Positives:

1. I appreciate the goals of this service to incorporate evidence-based practices into services. Increased training for all staff and having QMHPs be more aware of evidence-based treatment approaches will improve the overall quality of services and provide more direction. I think this structure can be very helpful if some of the concerns are addressed!

2. I also can appreciate the desire for increased family involvement - this has a huge impact on the success and therapeutic outcomes of services. Similar to above, I think there are concerns that need to be addressed with this requirement, but the intention and evidence-based approach is beneficial as caregiver and social support involvement is a huge factor in successful outcomes.

3. I appreciate SRAs being approved in the shorter time-frame and for 180 days instead of 90! My main concern here is that MCOs truly review and approve based on client need. If MCOs are genuinely approving based on need and are providing the required units, this could be a good change! However, there have been situations of clients meeting medical necessity and being declined for various reasons. I have even heard of doctors in peer-to-peers agreeing that clients need more units but expressing that insurance companies were not willing to give additional units.

QMHP and Workforce Concerns:

1. I have concerns about the limits being placed on QMHPs both for billable service hours and for their role in the team. It was my understanding that QMHP-A and QMHP-C were combined to increase workforce accessibility and numbers due to staffing shortages throughout the state. In the CPST-Community model, QMHPs are very limited in what services they can offer. QMHP-Ts are even more limited, and I wonder how this will impact QMHP-Ts abilities to gain their hours to become full QMHPs or work with more experienced providers to gain experience. Consider increasing a QMHPs capabilities with what they can provide (i.e. Treatment planning which is then approved by LMHP or QMHP supervisor; allowing QMHP-Ts to provide Restorative Life Skills Training; etc.).

2. In addition, the VA board of counseling is implementing a process for QMHPs with experience and training to provide supervision to other QMHPs, but this is not allowable under the CPST Draft proposal. This increases administrative requirements on licensed staff and decreases the value/capabilities of qualified QMHPs with significant experience. There needs to be increased flexibility in providing supervision from Licensed-eligible staff and QMHPs with supervisory qualifications from the Board.

3. It also appears that QMHPs cannot sign documentation, even for QMHP-level services. I DO agree with LMHP oversight as a principle; however, increased administrative burdens on LMHP providers can actually decrease the quality of services as they are not able to meet all of these requirements with high quality. Allowing LMHP-eligible staff and QMHPs with experience and supervision training to sign documentation would likely improve the quality of supervision and auditing of documentation due to increased time.

4. I personally am excited for the training components (as I mentioned above). However, there are also challenges/complications with the numerous training requirements. How will agencies afford the extensive training requirements (both paying for the training and paying staff for their time attending)? I recognize that this is supposed to be built into the rates; however, it does not feel like the reimbursement rates will be timely enough or high enough to afford this, specifically since training must occur before any services can be provided and reimbursed. This also has to be considered in the onboarding process - how long will staff have to wait on training before they can begin providing services?

Community vs. School-based:

1. I recognize that this CPST draft is specifically for the Community/Home setting, so I am hoping that some of the concerns about school-based services are addressed in the school-based draft. One major concern I have is ensuring that clients are eligible to receive both Community and School-based CPST without those billable service hours being combined. I echo the sentiments of other TDT service providers that the need in the school-setting often looks different than the home setting. Many (most) of our clients need both in-home support including with guardian as well as school-based/peer support during the school day. I would like to see clients be eligible to receive services both locations with the billable service hours authorized per service rather than for CPST as a whole (i.e. 28 hours of in-home + 28 hours in school, if those billing caps are going to remain in place).

