I share the concerns that most other commentors have already raised. I will identify my most significant concerns:

1. As has been repeatedly stated throughout the redesign process, the proposed staffing structure and requirements is in direct contrast to the acknowledged shortage of licensed behavioral health workers in Virginia and nationwide. It will be impossible for smaller organizations to meet the proposed requirements for licensed staff, and extremely difficult even for larger organizations, due to the shortage of licensed workers. It will be made even more difficult by the inadequate reimbursement rates as most agencies will be unable to offer licensed positions at a competitive salary. Lastly, the increase in responsibilities for licensed staff seems in contrast to the beliefs and recent actions of DBHDS who recently reduced barriers to lower levels of mental health certification such as QMHP and QMHP-T. DMAS and DBHDS do not appear to be on the same page regarding staffing structure and that is a huge problem.
2. The exclusion that CPST and Clubhouse may not be provided simultaneously suggests that these services are duplicative in nature, when in reality they are very different yet complementary, both in setting, nature, and with regard to treatment goals. One service provides individual, community/home-based skill-building with the focus on learning skills and managing mental health treatment; while the other is offered in a center and provides socialization, daily structure, and opportunities to practice many of the skills learned in CPST. I suggest reconsidering Clubhouse as an exclusionary service as it is objectively beneficial for many individuals to receive both services.
3. The recommended length of stay for CPST is shockingly short and reflects a lack of understanding of the nature of progress in treatment for serious mental illness. I would question how the recommended LOS was determined and what data was used to form this recommendation. I would suggest increasing the recommended LOS or removing this recommendation entirely.
4. The requirement that individuals must be referred out to other services that the CANS-Lifetime finds them eligible for is impractical and will create a barrier to treatment. Especially as smaller (and often rural) organizations disappear because they cannot meet the new staffing requirements, there will be fewer treatment options available, and if an individual must be referred to other programs and wait to be rejected, wait-listed, or to find out that those services are not geographically available, then that will, at best, delay an individual's treatment; may deter them from treatment entirely; or, at worst, may lead to a crisis and/or harmful event while an individual is waiting to be approved for a treatment that they otherwise could have accessed. This requirement will lead to increased hospitalizations at the very least.
5. I am concerned about the level of crisis support required to be offered in a service that is fundamentally not a crisis stabilization or crisis intervention service. I understand that crisis support is a required component and I have no issue with that, but the service is otherwise not designed or financially or structurally able to act as a 24/7/365 crisis stabilization program. Those services have much higher reimbursement rates, because they are expensive, require highly credentialed staff, and have to offer attractive salaries to staff programs 24/7/365. None of the other 7-8 components of CPST should be offered round-the-clock. It is illogical and impractical to require just one component of the service be available 24/7/365. Isn't that what other crisis services are for? Providing crisis intervention during business hours with a clear plan for accessing crisis services after hours seems sufficient for what CPST is supposed to be.