With Community Stabilization changing to an authorization request instead of registration, there are a couple concerns from a provider perspective:

1) MCO interpretation of medical necessity criteria has shown to be inconsistent for other services. It will be essential for this service that MNC be applied consistently. Creating an authorization form that allows minimal interpretation or subjective content would be helpful. Additionally, as MCOs are indicated as a referring entity, it will be essential for MCO Care Coordinators to have an appropriate understanding of the service definition and MNC. The provider experience has been that often Care Coordinators make referrals for a service only for that service to be denied by the MCO's utilization team. These inconsistencies would create a detriment to persons served as seemingly appropriate admissions would be interrupted if MCOs do not interpret and apply MNC consistently. With the intention of Community Stabilization being to mobilize effective community supports that do not yet exist, abruptly ending a service will place the individual at risk of returning to a higher level of care unnecessarily. The more flexibility MCOs have to interpret and apply MNC, the more commonly that will occur.

2) The time frame for MCO response to Community Stabilization authorization requests should be indicated. Categorizing Community Stabilization as an Urgent request type per NCQA or indicating a specific time frame would be helpful. Currently it is indicated that providers must submit requests within 1 business day of admission. However, there is no indication of the time frame in which MCOs must review and respond to a request. Due to the nature of service, services must start immediately to be effective. Providers are therefore expected to serve individuals with no authorization during the review time frame. While it is the provider's responsibility to ensure the individual meets MNC, flexibility on the part of the MCO to interpret and respond to requests will ultimately create an undue burden on providers. 

3) Currently, the assessment for services cannot be billed separately for Community Stabilization services. It is billed as part of service provision under S9482. If that will continue to be the case now that the service requires authorization, then the provider could not be reimbursed for time taken to assess the individual and identify if MNC are met. 

Ultimately, it would be helpful for a provider be able to render services for a limited number of units regardless of approval. 

1. Changing the current registration process to a service authorization will likely pose an issue in terms of individuals quickly accessing care. Currently the regulations do no state how long MCO's have to make a determination which will leave providers in limbo in terms of their ability to quickly provide services. Also there is inconsistency among the MCO's in terms of medical necessity criteria and the amount of units they allow for different programs. This is a recurrent issue that has not been solved, so adding community stabilization to this will only heighten the issues. Also there is a clear shortage of licensed and licensed type staff in community mental health; however we are required to employ them and pay them for their expertise; but when they determine medical necessity criteria, the MCO's can dispute this and this undermines their clinical judgement and perceived value adding to burn out and departure from community mental health.
2. Providers across Virginia are struggling to retain qualified staff in order to provide the new BRAVO services in addition to the original services. Changes are expected; however drastic changes such as this in addition to the additional administrative burdens attached with Project Bravo and the database are concerning and may result in less Virginians being able to access quality care. 

Mobile Crisis Response - Continued Stays "Not available for this level of care. If additional units are needed, providers should submit a new registration form with the Managed Care Organization (MCO) or Fee-For-Service (FFS) Contractor and any necessary call center engagement in accordance with DBHDS guidelines"

Currently MCOs deny new registrations if they are requested consecutively (ex. Registration is for 5/15/22 - 5/18/22 and is approved; program is asked to reassess the individual on 5/19, puts in a registration and it is denied due to being a consecutive request); At this time, a provider may be asked to reassess numerous times over the course of a week, particularly if the person is awaiting a bed for hospitalization.

It is recommended that language be added that allows for consecutive registrations under these circumstances.

• “Intent of CS is to folks that are being discharge to the community from a higher level of care to the community and the community services is not available at that time. Must be coming from another crisis services. “from Dr. Wards video. Does this eliminate Community based referrals from PCPs, Schools, other Outpatient therapist, case manager?  As the guidelines are written in this draft, there is no pathway for these Community Providers to make direct referrals to CS which often is used when the consumer may be showing signs of escalating behaviors that place them at risk of a higher level of care.  So, this language essentially eliminates that pathway to CS.  The community will not be prepared for this shift and this may truly create a barrier to access for some and may  result in higher utilization of Mobile Crisis-Responses and specifically Prescreening Evaluations, where staffing shortages have made it difficult or in some cases impossible to have fully functional mobile response teams.  
• Service Authorizations: As written in the draft a service auth will be required instead of registration, and that the units will be based on MNC. This creates the same level of inconsistency that was present prior to Dec 1, 2022 Comprehensive Crisis Changes, when depending on the MCO and even the MCO care coordinator reviewing the auth, services could be authorized for anywhere from 3 days -7 days.  An authorization in place of a registration may leave consumers who are “in a crisis” waiting 1-2 days for the MCOs to approve the services as agencies may want to avoid the possibility of initial services being provided and not authorized.
• Community stabilization proposed regulation updates indicate that care coordination must be included and involve the MCO for service Coordination. What does this include, calling the MCO and asking for providers. With major shortages of providers MCO has been sought out by CS provider to obtain information on providers in catchment area only to be told by several specific MCOs to “go on the website and search for providers” and not offering any valuable input to the care coordination process? What will be the MCOs role in the new regulation for Care Coordination?
• Can you clarify the use of QMHP-E in Community Stabilization? As it is written now QMHP-E are only a part of the team composition with a LMHP. With agencies experiencing tremendous staff shortages it is crucial to be able to use QMHP-Es as part of Team composition 1 HN 1 QMHP-A or QMHP-C or 1 CSACx

Proposed reg changes show switching Community Stabilization from a registration to a preauthorization. This will likely put providers in a scenario where they are unable to start crisis services for a client in immediate need due to a delay in receiving authorization. It would behoove the state to consider eliminating that proposed change in order to continue to allow immediate access to crisis services, a service that is meant to be an immediate intervention.

For community stabilization, it appears that a referral must come from one of the ones listed in the regulations, but not from other community providers (school, case managers, other DD/MH provider) or a self-referral. This may limit the number of individuals who can access this service and for us a provider to be reimbursed. In addition, it appears the new requirement for a prior authorization will delay the initiation of this service, which is intended to be a crisis service. 

REACH CTHs are being included in the RCSU DMAS requirements for 24/7 on-site nursing.  RCSUs cover 16 bed facilities that serve individuals primarily with MH/SA diagnoses; these facilities are TDO accepting and provide residential medical detox (both of which REACH CTHs do not provide).  REACH Crisis Homes are short term stays and currently utilize a mix of on-site (daytime) and on-call nursing (nighttime) to ensure 24/7 access to nursing support if needed.  This model meets the needs of individuals supported.

Requiring 24/7 on-site nursing for REACH CTHs increases the operating costs of the program tremendously without increasing revenue opportunities.   

Guidance for timeframes seems to have been removed from both criteria, as well as from the length of service provision.

Criteria used to indicate that a behavioral health crisis must have taken place within 72 hours. With this being removed, it leaves it up for the interpretation of the provider, who is then subject to the MCO's interpretation and approval. 

Length of service was previously indicated as 7 days with the option to reauthorize for up to 14, if the client was still actively in crisis. This timeframe was also removed, making it unclear how long the provider can facilitate this service. Length of service should be clearly defined to avoid confusion amongst providers, MCOs, and clients and their expectations of the supports they are receiving. 

