Thank you for the opportunity to comment publicly on the proposed draft for CPST – Home/Community Setting. As a current provider for MHSB, there are several concerns I have related to this draft and the redesign overall.  Upon reading through the other comments already posted, it appears that there are a lot of points of consensus being reached by those commenting.  Due to the various concerns (TDT being replaced by CPST as well as various questions/concerns related to MHSB transition to CPST as well) I strongly urge and hope that DMAS will reconsider these changes either in part or fully and at the very least delay plans for implementation until further collaboration regarding this redesign can occur with more direct input from service providers.  Upon reading the draft proposal, I can pinpoint that there appears to be a significant disconnect between the drafter(s) and those who are on the front lines providing these services as I cannot see how some of the changes would be made by anyone with direct experience providing these services.

To start with, the draft itself appears to be difficult to comprehend at times with many layers that impact one another and require extensive deciphering.  Sometimes the mantra of “less is better” can have its merits. Previous comments have indicated questions related to telehealth vs in person vs face to face being mentioned sometimes in a contradictory nature.  The tiered system and how teams are to be implemented can be difficult to comprehend and understand as well, not to mention the extensive rule outs of other services that must be completed first.  The supervision requirements are also difficult to understand and makes work on a plan to implement them difficult (ie how much can be in person for each level, how much must be “in person” or “face to face”, how many hours can be groups, how an LMHP can implement the hours required for supervision into a 40 hour workweek, etc.)  One commenter posted that if an LMHP were to be supervising 9 individuals that providing an hour of supervision would result in 18 working hours devoted to this task alone, much less meeting with clients, reviewing and preparing documentation, and all the other various oversight tasks LMHP staff should be doing to ensure good quality of service.  My fear regarding the intricacy of how this program is designed is that it will lead to confusion, chaos, and lack of uniformity related to oversight/approvals by MCOs and the providers as well.  The current recommended service times are in no way enough time to actually help an individual with Serious Mental Illness (SMI) achieve results and stability that will last.  While discharge information is addressed, I would suggest having measurable discharge qualification(s) set.  Currently MCOs are formulating their own ideas of when a person should be discharged (example one MCO telling us that a person cannot have MHSB for more than 6 years, while others state 2 or 3 years or sometimes less) – with no accounting for ongoing medical necessity need exhibited being taken into account.  Currently denials for MHSB and pushback from MCOs have appeared to increase, resulting in reports being heard of some agencies/providers considering having to close their doors (and some have). At the end of the day, whom this will affect most will be those in desperate need of dignified and quality care.  While I recognize that we want to be providing services with rehabilitation in mind, I feel that we are currently missing recognition of the ongoing nature of SMI and impacts on those who are at a level that they need this form of support to begin with. During planning for this redesign one point that was brought up was the need for those with serious mental illness to have some sort of a maintenance level type of care to avoid relapse and falling through the cracks. The way I read this draft there appears to be a mentality of “treat and street” along the lines of a medical model rather than taking the perspective of a wellness model.   

There is also a question that was posed by another commentor along the lines of “who is the population that this service is to serve.”  I agree with this statement.  While I think that lessening restrictions on qualifying diagnosis is a good thing and more focus on needs exhibited is a good thing, it is concerning that (from what I am seeing) there is not even information being made available about the CANS Lifetime, what it will entail, and who would qualify for the criteria on it to receive services.

Another point of major concern I have as a provider is the provision regarding providing crisis support and having existing crisis supports excluded.  While I feel having some allowance for clients to have crisis support from those who are familiar with them and know them best (their existing providers) I feel that this requirement goes too far and will lead to increased burnout and financial impacts on agencies providing care.  Someone in crisis could, in theory, require many hours of support to work through it.  If someone needs 5 hours of service from a provider, this will be 20 units and 5 hours for one single event, taking up a significant amount of the max service time they can be approved for monthly.  Providing crisis care also discounts the advantages (and significant work that Virginia has placed into perfecting) of Mobile Crisis, 23 Hr Crisis, Community Stabilization, and residential crisis care.  The rates of reimbursement also do not make it financially feasible for a CPST to have the burden of providing crisis care.  This seems like a way to pay someone less for providing the most important care someone can need.  While clients having 24/7 access to their CPST team in some form also can have its merits, I do feel that this is going to be something that will make it difficult to retain current staff and to find new staff.  Work/Life balance is of upmost importance for mental health professionals, and this requirement will only reduce that.  Why not allow the wonderful services already available and extensive time and effort placed into developing them, provide this type of support?

Lastly, with the exception of psychiatric care from within the team and medication management directly by team staff, CPST appears to be strongly reminiscent of Assertive Community Treatment (ACT), however the rates of reimbursement do not reflect this.  I strongly urge that if this model and draft is to be approved to consider having this reflected in unit rates so that quality staff can be obtained and their tenure held, as well as to respect the nature of the care that they are tasked by the new regulations to provide, and to make it possible for agencies to actually be able to financially provide these vital services. If these things are not able to happen, a significant portion of our population is going to be left without care which lessens the quality of life for everyone in the Commonwealth.

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