CPST- Schools as written is operationally unrealistic, administratively excessive, and likely to produce unintended reductions in access to behavioral-health treatment in schools. The draft does contains positive clinical concepts. However, those concepts have been assembled into a service model without consideration for how the concepts interact in reality.The result is a service that is considerably more elegant on paper than it is operationally coherent.

 

Draft assumptions:

• Qualified staff are numerous and readily available
• School personnel are available, MOUs are in place/ easily obtained
• Staff are willing to be school, home, and community-based providers
• Families are able and willing to accommodate home services
• Providers can absorb extensive administrative and coordination requirements

 

Not a Functional TDT Equivalent as Written

The concern is not whether CPST is a clinically legitimate service- on paper it appears to be. The concern is if CPST-Schools is a functional replacement for TDT in the school building.  

 

The draft recognizes the need for the service to occur inside the school. However- what happens when the youth needs the intervention inside the school building- during the school day – but the authorized EBP replacement service (ex: FFT, MST) does not provide the intervention there?

If a child meets criteria for FFT or MST – the draft indicates requirement for referral to that service instead. How does this assist a child whose primary impairments and needs are at school?

The problem becomes particularly acute because these services are not simply being added to CPST to create a comprehensive plan for treatment. The draft's concurrent-service limitations mean the child may lose the school-based service altogether. There is a need to distinguish “clinically appropriate” from “clinically and functionally capable of addressing the specific impairment for which school-setting intervention is medically necessary”.

 

The draft describes CPST- Schools as a school-setting service, but much of the operational structure is substantially different from the type of continuous, embedded support associated with TDT.

The concern is that the result will be a reduction in actual support inside the school- how are these equal?

• TDT: up to 25+ hours per week 
• CPST: up to 5-8 hours per week

 

Crisis are inherently unpredictable. A youth receives a particular amount of units based on service authorization -however, needs can change based on circumstances. What happens when authorized units are exhausted well before the end of the identified authorization period?

 

Service Definition Concerns

The draft identifies the school as the primary service location and intended to address functional impairment inside the school. However, the service subsequently operates extensively outside the school- 24/7 availability in all settings.

 

CPST- Community (Youth) already exists. There needs to be a meaningful distinction between the two. The answer cannot simply be “the treatment goals relate to school”. A home-based service can also have school-related treatment goals- it does not make it a school-based service. If CPST-Schools is primarily defined by its ability to address impairment occurring in school then there should be a clearly identified expectation that all or most of the service is expected to occur in the schools. Parameters should be identified regarding the primary location versus allowable secondary location, circumstances permitting home/community delivery. 

 

“We can provide it in the home” does not mean best practice. Families may have crowded housing, transportation issues, unsafe environments, scheduling barriers, privacy concerns, and limited availability /willingness for home-based supports. School-based and home-based service models require different staffing structures. If school-based providers are expected to provide home-based services as needed and then consistently throughout the summer, they may encounter increased travel times, more evening appointments, and scheduling difficulties. 

 

Workforce Concerns

Requiring school-based staff to simultaneously provide home-based, community-based, and crisis services could intensify current workforce shortages. A staff may apply for and accept a school-based position for specific personal reasons- if the staff wanted to routinely provider services in the home, they could have applied for the numerous open home-based behavioral health jobs.Turning a school-based job into a hybrid school/home/community job through Medicaid policy is a material change in the position. This also impacts the ability of direct support that a provider is able to produce: a school-based staff can see multiple children in one school building; however, a home-based worker may spend substantial amounts of time traveling between client homes.

 

In a workforce environment where providers already struggle to recruit and retain qualified behavioral-health staff, this is not a trivial concern. This has a significant risk of worsening difficulties with recruitment and burnout/ staff turnover and ultimately lead to a reduction in ability to provide intensive behavioral health services in the schools. We cannot assume that a school-based provider can simply redirect its existing workforce to include crisis and home-based service delivery.

 

Documentation and Administrative Burden Concerns

The draft presents a service with extensive nonbillable administrative and documentation burdens.The mandatory administrative work required drastically reduces the provider’s time and capacity for actual direct clinical service provision.

