Lose the jargon- words that mean nothing and add nothing to understanding or delivery of services. Examples: systemic, dynamic, evidence-based, functional, etc. etc. Just say what you mean simply- the buzzwords add nothing. 

The present CPST – Youth, School Setting draft creates jurisdictional and role-boundary concerns for LMHPs overseeing care. While collaboration between behavioral health providers, families, and schools is essential, several proposed requirements appear to extend the responsibilities of LMHPs into areas governed by the educational system.

IEP/504 Role and Scope of Practice Concerns

The draft appears to require LMHPs to identify each IEP/504 goal related to behavioral, emotional, or social functioning; determine whether each goal is addressed by the IEP/504, CPST, or both; provide a clinical rationale for duplication or overlap; identify the school personnel responsible for implementing the educational component; attend an IEP/504 meeting as a condition of CPST authorization; submit clinical input to the IEP/504 team when attendance is not practicable; determine that a child’s mental health impairment adversely affects educational performance; and communicate that determination to the school team.

These requirements are problematic because an IEP/504 process is not a behavioral health treatment plan. It is an educational and legal process governed by the Virginia Department of Education and school-system procedures. While an LMHP can clinically assess whether symptoms of a mental health condition interfere with functioning, determining educational performance is not synonymous with determining clinical impairment and is part of an educational evaluation and process outside the scope of practice of an LMHP overseeing CPST care.

The proposed language stating that the LMHP “shall” attend at least one IEP or 504 team meeting per service authorization period also raises concerns. An IEP meeting is a school-governed process, and the school determines its team composition.

DBHDS regulates behavioral health services, while the Department of Education regulates the educational system. As such, CPST providers cannot establish requirements that govern how IEP/504 processes operate. CPST is distinct from educational services. Collaboration between behavioral health providers, families, and schools is an extremely important and necessary component of care; however, collaboration should not become regulatory role substitution.

Recommendation: DMAS should revise the final manual to include clear scope-of-practice language distinguishing behavioral health responsibilities from educational responsibilities. The final language should encourage LMHP participation and collaboration with schools and families when clinically appropriate, while making clear that LMHPs are not responsible for making educational determinations, directing IEP/504 processes, determining school-team composition, or otherwise assuming responsibilities governed by the educational system.

Referral to Standalone Evidence-Based Practices

Sections 3.2.1 through 3.2.3 of the CPST draft manual concerning referral to standalone EBPs create ambiguity regarding the relationship between CPST and those services.

If an EBP is clinically appropriate but unavailable, it is reasonable for a provider to document barriers to access and, when appropriate, assist the youth and family in pursuing access. However, a CPST provider cannot control the availability of a standalone EBP, geographic access, waitlists, authorization decisions made by another entity, or whether the individual and family chooses to pursue the referred services.

Being held responsible for notifying the MCO of barriers, coordinating to address access as soon as practicable, documenting all care coordination, and including a plan to transition when the EBP becomes available appears to place systemic service-access problems onto the provider that are outside of the provider’s control.

Furthermore, if an EBP is deemed clinically inappropriate, availability would not change that clinical determination. Requiring an ISP to include a plan to transition to an EBP that the assessing LMHP has determined is clinically inappropriate creates an internal inconsistency within the proposed requirements.

The treating LMHP should be responsible for assessing the youth’s behavioral health needs, determining the medical necessity and clinical appropriateness of CPST, making clinically appropriate referrals, and documenting reasonable coordination efforts. The LMHP should not be made responsible for guaranteeing access to another provider’s service or resolving systemic capacity problems.

Recommendation: DMAS should revise these provisions to distinguish between a provider’s responsibility to make clinically appropriate referrals and document reasonable care coordination efforts and the provider’s inability to control another provider’s availability, geographic access, waitlists, authorization decisions, or family choice. The final manual should also clarify that an ISP transition plan to a standalone EBP should only be required when that EBP has been determined by the treating LMHP to be clinically appropriate and indicated.

LMHP Caseload and Workload Protections

The present CPST – Youth, School Setting draft raises significant concerns regarding the expectations placed upon LMHPs.

The draft recognizes that excessive caseloads can negatively impact service delivery, staff sustainability, and client safety. It establishes explicit weighted caseload limits of 20 for staff providing the primary CPST components, including Restorative Life Skills Training, Care Coordination, and Crisis Supports. This demonstrates that the Department recognizes the importance of measurable caseload protections for staff providing direct services.

