Appendix D, Page 6, Critical Features & Service Components

• “Therapeutic interventions ... may range from brief check-ins (either by telephone or face-to-face) to more intensive sessions lasting up to two hours.” 

  • This language may create confusion with MCOs thinking this is a max session length. I recommend removing “lasting up to two hours.”

• “[T]he MST model expects that 10-20 therapeutic interventions occur within the first month. These initial therapeutic interventions typically occur three or more times per week in frequency and typically 60-90 minutes in duration. For the second and third months of MST, the model expects an average of six therapeutic interventions per month. The MST model expects that service frequency will be tapered over the last two months of service. Close to treatment termination, the MST professional contacts the family as needed to assure that treatment gains have been maintained by the family.” 

  • This language predicates what authorizations will look like rather than allowing them to be determined by the need of the client. Our records indicate an average of 10-12 sessions each month for the second and third months of service. I am fearful that this will be a standard used to limit. I recommend removing these references. Further up on Page 6, it states "Early in treatment, the MST Professional may meet with the family several times a week, but as treatment progresses, the intensity tapers. The frequency of therapeutic interventions is flexible based on clinical need, allowing the service to be responsive to periods of crisis or high risk and to decrease the intensity for families with lower levels of need." This language is sufficient to give a clear picture of the frequency of therapeutic interventions.

Appendix D, Page 8, Service Limitations

• It is noted that “other family members may be receiving one of the above services  and still participate in MST as appropriate for the benefit of the  individual receiving MST services”.

  • Functional Family Therapy should not be authorized for any other family members at the same time MST is being provided.

  • Will DMAS have any guidance on situations where sibling groups are referred for MST at the same time?

Appendix D, Page 10, Staff Requirements

• “The MST team composition includes a full-time LMHP, LMHP-R, LMHP RP, or LMHP-S who acts as the MST Supervisor, and a minimum of two to  a maximum of four MST Professionals”

  • What will be the expectation for teams of two if one MST Professional resigns? I recommend including language to protect teams that are actively hiring to backfill positions.

  • Are there any requirements for the team’s Back-Up MST Supervisor?

Appendix D, Page 11, Staff Requirements

• “A full-time MST supervisor may supervise: One MST team and provide MST services to one or two youth.”

  • This is limiting to teams who may be experiencing staffing changes. I recommend using the following language: “One MST team and provide MST services to an average of one or two youth.”

• “A MST Professional, on average, may provide service to four to six youth at one time.”

  • How will DMAS or the MCOs monitor the caseload of MST Professionals?

• “The MST model requires that all staff on the MST team shall participate in weekly MST-specific group supervision facilitated by the MST supervisor per MST model standards. All staff on the MST team shall also participate in weekly MST-specific telephone consultation provided by MST Services, Inc. or a licensed MST Network Partner training organization, with no more than 6 weeks a year without consultation due to the occurrence of quarterly trainings and holidays.”

  • My concern here is teams who have staff members who go out on maternity/paternity leave or FMLA. While they do not specify any specific consequences in the event that a staff member misses the 6 consultations, it is certainly a red flag. I recommend using the following language to clarify: "The MST Model requires that all active staff on the MST team...."

• “The initial assessment ... provides evidence of symptoms and functional impairment  that the youth has met criteria for a primary diagnosis ... within the categories of disruptive behavior, mood, or substance use disorders.”

  • Similarly to FFT, there may be youth who would greatly benefit from MST that do not have a diagnosis that fall in these categories. I recommend adding the following language: "There may be additional behavioral health conditions that may be expected to respond to the interventions of MST that may be considered on a case-by-case basis." 

Appendix D, Page 12, Admission Criteria

• “Ongoing dangerous or destructive behavior that places the youth at  risk for out of home placement. ... excessive preoccupation with sexual fantasies, urges or behaviors  that is difficult to control, causes distress, or negatively affects the  young person’s health);”

  • This is outside the scope of traditional MST. Also, it contradicts the exclusionary criteria of "sexually harmful or dangerous behavior" listed on Page 13.

• MST Medical Necessity Criteria #3

  • I recommend adding: "The youth is adjudicated and/or on probation, or returning home from out?of?home care, such as juvenile detention, treatment foster care, emergency shelter due to the youth’s behavior, or inpatient acute hospitalization, residential crisis stabilization or residential treatment and MST is needed as step down service from an out of home placement" as additional bullet point.

• “Within the past 30 calendar days the youth has been or is at risk of being admitted to an inpatient, partial hospitalization, residential crisis  stabilization unit, residential level of care, ARTS ASAM Levels 2.5,  3.1, 3.3, 3.5, 3.7 or 4.0 OR is being discharged from one of these  settings and demonstrated the above admission criteria prior to  placement;”

  • I recommend including juvenile detention, foster care, and emergency shelter as additional out of home placements that, if at risk, would meet criteria for eligibility.

Appendix D, Page 13, Admission Criteria

• “If there is an order through juvenile justice for participation in community-based treatment, the youth meets the other medical necessity criteria.”

  • This is listed as a required criteria, therefore excluding all youth not currently involved with the juvenile justice system. I recommend including it under the third criterion along with the above noted recommendation for Criteria #3.

Appendix D, Page 13, Continued Stay Criteria

• “Within the past thirty (30) calendar days, the youth has continued to meet  the admission criteria for MST as evidenced by at least two of the  following: … [2] No less intensive level of care would be appropriate for this youth; [3] The youth’s symptoms/behaviors and functional impairment persist at a  level of severity adequate to meet admission criteria; [4] The youth has manifested new symptoms that meet admission criteria  and those have been documented in the MST Treatment Plan;”

  • These criteria indicate a youth's behavior must continue to meet admission criteria despite the goal of services to be a reduction in referral behaviors. These criteria are similar to the criteria for IIH services, and we have seen many cases in which the continuation of services was denied prematurely because the youth no longer met admission criteria. This resulted in early decompensation immediately following discharge because the youth and family were not ready for such a significant reduction in support. There is significant concern that MST clients will be denied a full course of treatment by the MCOs because they are showing the progress we hope they will make. This could also lead, over time, to distrust in the effectiveness of MST: if the youth aren’t showing a reduction in behaviors (continuing to meet admission criteria), then MST is seen as ineffective; and if they are showing a reduction in behaviors, then MST could be discontinued early, likely resulting in poor long-term outcomes. I recommend reducing the required number of criteria met to one, and removing the second bullet point (“No less intensive level of care would be appropriate for this youth;”). This will reduce the pressure from MCOs to discontinue services that are showing progress and shift the focus to the goals of treatment - the final bullet point (“Progress toward identified plan of care goal(s) is evident ... but not all of the treatment goal(s) have been achieved.”).

Appendix D, Page 15, Discharge Criteria

• “Continued MST services are not necessary to prevent worsening of  the youth’s behavioral health condition;”

  • This language implies youth should be left on a flatline trajectory (“prevent worsening”) after discharge rather than a positive one. I recommend using the following language: “Continued MST services are not necessary as the youth and family have demonstrated an ability to use the skills and knowledge acquired during services to maintain, and continue to make, positive gains with respect to the youth’s behavioral health condition upon discharge;”

Appendix D, Page 15, Service Authorization

• “Service units are authorized based on medical necessity...”

  • Due to the concerns listed above related to the listed criteria for continued stay, I recommend including language here that an initial authorization should cover at least 240 units over four months to ensure adequate treatment dosage.