Access requirements to this service (ie- who can make a referral/how a client can access the service) and requiring authorizations instead of registrations seems to push the crisis system backward, in the opposite direction of the intention of the crisis now model. Continued changes, additional documentation requirements, and decreasing ease of access will continue to be a barrier to individuals in the community accessing services they need. This will result in more mobile crisis calls, escalation needing a higher level of intervention such as LE (not consistent with MARCUS alert initiative), and individuals continuing to show up to ERs and contributing to hospital boarding. For these systems to be successful, crisis support services should be accessible and the process should be streamlined. "Jumping through hoops" will result in less providers wanting to provide the service, decrease in consumer accessibility, and ultimately perpetuate a broken system.

As a provider who cares deeply about the work I do, I wanted to wait before posting a public comment about these recent changes. It is very clear from the other comments that the recent changes to community stabilization simply will not be effective for achieving solid continuity of care for individuals in our community who truly need help. When publishing the final policies, please look beyond the numbers for a moment and think about those of us who are NOT committing fraud/waste and how we are negatively effected by this. Another comment shared how many negative consequences adding additional barriers and challenges present, and I fully agree with everything stated. I have dedicated the last 15+ years of my life to helping our community and have worked tirelessly to do the right thing and empower our community and all of the staff that have worked for our company over the years. It really seems as though DMAS simply does not want us to utilize Community Stabilization at all with these recent changes, and if that is the case please just remove/replace the service entirely instead of slowly causing the service to deteriorate due to administrative burdens. This service was listed in the top 5 of the most crucial services needed to help our community by DBHDS and it simply looks like this is not the case now. All of the comments clearly outline a multitude of issues with the recent draft and I sincerely hope that you address them as you promised you would to prevent a huge implosion of community based behavioral health services across the state. Do remember that a lack of quality community based providers, services, and workers was what initially caused the overcrowded residential crisis in the state long before Covid-19 hit. If the state of VA had more options and support for private providers 10+ years ago, the DOJ issues may have never happened in the first place. DMAS should want to empower providers and push quality services forward not hinder us with more red tape and frustration. Quality community based providers of all sizes are the key to success and forcing us into closure, extreme stress, ongoing staff confusion/frustration is counterproductive to helping VA increase our quality of services. Imagine if your supervisor came to you every 90 days telling you that there were policy changes that would put your job in jeopardy? Think of how devastated you would feel and how this could literally drive you into a mental breakdown due to the ongoing uncertainty. Would you even want to engage daily in the very challenging and difficult policy work that you do? This is literally what we are left with as DMAS makes these changes over and over again. I appreciate your time reading and using the empathy that I believe you all have to understand the sincerity in these words.

The current REACH CTH model of care is evidence-based and a more cost effective model for the specialized population.  REACH would be losing the I/DD CTH level of care completely if we are required to align with RCSUs regulations.

Regarding the statement in the Community Stabilization draft, it states that the service may no longer be delivered to a group of clients, but rather with a 1:1 ratio or 2:1 ratio of clinician to client. How can clients who are struggling to be stable in the community be expected to re-integrate with the community if they are not allowed to engage in therapeutic group activities? When I worked in the inpatient hospitalization setting, we conducted multiple groups everyday to assess those patients' ability to participate appropriate with peers and others. This will be key as we are trying to help clients prepare to return to their school environments nine months out of the year. We understand that one clinician cannot bill for multiple clients at a time, but can several clinicians get their clients together and co-facilitate an activity for 30 minutes? Can we please get more clarification on this issue? 

• Agree with other comments regarding inconsistencies in expectations including referral sources for community stabilization, approval time, frequent changes overall negatively impacting opportunity to provide an essential service are resulting in a heavy burden on clinicians and the community. 
• Creating more barriers to accessing community stabilization additionally continues to leave families cycling through different systems in crisis, creating more stress and trauma for families and other providers/agencies involved rather than having clear and obtainable stabilization service through community stabilization to start the stabilization support we are intended to provide. 
• 24/7 in-person response expectation is not a realistic lift for the current workforce and can continue to be addressed in the mean time with collaboration with others and prevention planning with families.

In reading comments from other providers, we can see there is an overwhelming response to the concerns these changes are going to pose, not just for implementation, but for the community members that are in need of support. Constant changes to the hows and whens become so very frustrating for employers and their front line staff. Hearing every few weeks that something is changing and something new needs to be done adds to the stress of an already overwhelming role providing crisis services. Providers having to wait for an authorization to be approved in order to provide a crisis service is going to leave community members who are in ACTIVE need as the ones that suffer as a result of this change. Changes should drive positive outcomes, not further frustration and increased difficulty accessing services. I urge you to take into account the significant, and realistic, concerns that have been shared in this townhall. 

Mobile Crisis Response, pg. 12

 "The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services."

Currently providers enroll individuals in the data platform and obtain a reference number to accompany the MCO registration process. Does the change in language referenced here imply a change in this process? Establishing simple processes to initiate crisis services is essential in the provider's ability to respond rapidly and effectively. Providers of crisis services have established referral networks that currently work to divert individuals from higher levels of care. Adding additional steps to the referral process will delay response times and weaken positive service outcomes. Regulations should work to preserve a "no wrong door" approach.

Community Stabilization Medical Necessity Criteria pgs. 26-28

The proposed changes to the admission criteria exclude individuals who recently experienced a behavioral health crisis (within the past 24-72 hours) and who meet all of the medical necessity criteria except for discharging from a higher level of care. Arguably, these individuals are at high risk of needing a higher level of care, and community stabilization should be an appropriate service to adequately treat these individuals and to also divert from higher levels of treatment.

Please consider admission criteria to include:

1.) Individuals who recently experienced a Behavioral Health Crisis. (Recently may be defined as within the past 24-72 hours.)

2.) Documentation indicates evidence that the individual currently meets criteria for a primary diagnosis consistent with an International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis that correlates to a Diagnostic and Statistical Manual diagnosis in the most recent version of the manual; and

3.) The individual has demonstrated a level of acuity indicating that they are at risk for crisis-cycling or dangerous decompensation in functioning and additional support in the form of community stabilization is required to prevent an acute inpatient admission; and

4.) There is evidence that if immediate access to the intended referral service is not available, the individual is likely to go into crisis or experience a dangerous decompensation in functioning and thus community stabilization is necessary in order to maximize the chances of a successful transition to the intended service;

5.) A clinically appropriate and specific behavioral health service provider referral(s) has been identified and a plan for the timeline of transition from Community Stabilization to that

Community Stabilization, pg 27

I recommend omitting criteria iii., (a) The service that the individual needs and is recommended by a professional listed in item i. above or a professional coordinating the discharge plan from services listed in item ii. above is not currently available for immediate access;

Criteria iii. (b) and (c) achieve the same objective while simplifying the criteria.

Community Stabilization, pg. 35

Please consider authorizing a number of units to support assessment and initial planning activities within the first 24 hours, (which may span across two calendar days). This initial service funding should not be subject to a prior authorization process.

Given the proposed regulation changes from a registration process to a prior authorization process, it is critical that MCOs prioritize these reviews and responses. To avoid service disruptions or compromise to quality care, providers must be informed of authorization statuses within one calendar day.

