We identified two clients with serious mental illness Schizoaffective and Schizophrenia who have declined medication for over 12 months.  Both live in our community and can have involvement with CIT and ECO.  MHSS and MH CM continue to be provided to both clients to work closely with them to continue to engage them in services and address any health or mental health related issues that arise.  In the new regulations that require one to be prescribed a psychotropic medication in the past 12 months these clients would not meet that standard and could not receive the service.  While it is not ideal that they are currently declining psychiatric medications it can be the nature of the illness at times that medications are stopped for longer than 12 months.  With the new regulations the client could not receive MHSS and be at much greater risk for health and safety concerns as a result.  Not the intended consequence of the regulation.

A second concern was the discontinuation of the units for over 5 hours of services.  Many of our clients require travel to regional Hospitals or specialists for various medical care (UVA, VA Center in Salem).  Adding the fact that we are in a rural area it is not uncommon for our staff in MHSS to have at least one case per week that takes this type of time with a client to assure they get to their specialist and during the visit are aware of any changes to their treatment plans as well as returning safely to their home at the end of the day.  We would recommend the option continue a unit billing with the 7 hours and in order to better manage the number of such units it is recommended that the provider as part of the Kepro Authorization justify a limited number of the 7 hour units per client per authorization period.  This would allow some control of the use of the unit of billing based on the needs of the individual client.  NOTE: This is not the case management process of "linking" to medical services.  This is being with the client throughout the entire waiting (with their anxiety) for the doctor and with the client during the appointment.

The proposed changes will impact our ability to provide this service due to reduced rates and reduced numbers of individuals eligible for this service.  Community Services Boards are required to provide services to eligible consumers regardless of their ability to pay, which means we have to provide these services to Non Medicaid consumers which desire the service, when eligible.  Reducing rates not only impacts Medicaid recipients but also impacts our ability to serve the uninsured population.  Reducing the basic limit to 4 units per day will impact our ability to cover the costs related to travel.  District 19 CSB provides services to nine localities in South Central Virginia covering a large geographic area.  Therefore each trip to a consumer’s location must provide the funding necessary to cover the costs of staffing and travel. 

I am concerned about what the ‘qualifying mental health diagnosis’ may be defined as, as there are significant impairments for any full DSM IV TR diagnoses.  I am concerned that it may be limited to affective or psychotic disorders, since they are not the only mental health population with significant impairments i.e. panic disorder, social phobia, conversion disorder.   

I have worked with numerous clients have no idea about or require significant assistance & encouragement to access available resources. Also, some clients even with impairments as significant as frequent suicidal thoughts, mania and psychosis  refuse to access services due to paranoia, fear of negative consequences especially those with children, the nature of mania and have to be constantly encouraged to access services.  I worry about limiting the service to those that have had recent more serious interventions such as hospitalizations, ECO / TDO, residential treatment since some clients may not have accessed more serious interventions with support of MHSS to stabilize them. 

Many clients have paranoia, co-occurring substance abuse, co-occurring development delay or cognitive issues that combine with mental health issues that results in lack of understanding of the need for, fear that others are trying to hurt them with, fear of medications causing relapse to substance dependence such that they refuse to access psychotropic medications sometimes for years, or are prescribed them and are chronically non-compliant. I often have to encourage clients to access the services that could assist in stabilizing their symptoms, but there are some clients that do not do so despite on-going symptoms and recommendations, but still need services. Plus, DMAS should think about client rights and how do these criteria fit into (or do not fit into) client rights.

There needs to be thought on how to mitigate the negative impact of limiting hours / units on providers and clients in rural areas with limited resources to meet mental health & medical needs. If you support client rights and the right to choice, there must be ability to access providers or community resources even if they are 1.5-2 hours away.  As a provider living in a rural area, the limitations to units would make it difficult to assist clients and could even result in harm to clients that are significantly impaired to the point of not accessing services without a supportive other.  While the end result of mental health support services is to support independence, there should be ability to approve overage units for those clients in rural areas even if the overage units able to be approved progressively reduce over time in order to teach independence.

I am concerned that the proposed changes along with the reduction of mental health beds in hospitals and ability to access other services will result in increased legal issues in the community, jails instead of treatment, resurgence in hospitalizations, and will result in an increase in spending in other areas since services act as a protective factor to reduce these issues. This could result in harm to our clients as well as our community, and I am not in support of changing the criteria to be so limited that clients that need the service cannot access it.

We reviewed the responses of the other CSB’s/BHA’s on the table and most of them address the concerns we identified at our CSB.  As with other CSB’s/BHA’s, the changes in reimbursement will significantly impact our revenue with a decrease of about 50%. We also have concerns that since the original definition of the service described MHSS as “training and support” and now the new definition describes it only as a “training service” that some of our individuals who receive this service will no longer be eligible.  We have individuals who live in the community but recovery/training has been slow or intermittent so support services are required as we continue to help these individuals maintain their independence.

The continuum of care within the CSB system is vital to quality care for all the folks we serve, especially those who must go into the hospital.  The BHSA does not, and cannot, have a case manager and other staff fully informed about the individual in the way a CSB can.  I would advocate for the removal of BHSA being approved as a pre-screener. 

The BHSA, as a contractor with DMAS, has a financial interest in keeping individuals out of the hospital and, from a risk management point of view, there appears to a conflict of interest.  This could also become a slippery slope in the direction of having a for-profit agency that is invested financially in the outcome be a primary decision maker (pre-screener) determining whether an individual should be hospitalized or not.

DBHDS also has a Full License which needs to be included.

DBHDS requires providers to have a license for Emergency Services/Crisis Intervention to do Crisis Intervention. Having an Outpatient license does not allow this.

Both Staff Qualifications and how part time experience is counted is under the purview of DBHDS. DMAS should defer to DBHDS on this issue.

Only certified prescreeners and LMHP should do crisis intervention services based on the level of clinical experience needed..QMHP's are not qualified to do this service.

ICT Services should include rehabilitation and supportive services under the included services.

Given the severe nature of mental health issues in a child qualifying for Intensive In-Home Services it should be made clear that counseling/therapy is a required element of the service.

The current elements listed that need to be provided for intensive in home may not be clear enough. Changing the elements to include " crisis intervention, counseling/therapy, life skills education/training ( i.e. anger management, communication skills), parenting skills, supportive mental health services" might be helpful.

As the clinical director for Hall Community Services in Roanoke, I am concerned about the recent memo that suggests that only licensed individuals (LMHP) would be able to provide intake assessments for MHSS, to the exclusion of license-eligible individuals (LMHP-E).  I am currently the only person with clinical licensure at this agency, however, we employee three masters level individuals who are under the supervision of a LMHP and doing an excellent job conducting our intake assessments.  When serving a population for whom homelessness is a risk, it is critical to initiate services as soon as possible.  A delay in providing an intake can easily lead to an individual becoming impossible to locate, therefore falling through the cracks and going unserved.

DBHDS has two different licenses for Crisis Stabilization and an Outpatient license does not qualify a provider to do Crisis Stabilization. To do Residential Crisis Stabilization a provider must have a " Mental Health Residential Crisis Stabilization Service" license. To do community based Crisis Stabilization a provider must have a :" Mental Health Non-Residential Crisis Stabilization Service" license.

I would like to bring to your attention the fact that so many individuals who are diagnosed with a severe mental illness will fall through the cracks due to the proposed changes about what constitutes as a history of qualifying mental health treatment.  Some individuals we serve may not have been in a psychiatric hospital or residential treatment faciltiy but they are prescribed antipsychotic medication, see a psychiatrist, have been or are currently homeless and need significant training in independent living skills.  Please reconsider what qualifies for a history of mental health treatment.  Whether or not someone has been hospitalized or treated in a facility does not reflect the fact that they are at imminent risk for such circumstances should they no longer receive intensive services.  

In regards to medication being prescribed within the past 12 months, there needs to be a change.  First of all, some individuals may have stopped taking their medications (because this is a common occurance with this population) and/or not have access to medical or psychiatric treatment, especially those individuals in rural and remote areas.  Please do not include this requirement in the new regulations.  It makes it so much harder for an individual  to access needed services. 

I believe that an eligible licensed mental health professional (LMHP-E) should be able to continue conducting intake assessments as well as reassessments.  I am concerned because in the latest proposed changes to MHSS regulations, it appears that only licensed mental health professionals can conduct assessments.   As an LMHP-E, I have a masters degree and I am working towards becoming a licensed professional counselor.  I have conducted well over 100 intake assessments and believe that I am very competent in gathering information and using that information to make informed diagnostic conclusions.  I think that the opportunity for individuals who are already being supervisied by a licensed professional to conduct these assessments is so educational and is a critical part of our job function.   Please allow LMHP-E individuals to continue to conduct assessments. 

I wanted to share my concern about the changes to qualifying mental health diagnoses, specifically in regards to PTSD and anxiety disorders.  I fear that individuals with a diagnosis of PTSD, panic disorders, phobias, generalized anxiety disorder, etc will fall through the cracks in getting the services they need.  The physician determination process can be exhaustive and may become very overwhelming to pursue.  Also, it remains a question as to where to go from there to access services.  For example, someone who is diagnosed with panic disorder with agoraphobia is not able to leave the home due to crippling anxiety and isolates for days/weeks on end.  They may not see a physician, get to the grocery store, access needed community resources, seek psychiatric treatment thereby affecting their ability to get medications.  Anxiety can be a crippling condition.  To be diagnosed with an anxiety disorder, an individual is not able to function or functions minimally in daily life.  In regards to PTSD, it goes undiagnosed so often and severely impacts daily life.  Remember, people with this diagnosis have been through SIGNIFICANT trauma.  These individuals need one on one support and assistance with managing symptoms and living a life they want.  I do not think these diagnoses should be limited in any way.  They need no roadblocks to services.  Please consider including them fully withing the range of severe mental illness.   

I am very concerned that the population that is served through this service is going to suffer greatly if DMAS is successful in making the cuts and changes they are proposing. 

Severely mentally ill individuals greatly benefit from receiving MHSS and the taxpayers of Virginia benefit from the service as well.  MHSS is in place to reduce inpatient psychiatric hospitalization and time spent in the jail system.  The severely mentally ill can spend a lot of tax payer dollars by having repeated hospitalizations that can range from $766-$1,091 per day.  Severely mentally ill individuals receiving MHSS greatly reduce the frequency and need for hospitalization with the average cost of MHSS per week of $277.  A severely mentally ill individual who spends a year in the jail system costs an estimated $26,000 per year, whereas a year of consistent MHSS costs an estimated $ 14,200. 

