As many other comments have stated, the transition to the CANS Lifetime assessment presents significant concerns, challenges, and anticipated barriers ranging from removal of person-centered care to the elimination of client privacy. This writer is in agreement with points provided by other commenters, including:
For reference throughout, additional specific points under headers have been added to the end of the numerical point. For example, 9.1, #3, is listed as 9.1.3.
To begin, there are portions of the Appendix (TBD): Comprehensive Assessment of Needs and Strengths (CANS Lifetime) that are appreciated. Those specific points include:
Overall Concerns
This manual opens with “This Medicaid Provider Policy Manual establishes the requirements, standards, and procedures governing the use of the Virginia Comprehensive Assessment of Needs and Strengths (CANS) Lifetime 1.0 as a condition of Medicaid reimbursement for behavioral health services in the Commonwealth of Virginia…. This policy applies to all Medicaid-enrolled behavioral health providers, including but not limited to: 1. Community Psychiatric Support and Treatment (CPST) 2. Coordinated Specialty Care (CSC).” Throughout the manual, there are numerous references to the CANS Lifetime assessment being required for all Medicaid reimbursed behavioral health services, which an excessive burden that will create more of a barrier to services than any possible assistance it is currently seeking to provide.
Section 3
Will an option of “Not Applicable” be available for sections that do not apply to individuals, such as Independent Living Skills for younger clients?
3.1 – The statement that a rating of 2-3 “signals a need the ISP should address” directly opposing the idea of client choice and person-centered care and documentation. This suggestion or requirement will lead to formulaic and non-person-centered documentation and ISPs. Alternatively, the idea that this will require additional documentation to support not including this item in the ISP based on client choice will create an unnecessary burden on providers with the additional of all requested documentation.
3.3 – Please provide clarification and guidance on the listed “Crisis Mitigation Plan,” as it is unclear if this will be an item included within the assessment or if safety plans (or specified safety plans from 3.4) will be required.
3.4.1 – An explanation for the selection of modules required at launch as opposed to those elected as optional at launch would be insightful and helpful to assessors and the public at large. There are concerns regarding the lack of include of Sexual Aggression in the initial required modules due to the significant impact of these behaviors on others.
Section 4
4.4 – technical error on page 9 “[add VAC or manual references]”
Section 5
Please specify if event-based reassessments will reset the annual date for future assessments.
5.1.1 – Please clarify if the CANS Lifetime assessment is for all Medicaid reimbursement for behavioral health services or just those requiring a CANS-based authorization. If the CANS Lifetime assessment becomes the expectation for all Medicaid reimbursed behavioral health services, the administrative burden this places on providers will drastically impede their ability to provide services, increase workload to an excessive level, and impact services that are available to individuals and families. The barrier this creates alone during Same-Day Access would be prohibitive for families and providers.
5.1.1.A – What is the intended location for the CANS assessments verification and what will the verification process be for determining if a CANS assessment exists within the calendar year for an individual? Currently, accessing this information through MCOs requires extensive wait time and will impact a CSBs ability to complete all necessary activities related to Same-Day Access and connection with services.
5.1.2 – Is the term ‘youth’ used for all individuals under 18 years old? Some standardized measures incorporate individuals as young as 15 in adult measures.
5.1.4 – Please provide guidance regarding if services will still be able to be provided and reimbursed while awaiting the response to an event-based reassessment.
Who will be responsible for determining if an event is “worthy” of being reimbursable? Is the appeal process going to be expedited due to the limited timeframe offered for reassessments? Is the expectation that if an event is determined by the provider to necessitate an event-based reassessment, is the expectation that a reassessment still occur even if denied for reimbursement? Additionally, In instances where trauma in not disclosed in an initial assessment however is subsequently disclosed in a later session with provider, what period of time must have elapsed before an event-based reassessment becomes ‘valid’? (Also see 6.4)
5.2.2 – The explanation provided does not rationally make sense with the example given related to behaviors. The 30 day window is determined to be “the preceding 30 days,” and the example given lists “individual who has not engaged in self-injurious behavior in 28 days… shall still be rated at an actionable level.” Please provide an alternative example to more readily highlight the intended point that underlying risk factors that are present warrant an actionable rating regardless of if the associated behavior has occurred within or outside of the preceding 30 days.
5.5 – The “shared vision” the CANS is intended to represent seems to be vision of the draft authors and original proponents of implementing the CANS lifetime assessment as opposed to the vision of individuals and families. This is based upon the numerous references to requiring specific items be included in the ISP in place of person-centered care.
6.4 – Please provide guidance regarding the length of time that is permissible for amended or corrected CANS ratings, as well as what constitutes a correction or amendment for the purposes of this manual.
7.2.1 – Please clarify the accessibility of the electronic system and authorized users, as the ability to reference this system will have a dramatic impact on CSBs, particularly, with Same-Day Access. If an individual receives another CANS Lifetime assessment within the 5-day window to submit this information, how will this situation be handled as there way no assessment at the time of initial verification.
7.3.2.4 – Please provide guidance on anticipated turnaround and associated documentation required to submit for a “qualifying event” triggering a reassessment.
