How will DMAS address changes to the models by the developers? There is concern that if language is too prescription (as opposed to relying on the model), the manual could be inconsistent with the model and/or require changes every time the model changes.
Specific recommendations/questions/concerns
Page 3 and elsewhere where used – Should face-to-face read “person-to-person?”
Recommend replacing “face-to-face” with “person-to-person”
Page 5, Service definition, page 7, 1st bullet, page 11, Medical necessity criteria – MST model states this service is provided to youth who are 12-17 years old.
Recommend changing language to read, “youth who are 12-17 years old”
Page 6, 3rd paragraph – More flexibility is requested here, where therapeutic interventions are included. There is concern the items in the description may be interpreted as requirements by the MCOs, which is inconsistent with the MST model.
Language making it clear that the interventions described are “examples” is recommended.
Page 7, Required activities, 2nd and 3rd bullets – Align with the language used by the MST model, i.e., “weekly summaries.” These bullets appear to try to fit the MST model into the way behavioral health services are traditionally defined and described in Virginia, which doesn’t align with the model.
Recommend adding language that ensures alignment with the MST model for planning and reporting.
Page 8, first bullet, last asterisk – FFT is excluded for other family members.
Page 9, Provider qualifications, first paragraph – Note that the MST developer licenses teams, not agencies or individuals. Also concerned about allowing QMHP-Es to provide this service if they do not have the required experience, per the developer requirements. This would impact the fidelity of the model.
Page 10, page 21 – The language doesn’t align with the developer, which defines qualifications for individuals who provide this service in terms of having a “bachelors” and/or “masters” degree. The developer does not require that an individual be a licensed type, which is required per the draft language. The requirements related to licensed types are particularly challenging in rural areas. Need to ensure there is no deviation from the model to preserve the integrity of the EBP. It’s also important to note that the developer is involved in the hiring process, providing assistance with hiring and onboarding team members.
Recommend language that provides for flexibility in working with the developer from a worker qualification standpoint, as opposed to requiring something different from that.
Pages 10-11, Staff requirements
Wherever something is “required” in the language, recommend that language be added that states, “so long as consistent with the requirements and fidelity of the model.”
Recommend including language that protects teams who are backfilling positions after resignation(s) that put them out of the required ratio, for example a team with one LMPH-R and one QMHP whose LMHP-R resigns.
What is the plan for how DMAS or MCOs will monitor caseloads of staff and supervisors?
Page 11, Medical necessity criteria
Recommend language removing the requirement that the assessment be completed by a licensed type, allowing flexibility on the required qualifications for the person conducting the initial assessment to align with the model.
Also recommend allowing flexibility on the diagnosis requirements with language like – “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."
Page 12, #4 – There are a lot of things that are not listed that should enable a youth to be eligible for this service, such as being in foster care, juvenile detention, emergency shelter, as a few examples.
Recommend broadening language to allow access for youth who are at risk for out-of-home placement.
Page 13, Medical necessity criteria #8 – This is listed as a required criterion, therefore excluding all youth not currently involved with the juvenile justice system.
Recommend including it under the third criterion along with the above noted recommendation for Criteria #4.
Page 13, Continued stay criteria – Three of the five criteria listed 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.
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.”).
Page 15, Discharge criteria – The language of “Continued MST services are not necessary to prevent worsening of the youth’s behavioral health condition;” implies youth should be left on a flatline trajectory (“prevent worsening”) after discharge rather than a positive one.
Recommend changing this to: “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.”
Page 15, Service authorization – There is a lot of concern that the MCOs will try to “chop up” the service by authorizing in shorter durations and fewer units than called for in the model. This will impact the fidelity of the EBP.
Page 21, Required activities, 1st bullet – The FFT model does not require an LMHP-type clinician complete the initial assessment. In Chapter IV, 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.”
Recommend that this should apply to FFT.
Page 21, Required activities, 3rd bullet
Add language to recognize that/allow the FFT Behavior Change Session Plans may not happen until past the first 30 days of the process.
Page 22, Service limitations, third bullet, last asterisk
MST excluded for family members.
Page 24, 3rd paragraph – Flexibility on caseloads is important. With telehealth, a professional may have as many as 15 cases, could use part-time team members (particularly in rural areas). Recommend language that outlines caseloads as what may be “typical,” but not be required or assumed to be the expectation.
Recommend adding language that states that caseloads be “consistent with or approved by the developer.”
Page 24, Staff requirements – It’s important that the language be clear that the model doesn’t call for a supervisor for the first year with that role being played by the developer/consultant. The site supervisor assumes this responsibility in the second year. This person is typically not identified at the start of the service. This usually happens at some point within the first year of service. There is a lot of concern in being specific with respect to caseloads for the site supervisor. It was noted that the site supervisor really should not carry cases given their responsibility to manage the team members.
Recommend removing minimum requirements for caseloads.
Page 25, 5th paragraph – Same concern from page 21 about credentialling requirements of those completing initial assessments.
Page 26, #3, 2nd bullet – There is concern that the MCOs will push people to FFT because it is less expensive. It’s recommended that being at risk for out-of-home placement should be limited to MST, not FFT. FFT was noted as a service that is not generally intensive enough for a youth at risk for out-of-home placement.
Page 27, #8 –This is listed as a required criteria, therefore excluding all youth not currently involved with the juvenile justice system.
Recommend adding “If” to the beginning of this bullet (like MST) or including it as an additional option under the third criterion.
Page 27-28, Continue stay criteria – Same concern as with MST continued stay criteria. See notes from page 13 above.
Page 29-30, Booster sessions – The FFT model does not require booster sessions be completed in the same two-week time period.
This language disrupts the purpose of booster sessions.
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. Recommend that 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.
Page 31, Service authorization – It’s important that this language is not too restrictive so that the MCOs can use it to restrict the service. There is concern that the MCOs will authorize shorter durations and fewer units. Premature discharge will impact the fidelity ratings and fidelity of the model. All the phases should be completed, per the model.
Recommend minimums be added – Both Pennsylvania and Louisiana have averages as follows:
MST, at least 120 days, 240 units, 60 hours of direct service
FFT, at least 120 days, 120 units, 30 hours of direct service
Page 31, Service authorization – The FFT model describes the initial Engagement phase of treatment as between the initial referral and assessment.
Consider including an initial registration period for providers to complete, document, and be compensated for efforts during this phase a treatment.
