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The significance of the changes in the BH service delivery system which will be driven by the “redesign” were not as evident during the past conversations as they are with an actual written manual; and Section 3.2 is a perfect illustration of the dramatic shift toward significant reduction in services available for both adults and youth. Implementation of the requirements for “referral to standalone EBPs” will be unsustainable when you consider both the cost and the administrative burden of:
This requirement alone will result in significant disruption – perhaps that is the intent, but the cost in both dollars and human terms will be long lasting.
3.1.2 Other Clinical Assessments to Support Measurement Based Care
SBIRTs (Screening, Brief Interventions, and Rereferral to treatment) may also be a good clinical resource/tool(s) to utilize for adults as well as youth in this section.
I am concerned about the replacement of TDT with CPST. While CPST seems to have potential value as an individualized, community-based service, it is not an equal substitute for TDT. Removing TDT from the continuum of care would create significant service gaps for youth with the highest needs.
1. TDT provides 2-7+ hours of structured, therapeutic programming each day, often year-round. CPST, by contrast, is limited to 3-28 hours per month. The intensity of TDT is simply unmatched by CPST, leaving youth who require consistent daily therapeutic engagement without sufficient support.
2. TDT incorporates group-based treatment in a structured environment where youth practice skills with peers, build social competence, and benefit from therapeutic peer modeling. CPST, while permitting some group time, is primarily individualized and lacks the intensity of this essential group component, making it inadequate for youth who need greater amounts of supported peer interaction to develop social and behavioral skills.
3. TDT is delivered primarily in schools, bridging academic and mental health needs. This integration allows youth with severe behavioral or emotional challenges to remain in educational settings. CPST, while allowing some support in the school, is not school-based, and therefore cannot provide the same level of school support and classroom stabilization that TDT offers.
4. CPST requires active caregiver participation and availability for crisis consultation. While family engagement is critical, not all guardians have the capacity to meet these requirements due to work obligations, other caregiving responsibilities, or their own personal mental health/medical/etc barriers.TDT, by contrast, ensures children receive therapeutic services during the school day regardless of caregiver availability while still requiring involvement and communication with families regularly.
5. TDT serves youth with needs often identified as too severe for traditional school or outpatient settings—those at risk of hospitalization, removal from home, at risk of homebound placement, and demonstrating behaviors that lead to harm to themselves and/or others. CPST is designed for moderate to high needs in the home/community. These are distinct populations, and replacing TDT with CPST risks leaving the most vulnerable youth without appropriate care.
CPST is an important addition to the behavioral health continuum, but it does not replicate the scope, structure, or intensity of TDT. Eliminating TDT in favor of CPST will leave critical service gaps for youth requiring daily school-integrated therapeutic support.
As a current provider of PSR and MHSS services, we have several concerns about the proposed service definition.
QMHP supervisors – DHP just created a pathway for QMHP-T’s to be supervised by experienced QMHP’s. Because agencies worked together for Redesign, we are wondering why QMHP’s are not allowed to supervise under CPST.
CPST and Clubhouse – The regs read as though a Medicaid member may not participate in both CPST and Clubhouse. These are two very different programs that complement each other well. We would ask that members be able to participate in both. The regs also read that there is no member choice (3.2). If that is not correct, the wording could be clearer.
Caseload Cap – Controlling the number of billable services per employee makes sense. Controlling the caseload does not. A cap doesn’t allow members who need a few weeks to truly engage in the service and it doesn’t allow to titrate down. The cap means all 20 members need to be meeting often for companies to pay salaries. If someone is hospitalized for two weeks, which is common, then we would have to take them off a caseload and then add them back in when discharged so staff could see other members. Please consider eliminating this.
In person Supervision – The industry standard is face to face supervision, not in person. With the increased supervisory requirements and the inability to utilize QMHP’s as supervisors, please consider allowing virtual face to face.
4-12 Months: CPST, especially for adults, is going to be more successful with a little more time. 18-24 months is what we are seeing for members to show notable improvement. Having 4-12 months, even as a recommended timeframe, is going to lead to unsuccessful services.
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This is the first scrollable banner on the DMAS website:
Provider Services Solution (PRSS)
We don't want to lose our valuable providers! If you are a provider who recently received notice that you are no longer in a managed care network, the issue most likely can be fixed quickly with your help.
DMAS, the MCOs, and Gainwell are committed to working with providers to remedy the issue. Learn how to resolve common issues and enroll in PRSS.
Notice the bolded statement. Now consider the reality.
The number of changes introduced by the Commonwealth in the past year alone--consistent misalignment of the MCOs with state policy and regulatory guidance, inexplicable and continuous resurfacing invalid provider demographic information, MCO audits and recoveries hitting an all time high--would be enough to make any provider of integrity question whether they can continue to operate while accepting Medicaid clients. There is simply too much risk. And these are not just inconvenient patterns--they are existential threats. It is only with tremendous sacrifice that any provider continues to serve--sacrifice of both personal and organizational level magnitude.
And yet, the constantly rising bar to entry of administrative burden and operational red tape persists--in fact it is unrelenting. The failure to consider the cost of doing business is no longer a forgivable blunder, it is an egregious oversight. This all looks great on paper (and truly, the formatting of this document far exceeds what we're used to, so kudos). But it lacks any meaningful content because it is simply unsustainable in practice. It is a dream shrouded in name brand EBPs that cost providers out of pocket to maintain compliance with while the state offers laughable returns.
But there is more at stake here than just money. Communities will suffer. Who will provide the right help, right now when no providers are left standing?
