Overall comments: 

• This document is extremely too specific and prescriptive for the service given the companion Licensing and Department of Health guidelines that would also apply to services and staffing credentials. It appears to be attempting to address negative behaviors from providers that should be addressed in other ways such as through audits and not by adding burden and regulation to the system as a whole. 

• Staffing- challenges with workforce in general and heavy reliance on Licensed staffing- for example- not allowing QMHP’s to supervise as was just established to support workforce goals. 

1. Định nghĩa 

• Why create an “Early serious Mental Illness” (Adults) it’s the same as SMI but the “initial onset” what purpose does this serve? 

2. Service Definition/Critical Features 

• This does KHÔNG list a requirement that services be provide or available 24/7 YET in further sections there is some requirement for 24/7 on call AND Crisis supports. This will create barriers to staffing and agency ability to provide and is a duplication of other services such as ACT and Crisis Continuum which are already having capacity and workforce challenges.   

2.1 – CPST Teams- provides limited role for QMHP-T and BHT; given our national and state workforce challenges AND efforts to grow our workforce this has a direct negative impact on those efforts and opportunities and is counter to the work we have seen to be beneficial for the consumers served. 

• The over reliance on LMHP types continues to strain the system and again creates a barrier to capacity potential in providing CPST 

2.3 Service Goals for Youth- The statement “when services are delivered to younger children, the majority of the services must be delivered with a caregiver or legally authorized representative participating with the youth as the services are delivered.” Provides Concern 

• No definition of “younger children“ 

• It isn’t always indicated to provide the services WITH the adult- but indicates that is the intent? 

3. Required Evidence-Based Practices 

3.1.1 CANS Lifetime- where can this be found and who will train and “certify” staff to be able to administer this assessment? Will there be sufficient initial and timely ongoing trainings to manage the staff turn-over needs and challenges?  This does not appear to be an evidenced based assessment tool that is normed and utilized to a larger extent, and so it would cause question as to why as a state we are implementing a tool that is not evidenced based yet working towards ensuring a more evidenced based system of care. 

3.1.2 Other Clinical Assessments to Support measurement Based Care 

• This states we are strongly encouraged to utilize ongoing clinical assessments and symptom checklists to monitor progress and lists many- the concern is that these may be required or essential when requesting continued authorizations and therefore create added burden and challenges to our staffing and workforce. 

3.2 Referral to Standalone EBPs 

• States that individuals MUST be referred to any standalone EBP’s that they show eligible for following the CANS Lifetime prior to seeking CPST, like ACT, Clubhouse, Functional Family therapy- AND that it must be documented if it’s not available and why-  

• Added Burden to monitor so specific- as a system it is expected that we refer to those services that align with consumer service needs and evaluated on authorizations with MCO’s there is no need to be some prescriptive within this specific service.   

• Also this states that “if an individual is not making progress in CPST after the auth period, the individual shall be referred to the appropriate EBP.” 

• Same as above and concern about the focus on progress exclusively, there are times that sustaining and ensuring an individual does not move to a higher level of care IS the goal and supports them AND our system. 

• Clinical best practice guidelines shall be maintained and regularly updated in agency policy, particularly for the most common presenting problems to include Schizophrenia Spectrum Disorders, Bipolar I and II, Major Depression, and PTSD based on the population served. Unrealistic expectation to maintain such a document for each agency we rely on those best practices and already strive to keep current with the industry. 

3.3 Service Delivery for CPST populations 

• For both Youth and Adult- this prescribes a LARGE extent of required training modules- 

• Doesn’t account for the credential of the staff and what training they did to gain that credential such as QMHP hours already required or continuing education hours already required- Adds Barrier to staffing and maintaining. 

• Câu hỏi: 

• Who will be providing? 

• Will there be enough capacity and TIMELY capacity as we onboard staff? 

4. Required Service Oversight and Supervision 

• In general the reliance on Licensed Staff and limitations on # supervised and excessively prescriptive supervision schedules create quite a barrier and duplicate regulation for providers.  Yes we want our staff supervised and doing quality services, but to regulate to this extent creates significant challenges for agencies and staff.  

3. LMHP oversight  

• VERY heavy reliance and the concern is that many Licensed staff will not be comfortable being in such a position to provide critical supports to those with SED, SMI given the strict language within these proposed regulations.  And again given the workforce challenges this creates quite a barrier to capacity. 

