I wanted to post a public comment on these proposed changes, specifically those listed in Appendix G. As a provider who has over 15 years of experience in the mental health field in Virginia I find it very disappointing to see how many additional barriers these new policies are adding to an already extremely difficult duty of providing quality services to individuals in crisis within our community.

Im not sure if these proposed changes are attempting to eliminate the ongoing waste of medicaid funding for community based services, but I will say that not all companies are abusing the system and it feels like a direct attack on all private providers to add even more barriers to service delivery for our clients. 

This particular policy shows one of many extremely difficult aspects we face as a provider:

It is absolutely disheartening to see the new changes that are being proposed. Medicaid services are for the marginalized and low income communities where mental health is at outmost importance. These changes will not only makes thigs harder for us providers, but will make it impossible to hire the right help to provide the necessary services.  It does unfortunately seem like the state is trying to punish both providers and the community needing the services, because of a few apples that might be taking advantage of the state funds. In the area of COVID where mental health has suffered the most, it is upsetting to see how both clients and providers of mental health are treated. 

Thank you 

Will providers now be allowed to bill for crisis intervention that is conducted through telephone? Providers/staff spend a lot of time mitigating risks and providing crisis intervention to clients that need the extra support, that often eliminate the need for hospitalization. The issue of being unable to bill for crisis interventions that is conducted through telephone has been brought up and addressed by several providers, however the drafted manuals do not appear to clarify this matter any better than before.

As we all know, the lack of available public housing resources is literally a crisis in itself that amplifies the ability for our consumers to make legitimate progress. While I 100% agree that private providers should not be attempting to deal with this crisis using Medicaid funding, there should be some true resources available to deal with the nationwide housing crisis. It was noted during the Youtube training video that the MCO's should be informed about housing difficulties as they have "available resources" to help and this simply is not the case by any stretch of the imagination. If even a single legitimate and effective housing resource can be provided by DMAS, DBHDS, or anyone at the MCO's I will make it a personal mission of mine to share this with the population we serve, professionals who may be less connected to state information, and other individuals in the community who are passionate about legitimately helping those in the state of Virginia.

Do note that while there may be quite a few additional Medicaid funded services integrated with BRAVO to support our consumers, the chances of them being utilized are slim to none if they are not having their most basic foundational needs such as housing, physical safety, and food met. Their chances of cycling in and out of community based and residential crisis services remains extremely high no matter how helpful/available these mental health services are.

Please keep this in mind and attempt to allocate additional services and funds that towards this crisis to prevent even more state-wide deterioration and poor statistical outcomes in the future.

All of the hard work that was done to revamp the Medicaid funded services in the state of Virginia that seemed initially designed to provide additional access to consumers and positive outcomes should not go to waste. Do note that the recent trends and data were observed/obtained after only a few short months of information that came during the ending Covid-19 crisis that was obviously an additional stressor for all parties involved from consumers to congress.

1. There is verbiage in the proposed manual that clarifies the usage of funding on housing - the majority of clients who enter services are suffering from homelessness and substance abuse issues. Many have burned bridges with what used to be their natural support systems, but for individuals who attempt to go through non profits or state resources for the shelters —-they can’t get in due to a shortage on beds and Richmond just closed a shelter that displaced 1100 people. Tent city was removed - the state had no issue at that point housing those individuals in local hotels until they didn’t and those same individuals either resorted to crime, heavy drug usage, or crisis services with the hope of getting assistance. How do you propose we address the homelessness issue that arise when there are no housing resources available to the homeless population that is growing by the day? 
   
   
2. The HUB: This was thrown at private providers, clients, and the CSBs with 2 weeks to make a miracle happen. There has been a significant uptick in burnout and no one seems to care except those of us who are on the ground facing these clients daily. The Hub has had more issues than an Android phone. There was an attempt at a training but the things that were promised as far as tracking, communication across the board , etc have not been delivered. Not to mention, who is operating this Hub when the CSBs have limited staff and can barely deliver their mandated services ? RBHA just started Mobile Crisis so how do we ensure that the calls that come in don’t all go to the CSB before making its way to private providers? 
   