And one other thing I have to offer: get the PRSS system to start passing through an actual term date on the JSON file so that the inactive provider locations actually end instead of passing through with 99991231 as the tech specs suggest they do. The recycling of old data is getting old and the chaos is compounding.
Virginia’s track record speaks for itself: policy changes roll out on paper long before they work in practice. If IIH, TDT, MHSS, and PSR are shut down on a fixed date without true continuity of care, vulnerable individuals will lose services, providers will collapse, and communities will ultimately pay the price.
This isn’t just bad planning, it’s legally risky. The Commonwealth is still under DOJ oversight precisely because it has failed to maintain reliable community-based services. To end core supports without a workable rollout for CPST isn’t reform, it’s negligence. The state can’t afford another Olmstead violation, and families can’t afford to be left without care.
While the intent of CPST is presented with an intent go expand access to mental health services, CPST presents significant financial and operational challenges for mental health agencies. The service model is not cost-effective, lacks scalability, and poses threats to both revenue stability and workforce sustainability.
CPST requires greater amounts of licensed or licensed-eligible staff than the legacy services it is designed to replace. CPST will increase the activities required by those staff and decrease the abilities of QMHP level staff to provide adequate support and intervention due to severe limits on service units provided. With recent changes to QMHP training and supervision requirements, how is this helpful in reducing the burden placed on LMHP type staff and supporting the appropriate utilization of QMHP staff?
Proposed reimbursement rates do not align with actual costs including salaries, training, travel, and supervision. The margins are slim to negative, making sustainability unrealistic. CPST is billed by time units, making income dependent on client attendance. With caseload caps, no-shows and cancellations have a higher probability of directly cuting into revenue while staff costs remain fixed. Limitations on these proposed units are not realistic based on levels of client need. When provided units are exhausted rapidly due to the unpredictable nature of crises and the requirements of the CPST team to provide the crisis support, this leaves gaps in the ability of the agency to receive appropriate reimbursement to sustain the service.
Heavy training, documentation and prior authorization requirements add unreimbursed staff hours and significant burden on the company and staff providing the service. High-stress, high-acuity, community-based work leads to burnout and turnover. Recruiting and training replacements increase expenses. Overall, implementing CPST as a proposed alternative to the legacy services does not appear to be a financially sound decision for companies both related to their bottom line and ability to sustain staff.
There is already a severe shortage of providers in the mental health field. There simply are not enough licensed mental health clinicians to meet demand. The acuity of client needs is increasing while the number of youth and adults seeking services continues to simultaneously increase, thus making the shortage worse. In addition to a shortage of qualified providers, behavioral health positions have very high turnover rates in public and community settings. Burnout is extremely common among behavioral health workers. That leads to people exiting the field or scaling back their hours.
CPST requires more highly trained/licensed clinicians. But getting people through the process is slow. Educational requirements, clinical supervision requirements, credentialing, and meeting state and local requirements takes time. This means that even when there are potential applicants for positions, it can delay when a clinician can actually see clients. These delays mean positions may sit empty or be underused. Rural, underserved, or remote communities also have greater challenges hiring and retaining clinical staff. Specialty areas (ex: crisis services) are especially hard to staff, but for CPST you need clinicians who can manage higher acuity cases. This increases likely challenges with appropriate staffing. When staffing is unstable, clients can have inconsistent service: clinicians leaving means gaps in care, shifting caseloads, disruption in therapeutic relationships, which undermines outcomes. CPST, given its more intensive, personalized nature, is especially sensitive to such disruptions. CPST handles crises and high-need clients. That requires clinicians with higher training, more oversight, and greater readiness to respond in less structured settings (due to the focus on community based support instead of clinic based). These are exactly the types of providers in shortest supply and highest burnout risk.
Because of these workforce realities—scarcity of qualified providers, high burnout and turnover, licensing/credentialing delays, and uneven geographic / specialty distribution—staffing a CPST program well (i.e. enough staff, with sufficient training and supervision, with manageable caseloads) is a substantial challenge
It maybe a less obvious issue, but in addition to the substantial cost in absolute fees, loss of “billable time” and wages for the very specific training which will be required for both professional and paraprofessional staff, the significant reduction is hours of service per person per week from the current accepted level means an equally significant increase in travel time. Not only is this time for which staff wages are paid, but it also disproportionately increases the ratio of non-billable to billable time. Add to this the increase in the number of notes to be written (more clients, fewer hours per client per week) and the required weekly team meeting, and you have tipped the ratio of non-billable to billable time to be unsustainable.
It maybe a less obvious issue, but in addition to the substantial cost in absolute fees, loss of “billable time” and wages for the very specific training which will be required for both professional and paraprofessional staff, the significant reduction is hours of service per person per week from the current accepted level means an equally significant increase in travel time. Not only is this time for which staff wages are paid, but it also disproportionately increases the ratio of non-billable to billable time. Add to this the increase in the number of notes to be written (more clients, fewer hours per client per week) and the required weekly team meeting, and you have tipped the ratio of non-billable to billable time to be unsustainable.
This is very concerning and cannot be viewed as a TDT replacement. Continuous cuts in mental health for our children and families yet increases in mental health needs - we need more support!
CPST does not replicate TDT's scope, structure or intensity. Support services will be reduced from 25 per week to 7 per week at best.
Greater parent involvement is a great thing but also becomes a barrier as the general population TDT services has minimal parent involvement to begin with. Requiring 8 hours of parental involvement will eliminate so many children who need this help and service.
Summer is the most difficult time for our students and CPST offers NO summer programming.
