DMAS
DRAFT – FAST TRACK
REGULATION PEER SUPPORT SERVICESFebruary 9, 2017
12VAC 30-130-5230 Peer Support Services and Family Support Partners: Definitions.
The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:
"CPRS" means an individual who has been certified by the Department of Behavioral Health and Developmental Services (DBHDS) as a Peer Recovery Specialist to provide peer support as a self-identified individual with lived experience with mental illness, substance use disorders, or co-occurring mental illness and substance use disorders who is trained to offer support and assistance in helping others in the recovery and community-integration process.
"CPRS-Family" means an adult who has been certified by the Department of Behavioral Health and Developmental Services (DBHDS) as a Peer Recovery Specialist to provide peer support with personal experience as a family member of an individual with a mental illness or substance use disorder or co-occurring mental illness and substance use disorder.
“Direct supervisor” means the person who provides direct supervision to the Certified Peer Recovery Specialist or Certified Peer Recovery Specialist-Family.
“Family” or “Legal Guardian” means the family members, friends, or neighbors who provide unpaid assistance to a Medicaid member with a substance use disorder or co-occurring mental illness. "Family” or “caregiver” does not include individuals who are employed to care for the member.
“Recovery-oriented services” means services that support and assist an individual through a process of change to (i) improve the individual’s health, recovery, resiliency and wellness; (ii) live a self-directed life; and (iii) strive to reach his full potential.
“Recovery resiliency and wellness plan” means a written set of goals, strategies, and actions an individual creates to guide him and his healthcare team to move the individual toward the maximum achievable independence and autonomy in the community. This comprehensive document wellness plan shall be developed by the individual, the CPRS or CPRS-Family and the supervising CPRS or CPRS-Family within 30 days of the initiation of services and shall describe how the plan for peer support services and activities will meet the individual’s needs. This document shall be updated as the needs and progress of the individual changes and shall document the individual’s request for any changes in peer support services. The Recovery, Resiliency and Wellness Plan is a component of the member’s overall plan of care and is to be maintained in the individual’s medical record.
“Resiliency” means the ability to respond to stress, anxiety, trauma, crisis, or disaster.
"Review of Recovery Resiliency and Wellness plan" means the CPRS or CPRS Family evaluates and updates the individual's progress toward meeting the plan’s goals and documents the outcome of this review in the individual’s medical record. For DMAS to determine that these reviews are complete, the reviews shall (i) update the goals and strategies as needed to reflect any change in the individual's recovery as well as any newly identified goals; (ii) be conducted in a manner that enables the individual to actively participate in the process; and (iii) be documented by the CPRS or CPRS-Family in the individual's medical record no later than 15 calendar days from the date of the review.
“Supervision” means the ongoing process performed by a supervisor who monitors the performance of the person supervised and provides regular documented consultation and instruction with respect to the skills and competencies of the person providing peer recovery services.
“Supervising CPRS” or “Supervising CPRS-Family” means either: 1) A CPRS with two consecutive years of practice experience as a CPRS or CPRS-Family, and who has completed the DBHDS CPRS supervisor training; or 2) A qualified mental health professional with at least two consecutive years of experience, and who has completed the DBHDS CPRS supervisor training. The supervisor CPRS or CPRS-Family provides direct supervision to the Certified Peer Recovery Specialist or Certified Peer Recovery Specialist-Family.
12VAC 30-130-5240 Peer Support Services and Family Support Partners: Service Definitions and Descriptions.
A. Individuals 21 years or older and families or caretakers of youth 17 and under who participate in Medicaid managed care plan, GAP, FAMIS, FAMIS MOMS, or Medicaid fee for service and who meet the admission and continued service criteria set forth in this section shall be eligible to receive Peer Support Services.
B. Peer Support Services shall target either:
1. Individuals 21 years or older with substance use or co-occurring mental health disorder which is the focus of the support; or
2. Adolescents and children under 17 years old who have a substance use or co-occurring mental health disorder which is the focus of the support and their families or caregivers.