The drafted criteria is so overly cumbersome that it makes it very difficult to navigate and some ways the criteria negates itself. For example, In criterion 2. “The individual has demonstrated a level of acuity indicating that they are at risk for crisis-cycling or dangerous decompensation in functioning and additional support in the form of community stabilization is required to prevent an acute inpatient admission”.  This criterion to me states that the individual can be at risk of crisis cycling or decompensating in a way that community stabilization is required to PREVENT acute admission, however later in the criteria (#3)  it implies that only individuals stepping down from higher level of care (ie acute psychiatric inpatient, ER, 23-hour crisis stab ect) will meet the full criteria and does not allow someone who is simply “crisis cycling or decompensating” to access the services unless they are assessed by SDA. So we send those that are simply decompensating and at risk for acute hospitalization through either SDA or Emergency Services, which are already programs that are overwhelmed with the influx of consumers and lack of mental health providers to connect consumers to.

While Region 4 supports the long-term vision of the state for a single point of entry to the crisis services system when possible and appropriate, the regional crisis call centers are already expecting call volume to at least double with the implementation of 988 beginning 7/16/22 driving that system to operate at or above capacity. As such, we strongly recommend that any requirement of providers to coordinate or engage with the call centers be retracted. Providers should continue to engage with the DBHDS data platform, not necessarily call center personnel, to obtain a reference number, record and coordinate
care. Specifically, the draft regulations require coordination with the DBHDS crisis call center (under ‘care coordination’), engagement with the DBHDS crisis call center prior to initiating
services under ‘required activities’, and further requirement under ‘service
authorization’ to engage in required DBHDS call center engagement…according to
DBHDS guidelines.  The DBHDS data platform dispatch feature is not functional for
Region 4 at this time. As such, the call center personnel will be challenged beyond
capacity to both triage the crisis callers while simultaneously coordinating and
engaging with approx. 600 mobile response provider staff identified in Region 4,
as required in these regulations and in a manner that enables safe and
timely connection of resources for individuals. If DMAS cannot retract this language,
then at a minimum it needs to postpone implementation of this requirement
for at least 6 months until such time that the required features in the
DBHDS data platform are performing to standard and further clearly define
the terms “coordination and engagement” with call center to inform complex
operational workflows at local, regional, and statewide levels.

1. Recommend that a timeframe for documenting the assessment be defined, as opposed to “At the start of services.”

2. Recommend that a timeframe for documenting the treatment plan and CEPP be defined, as opposed to “development of an immediate plan.”

3. Mobile Crisis, page 16—Recommend adding the word “or” for staff who can provide care coordination and treatment planning as the current wording could imply that all these professionals must provide these services to the individual.  The word “or” is used in the community stabilization section (page 32).

4. Community Stabilization, page 25—This wording implies that the treatment plan must be signed by a LMHP, LMHP-R, LMHP-RP, LMHP-S.  Page 32 indicates that a QMHP can provide treatment planning.  Is a LMHP, LMHP-R, LMHP-RP, LMHP-S required to sign the treatment plan?

Treatment Planning: · Individual Service Plans (ISPs see Chapter IV for requirements) shall be required during the entire duration of services and must be current. The treatment planning process should be collaborative but must be directed and authorized by a LMHP, LMHP-R, LMHP-RP, LMHP-S.

Mobile Crisis Response

• On Page 8, under Service Definition, it says Mobile Crisis Response services are available 24 hours a day, seven days a week to provide rapid response, assessment and early intervention to individuals experiencing a behavioral health crisis”.  Our mobile crisis team is not available 24/7 as of yet and will not be for several months to a year.  This requirement will cause the team to be out of compliance.  It is recommended that this requirement be removed until all regional mobile crisis teams are available 24/7.
•  
• Page 11, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services”  This requirement will lead to increase call volume that call centers do not have capacity to receive.  It is recommended that the requirement be removed totally or amended to require engagement with the data platform only.
•  
• On Page 15, under Staff Requirements, the billing structure and team composition only allows a peer to provide services when paired with another professional.  In crisis response, there are many instances that a peer can independently engage, support, transport and perform activities that will assist with the de-escalation of a crisis episode.  It is recommended that peers be allowed to bill independently for Mobile Crisis Response services if the individual has been assessed and determined that peer recovery services are appropriate to assist with crisis resolution.
•  
• On Page 18, under Service Authorization, it states that the registration permits eight hours (32 units) in a 72 hour period”.  Billing should be allowed for the entire time that the service is permitted, which is 72 hours.  It is recommended that Mobile Crisis Response be permitted for billing up to 72 hours.

Community Stabilization

• On Page 22, under Service Definition, it says “Community Stabilization services are available 24 hours a day, seven days a week, to provide for short-term assessment, crisis intervention, and care coordination to individuals experiencing a behavioral health crisis”.  All regional mobile crisis teams are not operational 24/7 and this requirement would lead to automatic noncompliance.  It is recommended that this requirement be removed until all mobile crisis teams are available 24/7.

• On Page 24, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis data platform prior to initiating services.”  Please define the term “engage”.  It is recommended that “prior to initiating services” be removed and replaced with “as services are initiated”.  Services should be client-centered and aim to assess prior to engaging with data platform.  The revision gives flexibility to providers as services are being started.

• On Page 27, under Admission Criteria, there is a requirement that an individual must be discharged from one of the 10 services or settings in order to access/provide the Community Stabilization service.  The requirement disregards the notion that clients can experiencing a crisis while receiving another community-based service such as case management or TDT.  This limits access to this service and forces the individual to wait until the crisis is acute before the service is accessible.  It is recommended that the services be allowed and accessible at any point as long as admission criteria are met.

• On Page 30, under Exclusions and Service Limitations, #1 indicates that an individual receiving MHS or ARTS services “more intensive than standard outpatient psychiatric services for mental health and substance use disorder,…”  The term “outpatient” is used differently and can many services can be placed under that general term.  Please clearly define “outpatient psychiatric services”.  It is recommended that individuals who are connected to outpatient services have access to this services as crises are experienced by these individuals as well.  This would exclude individuals in case management, TDT, medication management or therapy.

• On Page 32, under Staff Requirements, peers are not allowed to provide services independently.  It is recommended that peers be allowed to provide Peer Recovery Services without the presence of another professional.  The best engagement is often times when peer-to-peer services are provided independently.

• On Page 34, under Service Authorization, Community Stabilization no longer allows for registration.  It is recommended that the registration process remain for this service and the timeframe be shortened, if necessary.

We share many of the same concerns as prior comments regarding turnaround times for service authorizations and if there will at least be a minimum number of units to ensure the agency can work with a client for a set amount of time if the authorization has not been sent. 

Page 36, "The referring provider must determine what other services the individual is receiving prior to referring to Community Stabilization. It is the responsibility of both the referring provider and the Community Stabilization provider to determine if the individual has another community behavioral health provider and should contact the MCO/FFS contractor, caregivers and natural supports prior to initiating Community Stabilization services."  Currently, several MCOs (including Optima and Virginia Premier) will not share what authorizations a client has open at the time of admission to a new provider, citing a "HIPAA violation." Our agency already checks for existing Community Stabilization authorizations before assessing a client to avoid duplications in services and are unable to verify the status with those 2 MCOs consistently, and occasionally with United Healthcare. There is not a current means to reliably check the status of current authorizations without MCO engagement and they'd need to be informed to release the information unilaterally, across services to include IIH, TDT, and MHSS if Community Stabilization providers are expected to know a client's status in those services at admission. 

• The manual notes Preadmission Screening Clinicians (prescreeners) who are not LMHP or in supervision need to have their assessments signed off by a LMHP. 
  • We continue to advocate that billing for this level of staff be allowed based on existing State Level Certifications (suggest attempting to get a waiver to make it allowable). Staff that meet the 2016 certification document standards are well trained and qualified to provide the service, many have been doing so competently for many years. 