Our kids are without services for 3 months and expected to make strides in behaviors and mental health stability?? This is simply a BAD plan and hurts our students. Virginia childrent deserver better than this - ALL children deserve better than this- come on , you can and should do better.
To provide these level of services versus the minimum and maximum approved hours per month per consumer/client/member, etc, does not allow for an appropriate amount of time spent with them in the community to be effective! In rural Virginia, sometimes, it can take 45 min to 1 hr in one direction just to get someone to a viable appointment. If we can only spend 1 to 2 hrs per week with someone, there is no way we can measure any kind of progress or lack thereof.
Additionally, whereas these community programs are the core of our overall budget, the reduction in hours per month cut us specifically across the board at 75%. That will put us out of business.
You are increasing the requirements of providers which is fine but yet also reducing the large amount of measureable time that we can spend with each consumer.
We believe you should reevaluate the amount of time (hours) per month/per tier that you can spend with a consumer. There is a minimum need of 8 hours per week that is needed effectively determine progress or lack thereof of each consumer.
I appreciate the opportunity to provide feedback on the draft provider manual for Community Psychiatric Support and Treatment (CPST) services. As a school division leader, I want to express concern about the impact of this redesign on students, families, and schools across Virginia.
As you know, Therapeutic Day Treatment (TDT) will no longer be funded after June 30, 2026. While CPST is intended to serve as a replacement, the proposed model is not equivalent in scope, structure, or intensity. This raises significant concerns about whether the needs currently met by TDT will continue to be addressed.
Key concerns include:
Reduced Intensity of Services – TDT can provide up to 25 hours of therapeutic support each week, while CPST is capped at 28 hours per month. This reduction to a maximum of 7 hours per week represents a dramatic scaling back of direct support for students with intensive needs.
Shift Toward Family-Based Hours – CPST requires a substantial portion of services (at least 8 hours per month) to occur with parents or guardians. While family engagement is important, this reduces the availability of direct school-based support during the instructional day. For many students, especially those with limited family involvement, this creates a barrier to access and could mean losing critical support altogether.
Barriers to Access – Many students who currently benefit from TDT do not have consistent parent/guardian participation. Under CPST, these students would be at risk of losing the intensive behavioral and therapeutic services they need to succeed in school.
No Summer Programming – Unlike TDT, CPST does not extend into the summer months. The loss of year-round support will disrupt continuity of care and leave many students without services during a critical period.
Financial Viability – Based on current modeling, providers estimate they would operate at a deficit of several hundred thousand dollars annually if they attempted to deliver services comparable to TDT under the CPST model. This calls into question the sustainability of the program.
Recommendation:
While CPST may work well in certain community-based settings, the proposed model does not adequately replace TDT in schools. I encourage DMAS to consider modifications that would:
Without these adjustments, Virginia risks leaving many students without the intensive supports that allow them to remain in school and make academic and behavioral progress.
Thank you for the opportunity to comment and for considering these concerns as you refine the CPST model.
I have great concerns about this possible change. Mental Health issues in children is at an all time high both in and out of schools and, yet, we want to make a change that takes valuable resources away from them?
TDT in both Pulaski County Schools and Radford City Schools made a huge difference in supporting our students. If this resource is taken away, we will see an even larger increase in student mental health issues and not have the appropriate resources to provide support. Please reconsider this decision!
As a current (and seasoned) school employee, I have grave concerns with the transformative TDT to CPST model. Schools are often the "safe place" and most feasible location to offer life transforming services to students. TDT services in schools have been a true partnership between mental health and the public school system, assisting students to access their educational, social and emotional goals in a setting that is familiar to them amongst a group of their peers. This new model will reduce the number of support hours in school, and less group-based treatment, which may equate to lessen academic and social success. In addition, CPST requires great caregiver participation. For those students who have little active parental participation, this will be a barrier to services (as we have seen in other facets of the school setting). Furthermore, the summer gap months for students are critical to engage students and continue progress made prior to summer break. CPST does not allow summer programming, as does TDT. I can't stress how important this summer program is in order to "bridge the gap" and continue an already consistent program and relationships, something these students often do not possess. Please re-consider your proposal and the ramifications of such.
As an educator, I have serious concerns regarding the change in programs from TDT to CPST. I have first hand experience working alongside TDT providers who make huge differences in the lives of students and the ability of schools to effectively meet all needs of students. This change is moving in the wrong direction to support our children. In a time where we see the impacts of mental health on children, it is not prudent to decrease services. More specifically:
This is not the time for additional barriers for support and decreased service time for mental and behavioral health to be put in place. Some students need more intensive, in school, support in order to access education. The proposed change is detrimental to student success and health.
With the massive reduction in TDT services since the MCO’s replaced Magellan for service authorization, I’ve been hopeful for a better redesign for a long time, but upon reading the proposed changes and watching the PowerPoint presentation, this seems like it will be even worse than our current system. TDT services once created a safety buffer for our schools and children’s mental health services. When I see school related tragedies in the news now, I wonder if they could have been prevented if the state hadn’t lost so many TDT providers in the last 6 years. COVID was an excuse to explain the reduction in services, but it had already begun with the MCO’s long before COVID became a problem. We had already seen a large cut in providers in our area before COVID even started and now we have no TDT providers in our area. A service that once flourished and was considered by many to be the most important program in the community no longer exists in the area where I live due to the difficulty of getting approvals and low reimbursement rates. With the redesign I see many new challenges that will likely save the state more money and continue to reduce the effectiveness and availability of services. First, I don’t agree with using the CANS for the assessment. As someone who has worked with many providers through the years and has seen the variance in ratings with the CANS, this tool is completely unreliable, despite how it may be presented. Second, requiring LMHP’s to write treatment plans is another difficult addition in a state where we already have a shortage of LMHP’s. QMHP staff are more than capable of writing a treatment plan. This would be a waste of our LMHP’s time. The new rates being below average of what other states pay is also disappointing, especially in a state with a higher minimum wage than thirty other states. How are we supposed to pay staff a competitive salary when we have one of the lowest billing rates of states but have one of the highest minimum wage rates. The short authorization periods are not realistic for kids who are dealing with generational trauma and/or have severe mental health concerns. Upon reading this, I initially thought that this is going to be even harder to get approvals, more waste of time doing paperwork, shorter treatment windows, less effective treatment, more difficulty in having a program that can break even financially, and less help for our youth dealing with mental health needs. Lastly, why is this comment period so short?