   
3. Housing: I want to point out that the new language condemns the usage of Crisis funds for housing clients but Anthem started their own crisis program on Dec 1 for their members up to the age of 25. Will they be required to adhere to the same guidelines? 
   
   
4. Biggest question: What’s the goal ? Is the goal to weed out providers who are misusing funds ? Is the goal to eliminate the crisis program altogether ? I think it would be easier for all parties involved if we actually knew what you all were thinking. Are we fighting an uphill battle? Are we going back and forth just to find out that the entire service will be eliminated in 1 year? If fraud is an issue- get a task force together. No need to punish people who set out to do the right thing and help clients in need. 
   
   
5. Service units : What can really be done in 3 days and 12 hours ? It takes longer to be approved for an apartment. When these decisions are made, are you talking to actual counselors for input or is this based on hearsay and assumptions? These clients deal with unspeakable trauma. Think about sitting down with a therapist. The first session is not where you lay it all out. It takes time. Rapport has to be built. As a state we are headed for a downward spiral. If the hospitals are at capacity, shelters are at capacity, and providers are being heavily policed ——where do you think the clients end up as a result? My guess is death, partaking in violent crimes , or flooding the cities. 

Here’s a suggestion. Allow 14 days (16 units per day) and still require the clients to be out of services at least 30 days before they can enter into the same service. 

This could reduce cycling and actually allow progress to be made with clients. 

:

As a provider that does not abuse the system, it is disheartening to read the proposed changes.  Once again, those affected are the ones who need the most help. How do we, as providers assist those in crisis in a manner of three days?  How do we get the referrals if these same services are being provided by the Hub?  It takes sometimes 2 days to receive the authorization, despite working with the client and most of the clients that we as an agency have helped are homeless, have no supports in place, some don't even have income.  We are told to refer them to the homeless hotline, well... the hotline refers them to Crisis..... It takes a few days before the client is able to be forthcoming and even so, it is not the entire picture.  We cannot put a bandaid on the issue but cutting these services is severing the artery.  Sure, there are companies that are abusive and yes, there are some clients that are crisis jumping, put a cap on how many times a client can be admitted in crisis in a 3 month period.  More importantly, what is the state doing about the housing shortage?  Three days is just barely enough to get the medication appointment scheduled, what can be accomplished in three days?  I propose keeping the 7 day time frame and decreasing the amount of times a client can use crisis.

After reading the proposed changes, I am left wondering if the client needs are the main priority.  Not much can be accomplished in a manner of three days.  It would be helpful to ask the client what their needs are since this is affecting  them most.  Yes, abuse is out there, but cutting down the service and strong holding the agencies that provide these services is not the answer.  This will only fuel more struggles within an already marginalized community, which is the community that we are supposed to be working to provide assistance for.  Please re-think decreasing the days of services provided and re-direct the efforts to save money but focusing on how to provide the critical care needed to deter re-entry.

I wanted to follow up to inform DMAS that this billing requirement should be removed until the MCO claim systems are set-up properly to accept Telehealth claims using the "GT" modifier:

Greetings  Thank you for the information regarding the proposed changes to mental health manual.  I would like to comment specifically on some of the changes in community stabilization services, especially the proposed reduction of services to 3 days and 48 units.

In our experience, 3 days and 48 units would not be enough time to conduct the "warm handoff" spoken of during the presentation.  From our understanding, part of the intent of the service is to ensure the that a member moves as seamless as possible from a higher crisis service to a community service or some lower level service.  Individuals coming out of these high-level services often times aren't in the mental capacity to receive much less intensive services and support within 3 days.  In most instances, the ability for individuals to do this is between 5-7 days.  This proposed change does not appear to keep in mind the physiological effects that can be caused by crisis, and instead seeks to rush a person through treatment and support.

Also, the proposed authorization change of qualified members must be transitioning from another crisis service not only presents a barrier to the member, but alters the service definition.  The current service definition states that: 

Please consider the clinical impact of reducing Community Stabilization to a 3 day admission. If the initial registration is 3 days, it is setting a standard expectation that service delivery can often be accomplished successfully within 3 days. With the revised eligibility criteria, it is unlikely most individuals who meet service criteria will be able to have needs met within 3 days. A warm handoff will be extremely challenging and rare. Individuals entering service over the weekend will be especially disadvantaged due to the limited opportunities to coordinate care outside of normal business hours. Their admissions will be ineffective, as it is unlikely MCOs would consider a weekend admission sufficient clinical rationale for a continued stay. 

