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• Various sections indicate that any “incomplete, missing or outdated” documentation will result in denied reimbursement.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.