May 27, 2022

Thank you for the opportunity to provide this public comment.

Please note:  In this document, I will use the term “peer supporter” as a general reference to the Peer Recovery Specialist, Family Support Partner, and Youth Support Partner.

As the peer support workforce in Virginia has grown and continues to grow, we now have the role of Youth Support Partner (YSP).  This form of peer support is a young adult, typically 18 – 30 years of age, who have direct system(s) experience as a youth.  The YSP is in recovery from their behavioral health challenges and is assigned to work with children, adolescents, and/or young adults to support them on their recovery journey.  A portion of the YSPs currently working in Virginia have completed the PRS Training and are working on obtaining their certification as a PRS.  I would offer to add this role as a recognized form of peer support by DMAS.  I would suggest adding this title in all areas that reference “Peer Support Services and Family Support Partners” to state:  Peer Support Services, Family Support Partners, and Youth Support Partners.

As peer support is a universal form of support for youth, their family members and individuals on their recovery journey, regardless if it’s mental health or substance use-related, is it possible to not segregate ARTS-specific information from mental health-specific information?   I would offer to remove these references to reflect peer support as a form of support for anyone on a recovery journey.

Throughout this document, there are references to “mental health conditions and substance use disorders” and “mental health and substance use disorders”.  With the needs of youth, they may not necessarily have actual diagnoses of mental health and/or substance use disorders, however, they do display challenging behaviors.  There may be youth with school-related needs that stem from their behaviors, resulting in a 504 Plan or an Individualized Education Plan (IEP).  Only using the reference to “mental health and substance use disorders”, may exclude these youth and their caregivers from receiving peer support services that could be instrumental in supporting positive outcomes for these individuals and the overall education system.  I would offer to expand the description of caregivers being eligible for a Family Support Partner to include “youth with mental health, emotional and/or behavioral challenges, and/or substance use challenges”.  I would offer the same reference for youth who may benefit from the direct support of a Youth Support Partner.

In addition, this document has multiple references to “his or her”; I would offer to use the term “their” to be more gender-inclusive.

PEER RECOVERY SUPPORT SERVICES

1^ST Paragraph: 

• Peer Recovery Support Services are delivered by trained and certified peer recovery specialists… peer supporters don’t currently have to be certified (in most instances) to work as a peer supporter.  We do have to be certified by the Virginia Certification Board and registered with the Board of Counseling in order to bill Medicaid for peer support services.  I would offer to remove “and certified” from this sentence.
• Further in this same sentence, it is referenced that “…extend the reach of treatment beyond the clinical setting into a member’s community and natural environment…” yet, there is a heavy lean on clinical requirements for the role of a peer supporter.  I would offer for DMAS to consider re-evaluating the restrictions around peer support being lumped in with clinical requirements as peer support is a non-clinical form of support that is a highly effective evidence-based model of care, as noted in the next sentence.
• The final sentence – “…consumers of mental health and substance use services…” I would offer to change the term “consumers” to “recipients” or “participants” as the word “consumer” may have a negative connotation.  This term isn’t typically used in the work as a peer supporter.

2^ND Paragraph:

• “…expanded the Medicaid benefit to allow for credentialing and reimbursement…”  The term “credentialing” in this sentence implies that as peer supporters are working through the credentialing requirements, i.e., 500 practice hours with supervision, we can bill Medicaid for this time.  Is this the intention?

DEFINITIONS:

• Behavioral Health Service:  I would offer to instead of using the term “mental health and/or substance use disorders” repeatedly throughout this manual to reference “behavioral health challenges” except where specific information is referencing youth.  I would offer to use the phrasing as listed at the top of this document.
• Caregiver:  I would offer “any responsible adult in the primary role of parenting a youth”.  The current description may exclude the role of a foster and/or kinship family member.  The term “employed” may need to be expounded upon to reflect whether or not foster and/or kinship parents/caregivers are considered “employed” if they receive funding to support their respective youth.
• Family Support Partners:  I would offer:  …provided to the Caregiver of Medicaid-eligible members under age 21 that is the focus of support.  Family Support Partners are Caregivers who are successful in the navigation of the child behavioral health system (to include courts, schools, social services, etc.), with their own youth, who is trained to offer support and assistance in helping the Caregivers determine their needs around how to best support their youth and how to access and utilize the resources to address those needs.  The services provided to the Caregiver…  Services are expected to improve outcomes for youth with challenging behaviors and/or complex needs who are involved in one or more systems and increase the youth and Caregiver’s confidence…  These services are rendered by an FSP who is (i) a direct Caregiver of a minor or adult child with a history of challenging behaviors, or (ii) an adult with personal experience with a family member with mental health and/or substance use challenges with direct experience navigating behavioral health resources, services and/or supports. 
  • PRS (should be FSP) shall perform the service…” or add this same verbiage to the definition of the ”Peer Support Services”.
• Peer Recovery Specialist:  second sentence – “…from the effects of mental health, substance use disorders…”  last sentence – add Youth Support Partners
• Peer Recovery Support Services:  In acknowledging that the definition in the cited code uses the phrase “mental illness, addiction or both”, this is inconsistent with the terminology in this document.  I would offer to use either “behavioral health challenges” or “mental health and/or substance use disorders” to maintain consistency.
• Peer Support Services:  last sentence – I would offer to remove “illness or disorder” and use the suggested terminology referenced in the previous definition as stated above.
• Progress Notes:  as peer supporters don’t offer “treatment” per se, I would offer to replace this term with “experiences”.  In the behavioral health field, the term “professional” is typically used to identify clinical personnel.  I would offer to either add a definition to describe “professional” to show that it encompasses the role of a peer supporter, or remove it from this definition.  Because this document is specific to peer support work, I would offer to replace “…staff interventions…” with “PRS/FSP/YSP interventions” or “peer staff interventions”.