As a seasoned Children's Services Act Coordinator, I have many concerns regarding replacing TDT and IIH with CPST. Recently, our locality has seen a sizeable increase in children with mental health issues. Moving forward with this change in services would be devastating for many reasons. CPST does not even come close to comparing to TDT or IIH in regard to level of support offered. CPST provides for a dramatic decrease to the number of hours available per week and a lack of summer programming. This is simply not acceptable. Expecting these children to go three months without services is asinine. The lack of structure and support that summertime brings often escalates behaviors. It is imperative that these children are provided with the services that they deserve regardless of whether school is in session. Furthermore, CPST requires 8 hours of parent/family engagement per month. While I feel that family involvement is of the utmost importance, the children typically accessing these services do not have that luxury. Lack of family engagement will end up preventing many children from getting the help that they so desperately need. Lastly, this proposal will be financially devastating for service providers and localities. Our local CSB has estimated that providing CPST under the proposed guidelines would result in an annual deficit of several hundred thousand dollars. How could this possibly be sustainable? Due to the reasons mentioned above, localities will likely see an increase in referrals to access Children's Services Act funding to fill in the gap created by CPST. Many localities are going to be unable to shoulder this increased financial burden. I implore you to reconsider these unnecessary and unviable changes.
I have concerns with the reduction in hours for TDT. I have seen firsthand the benefits of having TDT in schools. In many cases, they have helped calm situations that may become problematic. They build relationships with students, and in many cases, students need those realtionships in their lives. A reduction in TDT will cause increased discipline in our schools. It aslo gives less opportunities for students to beable to get the counseling and support they need. Please consider the importance of TDT in schools. Reducing the hours in today's day and age is not helpful.
Why Keeping TDT in Schools is Necessary
1. For the Kids Receiving It
Students in TDT have the most intensive emotional and behavioral needs that go far beyond what general school staff are trained to manage. Without immediate, daily, school-based therapeutic support, these students are at higher risk of academic failure, suspensions, or being placed in restrictive settings.
School-based TDT eliminates barriers like transportation, scheduling conflicts, and stigma—meaning students actually receive consistent care rather than falling through the cracks.
2. For Other Students
When TDT students get targeted interventions, the classroom environment is calmer, safer, and more focused, which directly benefits peers.
Preventing and supporting crises in real time reduces disruptions, exposure to unsafe incidents, minimizes trauma exposure for other students, and supports uninterrupted learning for the whole classroom.
3. For the School System
Teachers are not mental health providers. They are not trained or resourced to handle clinical-level behavioral health needs. School administration is stretched thin and cannot be addressing every child in crisis and not every behavior necessitates disciplinary action. Without TDT, these demands shift onto staff who are already overstretched and under prepared, accelerating burnout and turnover.
TDT reduces costly disciplinary actions, alternative placements, and dropout risks. It allows schools to stabilize students within their home community rather than relying on expensive, less effective out-of-school options.
By stabilizing students within their home school, TDT supports inclusion and helps schools meet both academic and behavioral accountability standards
4. Financial Impact
If TDT is removed from schools, many students will need services elsewhere. Those costs will shift to CSA funds and local school budgets—both of which are already strained.
Out-of-school placements or intensive private services are significantly more expensive than keeping a student supported within their school. For example: Private day schools or residential placements can cost 3–5 times more than school-based TDT.
Schools may be forced to fund additional 1:1 aides, alternative placements, or costly disciplinary processes without TDT in place.
Ultimately, removing TDT doesn’t reduce costs—it transfers them to more expensive systems, draining funds from education and CSA that could otherwise serve a broader pool of children.
Bottom line: Keeping TDT in schools is not only the most effective clinical option—it’s also the most financially responsible. It prevents schools and CSA from shouldering higher, long-term costs while protecting the highest needs students in the system. Removing TDT doesn’t just affect the individual student—it destabilizes classrooms, increases teacher burnout, and places schools at higher risk of failure in serving all students. Keeping TDT in schools ensures kids with the highest needs are supported, peers can learn in a safer environment, and educators can focus on teaching
I am writing to express my serious concerns regarding the proposed reduction in hours for the Therapeutic Day Treatment (TDT) program. I have personally witnessed the significant benefits of having TDT staff present in our schools.
TDT professionals play a vital role in de-escalating potentially problematic situations, creating a safer environment for both students and staff. They also build vital relationships with students, many of whom may not have access to such positive and supportive connections elsewhere.
Reducing TDT hours will likely lead to an increase in disciplinary issues and would limit students' opportunities to receive the essential counseling and support they need to be successful in the classroom. Given the current challenges facing our youth, cutting these services would be counterproductive and detrimental to student well-being and school climate.
Please reconsider this decision and to recognize the indispensable value that the TDT program provides to our school community.
