Positive Feedback

CPST is an enhancement of current services in at least the following ways:

• CPST gives opportunity to support youth who are not severe enough in presentation to be at risk for out of home placement but who otherwise would not have a level of care more intense than outpatient therapy
• Provides the opportunity for tiers that meet the client’s level of need
• Requires a higher level of clinical oversight
• Allows flexibility to provide services to the caregiver/parent without the individual present, which is a current barrier to providing effective family work in IIH.
• Removes restrictive medical necessity criteria for mental health skill-building that were often a barrier to access.

Concerns:

Additionally I would like to present the following concerns:

Định nghĩa

There are no definitions of several positions referenced throughout the manual: Clinical Director, QMHP and BHT. QMHP-T and QMHP are referred to separately in some places and only QMHP referred to in the chart of CPST staffing patterns (2.1 CPST Teams).

2.2 Service Goals for Adults

One goal of the service is to assist in stabilizing acute symptoms of mental illness which suggests crisis stabilization. This is inconsistent with the limitation in hours provided per week to these individuals (e.g., it is possible that individuals will be authorized for 1 hour per week for this service).

3.1 Measurement Based Care

While a level of need assessment seems like an improvement, it is challenging to offer feedback on the CANS Lifetime without any knowledge about what the assessment tool will look like.

3.2 Referral to Standalone EBPs

It is reasonable we will see waitlists for the standalone EBPs based on current availability of those programs. When this occurs, more clarity is needed as to the provider’s role while the individual is on a wait list. Is the provider responsible for seeing them temporarily while they are on a wait list? Or does the provider cease working with the individual after making the referral and notifying the MCO? The manual seems to suggest the provider could request authorization regardless of the CANS determination but is vague. Ambiguity here may lead to liability on providers for being the only available provider at the time of the CANS determination but also not able to meet the individual’s need per CANS recommendation.

3.3 Service Delivery for CPST Populations

More detail is needed regarding the training requirements for MAP, Youth Mental Health Rehabilitative Supports and Services training, Adult Mental health Rehabilitative Supports and Services training and CANS Lifetime certification. Specifically, there is no requirement as to how often the training must be completed, how long new hires have to be trained and whether there are any required entities that can/cannot provide these required trainings. Train the trainer opportunities would be valuable. A searchable database or means of obtaining proof of a new hire already being in compliance with trainings would also be helpful to prevent the burden of cost for training and onboarding.

4.5 Supervision of individual staff

There is a firm limit of 9 supervisees allowed per fully licensed LMHP Clinical Supervisor/Clinical Director. This does not account for the overall caseload size being supervised. There is significant detail about the size of caseloads that constitute full time vs part time staff which creates great variance about the total workload/caseload being supervised by the LMHP Clinical Supervisor. The LMHP Clinical Supervisor’s limit should be more reasonably based upon the overall caseload size they are supervising to extend beyond a maximum of 9. This could be accomplished by a limit on the number of full-time equivalent staff being supervised or be based solely on the total caseload count among supervisees. 

Additionally, the requirement that half of supervision hours must be completed in person creates an unnecessary burden on entire teams with 10 individuals driving to a meeting location likely twice per month. This is particularly burdensome for rural areas. It is unclear how the value of in person vs face to face supervision outweighs the burden.

4.6 Staff Caseloads

The requirement that non-licensed staff may provide no more than 504 units in a month will limit the staff to 29 hours/week of billable time. Even with the assumption that non-billable hours would be paid for up to 11 hours/week, this largely prohibits CPST staff from overtime. The rationale for this limitation is not clear when other forms of intensive mental health treatment do not place such strict limitations on the number of hours a mental health worker may provide direct care in a given week/month.

Additionally, the calculations for determining caseload maximums are cumbersome. This combined with the limitation of hours will create burdens on small organizations, especially those in rural areas that face significant workforce challenges.

Lastly, given the requirement of psychotherapy as a service component, the caseload limitations should not apply to LMHP types who provide direct care. It is unclear of the rationale for limiting an LMHP who provides psychotherapy to no more than 20 tier one individuals and no more than 8 tier two individuals. If it was not the intention to include LMHP types in the category of non-licensed team members in section 4.6, this should be clarified.

5.3 Crisis Support

Crisis intervention as a component of the service regardless of the tier assumes a significant burden to the provider when considering the maximum authorized units allowed per tier. The requirement for 24/7 crisis response without the immediate engagement of mobile crisis response will cause providers to quickly overutilize units for those individuals at high risk for crisis. Based upon the medical necessity criteria, individuals who meet the Personal Safety and Self-Regulation criteria will be at considerable risk for needing crisis response.

8. Exclusions and Service Limitations

This section appears to prohibit a CPST provider from providing crisis services to any individuals to whom the provider currently supports for CPST. Without this limitation, the only reasonable way for a provider to serve individuals in crisis would be to serve them temporarily in a crisis stabilization service. However, the provider must refer that individual to an unfamiliar provider to resolve a mental health crisis. This process is inefficient and is not trauma informed for person in crisis. Further, the rationale for this limitation is unclear given the service definitions of crisis services which are clearly distinct from the intent and purpose of CPST. This appears to be limiting on provider choice should the member have an established relationship with their CPST provider. It also poses a barrier to access and timely mobile crisis response, particularly in rural areas that have a limited number of MCR or CPST providers or areas that rely heavily on one large provider (e.g., CSBs).