The draft regulations indicate that an individual would be discharged if hospitalized or incarcerated for 31 days.  This would limit our ability to support with discharge planning and continuity of care to help these individuals transition back into the community.  Please consider aligning this criteria with the current ACT regulations, which state "Incarceration of the individual for a period to exceed a year or long term hospitalization (more than one year)".  We understand that we cannot bill while they are hospitalized/incarcerated, but discharging them after 31 days would be detrimental in most cases.

Community Stabilization:

To get to the point, there are a few areas of concern I would like to address on this platform that I hope can bring ideas for a fair compromise between DMAS and providers who are doing what is needed of them. So far, the comments all speak of the same importance and some really go in-depth with the same concerns I have as well. As a provider who is still gauging the changes made 3 months ago, I believe these changes are not in the best interest of the clients or providers. Burnout is real and so is experiencing a crisis. The changes do not logically make sense as to how this program can assist with the development of skills to navigate away from acute crisis and to prevent crisis-cycling with the reduced admission days.

To be frank, the initial 7 days sometimes is not enough. Truthfully, clients are just starting to build rapport while making some form of progress in the first seven days, then switching them to a lower level of care before services can be fully rendered has a high potential for a negative impact. Also with the reduced days, this leaves more continued stays to be submitted via an agency and depending on the speed of the MCOs can leave providers working on a case that is denied coverage, which is not helpful for providers and clients because this takes away developing support and entry into the mental health services clients are in need of. 

Also, in the video, which was helpful to pinpoint the changes, I interpreted these services to be from a higher level of care to a "warm handhold", but what about individuals who experience an acute crisis while receiving MHSS, PSR, IIH, or TDT? Is it expected for them to go into the hospital first, instead of utilizing the services created as "a diversion to a higher level of care"? How are providers to services individuals already placed into a lower level of care program, but happen to experience a true crisis that does not fully require inpatient treatment? There needs to be a way to focus on multiple aspects of crisis and people being services instead of common trends and making changes based on that. 

Crisis call center and data platform: is there a way a channel can be made for providers who may experience a client who is indeed crisis-cycling, so as providers doing their due diligence can take action to stop that? Gaining access to documents on a secured platform and tracking data focusing on helping the clients find and access services that can be put into place to help stop crisis-cycling and start providing yielding results of progress in their homes and communities. 

Housing: I completely understand housing not being reimbursable, but there are clients who are facing housing difficulties daily, and only giving providers 7 days, now proposed 3 days to help with stabilization in the community, does not help clients navigate one of the primary and main concerns they are faced with: temporary lodging. Another comment stated that housing is a big issue, which it is, but asking MCOs for housing resources is like asking them to explain this service and how they do billing. Some type of assistance somewhere is needed. 

I think a safe and fair middle ground for providers and DMAS (and other entities):

** Based on what is current

Initial Authorization is 15 days up to 6 hours a day, 1 continued stay sent no earlier than 24 hours before the 13th day in service, to look at additional time if needed. Continued stay meets requirements and medical necessity (CEPP is sent in with continued stay). The CNA (or other approved assessments) and initial authorization are submitted within 48 hours of meeting ( this gives providers time to contact crisis call centers and conduct a thorough assessment, including suicidal/homicidal screenings, which can be optional to submit with initial and continued stay (can show progress). From here, I believe this can lighten the burden placed on providers doing their jobs, and effectively help and assist clients through their crisis periods while maintaining a good way for DMAS and other licensing entities involved to monitor how this service is being used.

The changes in question seem to eliminate the clients right of choice for a provider based on the guidelines of the call center. I think it is reasonable for providers to notify the call center but violates clients rights for the call center to assign clients to specific providers.

