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.