2. The parent/guardian requirement is extensive, particularly with “younger clients.” This is something that I think is beneficial when possible. My feedback is to be more specific on certain aspects and to expand exceptions to these requirements: 

   1. What ages are considered “younger clients?” 

   2. Does the same family member/caregiver have to participate each week (i.e. divorced parents where client is in multiple homes; clients living with both parents - could hours be combined?; client's living with grandmother but whose custody is with a biological parent that they stay with on weekends; etc.). It would be very helpful if multiple guardians could be included in the participation (i.e. 1 hour with Bio Mom and Bio Dad together = 2 hours. 2 hours with dad one week, then 2 hours with mom the next. etc.). 

   3. Can face-to-face and audio-only components be utilized with guardians to increase accessibility for guardians who work, travel, have medical complications, etc.? This is unclear in the current regulations that only specify they have to "commit to participating in covered service components" each week.

3. There also needs to be criteria for clients whose guardians are unavailable or unwilling to participate. If that is non-negotiable, then there will be many clients who lose access to these services. I agree that the participation is beneficial, but in many communities, it takes significant time to build rapport and trust with guardians. Can there be opportunities for the service with less enthusiastic or even opposed guardians, even though the end goal is to build rapport/trust and engage the guardians? Some accountability is necessary, but if requirements are too strenuous, the clients and youth are the ones who will suffer.

Billable Hours:

1. The limits on billable hours do not seem to account for various factors such as client and guardian absenteeism/no shows, the impact of client crises on needed hours, or even the length of the month. A longer month with 5 weeks would have the same number of units as a shorter month with only 4 weeks. This needs to be evaluated in light of number of business days per month, particularly in the school-based draft but also in the community draft as many families prefer weekday services.

2. A client experiencing a crisis is required to have 24/7 access to crisis services provided by CPST. If that is the case, will there be more billable hours permitted? Clients in crisis will need more hours than currently permitted, especially if they were a mid-level of need (i.e. LON 3 or 4). If a Tier 1 client experiences a crisis, their hours will rapidly runout. Additionally, if the staff providing that crisis support spends significant amounts of time with that client, they still have their billable hours capped at 504 units, potentially impacting their ability to see their other clients. This is a major impact if QMHPs are required to see the clients in crisis and QMHP-Ts cannot make-up service components with other clients or support in any way.

3. On the other hand, if clients no-show for services, are hospitalized, or if guardians do not show up for their required hours, QMHPs’ billable hours could be greatly reduced. With the cap on caseloads as well, there are only so many hours that could be made up with other clients, potentially lowering QMHP and agency income even further with no easy way to add hours.

Accessibility:

1. The requirement to refer to other services is likely to create significant increases in unpaid administrative time and delayed access to services. With limited providers in our area for the other services, there will likely be extensive waitlists. Are we expected to start CPST, then stop as soon as the client's spot on the waitlist becomes available? What is considered a "Reasonable effort" to make a referral before we can just begin services? Perhaps consider options for referrals rather than hard requirements and creating more specific guidelines for a referral process. 

2. Additionally, clients should always have a say in the provider and services; mandating what clients must participate in is a dangerous policy. There needs to be more flexibility and client choice incorporated into the language for human rights policies.

3. If the CANS lifetime can only be done by one provider, are we required to place clients in the Tier determined by the other provider and trust the quality/accuracy of their work?

   1. Sometimes, clients may need to start in Tier 2 then drop to Tier 1, or life events may occur that cause clients to increase need from Tier 1 to Tier 2. How easy will these transitions be [considering ease of transition between services was an original goal of the redesign]?

   2. What if we are unable to obtain the CANS from other providers?

   3. What is the CANS we receive is inaccurate/poor quality or does not reflect the LON we see out of the client? How can we move clients between LON and Tiers without this specific assessment?

Some of these are concerns that will need to be addressed over time. However, the reality is that there will clearly be an impact on the administrative burden for LMHPs, and in my opinion, a gross underutilization of LMHP-Es and QMHPs with several years of experience. I question the financial sufficiency of rates to have competitive wages (including PTO and other necessary expenses to reduce burnout) and to allow LMHPs to provide quality supervision/review if so much responsibility is on them that cannot be delegated.