However, comparable protections are not established for LMHPs despite the significantly broader and more clinically complex responsibilities assigned to them throughout the draft.

The limits addressing clinical caseload oversight in Section 3.2 do not fully resolve this concern. These limits do not necessarily account for the additional direct clinical responsibilities an LMHP may simultaneously carry.

The distinction between caseload and workload is therefore critical. For LMHPs, who carry significant clinical, supervisory, assessment, treatment-planning, psychotherapy, and crisis-related responsibilities, there is no objective minimum standard or measurable workload methodology to ensure that an LMHP is protected from excessive assignments. This is particularly concerning given the national shortage of LMHPs.

An LMHP may simultaneously be responsible for assessments, CANS requirements, treatment planning, required 90-day contacts, psychotherapy, clinical oversight, supervision, crisis consultation, documentation, and other clinical responsibilities. A numerical limit on clinical oversight cases does not necessarily account for these additional responsibilities.

Recommendation: DMAS should establish an objective LMHP workload standard in addition to the clinical-oversight case limits in Section 3.2. The final manual should recognize that an LMHP’s total workload includes both direct clinical responsibilities and clinical oversight responsibilities and should provide a mechanism for considering clinical complexity, psychotherapy frequency, crisis activity, supervision, and other required clinical duties.

24/7/365 LMHP Crisis Consultation Requirement

The most significant concern is the requirement in Section 4.5 that each CPST provider maintain an experienced LMHP who is available for crisis consultation 24 hours per day, 7 days per week, 365 days per year.

The concern is not with ensuring that youth and families have access to appropriate crisis support. Continuous access to crisis support is important. The concern is the manner in which the proposed requirement assigns responsibility for that continuous availability to LMHPs without establishing corresponding staffing or workload protections.

The draft goes beyond simply requiring that an LMHP be available. During the instructional day, the LMHP must be reachable through an immediate and direct method and respond to a consultation request within a timeframe appropriate to an escalating in-person situation, not to exceed 15 minutes.

Outside the instructional day, including evenings, weekends, school breaks, and periods when school is not in session, the on-call LMHP must be reachable and able to respond to consultation requests within 30 minutes. Furthermore, in-person response is required when clinically necessary or indicated by the youth’s crisis mitigation plan.

An LMHP who must remain available for a 15-minute response during the instructional day cannot necessarily be treated as fully available for other clinical responsibilities during that same period. The LMHP may be conducting psychotherapy, completing an assessment, participating in treatment planning, supervising staff, traveling, or providing another clinical service.

Similarly, an LMHP who is required to remain available for a 30-minute response outside normal business hours may have significant restrictions on where they can be, what other responsibilities they can undertake, and their ability to disengage from work-related responsibilities.

The 24/7 Requirement Requires a Staffing Model

The 24/7 requirement requires a staffing model, not merely an on-call policy.

There are 168 hours in every week that must be covered. If an agency relies upon a single LMHP to provide that availability, the practical expectation would be continuous responsibility for crisis consultation in addition to the individual’s normal workweek. Such an arrangement is not a sustainable staffing model and creates obvious concerns regarding fatigue, burnout, clinical judgment, and patient safety.

Even if multiple LMHPs rotate on-call duties, the CPST agency must account for the fact that the on-call LMHP may receive an actual crisis consultation during the assigned period and that the response can involve substantially more than a telephone call.

Recommendation: The final manual should establish or clarify the staffing methodology necessary to provide reliable 24/7/365 LMHP coverage without placing an unreasonable burden on individual LMHPs. The manual should also clarify how on-call responsibilities affect an LMHP’s allowable direct-service and supervisory workload.

In-Person Crisis Response

The requirement for in-person assistance creates additional workload as well. If an LMHP is expected to be available for in-person crisis intervention, geographic coverage becomes a significant staffing consideration.

An LMHP cannot reasonably be considered available for an in-person response if that individual is providing services at another location, traveling, engaged in another crisis, conducting psychotherapy, or outside a reasonable travel radius.

Therefore, an agency’s ability to comply with the requirement depends not only on the number of LMHPs employed, but also upon their geographic distribution, schedules, existing caseloads, and availability.

