been limited by the very illness that led to their need for services. For an individual experiencing the onset of mental illness, they will not have a "treatment history," yet could be in serious need of skills training and services in order to remain independent in the community. If an individual does have a treatment history, the very nature of serious mental illness often means difficulty in accurately recalling details of treatment, or in some cases even acknowledgement by the individual that they have a treatment history. Some individuals have not been prescribed medications because they have had no access to medical care. As numerous studies support, a large percentage of those incarcerated, and an even larger percentage of the chronically homeless suffer from serious mental illness, but do not necessarily have a history of "treatment" as defined in these regulations.

Changes to regulations in 2010 required intensive involvement and oversight in treatment planning by Licensed Mental Health Professionals. LMHP’s complete assessments for admission to services and are licensed by the State of Virginia. These professionals are highly trained specifically in regard to mental health and are more than qualified to make the determinations outlined in these regulations. How can a physician accurately and fully determine a patient’s “functional limitations” when there is no access to the patient’s home and they are completely dependent on patient report, or the report of others?

The emphasis of these emergency regulations on documentation both for psychiatric treatment and prescription of psychotropic medications creates bureaucracy with the sole purpose to stop access to services. The lack of documentation of treatment or medication as a reason to deny someone who is seriously mentally ill the services they are assessed as needing raises not only serious ethical questions, but human rights questions as well. Virginia DBHDS Human Rights Rules and Regulations state that “Providers shall ensure that all services…are at all times delivered in accordance with sound therapeutic practice.” If an individual meets the clinical standard established for a service and other criteria, such as a history of treatment, HOW can services be denied simply because there is not supporting documentation (that may not be available)? If providers are held to a standard to ensure clinically indicated services are not denied to qualifying individuals, it seems only fitting that the agencies overseeing those providers be held to the same standards. Accessing treatment records presents other challenges. There are state facilities that closed and records are not available. There are also clients who have received treatment, but because of their mental illness, cannot or will not provide information that allows records to be obtained. New regulations require that at a minimum, a phone call be made to verify services—yet this action is a violation of HIPAA.

If regulators are concerned that providers are misrepresenting the services they are providing, or are misrepresenting the seriousness of a person’s illness, there are already regulations in place to deal with those individuals/providers. Providers are licensed by the State of Virginia, and are subject to auditing by DMAS, yet there are providers out there who have NEVER been audited, and who have never received more than a cursory licensing review. There are well established agencies that have been repeatedly audited with limited corrective actions and few sanctions because they DO operate ethically and honestly. New regulations will not control unethical or dishonest providers—they will serve only to prevent services from being provided to people who need these services. It is shameful that the state’s failure to adequately oversee services and regulate growth will result in a denial of services to the seriously mentally ill who have no voice.

DMAS’ Agency Statement in the regulatory documents states “MHSS is being inappropriately utilized as evidenced by reports from DBHDS' licensing specialists and DMAS' auditors. Individuals who have been receiving the services are not measurably improving and this service is costing the Commonwealth millions of dollars.” This begs the question, WHY was this not dealt with on an individual basis with those providers?? The report also states “Imprecise Medicaid eligibility criteria and service definitions have allowed individuals who do not have a serious mental illness or a serious emotional disturbance to access Medicaid's MHSS.” Yet current regulations DO state that MHSS is to provide training to individuals with “significant psychiatric functional limitations” and additionally outlines very specific criteria that an individual must demonstrate to be eligible. Existing regulations ALSO require that measurable improvement be documented on a quarterly basis and that changes be made to service plans to reflect the progress of the individual.

DMAS and DBHDS have the ability to fine, demand corrective action, or close programs under current regulations. Yet, even while costs were increasing, new programs have continued to be licensed by the State of Virginia, and credentialed by Department of Medical Assistance Services. A failure to regulate this growth, using tools already available to those agencies, should not result in the loss of services for seriously mentally ill individuals who demonstrate a sound clinical need for services.

I started writing a comment two weeks ago and went back and edited it several times.  I wanted to make sure I was clear about why I oppose the Emergency Regulations changing Mental Health Supports to Mental Health Skill-building Services.  I asked a colleague to proofread my comment today.  He gave some constructive feedback and then called it what is was – “fluff.”  He then asked what I really want to say.  Here goes… 

I had to step in and assist at one of our sites last year when we were short-staffed.  I fielded a phone call from a client who shared the distress he was under after his former clinician who was no longer at our agency came to his home and tried to solicit him for the agency she had gone to work for.   I talked with the client about what “Choice of Provider” means and that it was up to him and that no one had the right to pressure him in any way.  He went on to tell me how the former clinician brought him a soda and kept asking, “Don’t you like me and want to work with me?”  The clinician also offered to take the client to the movies and other “non-MHSS” activities.  After my assurance that no one at our agency would be upset with him, regardless of his choice, the client chose to terminate services with our agency and went to the other agency.  About six months later, the client contacted the office in tears and asked to come back.  We reopened the case and made a new clinician assignment. 