As a Licensed Professional Counselor (LPC) and Regional Director of Therapeutic Day Treatment (TDT) services across several rural counties, I am deeply concerned about the proposed replacement of TDT with Community Psychiatric Support and Treatment (CPST). This plan does not replicate the scope, structure, or intensity of TDT and risks leaving our most vulnerable youth without critical supports.
TDT provides up to 25 hours per week (sometimes more) of structured, therapeutic intervention. This intensity allows for consistent daily support, relationship-building, skill reinforcement, and real-time crisis intervention within the school environment.
CPST is capped at 28 hours per month, which equals no more than 7 hours per week—a dramatic reduction in available service hours. Even at the maximum, students will receive less than one-third of the support they currently receive in TDT.
For students with serious emotional and behavioral challenges, daily repetition and structure are critical. Progress often comes from ongoing interventions, frequent redirection, and consistent therapeutic presence. Reducing contact hours undermines the therapeutic process and threatens student stability.
Daily therapeutic engagement cannot be replicated in 1–2 hours per week. Students who require immediate in-school support for behaviors, crises, and peer interactions will be left without appropriate interventions when they need them most.
Students at risk of hospitalization, removal from school, or homebound placement often rely on the daily structure of TDT. Scaling down to weekly or biweekly contact leaves them vulnerable to escalation and regression.
This change represents not only a service reduction but also a fundamental shift in the level of care available to Virginia’s children. CPST and TDT are not interchangeable; they are designed to meet different levels of need.
TDT provides year-round structure and therapeutic engagement, including summer programming that ensures continuity of care when students are not in school. This consistency is critical, as many children rely on TDT to maintain emotional stability, reinforce behavioral skills, and prevent regression.
CPST offers no summer programming, leaving students without services for an extended three-month period. For children with significant behavioral and emotional needs, this gap is not just inconvenient—it is destabilizing.
Summer is often the most difficult time for our students. They lose the routine of school, experience increased unstructured time, and face greater family or community stressors. Without therapeutic programming, crises and hospitalizations frequently rise during this season.
The expectation that students will return to school in the fall, after three months with no support, and demonstrate improved behavior or sustained progress is both unrealistic and harmful. Many children will regress significantly, undoing months of therapeutic gains achieved during the school year.
Without summer services, schools and providers are forced into a cycle of crisis management each fall, students re-enter needing intensive stabilization, educators become overwhelmed, and mental health providers must “start over” rather than build on existing progress.
This gap in care disproportionately affects students in rural and underserved communities, where alternative resources such as outpatient programs, community groups, or private providers are already extremely limited or inaccessible.
Eliminating summer therapeutic programming represents a major service gap that places vulnerable youth at increased risk of crisis, academic failure, and long-term negative outcomes.
CPST requires at least 8 hours per month of parent/guardian involvement.
While family engagement is important, many TDT families have minimal involvement due to work, transportation, or personal barriers.
Requiring this level of participation will exclude many students who need services the most.
This will also be a major barrier for clients who have unstable guardians or unstable living arrangements or even guardians who are already reluctant to participate.
TDT currently requires WEEKLY contact, but not 8 hours per month. This is unrealistic for school-based services to have parental involvement at this level and frequency.
The purpose of school-based services is to target this environment, where parents/guardians aren’t involved at a higher level. Schools may also not allow for parents to attend in school sessions at this rate, as this can pose school campus challenges.
Virginia already faces a severe shortage of licensed mental health providers. Rural areas are hit the hardest. Families often wait months for outpatient appointments or psychiatric evaluations. Agencies are competing for the same small pool of licensed professionals, making recruitment and retention increasingly difficult.
Rural communities are disproportionately affected. In many of the counties we serve, there are few, if any, alternative providers. If agencies cannot staff CPST adequately, children simply will not receive services at all.
CPST requires more highly trained and licensed staff than TDT. While this raises the clinical threshold, it also significantly limits the number of available practitioners. Burnout and turnover are already high in behavioral health. The work is emotionally taxing, underpaid, and administratively heavy. Adding higher documentation demands, crisis intervention responsibilities, and unstable caseload requirements under CPST will only worsen the problem, driving more providers out of the field. Our current system and documentation requirements have already caused many clinicians to leave altogether.
When agencies cannot keep positions filled, vacancies and staff turnover create service instability. Children experience disrupted care, shifting caseloads, and broken therapeutic relationships. This undermines trust, slows progress, and increases the likelihood of crisis escalation.
Requiring LMHPs to complete additional responsibilities such as treatment planning, supervision, and direct service provision on top of already high caseloads further stretches an already limited workforce. QMHPs, who are more than capable of managing many of these tasks (as they have for the past couple of decades), and will be underutilized by these restrictions.
The end result is a service model that is not sustainable. Staffing shortages mean that agencies may not be able to accept referrals, leaving children without services. Staff who remain may face overwhelming workloads, leading to further burnout, resignation, and disruption in care.
Proposed reimbursement rates are below national averages while Virginia has a higher minimum wage than most states. This makes it difficult to pay competitive salaries.
CPST billing depends on client attendance; cancellations and no-shows cut directly into revenue while staff costs remain fixed.
Caseload caps prevent flexibility in service delivery and reduce agency sustainability.
High training, documentation, and prior authorization requirements add unreimbursed staff hours.
School-based integration is one of TDT’s strengths, allowing students to stay in class and succeed academically. CPST does not replicate this school-based support.
Group-based treatment in TDT helps students build social competence and practice skills with peers. CPST lacks this intensive group structure.
Treatment planning requirements for LMHPs further strain an already stretched workforce. QMHPs are more than capable of developing treatment plans, and this change wastes LMHP capacity.
