There are some significant issues with the the change that this proposes. The first issue is that prescreeners outside of the CSB system are not connected to the services provided by the CSB and other community partners the way a CSB currently is. The CSB system has access to multiple avenues of services and funding streams that provides direct care regardless of the individual's ability to pay. It is also concerning in regard to the potential increase in hospitalizations if private entities are prescreening. CSB prescreeners are very sensitive to the hospitalization criteria and often have to intervene now to prevent unneeded hospitalizations requested by private providers.  However the area that concerns me the most is that the individual in the community as a private provider being "a designee of the Community Services Board that serves the area where the client is physically located during the time of assessment, or that provides outpatient treatment to the client with all powers granted under applicable law." Having worked with private providers within other services, there is little control over the quality of the services being provided and the outcomes of those services. I am fully opposed to this change as it would not improve the prescreening system, but would further complicate and already complex process and system for the community. 

This petition is especially concerning for me as well as the public behavioral healthcare system in Virginia, especially as regards some significant changes proposed in this petition. The first issue is that this petition includes private psychiatric hospitals as included in providing prescreening assessments.  This presents to me as a conflict of interest since prescreeners are making decisions that directly impact hospital admissions.  If private entities are allowed to perform prescreenings, this has the potential to significantly increase hospitalizations.  The public behavioral healthcare system is constantly working to reduce unnecessary inpatient admissions.

Furthermore, any prescreeners outside of the CSB system are not connected to the services provided through the public behavioral healthcare system and other community partners the way a CSB currently is.  This is part and parcel of the mission of the CSB system in Virginia.  The public behavioral healthcare system has access to multiple programs of services and various funding streams that provides direct care regardless of the individual's ability to pay.  This is not the case for the private sector. 

Public sector behavioral healthcare prescreeners at the CSBs are very sensitive to medical necessity criteria for involuntary hospitalization and often have to intervene now to prevent unneeded hospitalizations requested by private providers.  Furthermore, this petition, if approved, removes the ability of the public behavioral healthcare system to hire, screen, perform quality reviews, hold accountable, or discipline prescreening providers providing prescreenings outside of the CSBs. 

Overarching these concerns is that this petition, if approved, will designate the individual in the community as a private provider being "a designee of the Community Services Board that serves the area where the client is physically located during the time of assessment, or that provides outpatient treatment to the client with all powers granted under applicable law."  This essentially removes these private providers from under the direct authority of the CSB and sets them up a "a designee of the CSB" without any accountability to that CSB.  This is to me, unconscionable. 

Having worked with private providers within other services, and as a private provider myself, I would opine that there is little control over the quality of the services being provided and the outcomes of those services (outside of the marketplace).  This is not the case with the public behavioral healthcare system which labors under multiple administrative and reporting burdens that do not apply to the private sector.  I am diametrically opposed to the approval of the changes proposed in this petition.  They would not improve the prescreening system, but would further complicate and already complex process and system for the community and result in an increase in hospitalizations.

I would alternatively proposed that individuals in the private sector wishing to work with the CSBs in providing prescreening assessments could instead become involved in providing these services through temporary service agencies.  Alternatively, they along with the public behavioral healthcare system in the state could explore other contractual vehicles to expand the staffing capacity and ability of the CSB system to provide prescreening assessments. 

I am opposed to this amendment as conflating private providers and CSB prescreeners represents a significant conflict of interest, undo hardship on CSB's to have private providers conducting prescreens as  CSB designee's without the oversight and administrative authority CSBs currently have over staff employed at the boards/behavioral health authority, and the training and credentialing requirements etc. that CSBs currently meet to have well qualified prescreeners on their teams, as a start.  Also the MARCUS Alert legislation by no means requires private providers who are a part of the Crisis continuum to also be prescreeners. The goal of the Marcus Alert, STEP-VA Crisis step, and the implementation of the regional call centers is to provide services in the community and if the crisis requires a prescreen,  the CSB will conduct the prescreen if community based crisis interventions are unsuccessful or do not met the client's level of acuity.  

The amendment also does not speak to the intense work that goes into the civil commitment process including: bed searching for involuntary individuals, petitioning for TDO's, alternative transportation and other processes, facilitating and/or participating in hearings, facilitating MOT when ordered, liaison duties if the individual is placed at a state facility, and access to regional/ DBHDS funds to obtain certain funding and program resources.  As Virginia moves towards a more comprehensive crisis system all providers both public and private are needed to have this goal actualized.  However, data has proven,  CSBs are able to decrease unnecessary hospitalizations by following the stringent civil commitment laws, DBHDS polices, and other guidance that CSB prescreeners adhere to while providing emergency services regardless of an individuals ability to pay or specific to MCO/insurance carrier.