A couple months ago, another agency solicited several employees.  The owner took employees to dinner and bribed the clinicians, making promises to have all of their paperwork done for them and offered monetary incentives for bringing on new clients – a “bonus” if you will.  We lost several clinicians to this other agency.  Then, we lost each of those clinicians’ clients.  The clinicians were offered a job but could not get a start date until they “produced” a caseload.  These clinicians took their clients that had been longstanding clients of our agency.  One client did not get opened with the new agency but did stop in to our office to let us know that her former clinician (and our former employee) does have her over to her house for dinner on occasion and said she would help her out but didn’t want to open her to services at the new agency. 

Today, a current client contacted one of our sites to discuss closing and going with a new agency.  His former clinician (our former employee terminated for Medicaid fraud) was with that agency and he wanted to work with him again.  A member of our management team talked with the client and explored the reasons behind his desire for the change.  He said he missed going to the movies and to sporting events and that his former clinician always took him to those places.  We terminated his clinician for failing to provide appropriate MHSS. 

These are just 3 small examples of how our service delivery system of mental health services is failing our consumers.  The answer is not in stricter regulations.  The answer lies in increased oversight of service provision, fair auditing practices for all agencies, and just plain enforcement of the regulations.  Yes, the changes are a hardship on agencies but agencies will overcome them.  Some agencies will just find another service to provide, while other agencies will find a way to manipulate the new regulations.  However, our severely mentally ill Medicaid recipients will feel the true wrath of these changes just as they have felt the wrath of a poorly enforced/managed service. 

I want to end on a positive note.  And that is a note about the wonderful accomplishments and successes we see with so many of our clients.  Many clients refer to our agency as their “family.” A client told us that he was hospitalized several times a year prior to starting MHSS with our agency.  He has been hospitalized just once in the four years we have provided MHSS.  One of our clients moved out of state and contacted me asking how she could get MHSS started in her state because we saved her life and wanted others to get to experience the same amount of support and education she received.  For every unethical/disheartening story I give, I could provide twice as many success stories.  I don’t have to credit MHSS for the success, our clients tell us daily and we see it in the smiles on their faces.  Don’t punish consumers for others’ mistakes!

Cutting mental health services is absurd! We have already seen what happens to people who couldn't be helped by the system. The hurt to the poor is unconsionable. Mental health needs more funds not less. Please help Virginians in crisis.

In seeking to control expenses, state leaders should keep in mind that prevention programs reduce longterm costs to the state. Least-restrictive care guidelines are set up for multiple reasons - human rights and dignity, achieving recovery and independence, reducing high costs for inpatient care. Maintaining and expanding funding for  these programs is wise  fiscal and health management. 

I graduated from a prominent Virginia university, in large part because I had access to mental health services. I was a victim of sexual assault, as well as years of abuse when I was a child, and didn't realize the toll these events would take on my studies, my life. I was treated and received counseling for PTSD, and was very well taken care of. I recovered nearly completely (it is a lifelong recovery that only professional help can teach you to do).

It saddens me that I enjoyed such good care because I was a student, and that if I was not a student I would never have been able to afford psychiatric evaluations, therapy, prescriptions when I needed them, and group sessions. Now that I am not a student and not currently insured, I feel firsthand the dangers that come with not having adequate mental health support available to help me continue my recovery. I feel the despair of those who have nothing to build from, and their trepidation at entering a system that can so easily mistreat and take advantage.

We must not let the poor state of what mental health support there is now deteriorate more.

As a Virginia citizen and voter, I am tired of constantly being behind the eight ball when it comes to mental health issues and the support that folks suffering truly do need.  It seems to me that we could have learned something in the wake of Virginia Tech tragedy.  I honestly don't think that we have.  I wonder if what happened to Senator Deeds will be enough to spur some action so that these folks and their families can get the help, support, and respite that they truly deserve.  

People have the right to live in peace, why everything is getting harder and harder, I fully support peoples with Traumatic Stress Disorder (PTSD) and Anxiety Disorders, to have real smooth medical support.

Rgds

I am a  concerend  professional with  over 30 years of experience in the public sector of social service and mental health fields. I am well aware of the dilema that administrators and policy makers face when the bottom line does not mesh with expenditures. To coin a phrase, "I feel your pain". I therefore welcome this opportunity to shed some local, in-the-field light.. The budgetary problem that  faces this program is not the eligibility criteria of  recipents. Dollasr spent  on approriate  support and skills building for those currently eligible is money well spent,  for those individuals, their families and society.  The tragic events in the news in recent years underscore the need for broad based mental health services. The private stories of clients who have experiencd incredible successes as a  result of having received a multipronged plan of mental health treatment support that. The budgetary answer is not to limit those services or the population that is served. It is a time to address  a systemthat will  adequately monitor and audit the regulations that are currently in place. That is where your cost savings will be found without harming the people you serve. Thank you.

