Documentation of MH/SA Services

Meeting Date: 5/21/2015

Meeting Time: 10:00 am – 12:30 pm
Location: VACSB Office
Present: Mike Forster (DMC Chair), Bob Horne (DMC Vice-Chair), Joe Hubbard
(ED, Technical Administration Committee), Kippy Cassell, Heather
Rupe (QM Chair), Chris Rapp, Cheryl Holt, Jerome Newsome, Brandon
Rodgers, Kristie Jones (MH Chair), Ray Cruz, Karen Rifkin, Jennifer
Thompson, Nadeem Ahmed (SA Chair), Paul Gilding (DBHDS), Allen
Wass (DBHDS), Adrienne Ferriss (DBHDS)

Task
The initial task, as understood by the DMC, was to find a technical solution to solve the problem of
underreporting SA Services. This stemmed from a conversation between DBHDS and a couple CSBs
regarding the underutilization of SA Funds and that conversation continued into the ED Forum and
gained enough traction for the ED Forum to ask the DMC to follow up.

Discussion
The DMC Subcommittee met and had a very thorough and productive conversation. We identified the
multiple ways that SA Services are not being reported under SA but MH. For example – PACT. CSB’s bill
ICT, which is a MH service, but there is a SA component, by regulations. There is currently no
mechanism to report the SA service component even though the client has a SA diagnosis. In addition
with the higher MH CM rate if a service was done with a dually diagnosed individual it would be billed
under MH CM. We also discussed other possible reasons for the decreasing SA services that are outside
of our control. For example, decreasing SA services could be an accurate reflection of the static or
decreasing level of funding while the costs of services continue to increase. Finally, it is possible that the
implementation of EHRs contributes to the decrease in services due to limitations and restrictions in the
way clinicians are able to document services.

While working through numerous possible technical solutions the subcommittee continued to circle
around to the same place. Clinicians are treating the individual – they are providing a BH service, not a
MH service or a SA Service. (They drink because they are depressed, they are depressed because they
drink and lost their job – you can’t treat one without treating the other) There is no percentage of time
in an appointment where it is 40% MH and 60% SA .. it is 100% BH. SAMHSA’s recommendations on the
treatment of co-occurring disorders call for integration of services to treat the whole person. Forcing
clinicians or reporting into a non-integrated modality would represent a step back in the strides toward
integration within Virginia’s CSB system.
Looking Ahead
Adrienne reported that there is discussion at the Federal level that they would collapse the MH and SA
reporting which would significantly impact how DBHDS reports to the Federal level and in turn could
impact how we report to DBHDS. There is no timeframe but sounds promising. In addition, starting
October 1, 2015 all CSBs will be mandated to report ICD10 to DBHDS in the CCS extracts. With the
industry conversion from DSM4/ICD9 to DSM5/ICD10 this is forcing a fresh look on how clinicians
diagnose and the process for maintain these diagnosis on an ongoing basis. This will also provide an
opportunity for CSBs to update and clean up their diagnosis data.

Recommendation
After discussing multiple possible solutions the DMC came to the conclusion that there is currently not a
way to work out a solution. We should not come up with a quick fix that might cause more problems
than it solves. Any attempt to increase SA service reporting would result in a decrease in MH reporting
or would create an unacceptable burden on clinicians. In addition – there is not an acceptable clinical
way to partition out MH and SA services when it is one, integrated service. Beyond the technical
solutions we collectively agree that we do not know enough about our co-occurring population. We
need to understand our population, their needs and what they are currently receiving in order to best
reflect that in state reporting.

Moving forward the DMC recommends a small subcommittee, led by Karen Rifkin, from Region 10, to
examine the current data we have about our clients, their services, and their diagnosis. It is believed
that with the fresh look at all client diagnosis with the ICD10 transition that there would be a more
reliable data set to examine in Q1/Q2 of CY 2016. This data would then be compiled and analyzed to
paint a picture of our clients, their Dx, their current services, and what is needed moving forward. This
data could then be shared with the Department to work together to update reporting to reflect more of
BH service rather than a MH or SA service, including exploring merging state mental health and
substance abuse funds to reflect DBHDS’ commitment to integrated, co-occurring, person-centered, and
recovery-focused services.