• Manual notes “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services”

• • Considerations: is not know if a mobile crisis service is needed until assessing the individual. 
  • Engaging the call center and data platform first can slow down response time when someone is in crisis.
  • It is contradictory to the statement “At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service.”

Recommend allowing “within one business day” to enter information into the data platform and connect with crisis call center for calls not originating from the call center . This similar to the manual statement “Providers must submit a registration to the individual’s MCO or FFS contractor within one business day of admission.”

• Requiring mobile crisis be provided 24/7:  Requiring programs to provide 24/7 coverage may not be possible as programs are being implemented. 24/7 may not be possible due to work force shortages.  Providing some coverage, versus no coverage, should be allowable in order to benefit the community, as long as other service provisions are met. Alternatively, less than 24/7 could be allowable for a designated period of time of implementation and allowances made for good faith efforts to staff. 

• Manual notes regarding Required Services

"Care Coordination: Providers must follow all requirements for care coordination (See Care Coordination Requirements of Mental Health Providers section of Chapter IV)."

Also notes in several places:

“Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be required which includes care coordination and communication with the individual's MCO or FFS contractor, service providers and other collateral contacts.”  

It is not clear what this means in terms of MCO and FFS and why this is included? This wording is not referred to in chapter IV as a requirement.

There are also times a one time intervention will be all that is needed to de-escalate for mobile crisis, or, collateral and provider contact may not be allowed per patient request. Example- person having a SUD relapse, and they refuse to let staff contact their provider or family members. Additional example: family that calls about a child client who is having behavior problem; and the parent refuses follow-up care and referrals for additional services.

Recommend rewording throughout: “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be provided as appropriate and which can include other service providers and collateral contacts.”  Or- simply use the wording below from Chapter IV.

Chapter IV Definition: "Care Coordination" means locating and coordinating services across health providers to include sharing of information among health care providers and others who are involved with the individual’s health care to improve the restorative care and align service plans.

Chapter IV also notes “ Care coordination is based on 1) an assessment conducted by a care coordinator and 2) a centralized plan of care. For mobile crisis #2 may not apply.

• Several places in the manual refer specifically to use of a Psychiatric Nurse Practitioner. Many Nurse Practitioners have provided psychiatric care for numerous years. Psychiatric NPs are more rare, and relatively newer.  Nurse Practitioners in general should be allowed to complete evaluations for RCSU and 23 hour observation units if they are operating within their scope of practice. This is particularly appropriate in these settings that may see a number of individuals who have medical comorbidities and SUD problems at admission.

Recommend adding Nurse Practitioner throughout

Manual Notes: 

• "The RCSU provider may use a psychiatric evaluation completed within 24 hours prior to admission by a psychiatrist or psychiatric nurse practitioner to meet this requirement. Documentation that the RCSU psychiatrist or psychiatric nurse practitioner has reviewed and updated (as clinically necessary) the evaluation within four hours of admission, must be in the clinical record."

Requiring review by doctor level or NP level within 4 hours will still be a burden to the system, and reimbursement models do not support the cost of this coverage. It is not necessary to have a physician or NP to review if there has been an evaluation in 24 hours and there is already other clinical and nursing assessment happening.

Recommend changing and adding nurse: Documentation that the RCSU psychiatry, psychiatric nurse practitioner, nurse practitioner, or nurse, has reviewed and updated the evaluation within 4 hours of admission.

 Manual notes

• The 23 Hour Crisis Stabilization provider may use a psychiatric evaluation completed within 24 hours prior to admission by a psychiatrist or psychiatric nurse practitioner to meet this requirement. Documentation that the 23 Hour Crisis Stabilization psychiatrist or psychiatric nurse practitioner has reviewed and updated (as clinically necessary) the evaluation within four hours of admission, must be in the clinical record.

Requiring review by doctor level or NP level within 4 hours, will still be a burden to the system, and reimbursement models do not support the cost of this coverage. It is not necessary to have a physician or NP to review if there has been an evaluation in 24 hours and there is already other clinical and nursing assessment happening.

Recommend changing and adding nurse:  “psychiatry, psychiatric nurse practitioner, nurse practitioner, or nurse, has reviewed and updated the evaluation within 4 hours of admission.

Page 52; under service definition...

RCSUs provide short-term, 24/7, residential psychiatric and substance related assessment and brief intervention services. The service supports the following individuals:

• Individuals experiencing changes in behavior noted by impairment or decompensation in functioning that may result in the need of a higher level of care.
• Individuals stepping down from a higher level of care that need continued monitoring, stabilization and mobilization of resources.
• Individuals who need a safe environment for assessment, stabilization, and prevention of further escalation or decompensation. 

The above information is excellent, though it does not translate when looking at Medical Necessity / Admission Criteria

Medical Necessity / Admission Criteria #1 on page 58;

Individuals must meet all of the following criteria (1-5)*:

1. One of the following must be present:

a. The individual must be experiencing an active behavioral health crisis or

b. The individual is stepping down from a higher level of care after a recent behavioral health crisis and needs continued stabilization prior to returning to the community and...

**Can there be an option C added to address the individual we support who needs a safe environment for assessment, stabilization, and prevention of further escalation or decompensation?

 Exclusion Criteria and Service Limitations page 60-61;

1. RCSUs may not be billed concurrently with any other behavioral health service except when a service overlap with other community behavioral health services is needed as part of a safe discharge plan. Documented justification of the time needed for discharge planning and care coordination to other services is required. Overlap durations will vary depending on the documented needs of the individual and the intensity of the services but in no instances may exceed 48 hours.

**The above statement indicates that we are taking a few steps back and going back to and/or adding additional barriers for individuals moving through the crisis continuum and/or have a need for continuity of care.  Can you clarify, does this mean if a client has an open PA for another crisis service or behavioral health service (i.e. mobile crisis, community crisis stab., ACT, MHSS, etc.) that will overlap with a submitted R-CSU PA, the R-CSU PA will be denied? We provide services for many ACT clients and the language above sounds like this is going to be a more difficult challenge.

“Concurrently”, typically means at the same time, so can an individual have more than 1 crisis or behavioral health service PA active at the same time, just as long as, both services are not billing at the same time?  “RCSUs may not be billed concurrently with any other behavioral health service except when a service overlap with other community behavioral health services is needed as part of a safe discharge plan. Documented justification of the time needed for discharge planning and care coordination to other services is required.” - Can you clarify which service would need to provide the justified documentation?  If justifiable documentation is needed by insurance company, doesn’t that then become very subjective?

 Service Authorization; page 67

Providers must submit a registration to the individual’s MCO or FFS contractor within one business day of admission. The registration permits five calendar days/five units of service. Units billed must reflect the treatment needs of the individual and be based on the individual meeting medical necessity criteria.

**Can you verify, a registration, if submitted within 1 business cannot be denied by an MCO, since it is a registration and NOT an authorization?

“Continued stay requests are to be submitted no earlier than 48 hours before the requested start date of the continued stay and no later than the requested start date”

**Thank you for this, this is great news and much appreciated!

 Service Authorization; page 67

**the addition of 2 more documents to submit for continued stay requirement is adding to the administrative burden.  A current continued stay packet is roughly 35 pages with the addition of the ISP and Care Coordination notes it could be a 45-50 page packet. This can be an exhaustive clerical process to potentially ask for as little as 1 additional day of treatment. Please consider decreasing the number of documents needed for continued stay rather than increasing. This may have unintended consequences such as premature discharge given workforce shortages to dedicate extended time coordinating documents for MCO review with minimal clinical utility.