The severely mentally ill population often lacks any consistent positive social supports and lean on MHSS to assist them to be more productive members of society. The changes that are proposed will leave a lot of clients in the dark with no one to assist them.  This will undoubtedly place the burden back on the hospitals and judicial system.  The clients that are being served will endure high rates of homelessness and emotional turmoil without the continuation of MHSS in the capacity in which it is currently. 

These clients do not always have their voices heard and I would like to urge you to consider what these changes will do to the severely mentally ill people.  They are not just numbers, facts and figures.  They are people that have their lives changed and improved by the consistent support from MHSS.  I urge that you pay close attention to how much of a tax burden severely mentally ill clients without MHSS place on the hospitals and jails versus what having programs in place, such as MHSS,  that prevent them from enduring  repeated hospitalizations and incarcerations.

I would also like to encourage you to consider the employees that are working to serve the severely mentally ill population and the repercussions of such deep cuts.  Employees will be laid off and many will struggle to find other means of employment because the jobs for this field will be cut tremendously.  This will place undue financial burden on this group of taxpayers and hurt the local and state economy. 

I have multiple concerns regarding the proposed changes to mental health support services:

1. The proposed name change to "skill building" service is suggestive of a developmental disability type of service. While the primary focus of mental health supports is to assist individuals in development of daily living and other skills, the idea of a pure focus on training is indicative of a lack of understanding of the complexity of dealing with individuals who have a serious mental illness.

2. While sessions of longer than 5 hours should not be routine there are rare occasions when this may be appropriate and should be acceptable when accompanied by detailed documentation.

3. The requirement for a prescription for anti-psychotic or other psychiatric medication within the last 12 months will prohibit admission to this service for many who need it most. Due to lack of resources, geography, insight, and the illness itself, it is extremely common for this population to not see a Dr. or other medical professional for many years.  The need to help this population access medical/psychiatric service and understand the need for medications seems to me to be one of the primary functions of this service.  

4.  Licensed Mental Health Professional Eligible is not used in the language regarding who can do assessments.  If LMHP-E staff can no longer do assessments, this will dramatically slow down the ability to get individuals into much needed services. In the more rural areas of the state there are a limited number of LMHP's which will greatly inhibit access to service.

5. The limitations being placed on admission for anxiety disorders seems to be contradictory to the requirement of individualized assessment and service planning.  Admission should be based on need and functioning not solely diagnosis. PSTD and many other anxiety disorders are extremely debilitating and individuals with these disorders frequently require vast amounts of support.

The individuals who receive mental health support services are frequently some of the neediest and most ignored of all populations. Virginia offers very limited services to this population and in an effort to save a nickel ends up spending dollars on jails, prisons, emergency room visits and hospitalizations.  When implemented correctly, mental health supports actually saves tax dollars, makes our communities safer and provides individuals with serious mental illness an actual path they can follow on the road to recovery.

Thank you for your time.

DMAS currently requires an LMHP to do the initial assessment for intensive in home and MH Supports which from a clinical and risk stand point are less demanding than Crisis Stabilization. An LMHP or Certified Prescreener level assessment should be required for Crisis Stabilization before starting services.

The proposed regualtions seem to in effect remove Case Management as a service from the Intensive In Home Service. Children who need this service typically may not be part of the CSB system, and families have multple needs. In many cases these families are resisitent to change and intrusion into thier family system even though there is strong need. Bringing multiple providers may have a negative effect in the families eyes and prevent them accepting the service.  I understand from a standpont of a continum of services especially after the 6 month period that there needs to be links to CSB and other services, but feel that strong benefit of one provider coordinating services can be tremendously helpful for the child with linkage to CSB Case Mangement toward the end of services. Case Management needs tend to be intensive at the start of services and then should subside over the 6 month period. It is one of those things that in order to get well, you want to get the person to a safe home, have adequate food, have the benefit of a Psychiatric evaluation if needed which are all typical link and referral services that are provided by Case Management. It is my concern that if the Intensive In Home provider can not do those things then treatment will be much less successful.

The Utilization review section 30-60-143 only includes adults. It should also include children(section 30-51-30).

Thanks for the opportunity to comment. My comments for clarificaiton or strengthening the regulations are below:

“Activities of daily living” should be defined to include “shopping, budgeting, meal planning, etc.” to be more applicable to person with mental illness.

The definition of “Certified pre-screener” needs to be brought into be brought into conformity with the Code of Virginia, assigning this repsonsibility to CSB's.

“Service specific provider assessment” leads with obtaining information about “health status” that “includes history of the severity, intensity and duration of health care problems….” While understanding health issues that may contribute or impact mental status, the main focus of the assessment is to determine MH service needs and appropriate level of service and general health information is gathered related to that. The definition should reflect this.

Any section about inadequate documentation resulted in rertaction of payment should include wording that any failure needs to be significant, not minor and incidental, or that documentation that is not in “substantial compliance with regs” will result in refusal of reimbursement. The purpose of documentation review is to assure that a covered services is delivered to a covered individual in a clinically appropriate way. It should not be about a technical “gotcha”. This is the case wherever in the proposed regulations this wording is employed.

Crisis intervention. The regulation specifying what information shall be provided to the BHSO or DMAS to register seems excessive to be in regulations and probably more than a BHSO will require. Providing name, Medicaid number and provider name and NPI and date of initiation of service should be sufficient. In this service predicting the “ amount of service that will be provided” , for instance, is not practical.

Seems to require one delivering crisis services to be a certified pre-screener because of hte use of the prposition "and" in the definition. This implies that only CSB’s or those they designate can provide this service. This is also included in the crisis stabilization section. Later in the document the prefix used is “or” which is more likely what was intended.

To qualify for ICT the standard should not be “resistance to seek out and utilize appropriate treatment options” but should be similar to that for in home services, which is akin to “When services that are far more intensive than outpatient clinic care are required and services in the home and community are more likely to be successful”. If this is adopted,  The ability to come into a clinic setting on occasion should not be a bar to getting the intensive services that are needed. The ability to keep a monthly or quarterly appointment does not connote an ability, willingness or appropriateness to come to a clinic setting multiple times a week.

Wherever the requirement to “inform” the primary care provider is included this should be qualified “with the permission of the individual or guardian.”

It should be made clear in the regs that if a service provider and the case manager are working out of the same electronic or paper clinical record that reporting requirements to the case manager are met. It is redundant to require a worker to send a report that duplicates information the case manager already has in the record they regularly access and use.

VACSB Comments to DMAS on Proposed 2011 Mental Health Services Program Changes

The VACSB and our members understand the need to revise and, at times, tighten regulations to assure that those who need services receive them and that the services are of a quality that will maximize the benefits for recipients.  It is obvious that thought has gone into the proposed changes, but at this time, we would voice our concerns.

Our VACSB general comments fall into a few broad areas of concern:

• At a time when health care needs are expanding but service providers are not expanding in numbers, many of the proposed changes in staffing seem unnecessarily burdensome and restrictive.  For example, individuals who are qualified and wish to work or must work only part-time should not be excluded.  Many providers have developed ways to allow individuals who want/need part-time work that have proven beneficial to recipients of services, the employees and service provider organizations.  Language could be added to the proposed changes that clinical experience could be the “equivalent of” an amount of full time experience.  It may take a person longer to meet the requirement but would not restrict them completely.
• As well, grandfathering and approved variances should continue to be allowed and remain in effect.  Otherwise, the system loses many experienced and valued employees. If individuals are qualified under the current regulations, they should be grandfathered under these proposed changes, using the verification/documentation of clinical and supervisory experience under the existing regulations.  While our specific comments below address some of the proposed changes, please allow this general comment to serve as a request to retain grandfathering and variances throughout.
• Various sections indicate that any “incomplete, missing or outdated” documentation will result in denied reimbursement. Any section about inadequate documentation should include wording that any failure needs to be significant, not minor and incidental, or that documentation that is not in “substantial compliance with regs” will result in refusal of reimbursement. The purpose of documentation review is to assure that a covered service is delivered to a covered individual in a clinically appropriate way. Documentation should not be used as a vehicle to deny legitimate reimbursement. We request that the language be amended wherever in the proposed regulations this wording is employed.
• There are a number of places in the Proposed Regulations that appear to have changed or deleted the person-centered language that should remain in regulation if Virginia is to move into a truly person-centered health system.  Recipient planning and expressing preferences, goals, treatment options, and the like should be reflected as high values in the regulations.  As well, there are instances in the proposed changes that would appear to allow exchange of information without expressly stating that the recipient’s consent will be necessary.  Such language should be scrubbed and every attempt made to empower the recipients of services to take an active role in their treatment planning and implementation.
• Sections that describe Activities of Daily Living (ADLs) seem to reflect more of a focus for developmental disabilities than for behavioral health conditions.  We suggest that Instrumental Activity of Daily Living (IADLs) be added.    We have proposed appropriate language that would assist individuals with serious mental illness.  Adding IADLs would also address the language.
• There are areas of the proposed regulations that do not, but should, contain enough flexibility to be sure that a recipient who, by way of functioning or diagnosis, needs a more intensive level of service than what is available in the outpatient realm, is able to receive that service through some exception process whereby appropriate documentation would be forwarded to the pre-authorization contractor. 
• The section involving Crisis Intervention and Registration needs additional thought and change.  “Registration” should occur after the individual is triaged and in a safe clinical setting.  “Crisis Intervention, Amount of Service” should be documented after the person is triaged in a safe clinical setting, and initial level of care is determined.  Under both, the provider first meets the person where he/she is “clinically.” Triage occurs to determine a level of risk, level of crisis, harm to self or others and recommended level of care. Once this is determined and the person is safe, then proceed to register and document what is projected to be the needed level of care.
•  At the very least, separating clearly the role of CSB/BHAs mandated requirements in Code from what is termed Crisis Stabilization and Crisis Intervention should be accomplished. 

Specific comments:

12VAC30-50-226A- The use of the term “certified pre-screener” is a term of art that, in Virginia, is considered to be exclusive to CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention.  Under Virginia Code, no other entity can perform this function.  Suggest the language be amended in each section where it is used to be clear about the entity and the precise function.  Do not use the term “certified pre-screener” unless it is accompanied by the prefix “CSB/BHA”.

12VAC30-50-226A- “Clinical experience”:  Suggest deleting “on a full-time basis” or allow clinical experience to be the “equivalent of” an amount of full-time experience.  Otherwise, the pool of providers is more severely limited than what it is now and recruitment will be affected.  Parents and caregivers, for example, may need to work part-time.

As well, there should be a flexible process remaining in the regulations for approval of an alternate degree.

12VAC30-50-226A- “ISP”:  Language should be added to reflect person-centeredness and assure that the recipient is part of service planning.

12VAC30-50-226A-QMHP-A and C”:  Grandfathering and variances, as explained in the general comments, will be critical in retaining staff to provide these services.