• App. G page 15 notes goal of Community Stabilization service to be stabilization for the individual within their community and to support the individual and natural support system during three particular circumstances. These circumstances include transitional step-down from a higher level of care if next level of care is identified but not immediately available and/or as a diversion from a higher level of care. 
  • Seven days has most often not been a sufficient amount to meet goals and three days will certainly not be. If the goal is to stabilize within the community, I encourage further consideration of these proposed changes. The level of intensive therapeutic support and time needed to have opportunity to coordinate care for a stabilization service is not realistic to occur within these timeframes.
  • The parameters identified with community stabilization in Dec 2021 seemed to shift the service to reactive rather than preventative/responsive.  The two of the above criteria can be considered a preventative to have this tool/resource to offer in effort to prevent a higher level or care or irreparable harm and seem to connect to the service description for community stabilization; however, the parameters proposed do not support true stabilization goal and instead seem to be barriers to both referrals to community stabilization and benefit from the service for individuals/families. 
  • There is a significant value in the service and has been incredibly beneficial in our community. Please consider the barriers these parameters (specifically amount of time service can be involved, how the service is accessed) are adding to a much needed support, especially during a time that accessing longer term services is at a significantly longer wait time. 
• App G page 16- "The provider to engage with the crisis call center and data platform prior to initiating service." 
  • There continues to be concerns regarding confidentiality related to information in the data platform.
  • There are assessment and planning questions in the platform in addition to need to complete the CEPP as well as documentation needs for agencies. Especially with the bringing in the platform, there continues to be more requirements added in regard to documentation. This information is important for various reasons; however, with just continuing to add, there seems to be redundancy which becomes overwhelming for individuals/families who are already in crisis and is a heavy lift for clinicians. This also speaks to issue with how quickly there is turnaround expected for requesting continued stay which again is additional documentation needed. 
  • On page 18 regarding meeting medical necessity-noted is that a CSB same day access intake determines community stabilization need to prevent higher level of care and to link individual to appropriate community services.  Please clarify- is there requirements of who community stabilization can accept referrals from providing determined to meet medical necessity (ie call center, same day ACCESS, emergency services)? Again, accessing this service has seemed to become more confusing and challenging impacting use of a valuable resource.  
• App G. page 24- regarding overlap of community behavioral health services. Please clarify what services this may include or if in general means ANY behavioral health services.  What if client is in a service, such as outpatient therapy, and in need of more intensive support temporarily?
• App G page 17- regarding services must be available 24 hours per day, 7 days per week in home, workplace or other setting convenient and appropriate for the individual. 
  • This is not realistic. Workforce is already a challenge and this requirement would far exceed capabilities of the current workforce. We must care for our staff in effort to be able to provide quality care to our community. 

Horizon wishes to express concerns in regards to the proposed changes to the Appendix G draft.  The proposed regulations would change the initial registration period from 7 days to 3 days for community crisis stabilization.  The regulations state that within admission to the service the client must have some form of comprehensive assessment, a CEPP must be established or revised, and an ISP to address immediate safety concerns must be established per DBHDS requirements.  In addition there is an expectation that discharge planning start immediately and that care coordination be provided throughout the entire episode.  Also rapport building and the actual crisis interventions services.  All of these components are essential to stabilizing an individual and only allowing an initial 3 days of services and a total of 12 hours will not be realistic to address most clients in crisis.  Particularly those coming into services with limited resources.  In addition having to do more frequent initial service authorizations create an administrative burden for both clinical and reimbursement staff.

In addition to the concerns about the change from 7 days to 3 days there is concern about the different requirements for client’s that have received crisis stabilization services within the past 30 days.  This change places a burden on the provider to try to get a confirmation of whether or not the client received services within the last 30 days either from the client (who by nature of the crisis may not know when they had services), contact other services providers for confirmation, or attempting to contact the MCO.  We are concerned about being able to get this confirmation in real time while the client is in an active state of crisis and needs immediate stabilization.  The provider for the crisis services may have to choose between risking loss of revenue and delaying services until the MCO has approved the service auth.  An example is attempting to start services on a Friday or a holiday. 

Finally there is a concern about the first requirement under Community Stabilization Medical Necessity Criteria.  This criteria indicates that a client must be stepping down from an acute level of care or group home setting (1.a.), CSB SDA recommendation by and LMHP type (1.b.) or referred directly from the crisis call center (1.c.).  The concern is that clients already in an established level of care (such as case management) can only access this service if they utilize the call center or have been through a higher level of care.  How does this address clients that may not want to contact the call center but meet medical necessity for community stabilization services?  In addition it is not clear if prescreeners can directly refer clients to community stabilization services. 

