Overall:  The draft manual has a significant level of complexity related to medical necessity criteria, team composition, heavy administrative burden, heavy supervision requirements and heavy emphasis on LMHP to engage in non clinical functions such as signing off on LMHP-types assessments, frequent supervision sessions for qualified LMHP-types and QMHP staff and the 24/7 availability of LMHP and other staff for crisis supports.  Given the workforce shortages that Virginia continues to experience, it is recommended that the aforementioned is reconsidered and associated requirements are reduced.

Additionally, the requirement that in-person crisis support must be provided before any referral to a crisis continuum service is impossible to ensure.  First responders and other crisis service providers will not know who is currently receiving CPST services and how to contact the provider.  This requirement will cause significant access issues for individuals experience a crisis who are in immediate need.  Please remove this requirement.

Supervision of LMHPs:  The requirement of the Clinical director to provide one hour of supervision to LMHP staff is a heavy administrative burden and highly impossible for CSBs with a high number of LMHPs in the CPST service.  For example, we have 7 LMHPs in the school-based service who would need to receive supervision from our clinical director although they report to the Program Manager who is a licensed, tenured and heavily experienced.  It is recommended that this requirement be removed.

Supervision of LMHP-types and QMHPs – LMHP-types and QMHPs have had a sufficient number of work hours where they do not require weekly, or four hours per month, supervision.  This requirement is excessive, adds administrative burden and gives no regard to the level of experience that the LMHP or QMHP may have.  It is recommended that this requirement be removed.

Crisis Support: The prohibition of individuals utilizing Comprehensive Crisis and Transition Services denies access to potentially appropriate and needed services during a crisis.  Crisis support is not the same as crisis intervention.  Individuals’ crises may be acute to the point of needing a more intense and prolonged crisis intervention that is community-based.  This requirement may lead to more ED visits and more utilization of first responders.  Additionally, the requirement that the program be operational 24/7 adds costs as LMHP and QMHP have to be paid to work while responding to after-hours, weekend and holiday calls.  This will also be confusing for school staff and confuse policies, practices as much of this service is intended to be school-based.  It is recommended that the aforementioned requirements be removed.

Psychotherapy:  There are some youth who receive therapy outside of the service provider as this is a current allowance within the TDT service.  Some youth are referred to TDT and currently receiving therapy.  It is recommended that the CPST allow outside providers to provider therapy simultaneously to the CPST-school based service.

Accreditation:  Please consider other licensing or certification to suffice in lieu of CARF or other accreditations.  Examples could be CCBHC or existing CARF, etc.  Please consider removing this requirement as it is heavy on administrative burden.

Medical Necessity Criteria:  The criteria is very complex and nuanced.  Please consider simplifying the criteria to make it accessible to children who would benefit from the service.  For example, please consider removing the Intensity of Service section.  The hours of allowable service are extremely limited and do not allow staff to be available to the individual throughout the school day to provide intervention, support, reinforcement of coping strategies or to teach new skills.  The service is very prescriptive and does not allow flexibility to meet kids’ nuanced and specific needs.  It is recommended that number of hours be removed or significantly increased so that staff can be available throughout the school day.  Possibly consider a per diem for this service that covers all service components, administrative requirements and supervision requirements.

Please allow referrals to come from other partners in the school.  For example, Communities in Schools may make a referral to the CPST provider

Discharge Criteria:  Given the significant life experiences of many youth served including poverty, community violence, parental-supervision issues, in-home or community trauma and other social determinants of health, it is going to be highly unlikely that a child’s behavior and/or symptoms will be resolved within four months.  Many times, youth need additional support to manage at school because of the chronic factors aforementioned.  It is recommended that CPST be allow for at least one to two years.  If not, our children will fall through the cracks.