12VAC30-50-226A-Registration: When CSB/BHA clinicians are addressing emergency situations, triage and stabilization should be allowed and followed by a Registration, as explained in our comments above. 

12VAC30-5-226B1-Service-specific provider assessment:  Please clarify.  Is this the same as a comprehensive assessment?  And should the assessment include specifically the behavioral and primary health needs in “health status”?

12VAC30-50-226B -Crisis Intervention:  Amount of service that will be needed and provided can hardly be determined in advance.  Individuals in crisis can rarely provide comprehensive information so triage and stabilization is necessary before registration of any kind.  

12VAC30-50-226B “Intensive Community Treatment”: Licensure through DBHDS for this service is based upon the national PACT model.  We suggest this service remain as it is and that DBHDS issues guidance to CSB/BHAs as to how Licensure requirements will be reconciled with the proposed changes.  Also, VACSB recommends that the language in the current regulation be reworded to more accurately address the clinical profiles of individuals in need of ICT.  Delete the phrase “demonstrates a resistance to seek out and utilize appropriate treatment options” in Section 4.b. in the current regulations. Instead, insert the phrase “when services that are far more intensive than outpatient clinic care are required and services in the home and the community are more likely to be successful”.

12VAC-50-130 - Activities of Daily Living:  Proposed regulations state “Activities of daily living means personal care activities and includes bathing, dressing, transferring, toileting, feeding, and eating.”  VACSB suggests that the list of allowable activities of daily living should be expanded to include shopping, budgeting, meal planning, and medication management, all of which are essential activities for individuals with Serious Mental Illness. As well, include the language for Instrumental Activity of Daily Living (IADLs).

12VAC30-60-61A-Definition of “at risk”:  This more stringent definition in the proposed changes may easily result in fewer children and adolescents with SED qualifying for Intensive In-Home.  If a service such as the Strategic Family Services and Supports Services Model were available, this definition may not have the potential to deny services to those who need them.  That service is not in place, however, and outpatient, clinic-based services may not meet the need.  Again, flexibility and an exception process are needed.

12VAC30-60-143-PCP Notification:  With language that assures recipient’s consent to the notification, VACSB fully supports this provision.

12VAC30-50-226A:  Certified Prescreener is a term used for CSBs/BHA clinicians who are trained and able to provide emergency services and pre-admission screenings for involutary hospitalization.  Only CSBs/BHAs provide this service and this term should only be used to describe the CSB/BHA professionals trained to provide this particular service.

12VAC30-50-226A: The new regulations require clinicians providing direct services on a full-time basis.  I am not certain what is to be gained by limiting this to full-time.  Direct services should be dictated by education and experience and not if the clinician is providing services on a full-time basis.

12VAC30-50-226A-Registration:  Registering an individual before crisis interventiion/stabilization services seems burdensome especially since the individual is experiencing a crisis and thus needs immediate attention.  Registration should be allowed within some period of time after the beginning of the crisis period (e.g. 24 hours) after an assessment can be completed.

12VAC-50-130 Activities of Daily Living:  This should be expanded to include shopping, budgeting, meal planning and medication management as these are often the activities that individuals need to live successfully in the community and prevent homelessness and hospitalization.

Finally, reimbursement should only be denied when there is substantial or significant incomplete, missing or outdated documentation.  Documentation review should be to assure that services were appropriately provided.  When minor documentation infractions have occurred and a service has obviously been provided and provided appropriately, it should be allowable for documentation to be corrected in the record.

12VAC30-50-226A:  "Activities of Daily Living" - should be expanded to include shopping, budgeting, meal planning, etc.,

12VAC30-50-226A:  "Certified Prescreener" - should be consistent with the Code of Virginia in clarifying this role is the responsibility of the CSB.BHA.

12VAC30-50-226A:  "Human Service Field" - should include Therapeutic Recreation.

12VAC30-50-226:  Day Treatment Services should allow LMHP-e (licensed eligible) to complete face-to-face assessments with approval from a LMHP.

12VAC30-50-226:  Intensive In-Home Services should allow LMHP-e (licensed eligible) to complete face-to-face assessments with approval from a LMHP.

12VAC30-50-226:  Crisis Intervention and Crisis Stabilization proposed requirements for "Registering" with DMAS should be allowed within a designated timeframe following the crisis intervention - after the assessment is completed.  Additional information/training will need to be provided.

12VAC30-50-226A – Community Mental Health Services: The term certified pre-screener is a term that, in Virginia, is considered to be exclusive to the CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention. This proposed change would be in conflict with the current Code of Virginia and DBHDS Licensing Regulations.

12VAC30-50-226A - Requiring “full time experience” would reduce the pool of potential staff and adversely affect recruitment (i.e.: caregivers, part-time workers). There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, outside of the hiring entity, would be handled or documented?

12VAC30-50- 226A: Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list.  How will staff hired under the current list of disciplines be grandfathered?

12VA30-50-226 – ISP: Loss of person centered language is very concerning.  This should be added back into this section. In addition, providers with EHR’s will need time to reconfigure to meet any new requirements.

12VAC30-50-226A – QMHP-A and C: How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-226A – LMHP – it is our understanding that the psychiatric clinical nurse specialist will no longer be an obtainable specialty after 2013, as Masters’ level nurses are now being educated and will be credentialed (board certified) to provide services to children, and adults as nurse practitioners. The language will still need to reflect both psychiatric clinical nurse specialists and psychiatric nurse practitioners as those who are currently double board certified will be grandfathered.

12VAC30-50-226A-Registration: When CSB/BHA clinicians are addressing emergency situations, triage and stabilization, this should be allowed and a priority followed by a Registration.  This will add another administrative step, which we believe is already accomplished by filing a claim. Based on this requirement, will Crisis Stabilization and Detox programs still be able to do 24/7?

12VAC30-50-226B: Day Tx - Will existing variances be honored?

12VAC30-5-226B:  There is a need to clarify that a QMHP-A can continue to conduct the face to face assessment with the LMHP approval.

12VAC30-5-226B: Psychosocial Rehab. – Will existing variances be honored?  What about for LPNs?

12VAC30-5-226B1-Service-specific provider assessment:  Please clarify, what is this?  Is this the same as a comprehensive assessment? 

12VAC30-50-226B - Crisis Intervention: Amount of service that will be needed and provided can hardly be determined in advance.  Individuals in crisis can rarely provide comprehensive information so triage and stabilization is necessary before registration of any kind.   What will happen if the computers are temporarily down or for some other reason staff cannot reach DMAS? Individuals, in this case, may not always be able to provide Medicaid information for registration. As proposed, this registration would be completed only by a certified pre-screener, requiring that the evaluator would need to be an LMHP, QMHP and a pre-screener.  This would disallow many of the CSB current staff to perform this service, since not all of our pre-screeners are licensed.

12VAC30-50-226B “Intensive Community Treatment”: Licensure through DBHDS for this service is based upon the national PACT model. Removing case management as a required component conflicts with the national PACT fidelity standards.  Individual at this level of care require case management to assist with diversion from hospitalization and to assist with basic needs.

12VAC30-50-226B – Crisis Stabilization services regulations indicate that services are based on the assessment of a QMHP that are then later reviewed and approved by a LMHP within 72 hours. The LMHP is only reviewing and approving the service rather than performing the face to face assessment. Considering the acuteness and brevity of the service, at 3 days the consumer is often discharged.  In order to provide the level of service that is needed for crisis stabilization services the LMHP needs to be more actively involved in the assessment and treatment planning in the early stages of treatment, which would then provide the information necessary for service authorization and also provide for more delineation of the service from crisis intervention and mental health supports.

12VAC30-50-226B5: Crisis Stabilization: Must staff now be both LMHP, QMHP-A or QMHP-C and a certified pre-screener?

12VAC30-60-143-PCP Notification:  With language that assures recipient’s consent to the notification, fully support coordination with PCP.

12VAC30-50-130-5: Community Mental Health Services: The term certified pre-screener is a term that, in Virginia, is considered to be exclusive to the CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention. This proposed change would be in conflict with the current Code of Virginia and DBHDS Licensing Regulations and removes the CSB/BHA designation as the sole entity to fill the role of certified prescreener.

12VAC30-50-130-5: Requiring “full time experience” would reduce the pool of potential staff and adversely affect recruitment (i.e.: caregivers, part-time workers). There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, outside of the hiring entity, would be handled or documented?

12VAC30-50- 130-5: Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list.  How will staff hired under the current list of disciplines be grandfathered?

12VA30-50-130-5: ISP: Providers with EHR’s will need time to reconfigure system capabilities to meet any new requirements. Discharge plans are currently included in a variety of ways including in ongoing assessments.

12VAC30-50-130-5: QMHP-C: How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-130-5: LMHP – Substance Abuse practitioners are certified not licensed. 

12VAC30-50-130-5: Intensive In-Home:  IIH is one of the most intensive community cased mental health services provided to children and adolescents with serious emotional disorders (SED).  SEDs are chronic conditions that persist over time and it is essential that children and adolescents with DED receive targeted case management services independent of IIH to ensure that clinical needs of these children and adolescents are being met effectively, coordinated and addressed.

12VAC30-60-61A-Definition of “at risk”:  This more stringent definition in the proposed changes may easily result in fewer children and adolescents with SED qualifying for Intensive In-Home.  If a service such as the Strategic Family Services and Supports Services Model were available, this definition may not have the potential to deny services to those who need them.  That service is not in place, however, and outpatient, clinic-based services may not meet the need.  Again, flexibility and an exception process are needed. This model is designed by the VACSB, endorsed by Voices for VA’s Children.

12VAC30-30-60-143: Support PCP Notification with appropriate client Authorizations in place.

12VA30-130-3010:  Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

12VA30-130-3030A:  IIH -Removes the CSB/BHA designation as the sole entity authorized to perform

12VA30-130-3030B:  TDT -Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

Definition:

“Service-specific provider assessment” means the “face-to-face interaction in which the provider obtains information from the child or adolescent, and parent or other family member or members, as appropriate, about health status. It includes documented history of the severity, intensity, and duration of health care problems and issues and shall contain all of the following elements: (i) the presenting issue/reason for referral, (ii) mental health history /hospitalizations, (iii) previous interventions by providers and timeframes and response to treatment, (iv)medical profile, (v) developmental history including history of abuse, if appropriate, (vi) educational/vocational status, (vii) current living situation and family history  and relationships, (vii) legal status, (ix) drug and alcohol profile, (x) resources and strengths, (xi) mental status exam and profile, (xii) diagnosis, (Xiii) professional assessment summary and clinical formulation (xiv) recommended care and treatment goals, and (xv) the dated signature of the LMHP.