• Sr. Level LMHP must be available to staff 24 hours a day 7 days a week for consultation? But this wasn’t an explicit requirement of the service and so needs clarification. 

• LMHP who oversees the services MUST provide in-person services to the individuals at least every 90 days 

4. Collaborative Behavioral Health Services/Supervision of Team Members 

• Weekly FTF team meetings to briefly discuss status of ALL individuals-  

5. Supervision of Individual Staff 

• Too prescriptive, duplication of other regulations and creates unnecessary burdens 

6. Staff caseloads 

• Differentiation with Tier 1 and Tier 2 services provides concerns in relation to overall services and caseload numbers 

• CPST provider must keep an ongoing formal log of each team members caseload.  An average over six-month period shall be used to demonstrate compliance with caseload limits= Overly prescriptive and most EHR’s will do this- adds administrative burden without equal benefits. 

• Agencies must ensure that sufficient clinical capacity to offer the psychotherapy service component of CPST as part of an integrated individual service plan when indicated by the clinical presentation and goals of the individual/family/caregiver while also meeting all supervision requirements=  

• Psychotherapy is listed as an “additional” service component yet it seems it’s required?  

• And this again emphasizes the burden on overreliance on LMHP’s and workforce challenges and will negatively impact agencies ability and/or capacity to provide CPST. 

5. Required Services Components 

5.1 Standardized CANS Lifetime: (same as above) CANS Lifetime- where can this be found and who will train and “certify” staff to be able to administer this assessment? Will there be sufficient initial and timely ongoing trainings to manage the staff turn-over needs and challenges?  This does not appear to be an evidenced based assessment tool that is normed and utilized to a larger extent, and so it would cause question as to why as a state we are implementing a tool that is not evidenced based yet that is a requirement of the services within this model? 

• Must be in person 

• Staff must be “certified” – who will do that? And will they be ready to provide it timely for onboarding and ensure sufficient training capacity?  

• Every 365 days at min. 

5.2 Treatment Planning 

• Overseen by an LMHP 

• ISP Reviews every 90 days min 

• When determined that an individual is making limited to no progress or is not engaged the LMHP Clinical Supervisor, in collaboration with the CPST team, the individual and individual’s natural supports, must review and update the ISP to increase the possibility that the individual will make progress achieving the identified goals and objectives.  = the language here is concerning and subjective- what will be the expectation  

• The service location must be documented on the individual’s ISP and must be associated with a specific goal or objective. Services must be provided in locations that meet the treatment needs of the individual to include developing and applying skills in natural settings. =Very prescriptive and not always known at time of ISP development, some could vary by location so how will this be handled, burdensome to staff and services, should just be expectation of the service. 

3. Crisis Support 

• Disagree with this section in whole-  

• Crisis support includes crisis planning, crisis avoidance and crisis intervention. 

• Crisis support also includes the development and ongoing review and update of a crisis management plan to assist the individual and their natural supports with identifying a potential behavioral health crisis and steps to manage the crisis and restore stability and functioning after distress or crisis.  

• Must be provided by an LMHP or QMHP and Shall NOT include use of or referral to Comprehensive Crisis and Transition Services. 

• Be available 24/7 365 days per year to provide immediate assistance to the individual.  

• In person must be offered and available 24/7 365.  

• Folding this into CPST and carving out of our existing Comprehensive Crisis and Transition Services creates a significant challenge for CSB’s in regard to workforce and ability to provide CPST.   

4. Restorative Life Skills Training 

• Should be able to be provided also by QMHP-T and BHT- workforce challenges as stated elsewhere-  

• Some language looks to be duplicative of Supported Employment- needs clarity 

5. Care Coordination 

• Should be able to be provided also by QMHP-T and BHT- workforce challenges as stated elsewhere-  

6. Rehabilitative Skills Practice (Tier Two Only) 

• Must be provided to ALL individuals receiving Tier Two-  

7. Additional Covered Service Components 

• Psychotherapy-  

• creates barrier for teams and staffing-  

• can this be billed or provided outside the CPST team to ensure access and appropriate clinical care for the individual-  

• could be specific practice or models are most appropriate and certain teams may not have that specialty-  

• should be allowed to be billed outside of team. 

8. CPST Service Provision without the individual Present 

• Vague and unsure how this will be monitored or facilitated. 

