HopeLink thanks DMAS for the opportunity to provide comments on this draft policy.

3.1 Needs Domains Rating Scale 

• The requirement that “a rating of 2 or 3 on most indicators signals a need the ISP shall address” is in direct contrast to the concept of client choice. It is unethical and inefficient to require that an ISP address any needs categories. This requirement also opens the possibility that the ISP will need to address a high number of needs categories, which is in contrast to a general best practice that treatment plans focus on a low number of specific and targeted goals.
  • REQUEST: It is requested that this language be amended to encourage but not require addressing of any service-relevant rating of 2 or 3 in an ISP.

3.4 Conditional Modules

• It is unclear whether and how the safety plan, required whenever Suicide Risk or Danger to Others is a 2 or 3, is different from the Crisis Mitigation Plan that is required for all participants of the redesigned services. If the plans are separate and distinct, and both required for high-risk clients, this seems confusing for both providers and clients, who will have two similar but separate plans to review, follow, and update.
  • REQUEST: Please clarify whether the safety plan can be used in place of the Crisis Mitigation Plan for high-risk members. If the documents are meant to be separate and distinct, please clarify how the two are meaningfully different and why both are clinically necessary.

3.4.2 Optional Modules

• REQUEST: Can you please clarify why these modules are not being required at launch, but will be required later?

4.3 Annual CANS Recertification

• The process for initial certification is described in 4.2, but 4.3 does not explain how to obtain annual recertification. Is it the same training and reliability test every year?
  • REQUEST: Please clarify how annual re-certification is obtained.

5.1.1.A The CANS Follows the Individual

• REQUEST: Please clarify how the MCO or DMAS “designates the lead provider” when an individual does not receive CPST or CSC; what is the decision-making process for this?

5.1.2 Periodic Updates

• There is no information, in this section or in other sections where the periodic update concept is discussed, about what documentation is required to meet this requirement, or what level of review. There is no information about credentials for providing the periodic update (can this be done by a QMHP, for example?) or what the nature of the “update” is (for example, is a face-to-face meeting required?).
  • REQUEST: Please provide more information on the nature of the periodic update, including documentation, credential, and service requirements.

5.1.4 Event-Based Reassessment

• REQUEST: Please clarify what happens in instances where a qualifying event occurs, but the reassessment is not able to be completed in the required timeframe (for example, an individual experiences a hospitalization, but remains symptomatic upon discharge and is unwilling or unable to meet with provider until 35 days after discharge; or an MCO takes several days to issue an authorization that comes after the 30 day mark).

6.2 Timeliness of Documentation

• It is not uncommon for individuals who are highly symptomatic to require assessment to be spread out over more than 1 day.
  • REQUEST: For assessments that require more than 1 day, please clarify whether the “5 business days” clock starts from the first assessment day, or the last.

6.3 Electronic Documentation Systems

• REQUEST: Please clarify the following:
  • How the electronic system will be accessed
  • Whether client consent will be needed for providers to upload their records, or to access their records when completed by another agency
  • Whether the electronic system will be able to “talk” to EHRs (ability to upload assessment straight from the EHR)
  • While the electronic system is being built: where the CANS data and spreadsheet will live, who it will be monitored by, and how it will be accessed by providers
    • Or, alternately, if this information is meant to be monitored internally among agencies only, until the electronic system goes live: how to determine whether an individual already has a CANS on file (in cases where individuals and their supports are not reliable reporters)

7.3.3 Event-Based Reassessment Service Authorization Process

• REQUEST: Please specify whether it is permitted to submit an authorization request in anticipation of a qualifying event: for example, an individual is hospitalized. Do we need to wait until they are discharged to submit the auth request, or could a request be submitted so that the authorization is obtained and a reassessment is able to be done ASAP upon discharge and minimizing barriers to re-engagement in treatment?

7.4 Coordination with Managed Care Organizations

• We would like to again mention, as we have in previous public comments on other services, the ongoing difficulty providers face in communicating with MCO care coordinators. Some MCOs provide an easier process than others, but the process for identifying and reaching the care coordinator is inconsistent across MCOs and an extraordinary amount of time can be spent just trying to obtain the contact information for the care coordinator.
  • REQUEST: It is requested that DMAS work with MCOs to develop a uniform and improved process for providing providers with the contact information for the MCO care coordinator.
  • REQUEST: It is also suggested that an improved process for internal communication within the MCO be developed, so that the provider is not relied on to communicate information that happens within the MCO. For example, an MCO care coordinator should be able to know when an event-based reassessment has been authorized by that MCO, instead of relying on the provider to inform them. An MCO care coordinator should also have access to the electronic documentation system that houses the CANS-Lifetime assessments and should have a degree of responsibility for keeping themselves informed of the information they need, rather than reliance on the provider.

9.1 Provider Quality Assurance Responsibilities

• This level of oversight by DMAS about quality control seems excessive and is novel. This is not a policy that exists in any current regulations for the provision of community mental health services or the related assessment.
  • REQUEST: Consider leaving these requirements to the agency to determine and allow the requirements to be naturally fulfilled through the other requirements already established in other sections (for example, the annual recertification requirement for providers to do the CANS was already established in an earlier section; allow the agency to determine its method for ensuring this).

A.2 Levels of Need Model and Service Array

• The requirement at each level of need that states that individuals must be screened for specific other services (for example, “A.2.4, “Individuals at LON 4 must be screened for eligibility for Functional Family Therapy, Coordinated Specialty Care, and Assertive Community Treatment”) is understood. While the criteria for some of these services are clear and distinct (such as age and diagnostic requirements for CSC), others- such as many of the functional impairment criteria for ACT- overlap significantly with those for CPST. It is not clear from these regulations how the provider, and consequently how the MCO, is to determine that an individual is “more appropriate” for one service over another in instances where that determination is somewhat subjective. An assessing provider could make a strong clinical argument for placing an individual in CPST over ACT, but a reviewing MCO could disagree and the authorization could be denied, resulting in an individual not receiving needed and/or timely services.
  • REQUEST: Please provide more clarification about how individuals should be assessed for alternate services, how this should be documented, and clearer criteria for “choosing” one service over another in instances where the decision is somewhat subjective.