• Definition does not take into account that  a Crisis Intervention service can be provided by a Certified Prescreener who may not be an LMHP.
• CSB’s who have a centralized intake processes would capture most, if not all, of this information at the time of an Intake. Having each service area capture all of the elements on their service specific assessments would be redundant for those individuals who are receiving multiple services simultaneously.
• LMHP level documentation for the Service Specific Assessments would not be line with the current documentation credential requirements.

Definition:

            “Certified prescreener” means an employee of either the local community services board/behavioral health service administrator or its designee who is skilled in the assessment and treatment of mental illness and who has completed a certification program approved by DBHDS.

• Definition of Prescreener
  • Removes the CSB/BHA designation as the sole entity authorized to fill the role of “Certified Prescreener”

12VAC30-50-226

            “Clinical experience” means, for the purpose of rendering (i) mental health day treatment/partial hospitalization, (ii) intensive community, (iii) Psychosocial rehabilitation, (iv) mental health support, (v) crisis stabilization, and (vi) crisis intervention services, practical experience in providing direct services on a full-time basis to individuals with medically-documented diagnoses of mental illness or intellectual/developmental disability or the provision of direct geriatric services or full-time special education services. Experience shall include supervised internships, supervised practicums, or supervised field experience. Experience shall not include unsupervised internships, unsupervised practicums, and unsupervised field experience. This required clinical experience shall be calculated as set forth in 12VAC35-105-20

• Clinical Experience
  • Full time experience requirement will be reduce the pool of potential staff and adversely affect recruitment
  • Does not allow for calculating full-time equivalent experience
  • Supervised needs further definition as it pertains to (“supervised internships, supervised practicum’s, or supervised field experience”)
  • Need clarification as to how documented proof of “supervision” is to be verified when hiring new staff
  • Need ability to grandfather current employees who meet current regs and may not meet new requirement.

12VAC30-50-226

            “Individual service plan” or “ISP” means a comprehensive and regularly updated treatment plan specific to the individual’s unique treatment needs as identified in the clinical assessment. The ISP contains his treatment or training needs, his goals and measurable objectives to meet the identified needs, services to be provided with the recommended frequency to accomplish the measurable goals and objectives, and an individualized discharge plan that describes transition to other appropriate services. The ISP shall be signed by the individual. If the individual is a minor child, the ISP shall be signed by the individual’s parent/legal guardian. Documentation shall be provided if the individual, who is a minor child is unable or unwilling to sign the ISP.

• ISP
  • Discharge Planning as part of the ISP is new.
  • Proposed regulation does not allow for documenting when an adult is unable/unwilling to sign their ISP – only allows this in the case of a child.
  • Proposed regulations by requiring the parent/legal; guardian signature on the ISP does not take into account when a child has accessed MH/SA services without parental knowledge.
  • No language about the individual being included in the development of his/her TX plan

• Register/Registration
  • Need clarification of process
  • Need clarification of time frame for notification
  • Need clarification of purpose – is this a means of DMAS/BHSA determining medical necessity (?)
  • Adds an administrative step to clinical staff for a service that is provided 24/7 when client is under extreme duress and when administrative staff are not always available.

12VAC30-50-226

• Psycho-social Rehabilitation
  • Clarification needed that QMHP can continue to conduct the assessment with an LMHP approval
  • 30 day assessment period is not included- is this an omission? Is there another time frame expected.

12VAC30-50-226

            The service-specific providre assessment, as defined at 12VAC30-50-130, shall document eh individuals behavior and describe how the individual meets criteria for this service. The provision of this service to an individual shall be registered with either the DMAS or the BHSA to avoid duplication of services and to ensure informed care coordination. This registration shall transmit to DMAS or its contractor: (i)the individual’s name and Medicaid identification number; (ii) the specific service to be provided, the relevant procedure code, begin date of the service, and the amount of the service that will be provided; and(iii) the provider’s name and NPI ,a provider contact name and number, and e-mail address.

• Crisis Intervention 
  • A Service Specific Assessment would be a hindrance to providing very short term crisis service
  • Persons in crisis are often unable to provide comprehensive information for a comprehensive service specific assessment
  • Is a service specific assessment needed when a pre-admission prescreening form is completed
  • Specification of time frame for registration would be needed.
  • Crisis Intervention is a 24/7 service. Administrative supports are not always available – so would add an administrative step to clinical staff during the visit
  • Insurance information is not always known at the time of a Crisis Intervention Service
  • Client is not always able to supply insurance information at the time of the crisis

12VAC30-50-226

Crisis Stabilization services for nonhospitalized individuals shall provide direct mental health care to individuals experiencing an acute psychiatric crisis, which may jeopardize their current community living situation. Services may be authorized for up to a 15 –day period per crisis episode following a face-to-face service-specified provider assessment by a QMHP-A or QMHP-C that is reviewed and approved by an LMHP within 72 hours of the assessment. Only one unit of service shall be reimbursed for this assessment. The provision of this service to an individual shall be registered with either DMAS or the BHSA to avoid duplication of services and to ensure informed care coordination. This registration shall transmit to DMAS or its contractor: (i) the individual’s name and Medicaid identification number; (ii) the specific service to be provided, the relevant procedure code, begin date of the service, and the amount of the service that will be provided; and (iii) the provider’s name and NPI, a provider contact name and phone number, and an e-mail address.

• Crisis Stabilization
  • Is a service specific assessment needed when a pre-admission prescreening form is completed
  • Specification of time frame for registration would be needed.
  • Crisis Stabilization is a 24/7 service. Administrative supports are not always available – so would add an administrative step to clinical staff during the visit
  • Insurance information is not always known at the time of admission
  • Client is not always able to supply insurance information
  • Amount of service can not always be determined in advance.

Definition:

“Service-specific provider assessment” means the “face-to-face interaction in which the provider obtains information from the child or adolescent, and parent or other family member or members, as appropriate, about health status. It includes documented history of the severity, intensity, and duration of health care problems and issues and shall contain all of the following elements: (i) the presenting issue/reason for referral, (ii) mental health history /hospitalizations, (iii) previous interventions by providers and timeframes and response to treatment, (iv)medical profile, (v) developmental history including history of abuse, if appropriate, (vi) educational/vocational status, (vii) current living situation and family history  and relationships, (vii) legal status, (ix) drug and alcohol profile, (x) resources and strengths, (xi) mental status exam and profile, (xii) diagnosis, (Xiii) professional assessment summary and clinical formulation (xiv) recommended care and treatment goals, and (xv) the dated signature of the LMHP.

• Definition does not take into account that  a Crisis Intervention service can be provided by a Certified Prescreener who may not be an LMHP.
• CSB’s who have a centralized intake processes would capture most, if not all, of this information at the time of an Intake. Having each service area capture all of the elements on their service specific assessments would be redundant for those individuals who are receiving multiple services simultaneously.
• LMHP level documentation for the Service Specific Assessments would not be line with the current documentation credential requirements.

12VAC30-50-130

• The ADL definition should say “... personal care activities including ...” and should include money management , shopping, meal planning, etc.
• QMHP-E should be included as a definition; there is a definition in DBHDS at 12VAC35-105-20
• IIH - the term “care coordination” has replaced “case management” as a component; care coordination refers to collaboration and sharing of information among health care providers who are involved with the individual; add “If Case Management services pursuant to 12VAC30-50-420 or 430 are not being received, it is critical that the IIH provider link the individual and/or his parent or guardian with services and supports necessary to maintain or improve the stability of the home and family.”

12VAC30-50-226

• The Code requires that the pre-screening function be performed by a designee of the local CSB; employees of the BHSA would not & should not qualify
• The definition of Human Services field is not the same as it is in 12VAC30-50-130 and should be revised accordingly.  There also must be a provision for the “grandfathering” of all who have been hired under the current definitions. 

 12VAC30-60-5

• All new language about audit requirements; adds language which includes the following requirement “... DBHDS license shall be a full annual, triennial or conditional license.”  Insert a comma after the word “full” to accommodate licenses issued for less than three, but more than one year.

 12VAC30-60-61

• IIH Assessments can no longer be performed by an LMHP Supervisee or Resident; this is unnecessarily restrictive.
• In C. 5. the term “duplicated” is too vague and is, therefore, open to interpretation by auditors.  If what is meant is the progress notes should not be templates used for all or most participants, then that is how it should be described. 
• In C. 16. Add “If Case Management services pursuant to 12VAC30-50-420 or 430 are not being received, it is critical that the IIH provider link the individual and/or his parent or guardian with services and supports necessary to maintain or improve the stability of the home and family.

Many clients have paranoia, co-occurring substance abuse, co-occurring development delay or cognitive issues that combine with mental health issues that results in lack of understanding of the need for, fear that others are trying to hurt them with, fear of medications causing relapse to substance dependence such that they refuse to access psychotropic medications sometimes for years, or are prescribed them and are chronically non-compliant. I often have to encourage clients to access the services that could assist in stabilizing their symptoms, but there are some clients that do not do so despite on-going symptoms and recommendations, but still need services. Plus, DMAS should think about client rights and how do these criteria fit into (or do not fit into) client rights.

There needs to be thought on how to mitigate the negative impact of limiting hours / units on providers and clients in rural areas with limited resources to meet mental health & medical needs. If you support client rights and the right to choice, there must be ability to access providers or community resources even if they are 1.5-2 hours away.  As a provider living in a rural area, the limitations to units would make it difficult to assist clients and could even result in harm to clients that are significantly impaired to the point of not accessing services without a supportive other.  While the end result of mental health support services is to support independence, there should be ability to approve overage units for those clients in rural areas even if the overage units able to be approved progressively reduce over time in order to teach independence.

Will QMHP-E and LMHP-E staff continue to be used based on current standards outlined in the CMHRS manual?  Proposed regulations do not reference these types of employees.

Case management has been replaced by care coordination for IIHS.  Care coordination is defined as collaboration with health care providers.  Does this mean that billable case management activities must be confined to work done with health care providers as opposed to the broader definition of case management which would vary based on the individual’s need? 

Like many other providers across the state, Highlands CSB is concerned about the proposals that are being considered for implementation.

The Highlands CSB manages services for over 805 consumers and provides Mental Health Support Services for 100 individuals with serious mental illness. This is a population of individuals whose illnesses are so severe that they have lost much of their ability to navigate in the ways most people are able to care for themselves and function in their communities.  MHSS is one of the most vital services that assist these consumers to remain in their communities and to avoid repeated emergency room visits and hospitalizations or continuous hospitalization (or incarceration). 

As a CSB, our organization serves those individuals who are most ill and most in need of these supports along with other wrap-around services. MHSS and other supports are the very services that stabilize consumers' housing situations, one of the most critical core needs of consumers.  If the proposed unit of service/rate change for MHSS is adopted, it will compromise this CSB ability to provide this service for 100 consumers.  Without MHSS as part of the services plan, other wrap-around services will not be effective in maintaining their community tenure and these consumers will default to more restrictive and expensive levels of care, not necessarily in the fee for service system, but rather in managed care inpatient use or state hospital use. 