Now is not the time to further limit access to mental health treatment.  Cutting services not only affects the individual, but also family members.  The Legislators of the Commonwealth of Viginia think cutting services saves the State money.  In the end, those with treatable mental heatlh issues end up in the Emergency Room or even incarcerated.  These results do NOT save the taxpayer money.  If we only want to think in monetary terms rather than ethical terms, it makes fiscal sense to treat those with PTSD and other disorders in an outpatient manner.  No more cuts to Mental Health services.

I support mental health in the state of Virginia and am disturbed that the Department of Medical Assistance Services (DMAS) has just implemented "emergency" regulatory changes effective December 1, 2013 making it more difficult for individuals to receive Mental Health Support Services. 

This current piece of legislation is disappointing to say the least.  It is unfortunate that the mental health system continues to suggest that we as mental health professionals should wait until a patient/client is already in a chronic or severe state before being cleared for treatment.  While I do recognize that some providers have abused the system, it is inappropriate to penalize everyone (including the clients) for the poor judgment of only a select group of providers.  

My first concern comes with the restrictions to obtaining assistance with housing or GED-related goals.  It is impossible to make a meaningful change with client if they are not in safe and stable housing.  Such housing cannot be attained if the the access to services is so tightly secured.  In addition, given the population that qualify for this service, achieving and maintaing appropriate housing may very well be an ongoing problem and not simply a one-time initial goal for treatment.  With regard to the GED or education-related goals, it is completely ridiculous to name such a service "skill-building" while intentionally choosing to neglect one of the most basic skills for survival: development of abstract thinking and cognitive abilities at a basic educational level.  Telling clients they cannot receive assistance with obtaining further education is punishment because it denies them the ability to receive a basic academic experience that may have been compromised by the very mental health problem that brought them to us.

My second concern is with the requirement that clients be receiving specific medication treatment.  There is a significant amount of literature suggesting that questionable benefits of psychotropic or even other mood-stabilizing prescriptions.  We cannot fully help our clients if we require them to be on a heavy dosage of medication before we even have the chance to work with them.  What about the client's right to self-determination?  If we are giving the client the right to seek services then should we not also provide them the right to seek mental health services without medication?  

This brings me to my third and final concern: the restrictions on qualifiable diagnoses.  The current restrictions send that message that clients may not be severe enough to receive services.  Who is to say that clients not given a particular diagnosis are not going to get worse?  In fact, it is very possible that a client could be at a subclinical level of a serious mental health diagnosis and be denied a service.  As a result s/he may actually develop a clinical diagnosis in the future because the system failed to help them early on.  Apparently we need to wait until they are severe enough to provide them with the help they are seeking.  This legislation completely disregards the value of client-self report and places it in the hands of medical professionals who may then feel pressured to "diagnose up" in order to receive reimbursement.  This only contributes to the dramatic rise of potentially falsified or exaggerated diagnoses appearing on permanent health records and an increase in the severity of stigma in our society.

To close, I agree that there has been abuse and insurance fraud, but the clients should not be the ones denied the right to receive services because some providers have selfishly taken advantage of the system.  If this trend in the mental health system continues, then we will see an increasingly overwhelming amount of prospective clients knocking only to find that no one is willing to unlock the door.

I am lucky to currently work for an agency that provides sound therapeutic services to their clients. I can happily say that each and every client that is open in the company I work for is in need of this service despite their history of hospitalizations or lack thereof. A client’s need for services regarding taking care of themselves, their home, learning skills such as public transportation, obtaining a PCP, etc. will still be relevant regardless if they’ve been hospitalize 100 times or zero times. The clients we serve are unique individuals that cannot just be placed in one Yes/No category to justify their need for services.

If we look at all of the clients that will lose MHSS services if they’ve never been hospitalized or they’re lacking proof of hospitalization in the past, or don’t meet other “new” criteria that DMAS has implemented…where will they go? Who will be there to help them learn skills such as obtaining prescriptions for their mental illness or learning to advocate for themselves at the doctor’s office? These supported individuals will be left with no services, and will lose the progress they’ve made thus far, and it will potentially lead to hospitalizations, crime, exploitation of the client, lack of medications, and so on.

Why is this okay? The reason MHSS services exist is because there is a need for the service. It’s amazing to hear about clients that have never ever received services in the past and finally get a MHSS clinician for the first time in their life- they begin to make progress, become functioning individuals in the community, have a better quality of life, have a decrease in psychiatric hospitalizations and finally have someone one their team. Someone who wants to see them succeed in life and is going to be there to educate the individual to become independent and no longer need MHSS in the future.