Recommendation: DMAS should clarify the geographic and response-time expectations associated with in-person LMHP assistance and how agencies are expected to provide this coverage when an LMHP is already engaged in another clinical service or crisis response.

Recommended LMHP Workload Protections

The draft recognizes that caseloads should vary based on team composition, Level of Need, experience, and staff qualifications. However, that principle should be extended to LMHP workload.

DMAS should reconsider the LMHP workload provisions before finalizing the draft. At a minimum, the final manual should:

1. Establish objective LMHP workload standards in addition to the clinical-oversight case limits;

2. Establish how 24/7/365 on-call responsibilities affect an LMHP’s allowable direct-service and supervisory workload; 

3. Clarify whether an LMHP who is actively providing psychotherapy, assessment, supervision, or another clinical service can simultaneously be considered available for the required 15-minute crisis consultation response; 

4. Establish a minimum staffing expectation or staffing methodology sufficient to provide reliable 24/7/365 LMHP coverage without placing an unreasonable burden on individual LMHPs;

5. Clarify the geographic and response-time expectations associated with the requirement for in-person LMHP assistance;

6. Establish safeguards for LMHPs who have responded to significant or prolonged crises so that crisis response responsibilities do not simply become additional uncompensated workload layered on top of an already full caseload; and

7. Clarify how agencies will demonstrate during an audit that an LMHP’s total workload is clinically reasonable and does not compromise quality, safety, or continuity of care.

Conclusion

The intent of the proposed regulations—to improve access, coordination, continuity, clinical oversight, and quality of behavioral health services—is important and commendable. However, the practical ability of LMHPs to fulfill these requirements must also be considered.

The draft explicitly recognizes the need to protect other CPST staff from excessive caseloads and establishes measurable limits for those providing primary CPST components. It also establishes numerical limits for LMHP clinical oversight. However, these provisions do not adequately address the total workload of LMHPs who may simultaneously be responsible for assessment, treatment planning, psychotherapy, supervision, clinical oversight, crisis consultation, and other required functions.

Likewise, collaboration between CPST providers and schools is essential, but collaboration should not result in LMHPs assuming responsibilities that belong to educational systems. Similarly, LMHPs should be responsible for clinically appropriate referrals and reasonable care coordination but should not be held responsible for guaranteeing access to services controlled by other providers or systems.

The 24/7/365 crisis consultation requirement, including a 15-minute instructional-day response, a 30-minute after-hours response, and potential in-person assistance, represents a substantial staffing and workload obligation. These requirements should be accompanied by an appropriate staffing and workload model to ensure that LMHPs can fulfill their crisis responsibilities without compromising their other clinical obligations.

Protecting LMHPs from unsustainable workloads is not merely an employee-welfare issue. It is directly related to patient safety, quality of care, clinical judgment, workforce retention, and the ability of providers to comply with the regulations themselves.

For these reasons, it is respectfully requested that DMAS revise the final CPST – Youth, School Setting manual to establish clear role boundaries, distinguish provider responsibilities from systemic limitations, and create measurable LMHP workload and staffing protections. These revisions would support the Department’s goal of providing high-quality, accessible, and clinically appropriate services to Virginia’s youth and families while ensuring that the professionals responsible for delivering those services have the capacity to do so safely and effectively.

Key Concerns

1. Loss of Intensive School-Based Support TDT provides structured, therapeutic support throughout the school day, offering consistent behavioral interventions, peer interaction, and real-time skill development. The proposed CPST model offers significantly fewer service hours and relies on episodic interventions in home, school, and community settings (potentially reducing the amount of support provided in the actual school setting). This is not equivalent to the daily therapeutic environment many students currently receive and will not meet the needs of our high needs youth.

2. Increased Risk for High-Need Students Students with significant emotional dysregulation, trauma histories, behavioral challenges, and frequent crises benefit from ongoing daily support. Replacing TDT with intermittent services may result in:

• Increased behavioral incidents and crises
• More suspensions and school absences
• Greater use of emergency and hospitalization services
• Reduced academic success and school stability

3. Greater Burden on Schools Schools have relied on TDT programs to provide behavioral stabilization and therapeutic support within the educational environment. Under the proposed model, more responsibility will shift back to teachers, school counselors, special education staff, and behavioral support teams, many of whom are already stretched beyond capacity.