The Highlands CSB opposes this unit/rate change in MHSS.  While the MHSS claims will decrease if such unit/rates are implemented, the cost in alternative and less desirable services will be evident.  Even more, the progress that our 100 consumers have made will deteriorate because there is no other service that can substitute except a more intensive service, which goes against the best practice of least-restrictive service.

Thank you

As others have expressed, I am greatly concerned about the elimination of case management from the definition of Intensive In Home services.  Many conversations with stakeholders have been held as to the standards of this service and the need to improve quality provision.  Ideas such as developing a tier system and examining the hourly minimum and maximum have been voiced, with the caviat that  no significant positive changes to this service are possible without increasing the rate.  Best practice dictates that case management will be provided to these families by the in home worker.  They are dealing with such high degrees of disfunction and hardhip.  An In Home worker is going to determine that helping a parent get assistance is part of keeping the child safe and secure in the home.  An In Home worker wants to make sure a child does not miss his psychiatist appointment because if he misses another one, the psychiatrist will not see him any more and there are no other psychiatrists who accept Medicaid.  I cannot see where it is best practice to dictate that if case management is to be performed, yet another service provider should be introduced to a family who has already established a relationship with a worker who is in the home on a regular basis. 

Per the guidance document referenced in these commens that requires Intensive In Home to include therapy, I hope there will be continued discussion as to how to encorporate this effectively.  My fear is that, eliminating case management and requiring therapy and narrowing the definition of QMHP as well as maintaining the reimbursement rate will prohibit many of us from being able to provide this service at all.  This would be a disservice to our families in Virginia who so greatly rely on Intensive In Home.  Additionally, my fear is that these youth would undoubtedly end up in our of home placements.  Intensive In Home needs an overhaul  I'll be the first to admit.  But arbitrarily making these changes wihtout a thoughtful, strategic plan as to how the services could be improved could be disastrous.

Recently, there were several meetings held with stakeholders to look at Mental Health Support services.  In my opinion, these workgroups were very effective and a model for public-private cooperation.  I felt heard and included and I felt that intelligent people were collectively compromising and making thoughtful decisions.  Could not the same approach be taken looking at Intensive In Home?

I would also ask that the elimination of the QMHP-E be examined.  Our staff pool is quite limited as it is.  I get many many inquiries from eager new graduates who are excited to work and learn.  These individuals are finding it more and more difficult to locate places to get clinical experience.  Under the right supervision and an adequate training program, community mental health services can provide an excellent training ground. 

Thank you for the opportunity to voice these opinions.

Sincerely,

Molly Cheek, LCSW

Dominion Youth Services

Fairfax-Falls Church Community Services Board Comments on Proposed Changes to DMAS Mental Health Services Regulations

Part I

Staff review of the proposed changes generated the following comments for consideration:

12VAC30-30-60-143 – PCP:  Support PCP Notification with appropriate client Authorizations in place.

12VAC30-50-130-5: Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list.  How will staff hired under the current list of disciplines be grandfathered?

12VA30-50-130-5-ISP:  ISP  Providers with EHR’s will need time to reconfigure system capabilities to meet any new requirements. Discharge plans are currently included in a variety of ways including in ongoing assessments.

12VAC30-50-130-5 - Community Mental Health Services:  Community Mental Health Services  The term "certified pre-screener" is a term that, in Virginia, is considered to be exclusive to the CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention. This proposed change would be in conflict with the current Code of Virginia and DBHDS Licensing Regulations and removes the CSB/BHA designation as the sole entity to fill the role of certified prescreener.

12VAC30-50-130-5 - Intensive In-Home: IIH is one of the most intensive community cased mental health services provided to children and adolescents with serious emotional disorders (SED).  SEDs are chronic conditions that persist over time and it is essential that children and adolescents with DED receive targeted case management services independent of IIH to ensure that clinical needs of these children and adolescents are being met effectively, coordinated and addressed.

12VAC30-50-130-5 - LMHP:  LMHP – Substance Abuse practitioners are certified not licensed.  Does this mean that the CSAC will no longer be honored?

12VAC30-50-130-5 - QMHP-C:    How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-130-5 - Work Experience:  Requiring “full time experience” would reduce the pool of potential staff and adversely affect recruitment (i.e.  caregivers, part-time workers). There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, outside of the hiring entity, would be handled or documented?

12VA30-130-3010 - ICA:   Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

12VA30-130-3030A – Intensive In-Home:  IIH -Removes the CSB/BHA designation as the sole entity authorized to perform

12VA30-130-3030B – TDT:  Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

12VAC30-50-226 - Crisis Services:  Crisis Intervention and Crisis Stabilization proposed requirements for "Registering" with DMAS should be expected only after the crisis intervention has been accomplished; within a designated timeframe.  Additional information about how the registration information will be transmitted to and used by DMAS, as well as staff training will need to be provided.

12VAC30-50-226 - Day Treatment Services:  Day Treatment Services should allow LMHP-e (licensed eligible) to complete face-to-face assessments with approval/sign-off from a LMHP.

12VAC30-50-226 - Intensive In-Home Services:  Intensive In-Home Services should allow LMHP-e (licensed eligible) to complete face-to-face assessments with approval/sign-off from a LMHP.

12VA30-50-226 – ISP:   Loss of person centered language is very concerning.  This should be added back into this section as should the assurance that the recipient is part of service planning.  In addition, providers with EHR’s will need time to reconfigure to meet any new requirements.

12VA30-50-226 – ISP:  Providers with EHR’s will need time to reconfigure to meet any new requirements.

12VAC30-50-226A - Human Services Field:  Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list. Degrees such as Therapeutic Recreation, Educational Psychology and others that cover requisite knowledge and skills are omitted, without option for special consideration.  Flexibility in terms of exceptions should be built in. How will staff hired under the current list of disciplines be grandfathered?

12VAC30-50-226A - Clinical experience:  Suggest deleting “on a full-time basis” or allow clinical experience to be the “equivalent of” an amount of full-time experience.  Otherwise, the pool of providers is more severely limited than what it is now and recruitment will be affected.  Parents and caregivers, for example, may need to work part-time. As well, there should be a flexible process remaining in the regulations for approval of an alternate degree.

12VAC30-50-226A - Activities of Daily Living:  "Activities of Daily Living" - should be expanded to include shopping, budgeting, meal planning, etc.,

12VAC30-50-226A - Certified Pre-screener:  The term "Certified Pre-screener" - should be consistent with the Code of Virginia.  The proposed change would be in conflict with the current code of Virginia and DBHDS licensing regulations.

12VAC30-50-226A - Certified pre-screener: Suggest the language be amended in each section where it is used to be clear about the entity and the precise function.  Do not use the term “certified pre-screener” unless it is accompanied by the prefix “CSB/BHA”.Wording should be reworked to clarify the Certified Pre-screener role is exclusive to the CSB.BHA.

12VAC30-50-226A – LMHP:  After this year, we understand the Psychiatric Clinical Nurse Specialist will no longer be an obtainable specialty, as Masters’ level nurses are now being educated and will be credentialed (board certified) to provide services to children, and adults as Nurse Practitioners. The language needs to be corrected to reflect both psychiatric clinical nurse specialists and psychiatric nurse practitioners as those who are currently double board certified will be grandfathered.

12VAC30-50-226A – QMHP-A and C: How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-226A – Registration:  When CSB/BHA clinicians are addressing emergency situations, triage and stabilization, it should be clearly stated that the interventions are the priority, with Registration to follow. 

12VAC30-50-226A – Registration:  Registration adds another administrative step, which we believe is already accomplished by filing a claim. Based on this requirement, will Crisis Stabilization and Detox programs still be able to do 24/7?

12VAC30-50-226A – Registration: The details of the "Registration" process once the information is to be forwarded by the CSB/BHA need to be clarified, so CSBs can be able to advise individuals receiving services how the information will be used.

12VAC30-50-226A - Work Experience: Requiring “full time experience” and not considering part-time experience would dangerously reduce the pool of potential staff and would adversely affect recruitment of many qualified people who have gained experience as caregivers or part-time staff. 

12VAC30-50-226A – Clinical Experience: There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, work outside of the hiring entity, would be handled or documented?

12VAC30-50-226B - Intensive Community Treatment:  Licensure through DBHDS for this service is based upon the national PACT model.  By removing case management as a required component of ICT, Virginia’s regulations conflict with the national PACT fidelity standards.  Individuals at this level of care require case management to assist with diversion from hospitalization and to assist with basic needs.

12VAC30-50-226B - Crisis Intervention:  Amount of service that will be needed and provided can hardly be determined in advance.  Individuals in crisis can rarely provide comprehensive information so triage and stabilization is necessary before registration of any kind.   What will happen if the computers are temporarily down or for some other reason staff cannot reach DMAS? Individuals, in this case, may not always be able to provide Medicaid information for registration. As proposed, this registration would be completed only by a certified pre-screener, requiring that the evaluator would need to be an LMHP, QMHP and a pre-screener.  This would disallow many of the CSB current staff to perform this service, since not all of our pre-screeners are licensed.

12VAC30-50-226B - Crisis Stabilization:  Crisis Stabilization services regulations indicate that services are based on the assessment of a QMHP that are then later reviewed and approved by a LMHP within 72 hours. The LMHP is only reviewing and approving the service rather than performing the face to face assessment. Considering the acuteness and brevity of the service, at 3 days the consumer is often discharged.  In order to provide the level of service that is needed for crisis stabilization services the LMHP needs to be more actively involved in the assessment and treatment planning in the early stages of treatment, which would then provide the information necessary for service authorization and also provide for more delineation of the service from crisis intervention and mental health supports.

12VAC30-50-226B - Day Tx: It is important that existing variances be honored.

12VAC30-5-226B - Psychosocial Rehab:  As in other statements, will existing variances for Psychosocial Rehab be honored?  What about for LPNs?

12VAC30-5-226B - QMHP-A: There is a need to clarify that a QMHP-A can continue to conduct the face to face assessment with the LMHP approval.

12VAC30-5-226B1 - Service-specific provider assessment:  Please clarify and define what this is.  Is this the same as a comprehensive assessment?  Should the assessment include specifically the behavioral and primary health needs in health status?

12VAC30-50-226B5 - Crisis Stabilization: Crisis Stabilization  Must staff now be both LMHP, QMHP-A or QMHP-C and a certified pre-screener?