Provider Enrollment

While it is appreciated that this list has been expanded to incorporate more environments that a peer supporter could be utilized to impact a youth, their Caregiver and/or an individual’s recovery journey, this list is exclusive to the variety of peer-run agencies, Recovery Community Organizations, and the like, that are located throughout Virginia.  Maintaining this exclusionary list will negatively impact the accessibility to the evidence-based model of peer support for those either in recovery or wanting to start their recovery journey.  I would offer to add to both the ARTS and MH sections – “Recovery Community Organizations approved by DBHDS’s Office of Recovery Services”; and “Peer-Run agencies approved by DBHDS’s Office of Recovery Services”.

The ARTS list of providers has the General Acute Care Hospital and Hospital Emergency Department listed separately.  The MH list has them combined in the first listing.  I would offer to replicate the MH entry (#1.) in the ARTS list to maintain consistency.

Peer Recovery Specialists

Peer Support Services and Family Support Partners shall be rendered by a PRS who:  Being that there two different definitions for Peer Support Services and Family Support Partners, using “PRS” here seems to actually be excluding the FSP role, based on the definition listed in this manual for the Peer Support Services.  

• Is sufficiently trained and certified… does this need to be here if it’s included in the definitions of the roles?  Or, if it’s here, does it need to be in the definition?
• 12VAC35-250 – sections 10 & 20 do not incorporate the definition of the Family Support Partner. 
• Is registered with the Board of Counseling… - this is the first reference in this manual for a PRS needing to be registered in order for peer support services to be considered for reimbursement from Medicaid.  I would offer to add “Registered – Certified Peer Recovery Specialist” as a definition in the beginning of this manual.

In considering the effects of language and the fact that peer support services are nonclinical, I would offer the following:  remove the term “caseload” and replace it with “assignment load”; remove the term “client” and replace it with “youth”, “Caregiver” and “individual”; or remove it all together to reflect “…time allowing for new assignments as those…”

In addition, I believe assignment loads (FT – 15/ PT – 9) should be determined by the Supervisor and their peer support staff based on the peer supporter’s availability and ability to effectively provide the service, as well as the program’s needs.  Does DMAS offer these types of limitations on other professions?

Supervision of Peer Recovery Specialists

I would offer to expand this reference to include the Family Support Partner.

Direct Supervision of the PRS shall be provided as needed…

• 1.  …less than 12 months…
• 2.  …over 12 months and fewer than 24 months…

As referenced in the section above, supervision needs should be determined by the Supervisor based on their program’s needs.  I would offer to remove numbers one and two in this section.  Also, are these recommendations stipulated in other professions?

Service Delivery

• …services may be rendered in the provider’s office or in the community, or both.  Does the term “community” incorporate the youth and Caregiver’s or individual’s home?  Does it incorporate a school, court or other provider’s office?  In the role of the FSP (and YSP), this form of peer support is routinely provided in the home, at IEP meetings, during court hearings, and occasionally during medication management appointments.  The FSP functions as an additional set of eyes and ears on behalf of the Caregiver to ensure they are understanding what is being asked or expected of them, as well as encouraging and empowering them to speak up for their family’s needs.