Short authorization periods are unrealistic for youth with complex trauma or severe mental health needs.
TDT and CPST serve different populations. Replacing TDT with CPST is not a true substitution and will leave critical gaps. This redesign represents another cut to children’s mental health services at a time when needs are only increasing. Virginia’s children and families deserve more support, not less. Eliminating TDT in favor of CPST is a bad plan that harms students, families, providers, and schools. We urge decision-makers to:
Maintain TDT as part of the continuum of care.
Address workforce shortages with realistic staffing requirements and competitive pay.
Ensure reimbursement rates reflect actual costs.
Ensure the time allow to work with clients reflects what the actual need is for the client (entend the increment time per unit)
Remove unrealistic caseload caps and parental involvement barriers.
Expand services to meet the growing need, especially during summer months.
Virginia’s children deserve better. ALL children deserve better. This plan must be reconsidered.
The draft sets strict caseload caps, supervision ratios, unit limits, and service-hour requirements without accounting for the realities of in-home service delivery.
Travel time, workforce safety, family scheduling, and crisis unpredictability are not addressed.
Tier Two Rehabilitation Skills Practice is required to be exclusively in-person, which is not always feasible in rural or high-risk environments.
The unit cap makes it nearly impossible for staff to maintain full-time hours or a sustainable income. This will force providers to increase caseloads to compensate, which ignores long drive times in rural areas where a one-hour session may require more travel than service time. There's no way we will keep even our current staff if you tell them they can do less than they do now without the hours to meet full-time, staff will be forced to look for work else where- double check those numbers
Many staff already hold multiple jobs to meet cost-of-living needs; further restrictions on units and caseloads will worsen workforce instability.
It’s already difficult to meet the staffing needs currently, creating long wait lists, gaps in services and wearing down the current staff
The draft requires caregiver participation for youth services, with minimum time commitments, but does not address real-world challenges:
Caregivers may be unavailable due to work schedules, inconsistent participation, or unwillingness to engage. How would school based services support these needs of 2 hours of services per week in tier two, especially since you cannot contact them by phone?
There is no definition of “young children,” though the policy mandates caregiver presence for “the majority” of sessions. In practice, this can limit individual work with children, especially when parents are triggers when teaching skills or only available late in the evening when youth are tired or disengaged.
The document defines “in-person” as physically present and “face-to-face” as in-person or telehealth. This distinction creates billing confusion.
Several components allow telehealth “if clinically appropriate,” yet Tier Two rehabilitation skills strictly prohibit telehealth without a clear rationale.
This inconsistency risks inequitable access and administrative disputes.
Requirements to list “materials used” in sessions are vague and add unnecessary complexity.
Mandatory LMHP co-signatures further slow service delivery- and adds to the long list of non-reimbursable activities for a licensed staff.
While concepts of this redesign sound great, the implementation sounds like more licensed required activities, less QMHP required activities- where are all these staff going to come from? In the training DMAS said this will allow more flexibility but in fact its increasing in rigidity and even going against what DMAS has identified that can occur with supervisors (why change the ability to supervise to LMHP-R/S or QMHP senior staff if that wouldn't be allowable with this service?
The draft does not provide solutions to Virginia’s ongoing workforce shortage and, in some ways, makes it worse.
Requiring a senior-level LMHP to be available 24/7 is not feasible for most agencies.
Increasing LMHP components within CPST is unrealistic given the current supply. Most LMHPs are unwilling or unable to take on extensive home visits given existing caseload demands.
Team-based approaches are promising but impractical in rural areas where clients may live an hour away from the office, requiring multiple staff to travel long distances. This further strains staffing capacity and budgets.
The current proposal will really hurt agencies especially in rural areas. The limited hours billed don't even allow for full-time employment if I'm understanding the units to 15 minutes, but perhaps I'm misreading- not very clear regardless. More things for LMHPs to do, less hours for QMHPs is going to strain an already unstable workforce. Wasn't this suppose to help that issue. I feel we will lose a lot of providers to these strong and increased rigid regulations.
The draft excludes CPST if an individual qualifies for EBPs such as MST, FFT, ACT, or CSC. This creates multiple problems:
Gaps in service will occur if EBPs are not available locally or have long waitlists (common in rural areas).
Agencies that do not provide EBPs may struggle to identify eligibility or locate providers, creating an unfunded administrative burden on LMHPs.
This restriction prevents providers from planning caseloads effectively and may limit the ability to serve families who could benefit from CPST alongside—or blended with—other community-based services.
While additional training is valuable, the draft creates major challenges:
It is unclear whether trainings will be provided by the state or must be arranged and funded or presented by providers. This type of information needs to be clear for providers to begin to prepare to avoid gaps in between the two services changing over and retiring.
Many providers are already on long waitlists for MAP training due to limited slots. Without a contingency plan, access will remain inequitable. this was seen previously with MST and FFT training rollouts, leaving some agencies with no ability to provide those services due to astronomical costs, thus still losing more business if they have to refer to that service regardless.
These requirements will delay onboarding of new staff, worsening workforce shortages and really hurting the budget for these increased administrative costs
Additional trainings create significant administrative costs that many agencies cannot absorb. This is not sustainable without support some how
Weekly team meetings and high supervision expectations are not feasible under current workforce and budget constraints.
While group supervision is allowed, aligning schedules and discussing each team case within group limits will be difficult in order to have a in-house team meeting, with no reimbursement ability for anyone, yet it must occur weekly
These requirements increase administrative burden without clear reimbursement.