As a member of this community, advocate for mental illness, and employee to a company that provides sound therapeutic services, I’m deeply saddened by the choices of DMAS. I hope that the individuals making these decisions take into consideration all of the lives that will be affected by these changes. Clients, employees, and employers will all take a hit from these changes.

As an unintended consequence of the well-intentioned deinstitutionalization movement, our jails and prisons are full of individuals taking psychotropic medications who might not be incarcerated at all if they had received adequate mental health services.  We can reduce expenditures for correctional facilities by expanding access to appropriate treatment.

I would like to hope that these comments will make a difference.  I would like to think that this input will be read and incorporated into the decision as to whether or not these regulations will be passed.  I would like to think that the individuals in our state who will lose services because of the changes, will be ok.  Right now, I am just not sure.

As I sit here to comment, I am receiving emails and phone calls from offices that have already tried to enter clients into the Pre/re-authorization system under the regulation changes that are listed here as emergency regulations, but really went mostly into effect 2 days ago.  All of the authorizations have been denied.  In spite of assurances from regulatory agencies that they do not want clients to lose services, they are rejecting the very clients whose lives we touch every day throuhg MHSS.  In one case the client meets every eligbility criteria, but was not approved because we didn't list enough "hands-on" skills traiing in the narrative of the request.  We are being allowed to re-write the request, and hopefully we will get it right this time.  This is a client that struggles with suicidal thoughts on a consistent basis.  We have been told that issues like that need to be handled by a counselor, not by skills training such as coping skills.  In another case, the person meets every criteria and needs the service, but we cannot get the documentation of prior mental health services, so she is denied.  Again, a client with a history of sucidal ideations and one who deals with suicidal thoughts consistently.

There are many public and private MHSS providers who are ethical and try their best to provide good, therapeutic services to clients who have finally found a service that can meet them where they are and provide what they need to live independently in the community.  These providers have quality assurance measures in place, check for Medicaid fraud and do not tolerate unethical, fraudulant behavior from their staff.  Unforunately, there a many providers who not only do not have these measures in place, they actively participate in and encourage fraudulant and/or unethical behavior.  These new regulations will only benefit those providers.  Ethical providers will truthfully complete requests for authorization and dishcarge clients who do not meet new criteria.  Other providers are waiting in the wings to pick up those clients, take them out to a game or out to eat and bill the maximum units allowed for the client each week.  Spending in the state will increase again and MHSS will be cut completely.

In order to cut spending in this program, any regulation must be enforced.  If the previous regulations had been enforced, spending would not be out of control for MHSS.  Enforced regulations would also mean better quality services for the mentally population in our state.

The title of my comment is "Can we make a difference".  The truth is, many of us are making a difference every single day in the lives of the mentally ill in Virginia.  We are saving lives of those who suffer from the most severe symptoms of mental illness.  We are fighting the stigma of mental illness and fighting for the rights of those who suffer from it.  We are fighting those agencies who do not provide ethical services.  I hope we will continue to be able to truly make a difference for our clients. 

As a licensed mental health professional in VA, I am deeply concerned regarding emergency regulations pertaining to Mental Health Support Services, now Mental Health Skill-building Services (MHSS), that took effect on 12/1/13.

My concern is for the thousands of low income individuals in VA with severe mental illness who will no longer qualify for services due to misguided attempts to curtail spending. Many individuals with severe and chronic mental illnesses have been able to avoid the need for intensive services (psychiatric hospitalization, residential crisis stabilization, ICT, PACT, RTC, or TDO) thanks to quality community based services, such as MHSS, that have allowed them to remain independent in their homes and communities. These individuals will now be denied access to MHSS, thanks to more restrictive eligibility criteria, and will likely experience relapse without further reinforcement of skills.

Consider this scenario: You visit your doctor with severe and chronic chest pain. Your pain is causing impairment in major life functioning and has dramatically decreased your quality of life. In addition, your doctor warns you are at risk for heart attack or death. Your doctor then prescribes medication to treat your pain. After beginning the medication your pain reduces to the point that you are able to enjoy life again and your risk for heart attack or death has been drastically reduced. Several months later, your doctor receives a call from your insurance company stating, that due to overrunning costs, he can no longer prescribe you the medication because you have never experienced a hospitalization. You have not yet proven your illness is severe enough to warrant the treatment. After several weeks with no medication, your chest pain resumes.

Several months later, you experience a heart attack and die.

Too dramatic? I don’t think so.

Restricting access to MHSS will in fact be a life or death situation for some. For others, it will mean a return to severe isolation, avoidance, and increased suffering. MHSS currently provides consumers with the skills training, encouragement, modeling, prompting, and support they need to combat the symptoms of severe mental illness. Please do not punish individuals for not yet proving their mental illness is severe enough to warrant specialized care.