12VAC30-60-61A - Definition of “at risk”:   This more stringent definition in the proposed changes may easily result in fewer children and adolescents with SED qualifying for Intensive In-Home.  If a service such as the Strategic Family Services and Supports Services Model were available, this definition may not have the potential to deny services to those who need them.  That service is not in place, however, and outpatient, clinic-based services may not meet the need.  Again, flexibility and an exception process are needed. This model is designed by the VACSB, endorsed by Voices for VA’s Children.

12VAC30-60-143 - PCP Notification:  With language that assures recipient’s consent to the notification, fully support coordination with PCP.

Part II

The Fairfax-Falls Church Community Services Board endorses the general comments submitted by the Virginia Association of Community Services Boards as reflecting the concerns of our CSB.  Specifically, those comments are:

• The VACSB and our members understand the need to revise and, at times, tighten regulations to assure that those who need services receive them and that the services are of a quality that will maximize the benefits for recipients.  It is obvious that thought has gone into the proposed changes, but at this time, we would voice our concerns.
• At a time when health care needs are expanding but service providers are not expanding in numbers, many of the proposed changes in staffing seem unnecessarily burdensome and restrictive.  For example, individuals who are qualified and wish to work or must work only part-time should not be excluded.  Many providers have developed ways to allow individuals who want/need part-time work that have proven beneficial to recipients of services, the employees and service provider organizations.  Language could be added to the proposed changes that clinical experience could be the “equivalent of” an amount of full time experience.  It may take a person longer to meet the requirement but would not restrict them completely.
• As well, grandfathering and approved variances should continue to be allowed and remain in effect.  Otherwise, the system loses many experienced and valued employees. If individuals are qualified under the current regulations, they should be grandfathered under these proposed changes, using the verification/documentation of clinical and supervisory experience under the existing regulations.  While our specific comments below address some of the proposed changes, please allow this general comment to serve as a request to retain grandfathering and variances throughout.
• Various sections indicate that any “incomplete, missing or outdated” documentation will result in denied reimbursement. Any section about inadequate documentation should include wording that any failure needs to be significant, not minor and incidental, or that documentation that is not in “substantial compliance with regs” will result in refusal of reimbursement. The purpose of documentation review is to assure that a covered service is delivered to a covered individual in a clinically appropriate way. Documentation should not be used as a vehicle to deny legitimate reimbursement. We request that the language be amended wherever in the proposed regulations this wording is employed.
• There are a number of places in the Proposed Regulations that appear to have changed or deleted the person-centered language that should remain in regulation if Virginia is to move into a truly person-centered health system.  Recipient planning and expressing preferences, goals, treatment options, and the like should be reflected as high values in the regulations.  As well, there are instances in the proposed changes that would appear to allow exchange of information without expressly stating that the recipient’s consent will be necessary.  Such language should be scrubbed and every attempt made to empower the recipients of services to take an active role in their treatment planning and implementation.
• Sections that describe Activities of Daily Living (ADLs) seem to reflect more of a focus for developmental disabilities than for behavioral health conditions.  We suggest that Instrumental Activity of Daily Living (IADLs) be added.    We have proposed appropriate language that would assist individuals with serious mental illness.  Adding IADLs would also address the language.
• There are areas of the proposed regulations that do not, but should, contain enough flexibility to be sure that a recipient who, by way of functioning or diagnosis, needs a more intensive level of service than what is available in the outpatient realm, is able to receive that service through some exception process whereby appropriate documentation would be forwarded to the pre-authorization contractor. 
• The section involving Crisis Intervention and Registration needs additional thought and change.  “Registration” should occur after the individual is triaged and in a safe clinical setting.  “Crisis Intervention, Amount of Service” should be documented after the person is triaged in a safe clinical setting, and initial level of care is determined.  Under both, the provider first meets the person where he/she is “clinically.” Triage occurs to determine a level of risk, level of crisis, harm to self or others and recommended level of care. Once this is determined and the person is safe, then proceed to register and document what is projected to be the needed level of care.
• We request that DMAS separate clearly the role of CSB/BHAs mandated requirements in Code from what is termed Crisis Stabilization and Crisis Intervention.  

The following are comments/concerns regarding the proposed changes/language:

12VAC30-50-226A- The use of the term “certified pre-screener” is a term of art that, in Virginia, is considered to be exclusive to CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention.  Under Virginia Code, no other entity can perform this function.  Suggest the language be amended in each section where it is used to be clear about the entity and the precise function.  Do not use the term “certified pre-screener” unless it is accompanied by the prefix “CSB/BHA”.

12VAC30-50-226A- “Clinical experience”:  Suggest deleting “on a full-time basis” or allow clinical experience to be the “equivalent of” an amount of full-time experience.  Otherwise, the pool of providers is more severely limited than what it is now and recruitment will be affected.  Parents and caregivers, for example, may need to work part-time.

As well, there should be a flexible process remaining in the regulations for approval of an alternate degree.

 12VAC30-50-226A- “ISP”:  Language should be added to reflect person-centeredness and assure that the recipient is part of service planning.

 12VAC30-50-226A-QMHP-A and C”:  Grandfathering and variances, as explained in the general comments, will be critical in retaining staff to provide these services.

 12VAC30-50-226A-Registration: When CSB/BHA clinicians are addressing emergency situations, triage and stabilization should be allowed and followed by a Registration, as explained in our comments above. 

 12VAC30-5-226B1-Service-specific provider assessment:  Please clarify.  Is this the same as a comprehensive assessment?  And should the assessment include specifically the behavioral and primary health needs in “health status”?

 12VAC30-50-226B -Crisis Intervention:  Amount of service that will be needed and provided can hardly be determined in advance.  Individuals in crisis can rarely provide comprehensive information so triage and stabilization is necessary before registration of any kind.  

 12VAC30-50-226B “Intensive Community Treatment”: Licensure through DBHDS for this service is based upon the national PACT model.  We suggest this service remain as it is and that DBHDS issues guidance to CSB/BHAs as to how Licensure requirements will be reconciled with the proposed changes.  Also, VACSB recommends that the language in the current regulation be reworded to more accurately address the clinical profiles of individuals in need of ICT.  Delete the phrase “demonstrates a resistance to seek out and utilize appropriate treatment options” in Section 4.b. in the current regulations. Instead, insert the phrase “when services that are far more intensive than outpatient clinic care are required and services in the home and the community are more likely to be successful”.

 12VAC-50-130 - Activities of Daily Living:  Proposed regulations state “Activities of daily living means personal care activities and includes bathing, dressing, transferring, toileting, feeding, and eating.”  VACSB suggests that the list of allowable activities of daily living should be expanded to include shopping, budgeting, meal planning, and medication management, all of which are essential activities for individuals with Serious Mental Illness. As well, include the language for Instrumental Activity of Daily Living (IADLs).

 12VAC30-60-61A-Definition of “at risk”:  This more stringent definition in the proposed changes may easily result in fewer children and adolescents with SED qualifying for Intensive In-Home.  If a service such as the Strategic Family Services and Supports Services Model were available, this definition may not have the potential to deny services to those who need them.  That service is not in place, however, and outpatient, clinic-based services may not meet the need.  Again, flexibility and an exception process are needed.

12VAC30-60-143-PCP Notification:  With language that assures recipient’s consent to the notification, VACSB fully supports this provision.

The comments and concerns posted by Mary Ann Bergeron, Executive Director of the VACSB incorporate the concerns of Prince William CSB.  Those that are of particular importance are:

• Restricting qualifications of Behavioral Health staff.  We readily acknowledge the need for competency, we also know, that experience in the profession with good supervision results in highly skilled and effective staff.  Changes in qualification must be balanced between the competency required for quality services with specific client groups and the decreasing pool of new people entering our profession.   “Grandfather” staff who meet current DMAS qualifications is crucial.
• Documentation – references should be specific that payment retraction will result after failure to document substantial recording requirements and/or clear patterns of failure to document.  Incidental failures are not uncommon.
• For people with serious mental illness as well as some ID consumers who require assistance with daily living often include budgeting, shopping, travel training, etc. which need inclusion when “activities of daily living” is used. 

Families of people with mental illness who receive Medicaid-funded services and service recipients understand that revisions must sometimes be made to services in order to ensure that quality and effectiveness is maintained. Publicly funded services should be used in a way that is effective, both for the person receiving the service and for the system as a whole. We know firsthand how important it is for those who need services to be able to get them, and that there are many people who don’t get the services they need, often because there are not enough precious resources to go around and because the system can be complex, confusing, and difficult to navigate. Accountability is critical so that providers are held to high standards and service recipients and their families can feel confident that the services being rendered are beneficial.

As a general comment, Virginia should adopt practice models for Medicaid state plan options including intensive in-home, therapeutic day treatment, mental health support services, and crisis services to determine the types of interventions and outcomes that are needed and that should be expected from each type of treatment, and so that families and service recipients know what to expect of the service and the provider. Having defined practice models and outcome measurements will help to ensure that services are the most effective possible.

Specific comments about the proposed regulations include:

Prescreener qualifications: The BHSA has a financial interest in keeping individuals out of the hospital. There appears to be a conflict of interest with allowing the prescreener to be an employee of the BHSA. We ask that this be reviewed.

In several places throughout the proposed regulations, the term care coordination is added and case management is deleted. In other places these terms are used simultaneously (“care coordinator/case manager”). Please clarify what these changes mean.

Intensive community treatment: Removing case management from Intensive Community Treatment is troubling. Licensure through DBHDS for this service is based on a nationally-recognized PACT model. Removing case management as a required element of ICT conflicts with this nationally-recognized model. How will this change impact the service, licensure, billing, and service recipients?

The ADL definition should include budgeting and money management, medication management, budgeting, and meal planning/shopping. These are often typical activities and skills needed by individuals experiencing or recovering from chronic, serious mental illness in order to navigate one’s community and live successfully in it, and achieve a more typical, normal day-to-day life.

Regarding the proposed marketing rules, we are pleased to see these and support them.

New River Valley supports comments made by Beth Ludeman-Hopkins, Horizon Behavioral Health and Kathy Nelson, HRCSB. Specific comments are addressed below:

12VAC30-50-226A Amend language to be clear that the term "certified pre-screener" continues to apply exclusively to CSB/BHA clinicians in their role of providing emergency services and pre-admission screening for involuntary detension. Identify clinicians as "certified CSB/BHA pre-screeners."

12VAC30-50-226A Develop an equivalency consideration for full-time experience and a flexiblity consideration for alternative degrees to avoid severely limiting the pool of potential providers.

12VAC30-50-226A-QMHP-A and C - Grandfathering and variances will be essential to retaining staff to provide these services.

12VAC30-50-226B Continue licensure through DBHDS for ICT based on the PACT model. Consider language more appropriate to the client level of need such as "when services that are far more intensive than outpatient clinic care are required and services in the home and the community are more likely to be successful."