6. Provider Qualification Requirements 

• Licensure- Not Provided details as of yet 

• Accreditation within 18 months-  

• CARF does not accredit CPST and DMAS reported 9/12 that CARF doesn’t intend to add that as a “program” but that DMAS will provide a crosswalk to ‘like’ programs that CARF does accredit that agencies could get accredited in order to meet the requirements that are ‘like’ CPST-  

• Added Barriers to have two accrediting bodies- once accredited Licensure oversight should change in scope.  

7. CPST Medical Necessity Criteria 

• Confusing regarding Level of need in regard to the required elements- assuming it matches to CANS Lifetime in some sort of way, but this has not been provided. 

7.2 Additional Tier One CPST criteria for Youth 

• Caregiver/parent willing 

• The caregiver shall be a responsible adult (s) who lives in the same household as the youth and is responsible for engaging in family/caregiver psychotherapy and service-related activities to benefit the youth.  Unclear and may create barrier? Does this mean they have to be in their own therapy outside of CPST? How would that be monitored? What if they aren’t willing? Not an identified component of CPST? 

• The family/caregiver must commit to participating in at least 30 minutes of CPST covered service components a week.  Again how monitored if that doesn’t happen what happens, etc.  

7.4 Additional Tier Two CPST criteria for Youth 

• Same as above but family must do 2 hours per week of CPST be available for crisis within 2 hours on business days? May create challenges for families 

7.5 Additional criteria for workplace or instructional setting 

• Seems duplicative of Supported Employment-  

7.6 Continued Stay Criteria 

• CPST is a recovery-oriented intervention.  If the individual is not making significant progress after 90 calendar days, then the provider and health plan must develop an alternative Individual Service Plan.   

• Significant improvement? How is that measured?  

• The provider and health plan? What health plan helps with ISPs?  

• Concern this may limit the availability of necessary services for individuals and create increase needs for higher levels of care-  

7.7 Discharge Criteria 

• Recommended duration of services is four to twelve months depending on assessed needs of the individual. 

• Concern this may limit the availability of necessary services for individuals and create increase needs for higher levels of care-  

8. Exclusions and Service Limitations 

• The CPST provider or any affiliated provider or business of the CPST provider shall not provide Mobile Crisis Response, 23-hour Crisis Stabilization or Residential Crisis Stabilization to any individual receiving CPST. 

• Many concerns-  

• creates barriers for agencies in staffing and providing CPST due to workforce needs already existing. 

• limits access to appropriate care like 23 hours or residential services that aren’t in CPST 

• Individuals receiving CPST may not receive any of the following services:  

• ABA 

• ARTS- ASAM- 2.1-3.7 

• HÀNH ĐỘNG 

• Clubhouse 

• Coordinated Specialty Care 

• FFT 

• MHIOP 

• MHPH 

• Concerns again with limiting access to appropriate care, specifically with Clubhouse, and SUD services- those aren’t in CPST and maybe needed? I can see not providing them at the same exact hour but not within that episode of care is not clinically appropriate or person centered. 

• Other Limitations: Covered service components provided in the providers DBHDS licensed office location shall not exceed one hour a week (Sunday-Saturday) per individual and shall be for the benefit of the individual. 

• This seems to be saying the service is really exclusively community based which has not been stated elsewhere?  

• Adds burden of monitoring and ensuring- how will that be managed?  

• Prior presentations had an office based and community-based rate, that doesn’t seem present any longer- so What are the rates for providing this care given the majority is expected to be community based we would expect the rates to mirror those rate assumptions. 

9. Ủy quyền dịch vụ 

9.1 Level of Need 

• Indicates the allowed min. and max hours or units based on the LON but given the vast amount of services required to be provided- including therapy and crisis, these appear limited in nature and in our experience will not provide the necessary supports that mirror the LON as described. 

9.2 Preservice Authorization 

• This requires an ISP to be submitted which is a challenge to do a full ISP prior to any authorization?  

10. Additional Documentation Requirements and Utilization Review 

• Overly prescriptive and duplication of general requirements within documentation for DMAS services-  

• LMHP must review documentation of non-licensed team members at least every 30 calendar days as evidenced by a progress note in the individuals chart written by the LMHP or co-signature on the non-licensed team members progress notes.  

• Overly prescriptive and burdensome – reduces capacity of the LMHP