Appendix D, Page 21, Required Activities
“At the start of services, a LMHP, LMHP-R, LMHP-RP, LMHP-S, shall conduct an initial assessment”
The FFT model does not require an LMHP-type clinician complete the initial assessment. In Chapter IV of the Mental Health Services Manual of DMAS, on Page 13, it states “For services that allow a professional other than a … [LMHP-type] … to conduct an initial assessment, that assessment may be used for that service only and cannot be used as a Comprehensive Needs Assessment for other services.” I recommend that this should apply to FFT.
“A plan of care that meet the requirements of Individual Service Plans (ISPs see Chapter IV for requirements) shall be required during the entire duration of services and must be current. Within FFT, the Behavior Change Session Plan (as defined by FFT, LLC.) can be used as the ISP.”
The FFT Behavior Change Session Plan is not completed within 30 days of the initial assessment. Does that exclude FFT from the requirement of completing an ISP within the first 30 days of services?
Appendix D, Page 22, Service Limitations
It is noted that “other family members may be receiving one of the above services and still participate in FFT as appropriate for the benefit of the individual receiving FFT services”.
Multisystemic Therapy should not be authorized for any other family members at the same time FFT is being provided.
Will DMAS have any guidance on situations where sibling groups are referred for FFT at the same time?
Appendix D, Page 24, Provider Qualifications
“FFT professionals maintain a minimum caseload of 5 cases at any given time (20 hours per week) and an average of no more than 10 to 12 cases at any given time.”
How will DMAS or the MCOs monitor the caseloads of FFT Professionals?
The FFT model allows up to 15 cases on a single FFT Professional’s caseload in special circumstances. I recommend using the following language: “FFT professionals should maintain a minimum caseload of 5 cases at any given time (20 hours per week) and an average of 10 to 12 cases at any given time.”
Appendix D, Page 24, Staff Requirements
“The site supervisor is required to carry a minimum caseload of five active cases at all times,”
There is no clarification of how this should fluctuate with overall team utilization or team size. It might be possible for a FFT Supervisor to carry 5 cases if s/he has a team of two FFT professionals who are fully staffed and referrals continue to come in. It would be near impossible for a FFT supervisor overseeing the day-today functions of a team with 7 fully-staffed FFT professionals to carry any cases at all. I recommend using the following language: “The site supervisor may also carry a caseload of cases, ...” to allow the needs of the cases and the team to be determined by the FFT national consultant and site supervisor.
Appendix D, Page 25, Staff Requirements
“FFTs Supervisors must be a licensed mental health professional (LMHP), LMHP-Resident in Counseling (LMHP-R), LMHP-Resident in Psychology (LMHP-RP) or LMHP-Supervisee in Social Work (LMHP-S).”
Are there any requirements for the team’s Back-Up FFT Supervisor?
“Assessments must be provided by a LMHP, LMHP-R, LMHP-RP or LMHP-S.”
Again, fhe FFT model does not require an LMHP-type clinician complete the initial assessment. In Chapter IV of the Mental Health Services Manual of DMAS, on Page 13, it states “For services that allow a professional other than a … [LMHP-type] … to conduct an initial assessment, that assessment may be used for that service only and cannot be used as a Comprehensive Needs Assessment for other services.” I recommend that this should apply to FFT.
Appendix D, Page 27, Admission Criteria
“There is an order through juvenile justice for participation in community-based treatment and 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 as an additional option under the third criterion.
Appendix D, Page 27-28, Continued Stay Criteria
“Within the past thirty (30) calendar days, the youth has continued to meet the admission criteria for FFT 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 FFT 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 FFT 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 FFT: if the youth aren’t showing a reduction in behaviors, then FFT is seen as ineffective; and if they are showing a reduction in behaviors, then FFT 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 29, Continued Stay Criteria
“Booster Sessions may include up to three face-to-face sessions with an FFT professional over a two-week time period.”
While the FFT model does specify that families who discharge successfully are eligible for up to three booster sessions, the model does not require that these sessions be completed in the same two-week time period. This language disrupts the purpose of booster sessions. I recommend that the limitation on the authorized time period be removed or for the authorization period to last up to one year, with the authorization period for booster sessions to end exactly one year from the discharge date of FFT services.
Appendix D, Page 30, Continued Stay Criteria
“Booster Sessions must be pre-authorized …”
Pre-authorization contradicts the goal of using booster sessions for crisis intervention or stabilization, in response to a traumatic event, and in preventing out of home placement. I recommend changing booster sessions to either (a) be authorized as a registration, or (b) to be authorized for up to one year, with the authorization period for booster sessions to end exactly one year from the discharge date of FFT services.
Appendix D, Page 31, Service Authorization
“This service requires prior authorization…”
The Engagement phase of FFT occurs between the referral and the first session during which the assessments are completed. I recommend that FFT have a registration period of 14 days and 14 units during which time the provider can bill FFT services during the engagement phase. Once the engagement phase is complete and the CNA is completed, the provider would submit a continued stay request for the remainder of services based on the needs identified in the assessment.
“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 60 units over three months to ensure adequate treatment dosage.