The draft places additional strain on licensed staff by not fully utilizing LMHP-Rs, LMHP-Ss, and other license-eligible staff, despite current state policy allowing them to provide services under supervision.
As currently written, the draft CPST guidelines for in-home and community settings risk reducing access, worsening workforce shortages, and overburdening providers with administrative and clinical requirements that are not feasible in practice. Adjustments are needed to: build flexibility for rural service delivery, expand telehealth options, clarify caregiver expectations, reduce administrative burdens, andProvide realistic workforce and supervision supports Ensure training is accessible and will not put providers out of business. There are a lot of challenges within this proposal. In addition, perhaps there can be some examples of what the services could look like, as the tier 1 and tier 2 activities are very confusing and does not give a good picture of daily practicality. Also clarifying is Outpatient Therapy a stand-alone service for these youth receiving services- meaning when this transitions over and the individuals that are receiving outpatient therapy, will they have to switch providers to one that can fit into the CPST? Many of the clients are being seen in agency but some outside of the agency, individual choice. How will that work? There needs to be some more clarity. Team approaches are also a wonderful support- how do you determine who bills if there are members collaborating together, both in a treatment meeting, both requiring to be in the same place? This plan provides lots of restrictions without much practical application. Do the math and look at the numbers more closely- would you be able to pay even your most basic bills with the amount of hours you can bill? How will employers keep staff, it's already hard enough now with all the unpaid drive time and administrative tasks but now this plan puts more burden- more clients means more drive time, less hours, less pay, etc.
Claims and program data show a dramatic reduction in access to Therapeutic Day Treatment in Virginia over the last several years. Let me be clear- this is a reduction is access due to the following barriers, not a reduction in need nor effectiveness and value of the service.
The DMAS draft definition for CPST emphasizes clinical contacts, caregiver engagement, and community-based delivery but does not provide opportunities for the daily, in?school presence that makes TDT effective for high?needs students. Given workforce shortages, funding instability, and documented benefits of intensive in?school programs, replacing TDT with CPST as currently drafted will likely increase behavioral crises, suspensions, absenteeism, and long?term costs to schools and families.
Top concerns (without addressing the ridiculous training, documentation, supervision, and logistical cpst requirements):
1. Large loss of prior TDT capacity. State claims data show an ~80%+ decline in TDT membership counts in recent years, indicating many students lost access to intensive, structured in?school supports. This decline was driven by managed care carve?ins (2017 onward), reduced reimbursement rates, higher administrative requirements for authorization, and stricter medical necessity criteria — all of which discouraged provider participation and limited access for students.
2. Workforce and geographic gaps. Virginia and national reports document shortages of behavioral health providers and concentration of vacancies in many localities — limiting CPST supply, particularly for in?school coverage.
3. CPST requirements create access friction. The draft emphasizes caregiver engagement, repetitive clinical authorizations, and service documentation — all of which raise barriers for low?resource families and slow service startup/continuity.
4. Evidence favors consistent in?school presence. Systematic reviews and day?treatment studies show the biggest school outcomes when services are delivered consistently within school settings; removal of that presence correlates with higher suspension and disruption risks.
5. Funding instability risks program attrition. Many school divisions expanded mental health staff with one?time or temporary funds; as those funds expire, intended CPST coverage (if even feasible) is at risk of being reduced.
Potential outcomes of current plan:
More suspensions, expulsions, and out?of?school removals. Why- lack of on?site therapeutic de?escalation and daily behavior support; teachers/administration forced to manage crises.
Academic decline and higher absenteeism. Why- students with unmet behavioral/mental health needs are less able to access instruction, leading to falling achievement and missed school days.
Increased use of higher?cost systems. Why- untreated or intermittently treated students are more likely to require emergency services, hospitalization, juvenile justice, or special education—raising system costs.
Equity gaps widen. Why-caregiver?engagement and travel/time requirements disadvantage low?income, rural, and single?caregiver families.
Long waits and large caseloads. Why- workforce shortages produce long waitlists, brief contacts, and reduced treatment fidelity.
Requests:
1. Immediate moratorium on planned TDT cuts until parity is demonstrated. Require DMAS to publish a comparative access and outcomes plan showing CPST can match TDT capacity and outcomes before eliminating TDT.
2. Fund (appropriately) and pilot in?school CPST delivery. Allow CPST to be delivered via embedded school contracts (not just clinic/community visits) and fund pilot sites in diverse divisions (urban, suburban, rural) with outcome monitoring.
3. Relax family?engagement penalties and requirements. Where caregiver involvement is not feasible, allow alternative engagement strategies (tele?family contacts, school?based participation) so students are not denied services.
4. Stabilize funding for workforce development. Provide multi?year grants for recruitment, loan?repayment, and school?based clinician salaries to ensure sustainable staffing.
5. Measure and report outcomes publicly. Require quarterly public reporting (by division and DMAS) on access, wait times, suspension rates, school attendance, and clinical outcomes for youth receiving CPST and youth receiving TDT.
At a time when youth mental health concerns are at an all time high, when violence in schools is no longer a rare occurrence, when needs continue to outweigh provider availability- how is removing a vital support beneficial? TDT should be adequately funded, reimbursed, accessible, and staffed. That would be the appropriate redesign of the service.
The supervision requirements are contradictory to the new changes from the Board of Counseling (BOC). The CPST regulations for an LMHP only to be able to provide supervision not only contradict the recent BOC regulations, but it also impedes on learning and growth opportunities for LMHP-Es. Additionally, the staffing shortages of licensed individuals will make it increasingly difficult for providers to meet the 1:9 supervision ratio requirements and provide appropriate level of care. LMHP-Es should be permitted to do all the work of an LMHP as they are under strict guidance already while enrolled in supervision and obtaining hours towards licensure. Additionally, new regulations also permit QMHPs with the appropriate trainings and experience to provide clinical supervisions under the BOC which has not been included in the CPST regulations.