MHSS currently serves VA’s most vulnerable population, i.e. individuals experiencing both poverty and mental illness. I want to speak up loudly for this group because, due to their illness or circumstance, they may lack the skills or ability to do so for themselves.

As an alternative to more restrictive eligibility criteria, I suggest DMAS focus their efforts on ensuring greater adherence to current regulations. I believe this will create a “win-win” scenario for VA, i.e. costs will decline without denying individuals a service they need.

As a mental health professional for 11+ years, I am no stranger to change. I accept change as the norm in this field, as any agency funded by state or federal funds does. My colleagues and I are  part of the population that must implement any changes and explain the resulting impact to our clients, whether it be negative or positive.  I welcome any and all changes that would positively impact anyone utilizing mental health services in our state, as well as crack down on unscrupulous providers, but the newest changes in regulations for Mental Health Support Services are counterproductive in my opinion. I am on the frontline, working with individuals daily who have many, many challenges. I have had the privilege of working with individuals who have made great progress in better managing their Axis I symptoms and learned new skills that have been integral in decreasing or eliminating hospitalizations or incarcerations. MHSS is a lifeline to many upon entering services. Individuals, many fearful, distrusting of others, isolated and  reporting feelings of hopelessness enter services with a wall up or a sense that no one will be able to help them navigate through their specific challenges.  These are our mothers, fathers, children and siblings. They are not a diagnosis; they are wonderful people in need of specialized skills training to help them get to a place where they can live a quality life for days and years to come. To reduce them down to whether they have the "appropriate" checks marked off beside their name on the new, limited criteria for  services such as diagnosis, hospitalizations, medications, and even place of residence if under 21 is moving backwards and counterproductive. If changes are finalized as is, we will see an increase in hospitalizations, homelessness, violent crimes and incarceration. That is a fact. Programs such as MHSS are proven to decrease all of the above. I wish lawmakers could walk in my shoes for a week or even a day so they could see what life on the frontline is like for our clients, and while you consider my invitation, please coordinate with me to "walk the walk" on the day I have to tell clients I have built long term,  trusting relationships with that they are history and no longer welcome in our program despite making progress and requiring ongoing skills training and reinforcement to decrease probability of hospitalization, incarceration  or suicidailty, etc. because he/she does not meet criteria any longer. These days are upon us and devastating for many individuals who will return to square one and fall through the cracks because we pushed them. I hope our legislators hear our feedback and listen to the voices from the frontline to propel positive changes to current regulations.

I am a Mental Health Professional with 7+ years working on the front line. I work with client's, their families and numerous service providers to ensure that the best quality of care is given so that they can maintain in a community setting. I am truly saddened by the changes and this is why:

I currently work with a delightful client who will more than likely not qualify for continued services under the new regulations. I think it's important to know that without MHSS, this client would not have followed through with appropriate physician appointments, maintained prescription medication management, applied money management skills to secure and maintain appropriate housing, engaged in social/recreational activities or utilized community resources such as food banks.  It's a shame to see overall quality of care for client's that need services be compromised due to financial situations.

These same changes are supposed to save money? Without  the quality care of Mental Health Professionals, these same client's risk hospitalization, prison, homelessness and many other issues without the assistance/help of those organizations that can provide therapuetic relationships to lessen the frequency of these occurances.

I am in the field every day. I see the huge benefits of our services to those client's who might not otherwise have a chance at a normal life. A life that is filled with purpose, meaning and happiness. I see how not only do we assist the client, but their familes in knowing that they are not alone and that we are all working towards a common goal. I hear the positive feedback from service providers during PCP appointments, counseling sessions, etc..in the fact that we can provide information due to the strong relationship we have with the client in advocating for quality care.

Change is good, when the change is better for all involved. I hope that those people that can make the change look closely at the bigger picture. Let's make a difference and find ways to effectively find ways to improve Mental Health in VA.

The solution to the budget issues is increased oversight of services, increased auditing, and enforcement of the regulations with fines and obligations to pay back funds when services are misappropriated.    Hold the provider accountable not the consumer.  It is a sad day in Virginia when DMAS punishes a consumer for provider over utlization and inappropriate use of  a service.