 

The service staffing requirements as written present a substantial challenge for small and/or rural providers.

• Requirements: LMHP(s), QMHPs, back-up LMHP coverage, school MOUs, crisis procedures, 24/7 consultation, EBP training, MAP credentialing, documentation infrastructure, accreditation, authorization management, school coordination

If providers decline to offer the service because they cannot sustain the administrative and staffing model, we have an increased risk of fewer school-based providers and reduced geographic access.

 

The draft requires youth-serving agencies to meet MAP requirements, including having at least one LMHP MAP Credentialed Therapist and requiring credentialing or progress toward credentialing for applicable staff. MAP may improve treatment quality, but every additional credentialing requirement narrows the available workforce.

 

Crisis Support Requirements

The draft requires an on-call LMHP to be reachable 24/7/365. During the instructional day, the LMHP must be able to respond to a consultation request within a timeframe not exceeding 15 minutes.

 

The intention is understandable, the implementation problems are substantial. With the absolutely asinine amount of general obligations, administrative burden, and service requirements placed on LMHP staff, the probably of the LMHP being involved in another medically necessary client encounter is exceptionally high. If a provider only has one LMHP, how can this requirement be met without potentially compromising the clinical treatment of another client?

What about: simultaneous crises, multiple schools or staff requesting consultation at the same time, temporary loss of phone communications, times when the QMHP can reasonably act under existing crisis plan without consultation

 

The draft appropriately states that CPST- Schools crisis procedures must remain consistent with school emergency, behavioral threat assessment, and student safety procedures and school officials retain authority under those procedures. However, the draft simultaneously requires providers to make qualified staff available and attempt de-escalation before external crisis resources when CPST staff are present in the building. What happens when this is in contradiction to the schools’ safety procedures?

 

The draft as written requires continuous crisis availability and rapid LMHP availability and response. This transforms CPST-Schools into something considerably larger than a school-based behavioral health service.

 

If the provider is responsible for school-day intervention, after-hours support, weekend support, holiday support, crisis support, LMHP consultation, external crisis coordination, continuity after crisis intervention – where is the corresponding staffing and reimbursement? Requiring 24/7 staff availability is not cost-neutral.

 

School Concerns: MOUs

Requiring an MOU with participating school divisions is an appropriate and reasonable requirement. However, is dictating the terms and conditions of the MOU within DMAS’s authority?

 

Some requirements appear to exceed ordinary conditions.

Provisions are identified that require the school division itself to undertake ongoing obligations, including providing information, making personnel reasonably available, and participating in crisis-response arrangements. The MOU therefore appears to do more than authorize a provider to enter a school and deliver Medicaid services. It creates a required contractual relationship between the provider and the school division and prescribes substantial terms for that relationship.

 

Provisions addressing areas connected to safe, confidential, and lawful service delivery can be understood as reasonable conditions for coordinating services in a school.

Ex: background checks, building access, confidentiality, coordination

 

Other provisions – while not necessarily invalid – require further examination as they potentially cross from protecting CPST-Schools service delivery into directing school operations and participation.

• Personnel availability for treatment planning. Requiring school personnel to be “reasonably available” dictates the use of school personnel time.
• School-functioning data. Mandatory provision of school-functioning indicators creates an ongoing information obligation for the school division.
• Crisis and threat-assessment integration. Requiring CPST staff to operate within school emergency and threat-assessment systems may affect how the division structures its own response procedures.
• Sixty-day termination period. Requiring at least 60 days’ notice prescribes a contract term between a provider and local governmental entity.
• Scheduling and instructional time. Rules intended to minimize instructional-time loss and avoid repeatedly removing a student from the same class may direct how school operations accommodate a service and does not reflect person-centered care.

 

- What statutory basis authorizes DMAS to dictate the terms under which a local school division may enter into or terminate an agreement with a behavioral-health provider when the provider, not the school division, bills Medicaid?

- Who has the authority to direct school operations?

-What statutory basis compels a local school division to participate in clinical treatment of a child?