12VAC-50-130 Activities of Daily Living - Consider expanding elements of daily living to other basic need requirements for people with serious mental illness including shopping, budgeting, meal planning and preparation, and medication management.

12VAC30-60-61A The stringent definition of "at risk" may result in few children and adolescents with SED qualifying for Intensive In-Home. The absence of Intensive In-home services with this population weakens the outcomes of other services by creating significant service gaps. Outpatient and school-based services are not adequate to meet the needs of many of these clients.

Part I

12VAC30-30-60-143 – PCP:  Support PCP Notification with appropriate client Authorizations in place.

12VAC30-50-130-5: Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list.  How will staff hired under the current list of disciplines be grandfathered?

12VA30-50-130-5-ISP:  ISP  Providers with EHR’s will need time to reconfigure system capabilities to meet any new requirements. Discharge plans are currently included in a variety of ways including in ongoing assessments.

12VAC30-50-130-5 - Community Mental Health Services:  Community Mental Health Services  The term "certified pre-screener" is a term that, in Virginia, is considered to be exclusive to the CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention. This proposed change would be in conflict with the current Code of Virginia and DBHDS Licensing Regulations and removes the CSB/BHA designation as the sole entity to fill the role of certified prescreener.

12VAC30-50-130-5 - LMHP:  LMHP – Substance Abuse practitioners are certified not licensed.  Does this mean that the CSAC will no longer be honored?

12VAC30-50-130-5 - QMHP-C:    How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-130-5 - Work Experience:  Requiring “full time experience” would reduce the pool of potential staff and adversely affect recruitment (i.e.  caregivers, part-time workers). There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, outside of the hiring entity, would be handled or documented?

12VA30-130-3010 - ICA:   Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

12VAC30-50-226 - Crisis Services:  Crisis Intervention and Crisis Stabilization proposed requirements for "Registering" with DMAS should be expected only after the crisis intervention has been accomplished; within a designated timeframe.  Additional information about how the registration information will be transmitted to and used by DMAS, as well as staff training will need to be provided. Strongly recommend implementing EMTALA "like" guidelines if this moves forward

12VA30-50-226 – ISP:   Loss of person centered language is very concerning.  This should be added back into this section as should the assurance that the recipient is part of service planning. 

12VAC30-50-226A - Human Services Field:  Too many disciplines are being excluded. Nursing is not included as a human services field and should be noted in the list. Degrees such as Therapeutic Recreation, Educational Psychology and others that cover requisite knowledge and skills are omitted, without option for special consideration.  Flexibility in terms of exceptions should be built in. How will staff hired under the current list of disciplines be grandfathered?

12VAC30-50-226A - Clinical experience:  Suggest deleting “on a full-time basis” or allow clinical experience to be the “equivalent of” an amount of full-time experience.  Otherwise, the pool of providers is more severely limited than what it is now and recruitment will be affected.  Parents and caregivers, for example, may need to work part-time. As well, there should be a flexible process remaining in the regulations for approval of an alternate degree.

12VAC30-50-226A - Certified Pre-screener:  The term "Certified Pre-screener" - should be consistent with the Code of Virginia.  The proposed change would be in conflict with the current code of Virginia and DBHDS licensing regulations.

12VAC30-50-226A - Certified pre-screener: Suggest the language be amended in each section where it is used to be clear about the entity and the precise function.  Do not use the term “certified pre-screener” unless it is accompanied by the prefix “CSB/BHA”.Wording should be reworked to clarify the Certified Pre-screener role is exclusive to the CSB.BHA.

12VAC30-50-226A – LMHP:  After this year, we understand the Psychiatric Clinical Nurse Specialist will no longer be an obtainable specialty, as Masters’ level nurses are now being educated and will be credentialed (board certified) to provide services to children, and adults as Nurse Practitioners. The language needs to be corrected to reflect both psychiatric clinical nurse specialists and psychiatric nurse practitioners as those who are currently double board certified will be grandfathered.

12VAC30-50-226A – QMHP-A and C: How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment. 

12VAC30-50-226A – Registration:  When CSB/BHA clinicians are addressing emergency situations, triage and stabilization, it should be clearly stated that the interventions are the priority, with Registration to follow. 

12VAC30-50-226A – Registration:  Registration adds another administrative step, which we believe is already accomplished by filing a claim. Based on this requirement, will Crisis Stabilization and Detox programs still be able to do 24/7?

12VAC30-50-226A – Registration: The details of the "Registration" process once the information is to be forwarded by the CSB/BHA need to be clarified, so CSBs can be able to advise individuals receiving services how the information will be used.

12VAC30-50-226A - Work Experience: Requiring “full time experience” and not considering part-time experience would dangerously reduce the pool of potential staff and would adversely affect recruitment of many qualified people who have gained experience as caregivers or part-time staff. 

12VAC30-50-226A – Clinical Experience: There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, work outside of the hiring entity, would be handled or documented?

12VAC30-50-226B - Intensive Community Treatment:  Licensure through DBHDS for this service is based upon the national PACT model.  By removing case management as a required component of ICT, Virginia’s regulations conflict with the national PACT fidelity standards.  Individuals at this level of care require case management to assist with diversion from hospitalization and to assist with basic needs.

12VAC30-50-226B - Crisis Intervention:  Amount of service that will be needed and provided can hardly be determined in advance.  Individuals in crisis can rarely provide comprehensive information so triage and stabilization is necessary before registration of any kind.  

12VAC30-50-226B - Crisis Stabilization:  Crisis Stabilization services regulations indicate that services are based on the assessment of a QMHP that are then later reviewed and approved by a LMHP within 72 hours. The LMHP is only reviewing and approving the service rather than performing the face to face assessment. Considering the acuteness and brevity of the service, at 3 days the consumer is often discharged.  In order to provide the level of service that is needed for crisis stabilization services the LMHP needs to be more actively involved in the assessment and treatment planning in the early stages of treatment, which would then provide the information necessary for service authorization and also provide for more delineation of the service from crisis intervention and mental health supports.

12VAC30-50-226B - Day Tx: It is important that existing variances be honored.

12VAC30-5-226B - Psychosocial Rehab:  As in other statements, will existing variances for Psychosocial Rehab be honored? 

12VAC30-5-226B - QMHP-A: There is a need to clarify that a QMHP-A can continue to conduct the face to face assessment with the LMHP approval.

12VAC30-60-61A - Definition of “at risk”:   This more stringent definition in the proposed changes may easily result in fewer children and adolescents with SED qualifying for Intensive In-Home.  If a service such as the Strategic Family Services and Supports Services Model were available, this definition may not have the potential to deny services to those who need them.  That service is not in place, however, and outpatient, clinic-based services may not meet the need.  Again, flexibility and an exception process are needed. This model is designed by the VACSB, endorsed by Voices for VA’s Children.

12VAC30-60-143 - PCP Notification:  With language that assures recipient’s consent to the notification, fully support coordination with PCP.

Part II

The Arlington County Community Services Board endorses the general comments submitted by the Virginia Association of Community Services Boards as reflecting the concerns of our CSB.  Specifically, those comments are:

• The VACSB and our members understand the need to revise and, at times, tighten regulations to assure that those who need services receive them and that the services are of a quality that will maximize the benefits for recipients.  It is obvious that thought has gone into the proposed changes, but at this time, we would voice our concerns.
• At a time when health care needs are expanding but service providers are not expanding in numbers, many of the proposed changes in staffing seem unnecessarily burdensome and restrictive.  For example, individuals who are qualified and wish to work or must work only part-time should not be excluded.  Many providers have developed ways to allow individuals who want/need part-time work that have proven beneficial to recipients of services, the employees and service provider organizations.  Language could be added to the proposed changes that clinical experience could be the “equivalent of” an amount of full time experience.  It may take a person longer to meet the requirement but would not restrict them completely.
• As well, grandfathering and approved variances should continue to be allowed and remain in effect.  Otherwise, the system loses many experienced and valued employees. If individuals are qualified under the current regulations, they should be grandfathered under these proposed changes, using the verification/documentation of clinical and supervisory experience under the existing regulations.  While our specific comments below address some of the proposed changes, please allow this general comment to serve as a request to retain grandfathering and variances throughout.
• Various sections indicate that any “incomplete, missing or outdated” documentation will result in denied reimbursement. Any section about inadequate documentation should include wording that any failure needs to be significant, not minor and incidental, or that documentation that is not in “substantial compliance with regs” will result in refusal of reimbursement. The purpose of documentation review is to assure that a covered service is delivered to a covered individual in a clinically appropriate way. Documentation should not be used as a vehicle to deny legitimate reimbursement. We request that the language be amended wherever in the proposed regulations this wording is employed.
• There are a number of places in the Proposed Regulations that appear to have changed or deleted the person-centered language that should remain in regulation if Virginia is to move into a truly person-centered health system.  Recipient planning and expressing preferences, goals, treatment options, and the like should be reflected as high values in the regulations.  As well, there are instances in the proposed changes that would appear to allow exchange of information without expressly stating that the recipient’s consent will be necessary.  Such language should be scrubbed and every attempt made to empower the recipients of services to take an active role in their treatment planning and implementation.
• Sections that describe Activities of Daily Living (ADLs) seem to reflect more of a focus for developmental disabilities than for behavioral health conditions.  We suggest that Instrumental Activity of Daily Living (IADLs) be added.    We have proposed appropriate language that would assist individuals with serious mental illness.  Adding IADLs would also address the language.
• There are areas of the proposed regulations that do not, but should, contain enough flexibility to be sure that a recipient who, by way of functioning or diagnosis, needs a more intensive level of service than what is available in the outpatient realm, is able to receive that service through some exception process whereby appropriate documentation would be forwarded to the pre-authorization contractor. 
• The section involving Crisis Intervention and Registration needs additional thought and change.  “Registration” should occur after the individual is triaged and in a safe clinical setting.  “Crisis Intervention, Amount of Service” should be documented after the person is triaged in a safe clinical setting, and initial level of care is determined.  Under both, the provider first meets the person where he/she is “clinically.” Triage occurs to determine a level of risk, level of crisis, harm to self or others and recommended level of care. Once this is determined and the person is safe, then proceed to register and document what is projected to be the needed level of care.
• We request that DMAS separate clearly the role of CSB/BHAs mandated requirements in Code from what is termed Crisis Stabilization and Crisis Intervention

Alexandria CSB Comments to DMAS on Proposed 2011 Mental Health Services Program Changes

12VAC30-30-60-143 – PCP: Support PCP Notification with appropriate client Authorizations in place.

12VA30-50-130-5-ISP: ISP Providers with EHR’s will need time to reconfigure system capabilities to meet any new requirements. Discharge plans are currently included in a variety of ways including in ongoing assessments.