• Billing shall occur only for services provided with the member present. I would offer - Module 18 of the PRS Training curriculum discusses the aspects of advocacy to include self-advocacy, advocacy for others and system advocacy.  There are times when the peer supporter needs to communicate with system partners on behalf of the youth, their Caregiver or the individual to ensure their voice and choice is heard and understood by that system partner.  This also may occur when the system partner isn’t being heard and understood by the youth, their Caregiver or the individual, and the peer supporter can help bridge this gap/repair these relationships.  This is a form of advocacy within the role of a peer supporter and should be included as a billable service with clear documentation on the purpose and intent of these interactions. 
• Telephone time… Frequently, youth and individuals prefer to communicate by text messaging or virtual/video conferencing due to their diagnoses of anxiety and being comfortable with speaking on the phone.  This restriction “…to 25% or less of total time per recipient per calendar year.” may impede the effectiveness of the peer support service.  While peer supporters typically make every effort to meet face-to-face, this may not always be accomplished based on the member’s needs and challenges.  I would offer to expand the acceptance of text messaging as a recognized form of communication in providing peer support as well as the use of virtual/video conferencing.
• Contact shall be made with the member… I would offer to remove” receiving Peer Support Services or Family Support Partners” as this seems redundant.
• Peer Support Services or Family Support Partners may operate… Services shall not be delivered at the same time and within the same space of another service.  I would offer to remove this last sentence.  In the work as an FSP, it is routinely practiced that FSPs work alongside the Intensive Care Coordination service, Intensive In-home Services, Functional Family Therapy, Mental Health Skill-Building, and even outpatient therapy or medication management appointments.  The FSP supports the youth and their Caregiver in understanding what is being asked or expected of them and ensuring their voice and choice is being heard and understood by the other provider.  The FSP has been instrumental in ensuring the other provider’s expectations of the youth and their Caregiver are followed through on and there is consistent communication with that provider both from the family as well as the FSP.  This is usually referred to in reporting as “Team Collaboration”.
• Peer Support Services shall be an ancillary service…I would offer to remove this statement as there are aspects of peer support, i.e., emergency departments, crisis stabilization units, mobile crisis teams, etc., where the peer supporter is the first contact for recovery supports.  This indicates that the Peer Support Service is the primary service and could lead to the youth, their Caregiver or individual pursuing further forms of supports and/or services to enter into or maintain their recovery.

ARTS – Peer Support Services

• 3.  Demonstrate moderate to severe functional impairment… because peer support is nonclinical and it is expected to use a strength-based approach to include language – I would offer to rephrase “functional impairment” to “needs and/or challenges”.

ARTS Family Support Partners

• With the definition of the Family Support Partner including “…or (ii) an adult with personal experience with a family member with a similar mental health or substance use disorder or co-occurring mental health and substance use disorder with experience navigating substance use or behavioral health care services.” there is a consistent reference to FSPs being in the role of supporting the Caregivers of the identified youth Medicaid member.  There is no reference to the adult family member FSP being able to support another adult family member who is navigating the challenges of their loved one dealing with behavioral health challenges.  Is it DMAS’s intention that only Caregivers with youth can be supported by an FSP or is it intended that adult family members FSPs can support other adult family members of an adult individual-Medicaid member?  There seems to be confusion around the part 2 definition of the FSP and how this is intended to be implemented in Virginia.
• With the addition of the reference to “Individuals aged 18-20 who meet medical necessity criteria…” I would offer to add additional language to reflect that the Caregiver of this young adult may still have access to an FSP as well as add that the individual may opt to continue working with their Youth Support Partner, should they have one prior to their 18^th birthday or acquire a YSP after turning 18.

DOCUMENTATION OF REQUIRED ACTIVITIES

• Last sentence – “This documentation shall be written, signed, and dated…” Is the term “written” literal? 

Recovery, Resiliency, and Wellness Plan

• Second paragraph, second sentence – typo “qualitied” should be “qualified”

Review of Recovery, Resiliency, and Wellness Plan

• First sentence - …every 90 calendar days with the member and family or caregiver as applicable.  I would offer for consistency in language, remove “and family”.
• …(ii) be conducted in a manner that enables the member… I would offer to add “or Caregiver as applicable”.

Progress Notes

In this section, add “or Caregiver as applicable” where “member” is referenced.

Care Coordination Documentation

• First paragraph – last sentence – please see the above comments regarding advocacy in the role of the peer supporter and Team Collaboration.

SERVICE AUTHORIZATION AND BILLING:…

• Second paragraph – are there service delivery limits placed on other professions?  I would offer to allow the Supervisor to determine the needs of their peer support program to determine how the peer supporter is utilized.
• Rates for ARTS and Mental Health services are available on the DMAS website… the memo references the 12.5% temporary rate increase being valid through June 30, 2022.  Through a variety of stakeholder meetings and conversations with CSBs and private providers, billing Medicaid for peer support services has been a limited option for most due to the reimbursement rates that Virginia has in place.  I would offer to make it a priority to raise the peer support reimbursement rate permanently to ensure broader access to this evidence-based model.  And, has there been any research conducted to determine whether or not there was an increase in the billing for peer support services from July 1, 2021 through June 30, 2022 when the temporary increase was in place?

LIMITATIONS:…

• Last paragraph on page 22 – Family Support Partners is allowable only when the service is directed… with the definition of an FSP including an adult family member, are youth and their Caregivers the only target population for this role?

Respectfully submitted,

Cristy A. Corbin, CPRS

President-Family Support Partners of Virginia, Inc.

804.723.1215