7.3.3, #3-4 – The request for an event-based reassessment requires documentation of the qualifying event, its clinical impact, and clinical rationale, which is essentially a request for a pre-assessment to determine if a reassessment is required. Additionally, as non-treatment providers are expected to review authorization requests, what is the impact of clients’ requesting to limit the amount of information provided within the request?
8.1.2 – Please clarify expectations for linking individuals to residential stability services given the limited availability of this support in many areas of the state.
8.1.3 – Please provide clarification on “willingness” and participation in taking prescribed medications.
8.3.2 – Please provide clarification and guidance on ratings for individuals with complex trauma.
8.6.1 – The commonality of multiple household involvement with youth almost necessitates a minimum of 2 Caregiver Resources and Needs sections for all assessments. For rating additional households, are individuals from each household required to be present for assessment, or is it to be completed based upon the report of another individual?
9.1.3 & 9.2.5 – Please provide clarification on how inter-rater reliability monitoring will be conducted.
9.1.4 – Please provide clarification on the expectations for clinical supervision as it relates to CANS completion.
9.4.5 – Please provide clarification and guidance regarding how a determination will be made regarding “the same narrative language across multiple clients,” as many providers have a consistent ‘voice’ when writing narrative portions of assessments.
Attachment A
The entirety of this attachment is primarily written for adults with minor additions as they relate to youth services, such as the requirement of a screening for Functional Family Therapy prior to being enrolled in any Level of Need 3 (or higher) services.
A.1.3 – This section states individuals should receive services that “…provide them a vision and path to recovery however that is defined for the individual,” which appears to contradict sections 7.3.2.4 and 3.1 which focus on prescriptive treatment for needs.
A.1.6 – This appears to be the underlying crux of the redesign, which has resulted in an overall of a state-wide system, based on the actions of a few, while disregarding the impact on the masses.
A.2 #3-6 – The requirement that a screening be completed for specific interventions directly opposes clients’ rights and choice. Additionally, please provide guidance regarding what a screening “prior to enrollment in other Level of Need [#] services.”
Attachment B
The unit ceiling identified for services directed at youth is a significant decrease in supportive services from currently available services under the 'legacy' system. The current unit ceiliing for Functional Family Therapy (which youth at Level 3 or higher should be screened for) has a current unit ceiling of 160 for a 5 month authorization, with a 15 minute unit duration, which equates to an average of 2 hours per week for an intensive service. 160 units/4=40 hours, 40 hours/5months = 8 hours per month. While the underlying goal of the redesign appears to decrease cost overall, the drastic decrease in support is more likely to require additional costs in the form of increased higher levels of care due to the absence of community-based support at previous levels.
2.1 & 4.4
Please provide additional clarification regarding if this is a combined assessment or not. Is the CANS Lifetime assessment expected to be completed by a single person or a team? There are multiple clarifying points regarding QMHP, LMHP-E, and LMHP assessors and their roles. Is this section intended to provide ways for a treatment team to work together, such as case managers and other providers, or is this primarily aimed at MCO-appointed lead providers later identified in 5.1.1.A, #2 & #3?
2.1 - indicates the CANS Lifetime assessment is “the combined assessment document of record” and later states “the CANS ratings and the mental health evaluation are not separate documents.”
4.4 – “A QMHP who holds current CANS certification may complete the CANS rating” however the mental health evaluation cannot be completed by a QMHP.
5.1.1 & 7.2.1
Please provide guidance regarding the anticipated location and accessibility of information pertaining to verifying if a CANS has been completed within the calendar year.
5.1.1.A – What is the intended location for the CANS assessments verification and what will the verification process be for determining if a CANS assessment exists within the calendar year for an individual? Currently, accessing this information through MCOs requires extensive wait time and will impact a CSBs ability to complete all necessary activities related to Same-Day Access and connection with services.
7.2.1 – Please provide guidance regarding the anticipated permissible turnaround times given to MCOs if this is the required verification process, as this will significantly impact the ability to initiate services for individuals.
5.1.4, 5.4.2, 6.4, & 7.2.1.4
5.1.4 & 7.2.1.4 – Please provide greater detailed guidance regarding if services will still be able to be provided and reimbursed while awaiting the response to an event-based reassessment.
Who will be responsible for determining if an event is “worthy” of being reimbursable?
Is the appeal process going to be expedited due to the limited timeframe offered for reassessments, or will there be an extension granted for acceptable timeframe?
Is the expectation that if an event is determined by the provider to necessitate an event-based reassessment, is the expectation that a reassessment still occur even if denied for reimbursement?
In instances where trauma in not disclosed in an initial assessment however is subsequently disclosed in a later session with provider, what period of time must have elapsed before an event-based reassessment becomes ‘valid’?
5.4.2 - Will a declination of discussion regarding trauma by the family ever be determined to require punitive action, such as if a provider has multiple back-to-back refusal that are documented?
6.4 – Please provide guidance regarding the length of time that is permissible for amended or corrected CANS ratings. How long of a period of time is allowed for a retroactively modified CANS in situations such as these trauma disclosure after beginning services with provider?
Closing
Additional concerns exist related to the Level of Need algorithm which is currently undeveloped and the electronic documentation system for entering CANS information which is to be built following the implementation of the CANS Lifetime assessment requirements. When is the anticipated date for the DMAS algorithm to be finalized? Please provide additional information regarding the reliability and validity of this algorithm prior to launch of this redesign.