12VAC30-50-130-5 - Community Mental Health Services: Community Mental Health Services The term "certified pre-screener" is a term that, in Virginia, is considered to be exclusive to the CSB/BHA clinicians who provide emergency services and pre-admission screening for involuntary detention. This proposed change would be in conflict with the current Code of Virginia and DBHDS Licensing Regulations and removes the CSB/BHA designation as the sole entity to fill the role of certified pre-screener.

12VAC30-50-130-5 - Intensive In-Home: Intensive In-Home (IIH) is one of the most intensive community based mental health services provided to children and adolescents with serious emotional disorders (SED). SEDs are chronic conditions that persist over time and it is essential that children and adolescents with SED receive targeted case management services independent of IIH to ensure that clinical needs of these children and adolescents are being met effectively, coordinated and addressed.

12VAC30-50-130-5 - LMHP: LMHP – Substance Abuse practitioners are certified not licensed. Does this mean that services provided by the CSAC will no longer be eligible for reimbursement?

12VAC30-50-130-5 - QMHP-C: How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment.

12VAC30-50-130-5 - Work Experience: Requiring “full time experience” would reduce the pool of potential staff and adversely affect recruitment (i.e. caregivers, part-time workers). There is also need for guidance on the calculation of “clinical experience”. There needs to be a clear definition of the meaning of “supervised”. Also, what is the expectation of how internships, outside of the hiring entity, would be handled or documented?

12VA30-130-3010 - ICA: Removes the CSB/BHA designation as the sole entity authorized to perform independent clinical assessments.

12VA30-130-3030A – Intensive In-Home: IIH -Removes the CSB/BHA designation as the sole entity authorized to perform

12VAC30-50-226 - Crisis Services: Crisis Intervention and Crisis Stabilization proposed requirements for "Registering" with DMAS should be expected only after the crisis intervention has been accomplished; within a designated timeframe. Additional information about how the registration information will be transmitted to and used by DMAS, as well as staff training will need to be provided.

12VAC30-50-226 - Intensive In-Home Services: Intensive In-Home Services should allow LMHP-e (licensed eligible) to complete face-to-face assessments with approval/sign-off from a LMHP.

12VA30-50-226 – ISP: Loss of person centered language is very concerning. This should be added back into this section as should the assurance that the recipient is part of service planning. In addition, providers with EHR’s will need time to reconfigure to meet any new requirements.

12VA30-50-226 – ISP: Providers with EHR’s will need time to reconfigure to meet any new requirements.

12VAC30-50-226A - Certified Pre-screener: The term "Certified Pre-screener" - should be consistent with the Code of Virginia. The proposed change would be in conflict with the current code of Virginia and DBHDS licensing regulations, under which only CSBs/BHAs can perform this service.

12VAC30-50-226A - Certified pre-screener: Suggest the language be amended in each section where it is used to be clear about the entity and the precise function. Do not use the term “certified pre-screener” unless it is accompanied by the prefix “CSB/BHA”.  Suggest wording be reworked to clarify the Certified Pre-screener role is exclusive to the CSB.BHA.

12VAC30-50-226A – QMHP-A and C: How will grandfathering and variances be handled related to staff already hired – this is a critical issue. This change will impact the pool of potential staff and adversely affect recruitment.

12VAC30-50-226A - Work Experience: Requiring “full time experience” and not considering part-time experience would dangerously reduce the pool of potential staff and would adversely affect recruitment of many qualified people who have gained experience as caregivers or part-time staff.

12VAC30-50-226A-Registration:  When CSB/BHA clinicians are addressing emergency situations, triage and stabilization should be allowed and followed by Registration, as explained in our comments below.

12VAC30-5-226B1-Service-specific provider assessment: Please clarify. Is this the same as a comprehensive assessment? And should the assessment include specifically the behavioral and primary health needs in “health status”?

12VAC30-50-226B -Crisis Intervention: Amount of service that will be needed and provided can hardly be determined in advance. Individuals in crisis can rarely provide comprehensive information so triage and stabilization is necessary before registration of any kind.

12VAC-50-130 - Activities of Daily Living: Proposed regulations state “Activities of daily living means personal care activities and includes bathing, dressing, transferring, toileting, feeding, and eating.” VACSB suggests that the list of allowable activities of daily living should be expanded to include shopping, budgeting, meal planning, and medication management, all of which are essential activities for individuals with Serious Mental Illness. As well, include the language for Instrumental Activity of Daily Living (IADLs).

12VAC30-5-226B - QMHP-A: There is a need to clarify that a QMHP-A can continue to conduct the face to face assessment with the LMHP approval.

12VAC30-60-61A - Definition of “at risk”: This more stringent definition in the proposed changes may easily result in fewer children and adolescents with SED qualifying for Intensive In-Home. If a service model such as the Strategic Family Services and Supports Services Model, designed by the VACSB and endorsed by Voices for Virginia’s Children, were available, this “at-risk” definition may not have the potential to deny services to those who need them. That model is not in place, however, and outpatient, clinic-based services may not meet the needs of children and adolescents with SED in Virginia. Flexibility and an exception process are needed.

12VAC30-60-143 - PCP Notification: With language that assures recipient’s consent to the notification, fully support coordination with PCP.

The Alexandria Community Services Board endorses the general comments submitted by the Virginia Association of Community Services Boards as reflecting the concerns of our CSB. Specifically, those comments are:

• The VACSB and our members understand the need to revise and, at times, tighten regulations to assure that those who need services receive them and that the services are of a quality that will maximize the benefits for recipients. It is obvious that thought has gone into the proposed changes, but at this time, we would voice our concerns.
• At a time when health care needs are expanding but service providers are not expanding in numbers, many of the proposed changes in staffing seem unnecessarily burdensome and restrictive. For example, individuals who are qualified and wish to work or must work only part-time should not be excluded. Many providers have developed ways to allow individuals who want/need part-time work that have proven beneficial to recipients of services, the employees and service provider organizations. Language could be added to the proposed changes that clinical experience could be the “equivalent of” an amount of full time experience. It may take a person longer to meet the requirement but would not restrict them completely.
• As well, grandfathering and approved variances should continue to be allowed and remain in effect. Otherwise, the system loses many experienced and valued employees. If individuals are qualified under the current regulations, they should be grandfathered under these proposed changes, using the verification/documentation of clinical and supervisory experience under the existing regulations. While our specific comments below address some of the proposed changes, please allow this general comment to serve as a request to retain grandfathering and variances throughout.
• Various sections indicate that any “incomplete, missing or outdated” documentation will result in denied reimbursement. Any section about inadequate documentation should include wording that any failure needs to be significant, not minor and incidental, or that documentation that is not in “substantial compliance with regs” will result in refusal of reimbursement. The purpose of documentation review is to assure that a covered service is delivered to a covered individual in a clinically appropriate way. Documentation should not be used as a vehicle to deny legitimate reimbursement. We request that the language be amended wherever in the proposed regulations this wording is employed.
• There are a number of places in the Proposed Regulations that appear to have changed or deleted the person-centered language that should remain in regulation if Virginia is to move into a truly person-centered health system. Recipient planning and expressing preferences, goals, treatment options, and the like should be reflected as high values in the regulations. As well, there are instances in the proposed changes that would appear to allow exchange of information without expressly stating that the recipient’s consent will be necessary. Such language should be scrubbed and every attempt made to empower the recipients of services to take an active role in their treatment planning and implementation.
• Sections that describe Activities of Daily Living (ADLs) seem to reflect more of a focus for developmental disabilities than for behavioral health conditions. We suggest that Instrumental Activity of Daily Living (IADLs) be added. We have proposed appropriate language that would assist individuals with serious mental illness. Adding IADLs would also address the language.
• There are areas of the proposed regulations that do not, but should, contain enough flexibility to be sure that a recipient who, by way of functioning or diagnosis, needs a more intensive level of service than what is available in the outpatient realm, is able to receive that service through some exception process whereby appropriate documentation would be forwarded to the pre-authorization contractor.
• The section involving Crisis Intervention and Registration needs additional thought and change. “Registration” should occur after the individual is triaged and in a safe clinical setting. “Crisis Intervention, Amount of Service” should be documented after the person is triaged in a safe clinical setting, and initial level of care is determined. Under both, the provider first meets the person where he/she is “clinically.” Triage occurs to determine a level of risk, level of crisis, harm to self or others and recommended level of care. Once this is determined and the person is safe, then proceed to register and document what is projected to be the needed level of care.
• We request that DMAS separate clearly the role of CSB/BHAs mandated requirements in Code from what is termed Crisis Stabilization and Crisis Intervention.

The proposed regulations indicate that the ISP be completed within 24 hours of admission for crisis stabilization.  Previously, the requirement was within 10 business days of the assessment.   DBHDS regulations for Children’s Residential Facilities allow three days from the date of admission to develop the ISP.  As a residential crisis stabilization provider, we propose that the ISP be completed within 72 hours of admission to be in alignment with licensure regulations for residential services.  We currently develop the ISP within 24 hours of admission into our Crisis Stabilization Unit but sometimes parents are unable to participate in the initial planning and sign the ISP within the 24 hour timeframe.

I appreciate the opportunity to comment on the proposed changes to the mental health services program.

As a provider serving a large rural area, we consistently face significant challenges recruiting qualified individuals to deliver quality behavioral health services.  This has been compounded when we begin a service and an entire program based on an initial set of criteria, including staffing credentials, and then this changes at some point in the future.  While there has been consideration given to "grandfathering" staff for which we are grateful, staff attritioning out of our system need to be replaced under the new credentialing criteria.  What was difficult initially is now even more so.

Restricting clinical experience to individuals who have performed their functions in a full time capacity and eliminating the clinical experience of those who perhaps out of necessity gained the same clinical experience in a part time capacity appears to be discriminatory and narrowly focused.  Moreover, this will further reduce the professional cadre of staff available for hire at a time when there is an increased demand for services.

We respectfully request that the clinical experience apply to that experience gained in a part time basis and that "grandfathering" and approved variances should continue to be allowed and remain in effect.

We understand the need to provide thorough and comprehensive documentation; however, we have concerns that the proposed regulations appear to indicate that there is no distinction between significant errors that are clearly out of compliance with the regulations and those of a more minor category.  Both errors will result in a payback.  We respectfully request that distinction between those significant and minor errors be considered.

We do not agree with expanding the certified prescreener designation to other entities as proposed.  The Code of Virginia specifically limits CSB/BHA clinicians as the certified prescreeners.

We do not support the definition of activities of daily living as it appears in the proposed regulation.  We believe it reflects the need of some individuals with disabilities but should be broadened in order to more acurately address the need of individuals dealing with mental health issues.

Additionally, we support the comments provided by the VACSB.