In addition to the LMHP requirements for supervision, the weekly supervision requirement for QMHPs also contradicts the BOC regulations. QMHPs have underwent appropriate supervision and hours of direct service in order to be licensed as a QMHP and should be permitted to obtain monthly supervision rather than weekly. Increasing the supervision burden for a professional level of support is counterintuitive.
Throughout the draft regulations, QMHPs are referred to as paraprofessionals. This is inaccurate. QMHPs are licensed through the Board of Counseling and typically are the highest level of credential for a staff with that level of experience and education. This should be corrected throughout the document. QMHP = Qualified Mental Health Professional.
Throughout the CPST draft regulations, there are phrases like: "majority of" or "younger" (i.e. on page 4, section 2.3, last paragraph. Clear definitions here would more appropriate outline what that expectation is.
The extensive list of recommended clinical assessments does not elaborate on whether facilitation of these assessments will be billable activity under CPST or if providers will be permitted to bill add-on codes similar to outpatient counseling.
Throughout the CPST documents, it is mentioned about additional training mandates. For example, on page 7, section 3.3.2, the mandate for additional EBPs such as CBT for different diagnoses was not appropriately built into the rates and puts a significant burden on providers unless these will be offered to providers for free by DMAS/DBHDS.
This entire section above the graph is extremely difficult to understand and very convoluted. Managing staff caseloads at this level of intensity will be nearly impossible administratively by providers. More consideration should be taken to address caseload requirements at a level that is both supported by the Labor Law and manageable by providers. Additionally, these caseloads do not take into account the potential for crisis response.
Assessments should be permitted to be provided via telehealth or telemedicine-assisted. Since QMHPs are permitted to assist with assessments, telemedicine-assisted assessments should be supported. Telehealth is permitted for IACCT assessments which also uses the CANs, therefore, it is clinically appropriate to do the same for CPST using the same tool.
Is #8 of Section 5.2, the last sentence is very unclear. What is the intent here? The entire CPST services is written in a way to support a client in their natural environment, whether it be home, school, community, or workplace and often goals/objs/interventions will overlap across settings. I would recommend removing this barrier altogether as it makes no sense how it is currently written and would extremely impractical when actually providing services. Service location should be attached to progress notes, but not aligned on the service plan for each goal/obj.
This service is not designed or regulated as a crisis service and while 24/7 emergency supports can be provided, this service type and individuals providing services within do not follow MCR regs or training requirements. Specifically: section 5.3 bullets #2, 5, and 7 are concerning. No one providing CPST will be required to be trained at the level a mobile crisis response team is trained and therefore this service should not immediately limit access to that. 988 is a valuable resource and individuals should be encouraged to utilize this resource when in crisis. For a service that is time-limited as CPST is currently outlined, stating that a crisis mitigation plan may NOT include use of or referral to a Crisis service is setting up clients to lack appropriate insight into their available resources upon discharge. Additionally, #7 is a very risky requirement for providers in rural areas or serving large geographies. On-call support via phone or Telehealth is fine, but requiring in-person response for someone serving a 45-60 min radius and now allowing them to be referred to 988 is ultimately negligent.
Additionally under section 8, bullet 2.b.i, it should be noted that MCR response is geographically dispatched. Does this mean if the closes MCR team should decline a dispatch opportunity in the event they are already enrolled in CPST? Often MCR teams will not know if CPST is already being provided by the agency.
Care coordination should be billable via audio only when completed with other providers in coordinating care. Additionally QMHP-Ts and BHTs should be permitted to provide this service component.
QMHP-Ts should be permitted to provide Tier 1 support. If Tier 1 is considered a lower level of need as established via their CANs Lifetime score, then a lesser credentialed staff member should be qualified to provide support to these individuals. QMHP-Ts are significantly easier to staff and should be treated as QMHPs, not BHTs.
Additionally, Section 7.1.4.b - the outpatient counseling criteria is very counterproductive to the level of service being provided. Tier 1 was outlined as a lower level maintenance support, and outpatient counseling attempts should be considered as many individuals with SMI, talk therapy is not a clinically appropriate service.
At the level and hours of services expected to be provided, updating a service plan if no "significant progress" is made in first 90 days feels like a short time frame. In order to adequately build rapport, establish routines, etc. in the timeframe in a team-based service, six months is a more person-centered, clinically appropriate timeframe.
Concerns around the recommended duration of services. Some populations, age groups, and diagnoses will require more long-term maintenance level support to prevent decompensation, especially with OPT therapy is not an appropriate service per level of need. Consideration for this should be made.
Changes to bullet in Section 8.2.c should be made. Individuals that "meet the admission criteria" does not mean that the service is appropriate or even available in the community. Consider rewording.
CPST and Clubhouse should not be exclusionary. Individuals in Clubhouse may still require support consistent with CPST at home, school, or community.
#3.b - consider changing this to exclude in-office psychotherapy. In office psychotherapy may occur at one hour per week per CPST, but additional supports may also be supported in the office with individuals and should not be limited (i.e. neutral family meetings, restorative life skills training or skills practice, etc).
In Section 11, it says that services are billed with the modifier based on the team member for the component and that the team member providing the service should complete the progress note. In the chart, under the "Treatment Planning, if assisting the LMHP" Does this mean that the LMHP AND the QMHP will write a progress note and bill? If not, consider rewording to clarify.