I am concerned with the ethical, legal, and even fiscal consequences of the emergency regulations that impacted MHSS effective 12/1/13. Ethically, these regulation changes will harm community members with severe mental illness. Restrictive eligibility criteria will prevent those with severe mental illness from receiving vital community based support. Beyond that simple fact, the manner and timing of this transition have been extremely poor. These regulation changes were officially announced 10/31/13 through a Medicaid Memo, leaving providers 30 days to implement the changes, which at that point included transitioning to the latest Diagnostic Statistical Manual (DSM 5). In the 30 days leading up to the changes going into effect, it was determined that providers were not prepared to transition to the DSM 5 and that this transition would have to occur at a later date. It is laughable to me that DMAS and Magellan, who began as the behavioral health services administrator on 12/1/13, would take into account providers’ difficulty transitioning to using a manual for accurate diagnoses, but will not consider the difficulty for the clients who will be losing such an important service, especially at a time of year that statistically is very difficult for the mentally ill and has increased risk of suicidality associated with the Holidays. Conflicting reports of how this will impact clients only led to the confusion and difficulty in preparing clients effectively for possibly losing their services. Even clients who meet all eligibility are now being denied, because the service appears to be going “too in-depth” into their mental health needs.  It is contradictory for DMAS to report only those with the most severe mental illness will be allowed to receive MHSS, but providers will not be allowed to work therapeutically with these individuals and must limit their interventions to basic skills training, as this does not allow providers to address the “mental health” portion of Mental Health Skill-Building Services. Research in mental health and helping relationships consistently points to the therapeutic relationship as the most important aspect of facilitating change with clients. Attempting to pigeonhole providers into just doing surface skills training will not allow for stabilization of clients in the community and appears to be a very poor attempt at justifying DMAS’s recent encouragement for providers to hire less qualified mental health paraprofessionals to do this important work.

Ethically and legally, there are serious issues with the regulations within the emergency guidelines including violations of HIPAA and Human Rights. The emergency regulations note that providers may document past treatment through phone calls to outside providers. Releasing information such as this over the phone violates HIPAA. The regulations also state that providers must coordinate with the PCP regarding any medication non-compliance. However, this is a violation of Human Rights, as it is the client’s choice what to communicate with their providers. As a mental health provider, I have focused on educating clients about accurately reporting medication compliance and discussing any issues with their provider, as well as addressing any barriers to them communicating openly, but I have not violated their confidentiality by reporting to their provider regarding their medication compliance. Requiring this will create additional barriers to individuals receiving services, especially those who may suffer from paranoia and/or delusions that may impact their trust in providers. These portions of the regulations place providers at risk of either failing to meet regulatory requirements set forth by DMAS, or violating regulatory requirements established through Licensing and dictated by sound therapeutic guidelines for treatment.

As a tax payer, I appreciate fiscal responsibility, but I feel strongly that these regulations are fiscally irresponsible. Prevention and less restrictive community based services are fiscally responsible responses to the mental health needs of the Commonwealth. Limiting community based services to individuals will only increase the recidivism of psychiatric hospitalization and incarceration, which are far more costly to the State than preventive services. If the State is interested in reducing abuse of the system, enforcing the current regulations is the key, rather than implementing more restrictive regulations that will negatively impact our communities and lead to greater strain on our medical system and legal system. 

I urge lawmakers and community members to consider the impacts of these emergency regulations and if this type of detrimental regulation change is worth false promises of reducing costs for the State.

As someone who has worked it the mental health field in both the public and private sector, I have seen the direct impact skills training services have on hospitalization rates, incarceration, and most importantly the lives of our friends, family and neighbors with mental illness. New regulations seek to decrease costs for the state and taxpayers, but what is the real result when services are cut? Increased reliance on emergency services in an already overburdened system, increased incarcerations at taxpayer expense (especially when the capacity of emergency services is exceeded- See Florida as a prime example) and again most importantly the human cost of ignoring those most in need. Preventative in-home care saves money, and is the preferable treatment.

This said, there are many unscrupulous providers. These people have used bribes to enroll in services, provide services to those who do not qualify or who do not need the benefit, and occasionally commit outright billing fraud. These practices need to be stopped. If current preauthorization standards and audits of service were enforced, these companies would no longer be in business, and we would not be wasting what must be millions on unnecessary and unhelpful services. 

Please step up enforcement of existing industry regulations and do not reduce services for those who need them most. Virginia deserves better than the counterproductive measure proposed. 

I have many concerns regarding the changes to MHSS. As someone who has worked in this program for 8+ years I would like to give some feedback regarding the impact of these changes during day to day service delivery.

The move from Mental Health Support to Mental Health Skill Building appears to be more a move to decrease clinical interaction and promote only the increase of independent living skills. MHSS has always been a unique marriage of understanding and addressing a diagnosis while encouraging independence. You can't have one without the other. To provide training in independent living but fail to provide training in how to cope with the Axis I is a disservice. These clients experience problems with independent living precisely because of the Axis I. To pretend otherwise is to not provide client centered services.

Excluding certain Axis I diagnoses is to exclude many people suffering from a severe mental illness. As mental health professionals we see clients in the context of more than just their diagnosis. It should be relegated to the Licensed mental health practitioners to make the determination and not be bound by specific diagnosis. Providers will adjust and simply give widespread diagnosis of Major Depressive Disorder or Bipolar I in order to fulfil the requirement. This again will not be client centered and will cause clients to have treatment designed and administered around false diagnosis.

