The biggest concern regarding CPST is that there is no feasible way that the system will be ready to begin providing the new CPST services or other redesigned services on 7/1/2026. Given the policies & documents that will need to be created and the coordination between DMAS, DBHDS, and the MCOs before providers can begin to have a full understanding of what it will take in terms of staffing and training to achieve what is required to deliver the service, this plan is unattainable in this timeframe. Also, the education of members and community stakeholders is unachievable by this date. Listed below are many other concerns with the CPST paradigm.

Section 2.1 - CPST Teams: 

• The Tier/Level Team Matrix system is overly complicated and will lead to an increased operational burden that will impact the ability to provide care with no obvious increase in benefit to the individual served.
• Team definitions represent an extensive increase in reliance on Licensed staff. This will greatly increase the cost to provide the service as well as impact the ability of agencies to be able to offer this service due to the severe workforce shortage already evident for licensed providers.

Section 3 - Measurement-Based Care: 

• The CANS is an issue as it is an untested and not validated assessment. Also, there is an excessive amount of "recommended" assessments. Will all the "recommended" assessments become required?

Section 4 - Required Oversight & Supervision: 

• Clarification of the word "direct" is needed. Does this mean within the same agency? On-site? Face-to-face? Certain level of hours of supervision?
• 24-hour coverage by a licensed-type provider is a significant increase in cost to provide services.  Further, there is a significant workforce shortage for Licensed providers. 
• The requirement for the licensed provider to provide in-person services every 90 days further increases the cost to provide services which is exacerbated by the workforce shortage. Managment of providing this level of direct service as well as the required hours of supervision based on the provider type of staff decreases the feasibility of managing the multiple, increased requirements. The following describe the increased burden on LMHP staff:   minimum face-to-face team meeting weekly; nine staff maximum per LMHP; weekly supervision for all non-licensed staff; supervision documentation maintained in employee records; LMHPs to write progress notes reviewing non-licensed team members every 30 days; and DHP just created a pathway for QMHP-Ts to be supervised by experienced QMHPs, so why are QMHPs not allowed to supervise under CPST.

Section 4.6 - Staff Caseloads: 

• The staff caseload maximums are not fiscally feasible based on the rates presented for the services. The weights by caseload paired with the matrix methods described create extremely complicated, fiscally expensive requirements.
• The requirement for "formal log of caseload" every six months as the compliance requirement increases the administrative burden and is operationally difficult based on the fluid nature of staff caseloads.
• Staffing and administrative requirements that are burdensome and do not improve care should be reduced or removed.

Section 5.3 - Crisis Support: 

• CPST 24/7 crisis services are unnecessary due to the already established Emergency Services, Mobile Crisis Response, Regional Crisis Hubs, and 988 programs. Why are crisis services being limited for this program but not for other programs such as ACT?

Section 5.7.1 - Psychotherapy:  Why is Psychotherapy being provided under the CPST code a lower rate than under outpatient?

Section 7.6 - Continued Stay Criteria: 

• How is "not making sufficient progress" measured to trigger the need for an alternative service plan within 90 days? Also, ninety days is NOT sufficient time to make "sufficient progress."
• What is the requirement of expectation of improvement at the current level of service if individuals are at baseline but still meet the eligibility criteria?

Section 7.7 - Discharge Criteria: 

• 4-12 months is very limiting as it can take months to build therapeutic rapport with a client.
• Duration of services from 4-12 months is unrealistic, as is looking for improvement within 90 days from the start of services. These timelines need to be increased. 

Section 8 - Exclusions & Service Limitations: 

• The regulations state that members may not participate in both CPST and PSR Clubhouse. These are two very different programs that complement each other, and members should be able to participate in both.
• The regulations state that the provider shall not provide Mobile Crisis Response, 23-hour Crisis Stabilization, or Residential Crisis Stabilization to any individual receiving CPST. This will be a barrier to CSBs ability to provide CPST services.

Bản tóm tắt: 

Without considering the above changes, CPST could reduce service intensity, destabilize the workforce, and increase psychiatric hospitalizations. Revisions are needed to ensure that CPST is clinically appropriate, the workforce is sustainable, and the BH Redesign is responsive to the needs of Virginians with Serious Mental Illness. Please consider,

• Delaying implementation by at least one year, until stakeholder input can be considered and regulations, policies, staffing, and training can be in place.
• Create a program that is not so complicated, including revising the Tier/Level Matrix system.
• Find or create a more suitable measurement-based assessment and determine an exact list of other assessments to be completed.
• Reconsider the staffing requirements, decreasing the use of LMHPs and involving QMHP staff at a "higher" level.
• Allow PSR, crisis services, and other programs to be offered in conjunction with CPST.
• Remove or reduce burdensome accreditation, staffing, supervision, and administrative requirements that do not ultimately improve individuals' care.