4. Elimination of Valuable Summer Programming Historically, TDT has provided critical summer services for vulnerable youth. These programs offer:

• Structured peer interactions
• Ongoing skill development
• Monitoring of student well-being
• Access to meals and supportive adults
• Continuity of care during school breaks

Without these services, many youth risk regression, increased behavioral concerns, and reduced access to support. Many of the families receiving TDT are unable and/or unwilling to engage in services in the home and even the community setting.

5. Workforce and Training Challenges The proposed training and credentialing requirements are extensive and dependent on external certification processes. This creates significant challenges for providers, including:

• Delayed staff onboarding and confusion amongst team members
• Reduced workforce capacity
• Increased turnover
• Greater compliance risk
• Increased financial burden

At a time when behavioral health providers are already facing workforce shortages, these requirements may further limit service availability.

6. Unclear Guidance and Duplicative Requirements Several sections of the draft create confusion rather than clarity. Examples include:

• Unclear expectations regarding the Clinical Director's role in crisis response and in-person intervention.
• Uncertainty about whether the CANS assessment replaces or supplements existing comprehensive assessments.
• Potential duplication of care coordination duties already performed through Mental Health Case Management.
• Confusing crisis requirements and expectations.

7. Implementation Concerns The transition timeline raises serious concerns for schools, providers, families, and youth. Successful implementation requires adequate training of staff and school personnel. Starting the service without the new training requirements available does not make sense. Implementing the CANs as a paper/pen method will create confusion and burdens on agencies who are required to share the document. 

8. Alignment with Educational and Special Education Requirements

Given that a significant portion of these services will be delivered in school settings and directly impact students receiving special education and behavioral supports, schools should be provided with clear guidance and training regarding the new service model before implementation.

School divisions need sufficient information to evaluate how CPST services align with existing educational requirements, behavioral intervention practices, Individualized Education Programs (IEPs), Section 504 plans, and other school-based supports. Without clear guidance, schools may face uncertainty regarding roles, responsibilities, communication expectations, service coordination, and compliance obligations.

Do the service requirements align with Virginia Department of Education (VDOE) regulations including FERPA and applicable special education laws and requirements.

9. Financial Sustainability and Service Capacity Concerns

The proposed reimbursement structure, combined with extensive staffing, training, supervision, and documentation requirements, raises serious concerns about the long-term financial viability of CPST programs.

Providers will be expected to maintain a highly trained workforce while absorbing substantial administrative and operational costs. However, the number of billable service hours available under the model may not generate sufficient revenue to sustain these requirements.

Key concerns include:

• Low reimbursement potential relative to staffing expectations.
• Extensive onboarding, certification, and ongoing training requirements that require significant time and financial investment.
• Increased supervision requirements and clinical oversight that add non-billable costs.
• Significant administrative burden related to assessments, treatment planning, documentation, outcome tracking, continued stay reviews, and compliance monitoring.
• Workforce shortages that already make recruitment and retention difficult, particularly in rural and underserved areas.

Potential impact:

• Fewer providers willing or able to offer CPST services.
• Reduced capacity and longer waitlists for children and families.
• Program closures, particularly among smaller community providers and rural agencies.
• Increased staff turnover and burnout.
• Reduced direct service time as clinicians spend more time meeting administrative requirements.

Ultimately, a service model cannot be successful if providers cannot sustain it financially. If reimbursement rates do not adequately account for staffing costs, training expenses, supervision requirements, travel time, and administrative overhead, agencies may be forced to reduce services or exit the program entirely. This would result in decreased access to care for the very children and families the model is intended to support.

We urge decision makers to reconsider implementing CPST as a direct replacement for TDT without maintaining an intensive school-based treatment option. At a minimum, stakeholders should evaluate the impacts on service intensity, student outcomes, school functioning, workforce capacity, and access to summer programming before moving forward.

Children with the most significant mental health needs deserve services that match the intensity of their challenges. Replacing a structured daily intervention with a less intensive model risks creating gaps in care that will be felt by students, families, schools, and communities alike.

Before implementation, further fiscal impact analysis should be conducted to determine whether reimbursement rates realistically support the required workforce, training, documentation, supervision, travel, and infrastructure costs.

Without adequate funding and operational support, the transition from TDT to CPST risks reducing provider participation, limiting access to services, and creating unintended consequences for students, families, schools, and communities.