Some clarifications that are requested include the following:

1. Clarifications about whether Prescreeners are included in Mobile Crisis Response staff that can refer directly for community stabilization.
2. The term “registration” and “initial service authorization” are used under the “community stabilization service authorization and utilization review” section.  Currently to our knowledge there is only an “ARTS and MHS registration” and a “community stabilization authorization request form.”  Will there be an additional form created for the “initial service authorization”?

Draft regulations require an individual to be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year. 

Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year. 

Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year. 

Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year. 

Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days.  This would disrupt continuity of care.  It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers.  It would cause undue stress for individuals who are very fragile.  The regulations further stated that those individuals should be given priority for ACT services upon discharge.  This creates a great amount of unnecessary work and requires the individual to go through another intake process, which is completely unnecessary.  Please consider retaining the current language that would allow for discharge if individual's period of incarceration or hospitalization were to exceed a year.

Draft regulations require an individual to be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt the continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers during their stay in jail or hospital. It would cause undue stress for individuals who are very fragile and derail their treatment. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount of unnecessary work and requires the individual to go through another intake process, which is completely unnecessary and disruptive to services. Please consider retaining the current language that would allow for discharge if an individual’s period of incarceration or hospitalization were to exceed a year. 

Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year. 

Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year.

Discharge Criteria

• Extenuating circumstances occur that prohibit participation including:
  • b. The individual becomes incarcerated or hospitalized for 31 calendar days or more.

Recommend amending this as formerly written in the ACT regulations. The draft version is in conflict with VA code that allows 1 year: 12VAC35-105-1370

Consideration for discharge after a period of 31 days or more is potentially detrimental for clients as continued follow-up to ensure coordination of care for the transition back into the community upon release or discharge is greatly needed for this population. For example, many low level criminal charges carry longer sentences than 31 days, resulting in potential discontinuation of benefits needed to maintain community tenure. Continued contact with officers, jail personnel, physicians, social services agencies, and social workers is needed to coordinate client care in reference to medication management, case management, psychiatric follow up care, and other essential tasks needed to effectively transition back into the community from jail and/or hospitals. Remaining open to services is of paramount importance when working with this client population.

As a former administrator and educator in a Residential Facility I believe we need to be very cautious about blurring the line between what is good for an individual and what is good to them. We are to be sure we as their guardians and caretakers have THEIR best interest in every decision that is being considered. Many times, people in general do not make wise or healthy decisions for example unwanted pregnancies, drug usage, bad company, weapon handling. I have worked with and talked to young adults who talk just like you or me, but end up leaving the facility, getting pregnant in 2 months and then burning down the apartment building they live in. If this is going to be optional for providers, CSB, Individuals and guardians then I'm all for individuals expressing their rights and making decision's as long as it does not relinquish the caretaker's responsibilities of watching over them, and meeting all of their needs. Most of our individual's like to make their own decisions and do, but when it comes to decisions that can lead to their harm or hurt in ANY way, they do not understand the consequences of those decisions. 

                 Thank you

                 Laurie Midkiff

“Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year. “

“Draft regulations require an individual be discharged from ACT services if incarcerated or hospitalized for a period of 31 days. This would completely disrupt continuity of care. It would not allow the team to be involved in discharge planning and consultation with inpatient treatment providers. It would cause undue stress for individuals who are very fragile. The regulations further stated that those individuals should be given priority for ACT services upon discharge. This creates a great amount or unnecessary work, and requires the individual to go through another intake process, which is completely unnecessary. Please consider retaining the current language that would allow for discharge if a individual’s  period of incarceration or hospitalization  were to exceed a year. “

MRCS supports the concerns already repeated by several providers in this comment. We do not support the discharge of individuals that we know will return to services just to have them completely redo the large amount of paperwork in order to reopen when what they will really need at that time is a prompt restart of supportive care.

It does appear that Appendix G has been removed from the public comments AEB it's removal from the DMAS drafts website. We hope that prior to any final manual publication that another public comment period be opened specific to those proposed changes.