 

School Concerns: Coordination, Treatment Planning, Confidentiality

The draft appropriately recognizes that CPST delivered in a school setting must coordinate with school staff and avoid duplication of services that the local educational agency is obligated to provide. But collaboration should not become a requirement that school personnel become de facto members of the clinical treatment team.

 

Coordination of services and treatment planning do not disregard the continuing need for client rights, confidentiality, and minimum-necessary concerns. Behavioral health providers should not become responsible for: determining educational eligibility/ ability, determining IEP/ 504 eligibility or placement, implementing IEP services, providing educational instruction, conducting school disciplinary functions.

 

The draft should make clear that school participation is collaborative and subject to school policy, availability, parental consent (where required), and confidentiality. There needs to be a clearer distinction between educational and clinical responsibilities and roles.

 

Educational records/ IEPs/ 504 – these are subject to federal and state confidentiality requirements. Requirements in this draft appear to need further review to ensure all client information – educational or medical – is appropriately protected. Preventing duplication of Medicaid-funded and school-funded services can be achieved without making the school a participant in the youth's confidential behavioral health treatment to an extent that is unnecessary for the provision of educational services.

 

“Educational impact” can easily become confused with educational eligibility or school-based decision-making. Consider adjusting the language – “clinically observed effects of behavioral-health symptoms on school participation and functioning”.

 

The draft correctly states that CPST-Schools does not replace MTSS, IEP, or 504 services. But the service simultaneously requires extensive school coordination and addresses outcomes such as: attendance, disciplinary referrals, lost instructional time, school participation, classroom behavior, transitions. These are clinically relevant outcomes, but they are also educational-system outcomes.

 

The draft identifies school-specific need indicators including:

- school team referral with specific behavioral-health concerns/goals; or

- current IEP/504 with behavioral/emotional goals.

These are useful indicators; however, should not be a prerequisite for medical necessity. A child can have clinically significant impairment in the school without an IEP, 504, or formal school referral/ meeting. Parents/ guardians, clinicians, pediatricians, etc. can also identify the need.

 

The draft assumes school personnel can participate in treatment planning, provide data, coordinate with providers, and participate in crisis procedures. But schools themselves have staffing constraints and shortages, the CPST- Schools provider cannot be expected to compensate for school workforce shortages as well.

 

Eliminating Group-Based Summer Programming

Individual CPST in the home or community during school breaks is not CPST-Schools. Eliminating structured summer therapeutic group programming can have profound negative impacts on youth, families, schools, providers, communities, emergency systems, schools.

 

The proposed CPST-schools model creates a significant cap in continuity of care by expressly prohibiting providers from establishing group-based summer programming and instead requiring individualized support. For youth with significant behavioral, emotional, social, and functional impairments (those currently receiving TDT); the school year provides a highly structured schedule. Children who require this intensity of behavioral-health intervention require and deserve a similar structured, therapeutic, supervised and group-based environment during the summer. Individualized home/community-based visits are not a functional equivalent.

• There is a fundamental difference between individual skill practice and skill practice while surrounded by peers and environmental demands. A child with social impairment does not develop social functioning solely by engaging individually with an adult clinician. They require opportunities with peers to interact, negotiate, disagree, compromise, wait, share, repair relationships, read social cues, tolerate frustrations, management competitions, and navigate responding to unexpected behaviors from peers. These opportunities occur consistently in group-based programming. 

 

What happens to children whose clinical needs are best addressed through structured, therapeutic, socially interactive programming when the school environment disappears for the summer? They lose predictable routines and expectations, immediate and consistent behavioral feedback, facilitated and supported peer interactions, support in problem-solving, practicing transitions, opportunities for skill generalization, and practice of emotional regulation, communication, and conflict resolution.

• Skill regression - increased dysregulation, aggression, oppositional behavior, withdrawal, anxiety, social isolation, sleep disruption, difficulty with transitions, reduced tolerance for demands, loss of coping strategies
• Impacts on the next school year. A child who loses functioning over the summer due to loss of comparable structure and therapeutic peer skill practice does not necessarily return to school on the same level they left. The school may receive a child who now demonstrates a significant increase in behaviors/needs. Providers are then required to support more severe needs as school resumes. This is reactive care – preventative care is more appropriate. The impact is not just on the individual child but the teachers, school staff, and entire classroom.
  • Costs to schools: increased behavioral incidents, classroom removals, disciplinary referrals, burden placed on school staff, lost instructional time

The draft identifies attendance, disciplinary referrals, suspension, instructional time lost, and educational placement as school-functioning indicators. These outcomes are therefore directly relevant to the policy's own goals. The system can spend more money responding to the deterioration than it would have spent preventing it.

