A. Multisystemic Therapy

Definition

Multisystemic Therapy (MST) is an evidenced based treatment model designed to divert children and adolescents ages 11 to 17 from residential substance abuse and juvenile justice treatment systems or to support discharge from inpatient levels of care. While children/adolescents with disruptive behavioral and/or substance abuse symptoms are the focus of intervention, the model relies on ecological, family and systemic interventions to assist in the reduction of symptoms.

MST is an intensive home-based delivery system with an emphasis on the engagement and retention of the family, the recovery environment, and providing integrated case management. MST has developed fidelity measures based on research and MST principles as well as quality assurance systems to manage program drift.

Authorization Process and Time Frame for Service

This level of care requires prior authorization and can only be provided by a treatment provider who is an MST credentialed provider, certified by the Department of Children and Families.

MST services typically last 4 months. The number of sessions per week will be dictated by the needs of the child/adolescent, but contact (2 hours/session) is expected to occur at least three times per week for a minimum of 101 units (15min/unit) per month (4.2.weeks). Services may last up to six months or beyond with special review.

Level of Care Guidelines

1.1.0 Admission Criteria

1.1.1 Symptoms and functional impairment include all of the following:

1.1.1.1 Diagnosable DSM Axis I or Axis II disorder,

1.1.1.2 Symptoms and impairment must be the result of a primary substance abuse and/or disruptive behavior disorder: internalizing psychiatric conditions may be secondary.

1.1.1.3 Functional impairment not solely a result of Pervasive Developmental Disorder or Mental Retardation,

1.1.1.4 GAF<60

1.1.2 Presentation consistent with at least one of the following:

1.1.2.1 Recent and/or ongoing risk of deliberate attempts to inflict serious injury on another person; or

1.1.2.2 Recent and/or ongoing dangerous or destructive behavior as evidenced by indication of episodic impulsivity or physically or sexually aggressive impulses that are endangering to self or others (e.g., impulsive acts while intoxicated, running away from home or placement with voluntary return, fire setting, violence toward animals, affiliation with dangerous peer groups); and

1.1.2.3 Recent and/or ongoing substance abuse or dependency problem that is interfering with the adolescent’s psycho-social functioning in the community

1.1.3 Children/Adolescents appropriate for MST services are those for whom:

1.1.3.1 There is a family/caregiver resource that is available to participate in this intensive home-based intervention, and

1.1.3.2 Arrangements for supervision at home are adequate to assure a reasonable degree of safety, and

1.1.3.3 A safety plan has been established, and

1.1.3.4 The primary presenting problem is not an internalizing disorder or the child/adolescent is not actively psychotic or suicidal.

1.1.4 Intensity of Service Need

1.1.4.1 The child/adolescent has been admitted to, or is at risk of being admitted to a substance abuse and/or Juvenile Justice residential level of care or is being discharged from a treatment center and demonstrated the above admission criteria prior to placement; or

1.1.4.2 The child/adolescent is in out of home care and requires intensive in-home care to achieve the reintegration plan.

In addition to either of the above criteria, both of the following criteria must be met:

1.1.4.3 The child/adolescent’s successful reintegration or maintenance in the community is dependent upon an integrated and coordinated treatment approach that involves family members as primary intervention specialists and

1.1.4.4 The above symptoms cannot be contained, attenuated, evaluated and treated in a lower level of community based care as evidenced by one of the following:

1.1.4.4.1 Recent attempts to engage the child and/or family in intensive outpatient therapy have been unsuccessful or

1.1.4.4.2 The above problems occur in context of the ecology and recovery environment is a significant factor to initiate and maintain clinical gains

1.2.0 Continued Care Criteria

1.2.1 The child/adolescent has met admission criteria within the past thirty (30) days for MST as evidenced by:

1.2.1.1 The child/adolescent’s symptoms or behaviors persist at a level of severity documented at the start of this episode of care; or

1.2.1.2 The child/adolescent’s symptoms or behaviors persist at a level of severity adequate to meet admission criteria, or

1.2.1.3 The child/adolescent has manifested new symptoms or maladaptive behaviors that meet admission criteria and the treatment plan has been revised to incorporate new goals; or

1.2.1.4 The child/adolescent ‘s symptoms have increased sufficiently over the past 24 hours to warrant immediate increase of number of hours provided weekly to the family and

1.2.2 Evidence of active treatment and care management as evidenced by:

1.2.2.1 A care plan with evaluation and treatment objectives appropriate for this level of care has been established. Treatment objectives are related to readiness for discharge and progress toward objectives is being monitored weekly, and

1.2.2.2 Child/adolescent and family (caregiver) participation in treatment is consistent with care plan, or active efforts to engage the patient and/or family are in process. Type, frequency and intensity of services are consistent with treatment plan, and

1.2.2.3 Vigorous efforts are being made to affect a timely transition to appropriate lower level of care.

1.2.3 If child/adolescent does not meet criterion E.2.1, continued treatment may still be authorized under any of the following circumstances:

1.2.3.1 Child/adolescent has clear behaviorally defined treatment objectives that can reasonably be achieved through continued home based treatment and such treatment is necessary in order for the discharge plan to be successful and there is no less intensive level of care in which the objectives can be safely accomplished; or

1.2.3.2 Child/Adolescent can achieve certain treatment objectives in the current level of care and achievement of those objectives will enable the patient to be discharged directly to a less intensive community rather than to a more restrictive setting; or

1.2.3.3 Child/Adolescent is scheduled for discharge, but the community-based aftercare plan is missing critical components. The components have been vigorously pursued but are not available (including but not limited to such resources as placement options, substance abuse treatment or therapist appointments, therapeutic mentoring, etc). Authorization may be extended for up to 10 days. Child/adolescent should be referred to Intensive Care Management. (Intensive Care Manager will work with Managed Service System if child is DCF involved or directly with local providers or Community Collaboratives to address aftercare needs).

Note: Making of Level of Care Decisions

In any case in which a request for services does not satisfy the above criteria, the ASO reviewer must then apply the document Guidelines for Making of Level of Care Decisions and in these cases the child/adolescent shall be granted the level of care requested when:

1) Those mitigating factors are identified and

2) Not doing so would otherwise limit the child/adolescent ability to be successfully maintained in the community or is needed in order to succeed in meeting child/adolescent treatment goals.