Appreciated when historically crisis intervention could be provided for up to 3 services without the additional paperwork and barriers. Current process and paperwork requirements for mobile crisis are a burden to providers trying to deliver quick de-escalation services and slowing down response times. Mobile crisis works best, in its simplest terms, when responders are able to “go” and not worry about paper work and authorizations first. Suggest it flow like the below to be of maximum benefit to the community:

• • Individual calls or presents in crisis
  • Call is triaged (by mobile crisis, ES staff, or call center)
  • Mobile crisis clinicians respond if appropriate
  • Provide care: When meeting with the individual, professionals help de-escalate, build rapport, instill hope, assess for risk and immediate needs, make safety plan, provide short term intervention and connect the person with additional resources (examples: prescreening, community stabilization, 23 hours, RCSU, outpatient appointment, etc.).
  • Document service including safety plan and referral information after the visit.
  • Complete service registration and data platform requirement after the visit.
  • Other service providers/programs at the start of follow up services create treatment plans, completing consents to treatment, and other paperwork items for their service.
  • Mobile crisis team follows up to ensure linking to referral sources worked. 

Mobile Crisis Response:

• Requiring mobile crisis be provided 24/7:  Requiring programs to provide 24/7 coverage may not be possible as programs are being implemented. 24/7 may not be possible due to work force shortages.  Providing some coverage, versus no coverage, should be allowable in order to benefit the community, as long as other service provisions are met. Alternatively, less than 24/7 could be allowable for a designated period of time of implementation and allowances made for good faith efforts to staff. 
• Page 11, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services” This is contradictory to the statement “At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service.”   This requirement will lead to decreased response time, increased call volume that call centers do not have capacity to receive.  It is recommended that the requirement be removed totally or amended to require engagement with the data platform only.
• On Page 15, under Staff Requirements, the billing structure and team composition only allows a peer to provide services when paired with another professional.  In crisis response, there are many instances that a peer can independently engage, support, transport and perform activities that will assist with the de-escalation of a crisis episode.  It is recommended that peers be allowed to bill independently for Mobile Crisis Response services if the individual has been assessed and determined that peer recovery services are appropriate to assist with crisis resolution.
• On Page 18, under Service Authorization, it states that the registration permits eight hours (32 units) in a 72 hour period”.  Billing should be allowed for the entire time that the service is permitted, which is 72 hours.  It is recommended that Mobile Crisis Response be permitted for billing up to 72 hours.
• The manual notes Preadmission Screening Clinicians (prescreeners) who are not LMHP or in supervision need to have their assessments signed off by a LMHP. 

• We continue to advocate that billing for this level of staff be allowed based on existing State Level Certifications (suggest attempting to get a waiver to make it allowable). Staff that meet the 2016 certification document standards are well trained and qualified to provide the service, many have been doing so competently for many years. The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building the crisis system of care.

• “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be required which includes care coordination and communication with the individual's MCO or FFS contractor, service providers and other collateral contacts.”  It is not clear what this means in terms of MCO and FFS and why this is included?  There are times a one-time intervention will be all that is needed to de-escalate for mobile crisis, or, collateral and provider contact may not be allowed per patient request.  Recommend rewording throughout: “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be provided as appropriate and which can include other service providers and collateral contacts.” 

Community Stabilization:

• On Page 24, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis data platform prior to initiating services.”  Please define the term “engage”.  It is recommended that “prior to initiating services” be removed and replaced with “as services are initiated”.  Services should be client-centered and aim to assess prior to engaging with data platform.  The revision gives flexibility to providers as services are being started.
• On Page 32, under Staff Requirements, peers are not allowed to provide services independently.  It is recommended that peers be allowed to provide Peer Recovery Services without the presence of another professional.  The best engagement is often times when peer-to-peer services are provided independently.
• On Page 34-35, under Service Authorization, Community Stabilization no longer allows for registration.  It is recommended that the registration process remain for this service in order to provide services to individuals in an efficient, time sensitive manner that does not focus on paperwork.
• Page 35, where it indicates a documented referral from a discharge provider… this is another requirement that takes away from focusing on the individual and addressing their crisis in a timely, efficient manner.  Also a requirement to contact the MCO to determine what other services are being provided before starting services is a deterrent to the individual who is in crisis and the provider as it is an inefficient use of time and resources to ensure the individual is receiving timely services to address the crisis.

23 Hour Crisis:

• Several places in the manual refer specifically to use of a Psychiatric Nurse Practitioner. Many Nurse Practitioners have provided psychiatric care for numerous years. Psychiatric NPs are more rare, and relatively newer.  Nurse Practitioners in general should be allowed to complete evaluations for RCSU and 23 hour observation units if they are operating within their scope of practice. This is particularly appropriate in these settings that may see a number of individuals who have medical comorbidities and SUD problems at admission.  Recommend broadening the ability to utilize Nurse Practitioner throughout
• Page 48, requiring a LMHP to supervise the program.  There is no reason why an LMHP resident or social work supervisee could not supervise the programming when under supervision of an LMHP.  The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building this system of care.

• 24/7 nursing services at all CSUs does not seem reasonable given the model of service delivery and the scarcity of the nursing resource in the Commonwealth.  In particular smaller 6/8 bed units that service children and IDDD do not have a need for this level of care around the clock and use of medication and first aid trained staff with access to on call nursing or other emergent care are better aligned with the mission of a RCSU.  A potential solution is to look at different levels of care to better differentiate the needs of the population being served and tracking the same through modifiers to the billing codes.
• Psychiatric assessments still appear to play too prominent of a role in the RCSU regulations. While best practice for some, not necessary for all.  The requirements to have access to physician services in Licensing is sufficient coverage to ensure that the appropriate resources are available to meet the needs of the individuals served in a person centered manner.  Hard and fast timelines as spelled out will simply mean significantly more attention paid to auditing processes and exacerbate the fight with MCOs to retain funding for services that have been rendered and are not effective management of scarce resources available to meet an overwhelming need.
• Use of a psychiatric evaluation completed within the last 24hours was a helpful inclusion, it may be worth considering evaluations completed in the last 72hours with documented review at admission.
• The prohibition of billing a per diem for both a RCSU and 23hour Observation site when operated by the same entity is a deterrent to expansion of co-located facilities that operate within the Crisis Now Model and best practices in crisis care.  If these two services were provided by different entities the billing would be supported per this draft of regulations and given they are separate services with separate staffing patterns billing of one should not preclude billing for the other.

Given the current phase of development, build out, and system training coordination with the crisis call center and data platform should be better defined and understood prior to including in the regulations.  While this is an important step in ensuring that services are monitored, unduplicated, and coordinated in the best interest of the client being served, the platform and associated stakeholders do not yet have a current capacity to demonstrate effective coordination that is above reproach in the auditing and quality review of services thus increasing the administrative burden on providers of care that is both unnecessary and ineffective.

