Subject: Concerns and Recommendations Regarding EBP Implementation in Virginia

As a long-time Virginia resident and dedicated service provider, I’ve had the privilege of working closely with children and families across the state. I’m also part of a purveyor team for an evidence-based practice (EBP), and I care deeply about the quality and sustainability of behavioral health services in our communities.

Given Virginia’s stated commitment to expanding the use of EBPs and improving service quality, I feel compelled to share some concerns and recommendations. While the goals are commendable, the current approach risks undermining the very outcomes we aim to achieve—especially if the realities of workforce capacity, training needs, and implementation costs are not adequately addressed.

Providers are facing increasing pressure, and families are being driven toward CSA (Comprehensive Services Act) and DJJ (Department of Juvenile Justice) funding streams to access necessary services. This shift reflects systemic gaps that must be addressed to ensure equitable access and sustainable care.

1. Treatment Intensity and Reimbursement Rates

The proposed service hours and unit structures must realistically reflect the full scope of work required to deliver EBPs with fidelity. This includes not only direct care but also the substantial non-direct activities that are essential to effective treatment.

Without adequate reimbursement:

• Providers may be forced to take on unsustainable caseloads.
• Service quality may decline.
• Staff burnout and turnover may increase.
• Families may experience fragmented or delayed care.

To maintain fidelity and effectiveness, reimbursement models must support the full continuum of care activities.

2. Service Rate Structure

Rates should be designed to support both initial implementation and long-term sustainability. Specifically, they must account for:

a. Model Implementation and Ongoing Support

Initial training is only the beginning. Successful implementation of EBPs requires:

• Ongoing coaching and booster sessions.
• Fidelity monitoring to ensure adherence to the model.
• Supervision that goes beyond administrative compliance to support skill development and clinical excellence.

I strongly recommend:

• Requiring fidelity measures and periodic audits.
• Embedding outcome tracking into service delivery.
• Supporting supervision models that promote reflective practice and continuous improvement.

b. Non-Direct Time

Evidence-based care involves significant non-direct work, including:

• Treatment planning and coordination.
• Documentation and data collection.
• Crisis response and safety planning.
• Supervision and team collaboration.

These activities are critical to achieving positive outcomes and must be explicitly supported in the reimbursement structure. Failing to account for them jeopardizes provider capacity and workforce retention.

3. Clarity and Accountability

Terms such as “limited to no progress” must be clearly defined using measurable, objective benchmarks. Ambiguity in language can lead to inconsistent interpretations and undermine accountability.

Oversight mechanisms should include:

• Outcome monitoring systems.
• Feedback loops that help providers improve service quality.
• Transparent criteria for evaluating progress and effectiveness.

This clarity will support both providers and families in understanding expectations and outcomes.

4. Sustainability and Long-Term Impact

The current focus on billable hours risks incentivizing quantity over quality. Instead, reimbursement and staffing requirements should be aligned with the delivery of high-quality, evidence-based services.

To promote sustainability:

• Incentives should reward fidelity, outcomes, and workforce development.
• Funding models should support long-term capacity building.
• Policies should reflect the true cost of delivering EBPs with integrity.

By aligning financial structures with quality standards, Virginia can ensure that EBPs are not only implemented but sustained in a way that benefits children, families, and communities statewide.

Phần kết luận

Virginia has an opportunity to lead in the thoughtful, effective implementation of evidence-based practices. But doing so requires a realistic understanding of what it takes to deliver these services well. Providers need support—not just in training, but in infrastructure, supervision, and financial sustainability.

I urge policymakers and stakeholders to consider these recommendations as part of the broader strategy to improve behavioral health services across the Commonwealth. Together, we can build a system that truly meets the needs of our families and honors the commitment to quality care.

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