I am strongly opposed to this proposed petition.  Preadmission Screeners need to be independent to make decisions that are least restrictive to the client.  Private Companies have to consider liability more so than a public sector CSB.  They will be more likely to recommend hospitalization to cover that liability.  Additionally, there is a lot more to the preadmission screening process than just the evaluation.  The follow-up responsibilities after the preadmission screen are more arduous that the evaluation itself.  Developing Safety plans require a lot of coordination to ensure that the person can be safely released.  When the evaluator determines that the individual needs to be hospitalized, voluntarily or under a TDO, the onus is on the CSB to obtain an appropriate bed.  Preadmission Screeners need to be employed by a CSB because it is a public organization which is able to take calculated risks to place an individual in the least restrictive option.   

The other comments I believe cover the basic concerns and it is indeed a bad idea.  The other major concern is that a "memo" cannot be amended to change the COV.  

I stand in agreement with those opposed to this petition as the comments appear to cover the major issues.  In addition, I would add, the mentioning of the Marcus Alert somehow being related to this justification for the petition is unclear at best.  Mobile crisis responders do not need to be Certified Preadmission Screening Clinicians.  

Virginia Beach Behavioral Health and Developmental Services has concerns regarding Mr. Vaughn’s petition. While we recognize his goal of improving the flow of the assessment process, we believe the negative impacts outweigh the benefits. Clinically, this would work against the aims of the new crisis continuum of care as it would likely increase the number of TDOs and would increase, vs. decrease, the need to involve law enforcement officials in the process. Specifically, if an individual located in the community and a Mobile Crisis Response staff member supports a TDO, who would provide security and monitor the individual while the crisis worker looks for a TDO bed?

Allowing this change would also create an undue burden and risk to the CSB system. This process would have an unknown number of people employed by an unknown number of providers considered to be designees of a CSB. Which CSB? For example, if an agency provides Mobile Crisis Response to residents of Chesapeake, Norfolk, and Virginia Beach, are their employees considered designees of each CSB? When employees of an independent agency are considered designees of a CSB, there are numerous complexities, related to matters such as clinical oversight, training and personnel records, ownership of clinical documentation, reporting of incidents (i.e., reporting in CHRIS) and risk management, and state reporting requirements unique to the CSBs. Providers of Developmental Services Case Management have already learned the complexities involved in attempting to do this. These would be magnified when working within the context of crisis services. We respectful request that this petition not be supported.

I want to begin by saying thanks to the few of you that read and commented on my petition.  

As someone who has been a preadmission screener for the better part of twenty years and now owning my own practice, with this new opportunity arising from the integration of private providers into the public system, I wanted to be able to provide the complete spectrum of services to my clients. 

To clarify for some that misunderstood, this rule change would only apply to agencies (providers) that are fully licensed by DBHDS...just like CSBs have to be fully licensed by DBHDS.  Licensed providers have oversight and are fully within the authority granted to DBHDS by VA Code.  At present, those that are Certified Preadmission Screening Clinicians can take that certification and perform this task anywhere in the state.  My proposal makes that impossible, and gives ownership (as well as warranties) to the individual's employer. If an agency employs experienced people as I have suggested that properly train and prepare their clinicians, this could be an innovative way to solve the current workforce shortage and raise the standard of care for everyone.  

With that said, I will concede to one point that a couple of you made regarding hospitals.  One of the things that work in our mental health system is that there is always an objective third party to evaluate a person in crisis and make a decision.  When assessors employed by a hospital have the ability to insist that a client stay at their hospital, that does seem to create a conflict.    

Another of you made reference to ownership of documentation, and there is a simple solution to that...use one system that all licensed entities are forced to use.  Other states do it quite successfully.  But that is an entirely different rant.  

To be frank, CSBs have insisted on a monopoly over a multitude of services for the past 56 years with crisis services being one of the few strongholds.  This makes many of your comments not surprising because more than anything else, monopolies fear competition in a free market that can provide a better quality of service and bring innovative ideas to the table.  Competition also forces a monopoly to be accountable for the failings of the system which is not something that any public system excels at.  All jabs aside, I am sincerely afraid that the Marcus Alert system will go from the most progressive and innovative thing that this state has seen in many years, to what is simply a more complex elaboration on business as usual in Virginia's mental health system with an easier to remember phone number.  As a trench worker turned business owner, I think there is a place in all of this for me and those like me:  providers who are truly client focused that want to provide quality and compassionate care to anyone that needs it.  I would hate to see a public system turn us away out of fear of creating something great.