Mobile Crisis Response:

• Requiring mobile crisis be provided 24/7:  Requiring programs to provide 24/7 coverage may not be possible as programs are being implemented. 24/7 may not be possible due to work force shortages.  Providing some coverage, versus no coverage, should be allowable in order to benefit the community, as long as other service provisions are met. Alternatively, less than 24/7 could be allowable for a designated period of time of implementation and allowances made for good faith efforts to staff. 
• Page 11, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services” This is contradictory to the statement “At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service.”   This requirement will lead to decreased response time, increased call volume that call centers do not have capacity to receive.  It is recommended that the requirement be removed totally or amended to require engagement with the data platform only.
• On Page 15, under Staff Requirements, the billing structure and team composition only allows a peer to provide services when paired with another professional.  In crisis response, there are many instances that a peer can independently engage, support, transport and perform activities that will assist with the de-escalation of a crisis episode.  It is recommended that peers be allowed to bill independently for Mobile Crisis Response services if the individual has been assessed and determined that peer recovery services are appropriate to assist with crisis resolution.
• On Page 18, under Service Authorization, it states that the registration permits eight hours (32 units) in a 72 hour period”.  Billing should be allowed for the entire time that the service is permitted, which is 72 hours.  It is recommended that Mobile Crisis Response be permitted for billing up to 72 hours.
• The manual notes Preadmission Screening Clinicians (prescreeners) who are not LMHP or in supervision need to have their assessments signed off by a LMHP. 

• We continue to advocate that billing for this level of staff be allowed based on existing State Level Certifications (suggest attempting to get a waiver to make it allowable). Staff that meet the 2016 certification document standards are well trained and qualified to provide the service, many have been doing so competently for many years. The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building the crisis system of care.

• “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be required which includes care coordination and communication with the individual's MCO or FFS contractor, service providers and other collateral contacts.”  It is not clear what this means in terms of MCO and FFS and why this is included?  There are times a one-time intervention will be all that is needed to de-escalate for mobile crisis, or, collateral and provider contact may not be allowed per patient request.  Recommend rewording throughout: “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be provided as appropriate and which can include other service providers and collateral contacts.” 

Community Stabilization:

• On Page 24, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis data platform prior to initiating services.”  Please define the term “engage”.  It is recommended that “prior to initiating services” be removed and replaced with “as services are initiated”.  Services should be client-centered and aim to assess prior to engaging with data platform.  The revision gives flexibility to providers as services are being started.
• On Page 32, under Staff Requirements, peers are not allowed to provide services independently.  It is recommended that peers be allowed to provide Peer Recovery Services without the presence of another professional.  The best engagement is often times when peer-to-peer services are provided independently.
• On Page 34-35, under Service Authorization, Community Stabilization no longer allows for registration.  It is recommended that the registration process remain for this service in order to provide services to individuals in an efficient, time sensitive manner that does not focus on paperwork.
• Page 35, where it indicates a documented referral from a discharge provider… this is another requirement that takes away from focusing on the individual and addressing their crisis in a timely, efficient manner.  Also a requirement to contact the MCO to determine what other services are being provided before starting services is a deterrent to the individual who is in crisis and the provider as it is an inefficient use of time and resources to ensure the individual is receiving timely services to address the crisis.

23 Hour Crisis:

• Several places in the manual refer specifically to use of a Psychiatric Nurse Practitioner. Many Nurse Practitioners have provided psychiatric care for numerous years. Psychiatric NPs are more rare, and relatively newer.  Nurse Practitioners in general should be allowed to complete evaluations for RCSU and 23 hour observation units if they are operating within their scope of practice. This is particularly appropriate in these settings that may see a number of individuals who have medical comorbidities and SUD problems at admission.  Recommend broadening the ability to utilize Nurse Practitioner throughout
• Page 48, requiring a LMHP to supervise the program.  There is no reason why an LMHP resident or social work supervisee could not supervise the programming when under supervision of an LMHP.  The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building this system of care.

Mobile Crisis Response:

·         Requiring mobile crisis be provided 24/7:  Requiring programs to provide 24/7 coverage may not be possible as programs are being implemented. 24/7 may not be possible due to work force shortages.  Providing some coverage, versus no coverage, should be allowable in order to benefit the community, as long as other service provisions are met. Alternatively, less than 24/7 could be allowable for a designated period of time of implementation and allowances made for good faith efforts to staff. 

·         Page 11, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services” This is contradictory to the statement “At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service.”   This requirement will lead to decreased response time, increased call volume that call centers do not have capacity to receive.  It is recommended that the requirement be removed totally or amended to require engagement with the data platform only.

·         On Page 15, under Staff Requirements, the billing structure and team composition only allows a peer to provide services when paired with another professional.  In crisis response, there are many instances that a peer can independently engage, support, transport and perform activities that will assist with the de-escalation of a crisis episode.  It is recommended that peers be allowed to bill independently for Mobile Crisis Response services if the individual has been assessed and determined that peer recovery services are appropriate to assist with crisis resolution.

·         On Page 18, under Service Authorization, it states that the registration permits eight hours (32 units) in a 72 hour period”.  Billing should be allowed for the entire time that the service is permitted, which is 72 hours.  It is recommended that Mobile Crisis Response be permitted for billing up to 72 hours.

·         The manual notes Preadmission Screening Clinicians (prescreeners) who are not LMHP or in supervision need to have their assessments signed off by a LMHP. 

·         We continue to advocate that billing for this level of staff be allowed based on existing State Level Certifications (suggest attempting to get a waiver to make it allowable). Staff that meet the 2016 certification document standards are well trained and qualified to provide the service, many have been doing so competently for many years. The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building the crisis system of care.

·         “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be required which includes care coordination and communication with the individual's MCO or FFS contractor, service providers and other collateral contacts.”  It is not clear what this means in terms of MCO and FFS and why this is included?  There are times a one-time intervention will be all that is needed to de-escalate for mobile crisis, or, collateral and provider contact may not be allowed per patient request.  Recommend rewording throughout: “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be provided as appropriate and which can include other service providers and collateral contacts.” 

Community Stabilization:

·         On Page 24, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis data platform prior to initiating services.”  Please define the term “engage”.  It is recommended that “prior to initiating services” be removed and replaced with “as services are initiated”.  Services should be client-centered and aim to assess prior to engaging with data platform.  The revision gives flexibility to providers as services are being started.

·         On Page 32, under Staff Requirements, peers are not allowed to provide services independently.  It is recommended that peers be allowed to provide Peer Recovery Services without the presence of another professional.  The best engagement is often times when peer-to-peer services are provided independently.

·         On Page 34-35, under Service Authorization, Community Stabilization no longer allows for registration.  It is recommended that the registration process remain for this service in order to provide services to individuals in an efficient, time sensitive manner that does not focus on paperwork.

·         Page 35, where it indicates a documented referral from a discharge provider… this is another requirement that takes away from focusing on the individual and addressing their crisis in a timely, efficient manner.  Also a requirement to contact the MCO to determine what other services are being provided before starting services is a deterrent to the individual who is in crisis and the provider as it is an inefficient use of time and resources to ensure the individual is receiving timely services to address the crisis.

23 Hour Crisis:

·         Several places in the manual refer specifically to use of a Psychiatric Nurse Practitioner. Many Nurse Practitioners have provided psychiatric care for numerous years. Psychiatric NPs are more rare, and relatively newer.  Nurse Practitioners in general should be allowed to complete evaluations for RCSU and 23 hour observation units if they are operating within their scope of practice. This is particularly appropriate in these settings that may see a number of individuals who have medical comorbidities and SUD problems at admission.  Recommend broadening the ability to utilize Nurse Practitioner throughout

·         Page 48, requiring a LMHP to supervise the program.  There is no reason why an LMHP resident or social work supervisee could not supervise the programming when under supervision of an LMHP.  The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building this system of care.