It is no secret that in the Roanoke Valley there are many clients who come to us from other states. The documentation of prior psychiatric treatment is a huge barrier to those clients receiving services. As each state manages their own Medicaid funds, states are different in the programs they offer. The terms 'crisis stabilization, PACT, or ICT' are often unknown to clients even in our own state much less to clients from other states. As for the psychiatric hospitalization, I personally have spoken with two separate hospitals in the past two days in our area who have reported that the records for our client have been destroyed. I understand the need to document previous interventions and establish the chronicity of the mental illness but barriers in the healthcare system will cause clients to fall between the cracks.

I implore the powers that be to make appropriate changes to these regulations so that the clients will not be the ones to suffer. It is apparent to everyone that these services have grown exponentially and as with any household the budget must balance. The ultimate responsibility should fall to the providers not be bore on the backs of the clients. Implement tighter quality control measures. Mandate training. Consider creating a step down program.

I believe the scope of the program has grown so exponentially due to the fact there are really no other long term one on one services available for the adult mentally ill which provide sufficient support. Everyone agrees there are many problems with the current system. However, the proposed solutions are targeting the wrong problems.

When thinking of what to comment, the word that sticks out most in my mind is saddened. I am saddened that people who I have had the pleasure of making a difference for may no longer get to benefit from the service that has been truly life changing. As a mental health provider, I was so grateful to get to work in a community setting, because I have been able to help clients avoid psychiatric hospitalization while being in their own home, surrounded by familiar things and social supports. I feel strongly that when clients who have come to depend on this service for mental stability for many years will decline rapidly if they are suddenly left without services due to not meeting new criteria. Long term, I am saddened by the clients who once avoided hospitalization may seek it just to become eligible for services again, or because they have experienced a sharp increase in symptoms after losing such services.

Many clients I have had in the past have needed stabilization services due to changes in their lives, and for those who lose services, this may be one of the toughest changes they have faced. On top of that they will be forced to deal with the change without support from agencies that they have depended upon. it saddens me to think that the state is turning their backs on those people; the people who genuinely need help instead of the people who abuse the system.

Virginia has had many hard hits in the mental health community, most widely known being Virginia Tech in 2007 and Gus Deeds just recently. This is not the time to drastically change the face of community mental health in Virginia. This is a fragile mental health system in need of being built up, much like the clients we serve. To tell so many that they no longer qualify is a mistake I feel will have grave consequences on Virginia's mental health community, the judicial system, the health system, and the lives of those for whom we are called to "do no harm."

According to the memo that was sent out on 10/31/13 from DMAS these changes were to “ensure appropriate utilization and cost efficiency for Medicaid or FAMIS reimbursed services, and will clarify the rehabilitative focus of Mental Health Skill-Building Services.”

“Ensure appropriate utilization and cost efficiency”- First of all, this could have been done already if the regulations that have been in place were enforced a long time ago and across the board.  I know of many providers that have never been audited and they are the ones providing services to clients unethically, maxing out hours and units on them and in some cases committing Medicaid fraud.  Why aren’t these providers being regulated or shut down??  Who does this hurt when regulations are not enforced like they should be?  The client!!  It is unfair to clients to receive services that are anything less than what MHSS was designed to be.  Lawmakers you have not fixed this problem and it will not be cost effective for you.  The new/stricter criteria and requirements of documentation of prior psychiatric history BEFORE services begin will force these clients out of services or from receiving services.  This at-risk population will drastically be effected and hospitalizations, incarcerations, and homelessness will increase.  Providers who are unethical and have been cheating the system for their own financial gains will continue to do so and possibly even take on the clients that quality providers will let go as they will abide by the new regulations. These are not cost saving measures!!

“Clarify the rehabilitative focus of Mental Health Skills-Building Services”- The focus of MHSS has always been to provide support and assistance of mental health needs while providing active skills training to clients.  We have to be able to address the mental health side of things in order to address the skills training.  From the SRA denials that I have seen from Magellan we are now taking away the supporting of mental health issues and now focusing purely on skills training.  Assisting clients with coping skills, anger management or mental health issues is considered “talk therapy” according to the denials.  We are now to provide mechanical, action-oriented skills training and what? Refer clients to counseling?  I am an LPC and I believe that MHSS is a very valuable service to clients and the level of care that is provided by MHSS providers to clients is much greater than an outpatient counselor can provide as we only get to see them for one hour at a time in our office.  MHSS providers get to work with clients in their environment and have the ability to see firsthand how their mental health affects their daily living and work with them to resolve any issues.  This is why MHSS works and is a valuable program to the community! 