     Thank you for allowing me to comment on the proposed revision on the Behavioral Health Redesign.  Though the new proposal is linguistically rich in verbiage and may sound good on paper, I challenge the practicality of it.  For anyone who works in public schools, it is apparent that practical solutions are needed.  The public schools need 'boots on the ground' to make a real difference.  

     Therefore, let me address some of the challenges with the current proposal.  The CPST design will reduce the number of support hours for our students in schools by 72%.  This is a drastic difference, and one that will be felt by our school systems.  Providing direct service on the front end will prevent the need for proposed services retroactively.  Our children need direct services, not the indirect services that are being proposed.

     Eliminating summer programming for students will be a big mistake!  Summer programming provides the consistency our kids need to sustain and maintain their social and emotional growth.  This has been evidenced with academics on many occasions and is no different in regard for social-emotional health and learning.  Our children and their families are excited and look forward to the summer programs each year.  For children who often do not experience extracurricular activities and community events, this piece is crucial and has a large impact in many different capacities.  It assists in teaching social skills and emotional-behavioral skills and allows children to interact with their peers in a different environment.  It also serves as a respite for families and children can take those skills back to share with their families.

    Furthermore, if you have worked in a public school system, you will realize that parent involvement isn't always optimal, as much as we would LIKE it to be.  Requiring greater parent involvement may affect an agency's ability to deliver services.  Again, we need more direct services, not indirect.

     Lastly, increasing administrative requirements often places additional burdens on staff and directly impacts the time and resources available to give back to students and families in a practical manner.  While some administrative tasks are necessary, increasing those requirements only takes away from the population you are there to serve - the students.  We need direct services and practical solutions, like TDT.   I will say again, we need 'boots on the ground' to face the challenges that students and families are facing now.  

To what degree has VDOE been engaged in the proposed changes as the new requirements will have significant limitations on the availability of staff at the school site based on the proposed allowable units per week and per month? 

The medical necessity criteria is extensive and complex – leading the service to unintentionally create barriers to access.  The layers of requirements also pose equity issues as there are multiple requirements from urban school districts and caregivers who are navigating significant and complex challenges associated high levels of economic and social needs in very high-stress environments.  In urban areas with poor social determinants of health including poverty, community violence, limited educational support and limited to no family support, students heavily rely on TDT, and will do the same for CPST, to help them be successful in the school setting.  The aforementioned challenges may require long-term supports and treatment to help them cope in their school setting. Please consider minimizing the medical necessity criteria for equitable and timely access.

Section 4 Program Oversight

Heavy reliance on LMHP staff.  There is a current workforce shortage for licensed staff in Virginia and beyond.  Please reconsider the amount of oversight and involvement requirements of LMHPs such as attendance of 504 and IEP meetings, and signing off on ISPs.

Section 5.3 Crisis Support – Requires 24/7 support be available however the rate does not support the cost to have a LMHP or QMHP on-call.  The maximum of 7-8 allowable hours (for Tier 2 if approved by the MCO) per week, will not be sufficient in an instructional setting in addition to providing crisis support that may happen in evenings, weekends and holidays. Please consider removing the requirement of 24/7 crisis support from this service OR offer more billable hours.

5.3.1.1 Preventative and Recovery Strategies

Practice and rehearsal of self-initiated crisis contact into restorative life skills training and psychotherapy requires time.  If the weekly allowable units of 8 hours per week remains, there is not sufficient time to meet with the student to engage in rehabilitative skills practice, engage in psychotherapy, meet with school personnel, attend 504 or IEP or disciplinary meetings as scheduled, meet with caregivers, respond to crises as needed, intervene when the student displays disruptive behaviors in the classroom and teach emotional regulation in vivo.  This is not possible and not sustainable for the program.  Please reconsider the allowable units for this service as the limited amount does not support a sustainable service.

I am providing feedback again today, on the draft CPST Regulations for Youth within the School-Based Setting. Overall questions and concerns in regard to CPST implementation and potential negative impact remain and are recounted below.

*The CANS Lifetime has not been released for review, nor have updates been provided in regard to its development. However, it continues to be cited within draft regulations as the primary screening tool for assessment and determining the youth’s Level of Need (LON). It is noteworthy that significant concerns continue to be expressed by Child & Family service providers who have had long-standing experience with administering the CANS as related to CSA-funded services. The CANS as it exists presently, does not support all that is listed under 3.1.1, 1-5.