Mobile Crisis: Required Activities:
The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services.

This requirement seems counter-intuitive to crisis response. When an individual, family member, or collateral contacts a provider to respond to a psychiatric crisis, the goal is for the provider to engage with the individual and initiate assessment as quickly as possible. The provider should be singularly focused on obtaining the information needed to respond to the crisis. Establishing the requirement to engage with the call center and crisis data platform before mobilizing a response, and the associated potential for technical issues, delays response to the individual.
It would be helpful to understand how inserting this step before initiating a crisis response supports the goal of helping individuals in crisis.

If this change is implemented, it will be critical to outline the process for handling call system and data platform service disruptions or system outages.

Mobile Crisis

I concur with the concern about prioritizing an administrative process over clinical response times. Engaging in the call center and data platform prior to initiating services seems to do just this. I understand that it may be come helpful to use the data platform to review the CEPP as part of treatment and the need to track these events, but to prohibit the initiation of services until these things are done is counterintuitive to the work.

The 8 hour billing limits is problematic in many ways. The long process of bed searches, wait times for medical clearance, and often complicated presentations lead to significant and ongoing engagement of staff well beyond 8 hours in a 72 hour window.

Community Stabilization

I support Peers being allowed to provide supports independently, along with QMHP-eligible staff. We have a large peer program and have found the one on one engagement most beneficial as it supports the mutuality tied to that service vs a ‘interdisciplinary team’ approach. And QMHP-eligible staff receive significant supervision and training as part of obtaining their hours as do LMHP’s in supervision or residency. The latter is able to provide these services so it’s not clear why the former don’t share in this ability.

Moving Comm Stab to a service auth from registration is another example of placing administrative process of clinical.

Requiring this only be provided in an individual vs group setting doesn’t allow for the benefits that can come with a group intervention. These services should definitely be individualized, but if a program can offer a group that educates on a particular coping skill, etc. and that interaction is made more beneficial by sharing with others- why would we not want to take advantage of the opportunity?

Residential Crisis Stabilization

I agree that 24/7 nursing is not always the level of staffing needed to meet the needs of individuals. Staff are trained in medication administration as well as first aide, which meet the vast majority of needs and the availability of on-call support should be considered, especially with the RN shortage in the state.

Adjusting the psychiatric eval to occur within 24 hours is helpful, but as individuals may have been referred to the CSU by psychiatric providers, allowing for a window to extend prior to the admission would reduce the repetitive assessments individuals may already be experiencing with their admission.

We understand that co-locating the CSU and 23 Hour service is the ideal best practice model, but there seems to be some language that would prohibit the ability to bill which is counterintuitive to the model the state has promoted. And the inability to bill a per diem service with any other behavioral health service impacts either the CSU or the supportive service that may be trying to be a bridge from physical discharge from the CSU to the community supports they need.

Mobile Crisis Response:

• Requiring mobile crisis be provided 24/7:  Requiring programs to provide 24/7 coverage may not be possible as programs are being implemented. 24/7 may not be possible due to work force shortages.  Providing some coverage, versus no coverage, should be allowable in order to benefit the community, as long as other service provisions are met. Alternatively, less than 24/7 could be allowable for a designated period of time of implementation and allowances made for good faith efforts to staff. 
• Page 11, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services” This is contradictory to the statement “At the start of services, a LMHP, LMHP-R, LMHP-RP or LMHP-S must conduct an assessment to determine the individual’s appropriateness for the service.”   This requirement will lead to decreased response time, increased call volume that call centers do not have capacity to receive.  It is recommended that the requirement be removed totally or amended to require engagement with the data platform only.
• On Page 15, under Staff Requirements, the billing structure and team composition only allows a peer to provide services when paired with another professional.  In crisis response, there are many instances that a peer can independently engage, support, transport and perform activities that will assist with the de-escalation of a crisis episode.  It is recommended that peers be allowed to bill independently for Mobile Crisis Response services if the individual has been assessed and determined that peer recovery services are appropriate to assist with crisis resolution.
• On Page 18, under Service Authorization, it states that the registration permits eight hours (32 units) in a 72 hour period”.  Billing should be allowed for the entire time that the service is permitted, which is 72 hours.  It is recommended that Mobile Crisis Response be permitted for billing up to 72 hours.
• The manual notes Preadmission Screening Clinicians (prescreeners) who are not LMHP or in supervision need to have their assessments signed off by a LMHP. 

• We continue to advocate that billing for this level of staff be allowed based on existing State Level Certifications (suggest attempting to get a waiver to make it allowable). Staff that meet the 2016 certification document standards are well trained and qualified to provide the service, many have been doing so competently for many years. The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building the crisis system of care.

• “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be required which includes care coordination and communication with the individual's MCO or FFS contractor, service providers and other collateral contacts.”  It is not clear what this means in terms of MCO and FFS and why this is included?  There are times a one-time intervention will be all that is needed to de-escalate for mobile crisis, or, collateral and provider contact may not be allowed per patient request.  Recommend rewording throughout: “Active transitioning from Mobile Crisis Response to an appropriate level of care for ongoing behavioral health services shall be provided as appropriate and which can include other service providers and collateral contacts.” 

Community Stabilization:

• On Page 24, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis data platform prior to initiating services.”  Please define the term “engage”.  It is recommended that “prior to initiating services” be removed and replaced with “as services are initiated”.  Services should be client-centered and aim to assess prior to engaging with data platform.  The revision gives flexibility to providers as services are being started.
• On Page 32, under Staff Requirements, peers are not allowed to provide services independently.  It is recommended that peers be allowed to provide Peer Recovery Services without the presence of another professional.  The best engagement is often times when peer-to-peer services are provided independently.
• On Page 34-35, under Service Authorization, Community Stabilization no longer allows for registration.  It is recommended that the registration process remain for this service in order to provide services to individuals in an efficient, time sensitive manner that does not focus on paperwork.
• Page 35, where it indicates a documented referral from a discharge provider… this is another requirement that takes away from focusing on the individual and addressing their crisis in a timely, efficient manner.  Also a requirement to contact the MCO to determine what other services are being provided before starting services is a deterrent to the individual who is in crisis and the provider as it is an inefficient use of time and resources to ensure the individual is receiving timely services to address the crisis.

23 Hour Crisis:

• Several places in the manual refer specifically to use of a Psychiatric Nurse Practitioner. Many Nurse Practitioners have provided psychiatric care for numerous years. Psychiatric NPs are more rare, and relatively newer.  Nurse Practitioners in general should be allowed to complete evaluations for RCSU and 23 hour observation units if they are operating within their scope of practice. This is particularly appropriate in these settings that may see a number of individuals who have medical comorbidities and SUD problems at admission.  Recommend broadening the ability to utilize Nurse Practitioner throughout
• Page 48, requiring a LMHP to supervise the program.  There is no reason why an LMHP resident or social work supervisee could not supervise the programming when under supervision of an LMHP.  The shortage of professional counselors and social workers impacts directly services that can be provided in the community. Requiring stricter credentialing is a barrier to building this system of care.

The definition indicates that the service is designed as a follow up to mobile crisis response or a step down from a higher level of care.  Is the service not available to individuals receiving services currently and the provider recognizes their need for community stabilization without initiating a mobile crisis response?  This definition also seems in conflict with the admission criteria outlined in 3.b.i

Language that provider must “engage with the data platform” is unclear.