In summary, the reason for these changes as I quoted from the memo above would have not needed to occur IF regulations were enforced.  Providers would have been held to the regulations which in turn would save money and the focus of MHSS would have not needed clarifying.  All providers need accountability!  Clients deserve quality/ethical services!  Do not punish them with these changes!

Who's next is my question? I have worked in Law Enforcement for 6 years and as a QMHP-A for the past 6 years and when it comes to criteria for those eligible, this new change will increase our jail and hospital populations. Working with inmates who show visible symptoms of mental health illnesses could greatly benefit from MHSS services, but will continue to cycle through our judicial system without the services. I work with several clients who have mental illnesses that have experienced prison incarceration before being assessed for MHSS and when released, they come back into the community experiencing even greater symptoms of mental illness. I can testify firsthand to seeing this cycle being broken with the assistance, training, and encouragement that MHSS provides. If you implement these changes for mental health services, be prepared to experience the overwhelming negative consequences of people with mental illnesses becoming unstable and unable to live independently. Look past cost efficiency and take awareness of the long term goal. As a mental health provider I value everyday to see the clients I work with obtain independent stability so that they can rise above their mental illness and achieve the greatness they were destined for. I ask again Who is next? Don't let these people fall through the cracks but instead, give them every opportunity to receive the help they need. 

I have worked in the mental health field for over 8 years and have experianced many changes as mental health provider. This change will effect a far greater portion of our population than I believe than anyone realizes.Our mental health system is already overwhelmed and broken. Our jails are over populated and as we all saw on the news recently in Virginia our hospital beds for those who require inpatient mental health care are often full. I understand that these changes come down to increased spending and the states desire to reduce it, however this is not the approach needed. These efforts are misplaced. The mentally ills population continue to be treated as second class citizens when it comes to recieving care that is needed. Diabetics are not denied medication and the ability to see a nutritionist simply because they have not yet needed hospitalization. However we are now being asked to turn away  individuals who would benifit from treatment simply because they have never been hospitalized for there mental illness or because they happen to be under the age of 21 and live at home with there parents. This is an absurd idea and it will be one that results in a much larger problem that our state already faces. If our hospital beds are full now just wait and see how bad this will turn out. Not only will our hosptials be overwhelmed but so will the jails and our schools. Once these individuals get turned away for our services many parts of there lives will begin to be unmanagable and others who are not trained and skilled at providing the care needed to these invididuals will be forced to do so. I have encountered many individuals that with the prevenative support and clinicial care of MHSS system have reduced there risk of hospitilzation greatly. Please reconsider.

What are the older children ages 17,18 and 19 supposed to do. When there mental health has deteriorated or in my daughter case of Schizophrina it dosent fully devolop until the age of 21 or 22. Mental Health Support was there to try to help my daughter in the community as her diease progressed. She trust very few people and her Mental Health Support person is great with her. Her last day of services is the 17th of this month because of this change. Because she is 17 and a junior in high school not preparing to be on her own and chances are it may be many years before she COULD be on her own. Do the people making these changes not understand the severity of some of these disorders? I'm afraid that not just for my daughter but for all the clients affected by these changes that there are going to be DRASTIC negative results. I'm sure that for some their mental health support person is the only person they had. The results that come from this will be on your hands.

I am a very concerned Mental Health Professional who finds it very troubling to know that the proposed regulations will limit clients with no history of hospitalizations, when by their receiving services, has PREVENTED hospitalizations all together!!!  So here is my short and sweet opposition to these proposed regulations:

By restricting access to clients who benefit from MHSS will mean LIFE OR DEATH!!!  This will increase isolation, increase suffering and severly impact their lives!!!!!  Let's pay it forward by providing those a better chance at life instead of paying them back additional heartache, suffering and uncertainty. 

I LOVE what I do and wake up eager to start a new day.  But, with the proposed changes, my fear is we will not have a population to provide the assistance and with that, I am uncertain if the clients we provide services to will wake up the next day with the training and direction they deserve to make it through.  PLEASE look at what is being proposed and ask yourself.....Can you sleep good at night and wake up the next morning knowing there is someone suffering from YOUR mistakes????!!!!  I wouldn't want to carry that guilt. 

While I generally support regualitons that assure that these services are targeted to those with a serious mental illness, I fear that the qualifying criteria are too absolute and rigid given current day practice aimed at promoting recovery and preventing hospitalization. There should be the ability to grant exceptions when there is ample evidence that there is a serious mental illness and the functional defitis that justify the services even when an individual has ben helped to avoid hospitalization. The regulaitons also  need to take into account that many persons with a serious mental illness, early in their illness, may require extensive efforts at engagement and trust building before actual skills will be able to be addressed. The smae flexibility is required so that  the allowable activities and measures for service continuation undertsand that longer term assistance with various life skills is needed for some individuals and that completed skill acquisition will be elusive for some and ongoing services will be necessary for sustained community tenure.