*Additional Screening Tools are recommended, with 17 being listed for youth. Likewise, completing a Comprehensive Needs Assessment (CNA) appears to not be directly stated but rather implied, with the definition provided under 5.1. As such, it appears that the CANS and a CNA will BOTH be required … yes or no? If the CANS is permitted to take the place of the CNA, is there agreement with DBHDS on that? If not, can DMAS negotiate this with DBHDS?

*EBP service lines specifically recognized and reimbursed by VA-Medicaid are 4 in number, only 2 for youth, as identified in 3.2.2. While EBPs can produce optimal outcomes with model fidelity, they typically serve a niche population and do not have wide-spread application. EBPs are also expensive and cumbersome to stand up and sustain. This requirement of Referral to EBPs as outlined in Section 3.2 is a barrier to readily accessing services and will delay treatment for those youth & families most in need.

*Training requirements as delineated in Attachment 1.1 and 1.2 are extensive and burdensome. MAP training has been very limited; additionally, will resources be available to assist CPST providers with sustaining MAP relative to software and licensing costs? Likewise, the Foundational & Intermediate Skills Training and BHT Academy are seemingly not yet ready for roll-out. When will DBHDS make these be available?

*Draft regulations remain heavy in the arenas of LMHP service requirements and supervisory oversight. Not only does this create additional program burden, but it is unnecessary when there is a workforce of experienced/well-trained, Bachelors-level QMHP staff who have been composing treatment plans and delivering effective interventions in VA public schools for decades. Isn’t MAP designed to assist those providers with ‘lesser’ knowledge and skills a treatment path forward, complete with suggested goals, objectives, and interventions?

*Significant concerns surrounding financial sustainability remain, as the decreased, allowable units of CPST service simply do not support this intensive structure as presently designed. See Attachment 1, Section 4, Chart 2 for reference.

*Eligibility for CPST and the related Medical Necessity Criteria are incredibly complex and will undoubtedly pose barriers in accessing treatment, for those most at risk and most in need in our VA communities struggling with high social determinant of health! The criteria as outlined in Section 8 and the accompanying matrix in Attachment 1, Section 4, Chart 1 will present numerous opportunities for misinterpretation and CPST service denials.

At a time where the needs are greater than ever you create a service that limits services to Virginians. All of the emphasis nationwide is on evidenced based services and we are attempting to make up a service that has zero evidence. I asked DMAS about the evidence and they stated there is none. We will expect these teams to be on call and serve clients in crisis as well as daily. It makes ZERO sense. 

Services in schools are needed and schools in our area rely on services to function each day but this change will take away services in our schools, again at a time where the needs are greater than ever. 

Do everyone a favor and throw this to the side, then ask the people who deliver services how to make things better. Not some academic person who has never delivered services. Virginians deserve way better than this. 

The cost of implementation is also going to limit smaller providers. To say the cost is included is absurd. 

We need to DO BETTER for our clients and our State. 

Hello, 

Public Schools are supposed to exist for ONE primary reason. 

Academic Excellence. VA has not been performing Academically 

quite so well for about 25 years overall, and in large part 

due to creep of ‘Socio-Political Programs’ and chronic Mental-Healthing 

measures like ‘Social-Emotional Learning’ - Completely Ineffective, 

with virtually, zero ROI for Taxpayers OR The Parent’s

Children. This is how they want to Trans Your Kids. Make no

Mistake about it. Just. No. 

Hello, 

School Based Services Especially If Required for FAPE 

cannot be delegated to external providers. This is known as 

Non-Delegable Duty and School Divisions across the Nation

are beginning to hemorrhage grants funding for ‘double-dipping’ 

Mental Health Services. So, just like any other Personal Physician, 

they would NOT be routine IEP Team Members which potentially 

conflicts with VACBP statements. Schools Routinely REJECT QMHPs 

and other Privately Secured Providers to control ‘the process’ as 

well as all information about any given child/ren. 

These efforts are a massive intrusion upon the families to 

conduct Psychological/Mental Health Services without a Parent/Legal Guardian present. 

Vulnerable Children with Disabilites like Autism, should NEVER be subjected to 

any questioning, studies, without express parental consent and the IDEA mandates this.

RECOMMENDATION: Cancel This Initiative. It is harmfully invasive. 

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.