In exclusion criteria, it states “Community based behavioral health services means Mental Health and ARTS services more intensive than standard outpatient psychiatric services”.  More clarification of this is needed.

RCSU – Psychiatric Assessment (Page 55, 3rd Bullet)

• Requiring review by psychiatric provider within 4 hours is unnecessary burden that does not add value in itself and a full psych evaluation completed within 24hrs. Individual likely already admitted and services and nursing engaged. All CSUs have and appropriately use 24/7 psychiatric and medical coverage around the clock, which includes daily psychiatric services.
• Fails to recognize the significant investment programs have made already dedicating psychiatric services and coverage and now attempting to expand bandwidth to meet system’s critical needs.
•  Does not recognize the need to be good steward of already critical system-wide shortage of psychiatric providers. Additionally, another requirement not accounted for in the Mercer Rate Study years ago.
• Leads to potential of serious unintended consequences to access and sustainability in the system.

I concur that the allowance to use a psychiatric evaluation completed within the last 24 hours is helpful for those referred by psychiatric providers. However, it appears appropriate that consideration for a window to extend this period to 72hrs. with documented review at admission.

RCSU & 23Hr – same provider

The prohibition of billing a per diem for both a RCSU and 23hour Observation site when operated by the same agency creates unintended barrier for expansion co-located facilities operating consistent with the Crisis Now Model and best practices in crisis care that is cited.  This appears inconsistent with the allowance that if the 2 services had been provided by different providers that reimbursement would be supported.  

 RCSU Exclusion Criteria and Service Limitations page 60-61;

1. RCSUs may not be billed concurrently with any other behavioral health service except when a service overlap with other community behavioral health services is needed as part of a safe discharge plan. Documented justification of the time needed for discharge planning and care coordination to other services is required. Overlap durations will vary depending on the documented needs of the individual and the intensity of the services but in no instances may exceed 48 hours.

I concur with others that it would be helpful to have clarification regarding circumstances if a client has an open PA for another crisis service or behavioral health service (i.e. mobile crisis, community crisis stab., ACT, MHSS, etc.) that will overlap with a submitted R-CSU PA, the R-CSU PA will be denied? How would this impact services for ACT and MHSS clients as mentioned by others.

23-Hour Observation – Psychiatric Eval - clarification

Requirement that a psychiatric evaluation must be completed. 

 Draft Regs’ adjustment is significant.  Previously: “A psychiatric evaluation by a psychiatrist, nurse practitioner or physician assistant must be available at admission into the service”.  

This has been removed and replaced.  This had acknowledged that not all circumstances that an individual was in crisis and met the medical necessity of the service would require the need for a psychiatric evaluation to resolve the immediate crisis or prior to identification of supports or transition to another level of care.  It appears from the following that the Draft Regs are stated to meet the requirements there must be a psychiatric eval which may not be consistent with needs.

 Required Activity (Page 41)

Assessment

• A psychiatric evaluation must be completed at admission by a psychiatrist or psychiatric nurse practitioner.
• The 23-Hour Crisis Stabilization provider may use a psychiatric evaluation completed within 24 hours prior to admission by a psychiatrist or psychiatric nurse practitioner to meet this requirement. Documentation that the 23-Hour Crisis Stabilization psychiatrist or psychiatric nurse practitioner has reviewed and updated (as clinically necessary) the evaluation at admission must be in the clinical record.

 On Page 44

The following components must be available to individuals in the treatment program and provided in accordance with the individual’s assessed needs: (Starting on Page 43)

• At a minimum, required components of 23- Hour Crisis Stabilization include: assessment (psychiatric, nursing and LMHP), crisis intervention and care coordination. Providers must have the capacity to provide any of the above components for up to 23 hours based on the individual’s needs.

 Clarification needed.

Mobile Crisis Response:

Code of Va. mandated activities for Emergency Services not being carved out continues to lead to some potential confusion including by MCOs who do not always understand the activity and mandated role.   

Draft Regs are inconsistent with the current status of system resources including regional crisis call centers which lack capacity and 24/7 resources which will be further impacted by the Marcus Alert and other Co-Response activity that could not be supported 24/7 but is essential to build upon.

Page 8, under Service Definition, “Mobile Crisis Response services are available 24 hours a day, seven days a week to provide rapid response, assessment and early intervention to individuals experiencing a behavioral health crisis”.   Recommend notation of status referenced above.

Page 11, under Required Activities, the first bullet states “The provider must engage with the DBHDS crisis call center and crisis data platform prior to initiating services”.

• This does not align with needs or concurrent discussion regarding the call center/data platform capacity.  There are contradictory statements of requirement with assessment “at the start of services and that crisis data platform must be engaged “prior to initiating”.
• Engaging call center / data platform delays critical response placing priority on activity unrelated to clinical necessity or activity to assess or assist in resolving crisis in the immediate.

• For a Certified Prescreener – this service is mandated once the ECO has been issued and for the need to assess for the need of involuntary hospitalization.  
• Recommended that the requirement be removed as it is related to mobile crises or specifically mandated role of CSB Prescreener or mobile response (Marcus). 

The manual notes Preadmission Screening Clinicians (prescreeners) who are not LMHP (LMHP-R, LMHP-RP, or LMHP-S or in supervision need to have their assessments signed off by a LMHP.

Note for the record that concur with others how critical it is not to allow billable activity of a Certified Prescreener who is not LMHP or LMHP-Type.  Continue to advocate and agree with another statement that if necessary - Virginia should considering seeking waiver based on system-wide workforce challenges.  

• The work of the Certified Prescreeners is Code mandated activity. 
• Critical clinical activity necessary

• Those certified include a small number (very small) of staff in this category who are specifically trained, experienced, etc.  Inability to fund this activity based on Virginia’s once reported goal f a self-funded crisis system with significant workforce shortages adversely impacts the ability to support, deliver and expand other critical services in the continuum. 
• NOTE:  These activities are impacted significantly by other gaps or system inadequacies.
• Additionally noting that lack of ability to navigate supervision timely based on shortages of LMHP and/or delays with DHP beyond control.  Again, these clinicians specifically certified for this activity that only a select group can provide.

Inclusion of the Data Platform in Regulations

I have copied the following from another’s comment to emphasize support and the importance.

Given the current phase of development, build out, and system training coordination with the crisis call center and data platform should be better defined and understood prior to including in the regulations.  While this is an important step in ensuring that services are monitored, unduplicated, and coordinated in the best interest of the client being served, the platform and associated stakeholders do not yet have a current capacity to demonstrate effective coordination that is above reproach in the auditing and quality review of services thus increasing the administrative burden on providers of care that is both unnecessary and ineffective.

Appendix G Care Coordination

Support previous comment regarding Care Coordination within Appendix G related to Mobile Crisis and consideration to reword:  

I support comments that speak to eliminating the requirement for 24/7 nursing for CSUs, especially for smaller units and those that serve youth, as the need for this level of care has not been demonstrated in most of these settings; the use of medication and first-aid trained staff with access to on-call nursing/other emergent care responses that can fulfill a similar need and has been demonstrated as successful for these programs; and the severe shortage of nurses in the Commonwealth will not soon be alleviated. The cost of 24/7 nursing in relation to the per diem reimbursement is also cost prohibitive, especially for smaller units.