C. In compliance with CFR §440.130, Peer Support Service for Adults is a strength-based rehabilitative service provided by a Certified Peer Recovery Specialist (CPRS) to individuals 21 years or older to help reduce the disabling effects of a substance use, co-occurring, or mental health disorder that is the focus of support to assist the individual develop and maintain a path to recovery. Services are provided within a multi-disciplinary team approach. Peer Support Services are person-centered and recovery focused. Specific rehabilitative activities shall emphasize the acquisition, development, and enhancement of recovery. Services are designed to promote empowerment, self-determination, understanding and coping skills through mentoring and service coordination supports, as well as to assist individuals in achieving positive coping mechanisms for the stressors and barriers encountered when recovering from their illness.
D. Family Support Partners Service is a peer support service and is a strength-based rehabilitative service provided to the family or legal guardians of Medicaid-eligible youth 17 and under, with a substance use, co-occurring, or mental health disorder that is the focus of support, when these services are directed exclusively toward the benefit of the Medicaid-eligible child or adolescent. Services are expected to improve outcomes for youth with complex needs who are involved with multiple systems and increase the youth and family’s confidence and capacity to manage their own services and supports while promoting recovery and healthy relationships. These services are rendered by a CPRS-Family who is performing the service within the scope of their knowledge, lived - experience, and education. The service shall provide timely response to the basic needs of the family, direct and intensive levels of peer support, and intervention strategies that complement the youth’s environment.
E. Covered Services include individual and systemic advocacy, the development of community roles and natural supports, support of work or other meaningful activity of the person’s choosing, crisis support, and effective utilization of the service delivery system.
F. Peer Support Services shall be rendered on an individual basis or in a group.
G. Effective July 1, 2018 or upon the promulgation of emergency regulation whichever comes first, an individual must be certified as a Peer Recovery Specialist or Peer Recovery Specialist-Family by DBHDS in order to register with the Board of Counseling of the Department of Health Professions (§ 54.1-3503). An individual must be certified as a Peer Recovery Specialist or Peer Recovery Specialist-Family by DBHDS and registered with the Board of Counseling. Within 6 months of the promulgation of emergency regulation, certified peer recovery specialists must be registered with the Board of Counseling.
12VAC 30-130-5250 ARTS-Related Peer Support Services and Family Support Partners: Eligibility Criteria.
A. In order to receive Peer Support Services, individuals 21 years or older shall meet the following requirements.
1. Individuals shall require recovery assistance and support for:
a. the acquisition of skills needed to engage in and maintain recovery;
b. the development of self-advocacy skills to achieve decreased dependency on formalized treatment systems; and
c. increasing responsibilities for his /her own recovery.
2. Individuals 21 years or older shall:
a. have a documented substance use or co-occurring mental health disorder. The diagnosis shall be given within the past year by a practitioner qualified to provide a diagnosis and acting within the scope of their practice.
b. demonstrate moderate to severe functional impairment as a result of the diagnosis, and the functional impairment shall be of a degree that it interferes with or limits performance (relative to the person’s ethnic or cultural environment) in at least one of the following domains: educational (e.g., obtaining a high school or college degree); social (e.g., developing a social support system); vocational (e.g., obtaining part-time or full-time employment); self-maintenance (e.g., managing symptoms, understanding his or her illness, living more independently).
B. Families or caretakers of youth up to age 17 who qualify for admission to Family Support Partners have a youth diagnosed with a substance use disorder or co-occurring mental health disorder within the past year who requires recovery assistance, and who also meet two or more of the following:
1. needs peer-based recovery support for the acquisition of skills needed to engage in and maintain skills to be able to support the youth;
2. needs assistance to develop self-advocacy skills to assist the youth in achieving self-management of the youth’s behavioral health status;
3. needs assistance and support to prepare the youth for a successful work/school experience;
4. needs peer modeling to increase helping the youth to assume responsibility for their recovery.
C. To qualify for continued peer support and family support partners services, admission criteria shall continue to be met and progress notes shall document progress or lack of progress relative to the goals identified in the Recovery Resiliency and Wellness Plan.
D. Discharge shall occur when one or more of the following is met:
1. Goals of the Individual Recovery Resiliency and Wellness Plan have been substantially met; or
2. The Individual or the family or caretaker request discharge; or
3. The individual or the family or caretaker fail to make minimum contact requirements set forth in 12VAC30-130-5280(F) or the individual discontinues participation in services.
12VAC 30-130-5260 ARTS-Related Peer Support Services and Family Support Partners: Provider and Setting Requirements.