• Costs to families- clinical needs do not disappear, the families are left to absorb the gap. Families (many of whom are unable/ unwilling to do this) are now required to provide supervision, behavioral structure, social opportunities, emotional regulation support, crisis management, activity planning, behavioral reinforcement, and conflict management. This is inappropriate – families are not behavioral-health treatment programs and cannot be expected to replicate the structure and intensity of daily therapeutic programming. Families can and should participate in treatment, but it does not mean they have the capacity to provide the intervention and treatment themselves.
• Increased cost to the community system - when behavioral needs escalate, families may seek help through: crisis services, emergency departments, law enforcement, acute psychiatric services, and inpatient care. Not every child will follow this trajectory; however, policy should not ignore the possibility that reducing preventative structure will increase crisis utilization for some youth.
• Inclusion issues- without appropriate therapeutic programming, a child may spend the summer excluded from peer activities, recreation, community participation, structured social experiences.

 

Aside from lacking the therapeutic components of TDT summer programming, traditional summer “camps” and programs are limited in availability, cost prohibitive, require guardians who are able/ willing to provide transportation, and often exclusionary to youth with significant behavioral and emotional needs. The request is not that ordinary recreational programming should become Medicaid-funded treatment. The concern is the absence of a clear mechanism for structured therapeutic programming that is neither ordinary summer camp nor isolated individual home-based treatment.

What summer “camp” can safely manage aggression, elopement, severe dysregulation, emotional instability, significant social impairments, and behavioral crises?

 

Policy can establish safeguards so that group-based summer programming is genuinely therapeutic and medically necessary. The answer should be clinically meaningful regulation – not elimination. 

 

If TDT-style structured summer programming is eliminated, then what clinically equivalent intervention replaces the functions provided by that environment?

• The stated goals of school-setting CPST include improving attendance, behavioral functioning, participation in school, and a reduction of behaviors contributing to lost instructional time. If a structured group-based summer program helps prevent regression, eliminating works directly against these goals. A policy cannot reasonably define the desired outcome as improved school functioning while disregarding a period (summer break) that can substantially influence the child's readiness to return to school. Otherwise, the system risks doing exactly the opposite of what it intends: saving money on prevention while paying for deterioration.

And the deterioration will not occur neatly inside the Medicaid program.It will show up in the home, work for parents, other summer programs, classrooms, school disciplinary systems, crisis services, emergency departments, provider turnover, and in the broader community. 

 

Final Remarks:

The draft is not short on clinical language, requirements, documentation, or expectations. What it is short on is a convincing demonstration that the proposed system can actually deliver the appropriate staff, in the school, at the right time, with enough authorized capacity, to meet the needs of the child. That is the standard that matters. And right now, the draft does not meet it.

It is a service daft with substantial unresolved access, workforce issues, role issues, training issues, and equivalence problems. And those problems are not going to stay on paper, they are going to show up in clients, families, classrooms, schools, and communities. 

 

CPST-Schools staff are slated to an immense amount of pressure. CPST – Schools includes: school-based clinical treatment, home-based continuity, community intervention, after-hours support, 24/7/365 availability, rapid LMHP consultation, EBP implementation, school coordination, IEP/504 involvement, MOU administration, transition management, extensive documentation, family engagement, utilization management, school functioning measurement.

This is an extraordinarily demanding staffing model. If these expectations remain unchanged, the service reimbursement rates must reflect it.

 

The greatest risk is that Virginia will technically replace TDT with a service that is more clinically elaborate but less available, less embedded, less responsive, and less capable of delivering actual behavioral-health intervention where children need it most: inside the school. This is a problem that should be resolved before TDT is retired, not after.