Workforce Shortages & Capacity: Virginia struggles already with staffing in the behavioral health sector. Turnover is constant, recruiting is difficult especially in rural areas, and there are already an insufficient number of trained and licensed clinicians. Shifting to a more community-based care system without increasing provider capacity and compensation runs the risk of overwhelming existing providers and causing quicker burn-out adding to the shortage of providers.

Administrative Burden, Authorization, Billing Complexity: This newer model will come with more paperwork, more prior authorizations, shorter authorization periods thus causing more authorizations having to be submitted more often, and more regulatory complexity. Small or rural providers may really struggle with this and could lead to less services provided or even closing of services. Delays in authorizations will impede timely access to care.

Budget Neutrality Constraint: The law requires that redesigned services be cost-neutral and some fear that this constraint might lead to cuts or underinvestment in services, or force changes that reduce quality in order to stay within the budget.

Geographic Access/Inequity: Some regions, especially rural ones, already lack providers and staff or even the infrastructure. Adding more will only be more of a burden on these areas. Non-rural areas could still see a lack of qualified providers, lack of qualified staff, and lack of needed infrastructure to implement the new standards. There is already a lack of RCSUs in many areas which require clients to have long travel distances for services. There is an increasing shortage of psychiatric hospital beds available and due to the cuts in government funding, this problem is projected to skyrocket to an unmanageable level.

Loss/Change to Familiar Services: There is a risk that some people will lose access to services they are currently in, such as TDT. If programs like these are phased out and there is no sufficient replacement or alternative, then there will be an increase in behaviors in school with no programs available to help and so kids will end up diverted to the juvenile justice system instead and that will create a whole new level of problems. If these new services don't map well, many individuals could easily fall through the cracks and never receive the interventions or help they need.

Quality and Oversight: It is imperative that services are evidence-based and trauma-informed, with proper monitoring for efficacy. There are concerns on how to measure outcomes, evaluate success, and how to hold providers accountable. Many service providers will likely need to hire more staff to be able to audit and monitor these new and complex changes and this could burden those providers as there is already a shortage of workers.

Timeliness/Transition: The timeline for implementation is really aggressive for phasing out legacy services and implementing the new ones. This could be gaps in services if there are implementation lags, or short periods where some people are underserved.

Financial Sustainability/Reimbursement Rates: Reimbursement rates are already too low, and the new ones are horrible. It was said in one meeting that the company who provided them with information gave them a range for reimbursement rates, and they chose to go below the middle. If you want quality care for individuals, want to make a true difference in the mental health system and create lifelong changes for clients, you have to have higher reimbursement rates so agencies can attract quality staff who will stay at the agency and be able to provide quality care. Choosing to go below the middle is a slap in the face to the consumers as you are saying their care is not worth it to pay the providers. Especially when it comes to more intensive and complex cases. Agencies will not be able to maintain staff or take clients with more complex needs.

Consumer/Family Awareness: There is concern that the people served, and their families, may not be well informed about the upcoming changes, what the new services will look like, or how to access them. If communication or support is insufficient, people are not going to get the services they need. The new design makes it a "one size fits all" approach and is no longer making it a "person centered" approach.

Risk of Unequal Service Quality: There is concern that providers will prefer clients who are easier or less intensive, or that in order to keep costs down they might avoid very high-need individuals. This will leave those individuals that are in the greatest need no available services or help and that will become a bigger societal problem. There are also concerns about geographic inequities, or differences in service depending on provider capacity.