A. Services shall only be rendered following a documented recommendation for service by a practitioner who meets the definition of “Credentialed Addiction Treatment Professional” found in 12VAC30-130-5020, and who is acting within their scope of practice under state law. The CPRS or CPRS-Family shall perform peer services under the supervision and clinical direction of the practitioner making the recommendation for services who is enrolled with Medicaid, the BHSA, or MCO or who is practicing within an enrolled provider agency or facility licensed for one of the following ARTS levels of care.
1. Acute Care General Hospital ASAM 4.0 licensed by Virginia Department of Health.
2. Residential Placements ASAM Levels 3.7, 3.5, 3.3, and 3.1 licensed by Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5180 through 12VAC30-130-5202.
3. ASAM Levels 2.5, 2.1, and licensed by Department of Behavioral Health and Developmental Services as defined in 12VAC30-130-5161 and 12VAC30-130-5161.
4. ASAM Level 1 and licensed through the as defined in 12VAC30-30-5141.
5. Opioid Treatment Program (OTP) as defined in 12VAC30-130-5120.
6. Office Based Opioid Treatment (OBOT) as defined in 12VAC30-130-5121.
7. Hospital Emergency Department Services licensed by Virginia Department of Health
8. Pharmacy Services licensed by Virginia Department of Health
B. The CPRS or CPRS Family shall be employed by or have a contractual relationship with the licensed and enrolled Credentialed Addiction Treatment Professional or provider agency. Only the licensed and enrolled Credentialed Addiction Treatment Professional or provider agency shall be eligible to bill Peer Support Services.
C. The Supervising CPRS or Supervising CPRS-Family as defined in 12VAC30-130-5230 shall perform direct supervision of the CPRS or CPRS-Family as needed and at a minimum, once every 7 calendar days. Supervisors shall maintain documentation of all supervisory sessions.
1. If the CPRS or CPRS-Family has been employed by the supervising Credentialed Addiction Treatment Professional for less than 12 months, they shall receive face to face 1 to 1 supervisory meetings. Meetings shall be a minimum of 30 minutes and of sufficient length to address identified challenges and learning needs. The supervisor must be available at least by telephone while the CPRS is on duty.
D. The caseload of a CPRS or CPRS-Family shall not exceed 12-15 recipients at a time.
12VAC 30-130-5270 Peer Support Services and Family Support Partners: Documentation of Required Activities.
A. The Practitioner shall document their recommendation for Peer Support Services which shall include their dated signature and credentials. The recommendation shall be included as part of the Recovery Resiliency and Wellness Plan.
B. An individual Recovery Resiliency and Wellness Plan based on the individual’s perceived recovery needs and multidisciplinary assessment as defined in 12VAC30-130-5020 shall be required within 30 calendar days of the initiation of service. Development of the Recovery Resiliency and Wellness plan shall include the individual and, as applicable, the identified family member or caregiver involved in the individual’s recovery, the supervising CPRS or supervising CPRS-Family, and the CPRS or CPRS-Family. Individualized goals and strategies shall be focused on the individual’s identified needs for self-advocacy and recovery. The Recovery Resiliency and Wellness plan shall also include documentation of how many days per week and how many hours per week are required to carry out the services in order to meet the individual's goals. The total time billed for the week shall not exceed the frequency established in the individual's plan. The Recovery Resiliency and Wellness plan shall be completed, signed, and dated by the CPRS or CPRS-Family, the individual, and as applicable the identified family member or caregiver involved in the individual’s recovery. The CPRS or CPRS-Family shall be empowered to convene multidisciplinary team meetings regarding a participating individual’s needs and desires, and the CPRS or CPRS-Family shall participate as an equal practitioner partner with all staff in multidisciplinary team meetings. The CPRS or CPRS-Family shall act as an advocate to the individual, encouraging that individual to steer goals and objectives in the individualized recovery planning.
C. Services shall be delivered in accordance with the individual’s goals and strategies as identified Recovery Resiliency and Wellness plan and consistent with the recommendation of the referring practitioner who recommended services. As determined by the goal(s) identified in the Recovery Resiliency and Wellness Plan, services may be site-based, provided offsite in the community, or both. The level of services provided by CPRS or CPRS-Family shall be determined on an individual basis based on established medical necessity criteria, taking into account the intensity of the need of the individual receiving services, the experience of the CPRS, and the acuity of the individual’s condition.