NATIONAL CORE INDICATORSDATA FOR SYSTEMS CHANGE USE OF MEDICATIONS TO ADDRESS MOOD, ANXIETY, PSYCHOSIS AND BEHAVIOR AND STATE EFFORTS TO ADDRESS
MARCH 29, 2013
A Collaboration of State Members, NASDDDS & HSRI
Overview of National Core Indicators NCI Data Sources NCI Data on Utilization of Medication for Anxiety, Mood disorders, Behavior challenges and Psychotic
disorders NCI Findings and Recommendations on Medication Utilization Significant State Efforts to Address Overuse of Psychotropic Medications State Activities to Monitor and Reduce Unnecessary Medications
Agenda
Overview of NCI
National Core Indicators “NCI”
NCI is a voluntary effort by public developmental disabilities agencies to measure and track systemic performance.
Collaboration began in 1997
Coordinated by HSRI and NASDDDS
Currently 35 states participate plus 23 sub-state entities.
NCI was awarded a contract from the Administration on Intellectual and Developmental Disabilities (AIDD) with goal to increase participation to all 50 states and District of Columbia within 5 years.
NCI Goals
Establish a nationally recognized set of performance and outcome indicators for DD service systems
Develop and maintain reliable data collection methods and tools
Report state comparisons and national benchmarks of system-level performance
What is an “Indicator”?
A standard measure used across states to assess the outcomes of services provided to individuals and families.
Indicators address key areas of concern including employment, rights, service planning, community inclusion, choice, and health and safety.
Indicators and data collection instruments are reviewed regularly to update and reflect best practice in service delivery.
NCI Data Sources and Reports
NCI Data Sources
Adult Consumer Survey
In-person conversation with a sample of adults receiving services to
gather information about their experiences
Keyed to important person-centered outcomes that measure system-
level indicators related to: employment, choice, relationships, case
management, inclusion, health, etc
Adult Family, Child Family, and Family/Guardian Surveys
Mail surveys – separate sample from Adult Consumer Survey
Other state system data: Mortality, Staff Stability
NCI Reporting & Resources
NCI website is a public data source for: Annual national reports Annual state reports Publications: Data used by researchers for journal articles NCI Data Briefs: Medications, Employment Outcomes,
Autism, Dual Diagnosis, Living Arrangement, etc. Webinars: Managed Care, Interviewer Training Chart function for customized data analysis
http://www.nationalcoreindicators.org/
Ways States Use NCI Data
CMS Waiver Assurance Evidence Reports
Quality Assurance and Improvement
State by State Comparisons
Assist with Community Transition
DD Councils
Reports to State Legislatures
Demographic differencesWhat medications are taken forHealth differences
NCI Medication Data Brief: Findings
Source of Information
Adult Consumer Survey
Background Section
“Does the person take medications to address”:
Mood disorder
Anxiety
Psychotic disorder
Behavior
Who takes these medications?
Slightly older Slightly less racially diverse Less likely to live with
parents or relatives Less likely to be diagnosed
with profound level of ID Less likely to be diagnosed
with cerebral palsy and Down syndrome
Less likely to have a physical disability
More likely to be white More likely to live in group
homes More likely to be
diagnosed with mild level of ID
More likely to be diagnosed with Autism Spectrum Disorder
Residence Type and Medications
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
6%
35%
6%
18%22%
7%
1%5%
0%
6%
19%
3%
17%
47%
5%
1%3%
0%
At least one med
No meds
Other Disabilities
0%
5%
10%
15%
20%
25%
30%
ASD CP Seizure disorder/
neurological problem
Physical disability
Alzheimer's/ dementia
Down syndrome
13%
10%
23%
8%
2%5%
7%
20%
25%
12%
1%
13%
At least one med
No meds
Takes Medications to Address
53% of people with IDD receiving services are taking medications for at least 1 of these conditions: mood disorders anxiety behavior challenges psychotic disorders
Most common condition medications are taken for is mood disorders (38%).
14% of those taking at least one medication are taking them for all 4 conditions.
39%
29%
18%14%
Takes medications for….1 condition 2 conditions 3 conditions 4 conditions
Takes Medications to Address
88% of those with a co-occurring psychiatric diagnosis were taking medications for mood, anxiety or psychotic disorders.
However, 30% of people without a psychiatric diagnosis were also taking medications for mood, anxiety or psychotic disorders.
What Health Differences Exist?
Those who take at least one medication are:Less likely to be in very good or excellent health
More likely to use tobacco products
More likely to be obese / less likely to be of normal weight
0%
5%
10%
15%
20%
25%
30%
35%
40%
Underweight Normal Overweight Obese
4%
29% 30%
37%
8%
35%
28%29%
At least one med
No meds
Overuse of Psychotropic Medications: Not just a DD service system concern
Mental Health Aging Service System Initiatives Courts are involved in ensuring due process protections for people
recommended to take certain medications. Advance Directives for medication consent now are used.
Aging Service System Initiatives In aging services, Massachusetts nursing homes are monitored by state
licensing agency for overuse of these kinds of medications. Children using Medicaid & Foster Care
GAO 2012 report found that 18% of foster children were taking psychotropic medications. Utilization varied widely by the child’s living arrangement.
1.3 % of children in Medicaid took antipsychotic medications, that is twice the rate for privately insured children (0.5%).
Children's Mental Health: Concerns Remain about Appropriate Services for Children in Medicaid and Foster Care. GAO-13-15, December 10. http://www.gao.gov/products/GAO-13-15
Massachusetts Georgia Missouri
State Presentations
DD Service System Initiatives
Statute, policies and procedures in many states affirm that people receiving services cannot be chemically restrained, or prescribed medication that has an impact on behavior, without first conducting an evaluation to determine if there are medical causes for the behavior.
Some states require positive behavior supports be implemented prior to use of medications.
Human Rights Councils review restrictive practices and rights violations, including under what circumstance people can be prescribed multiple psychotropic medications.
Annual service planning allows for review of all treatment regimens and their continued efficacy.
Massachusetts Dept. of Developmental Services3 Tier Approach
DDS concerned about poly-pharmacy, co-occurring medical/psychiatric/behavioral issues; aging population; limited number of practitioners knowledgeable about DD issues
Established a Statewide Medication Review Committee to bring together physicians, psychiatrists, behavioral psychologists, psycho-pharmacologist, neurologist, and nurses
Approaches issue of over-utilization of medications on 3 levels focusing on patterns and trends as well as individual reviews Individual Case Review Targeted Outreach to clinicians utilizing multiple medications based upon
an analysis of Medicaid billing data Broad Outreach and education to clinicians regarding “Consensus
Guidelines
Massachusetts Dept. of DevelopmentalServicesReview Process for Individual Cases
Referrers submit complete package of documentation so that Committee Members can read in advance
All family, staff, clinicians involved are encouraged to come to meeting
Committee sends recommendations to DDS Area Office for distribution to involved parties
Committee may facilitate additional referrals to specialists, and follow up with treating community PCP and psycho-pharmacologist
Committee follows up in 90 days to determine status and next steps
Massachusetts Dept. of DevelopmentalServicesPreliminary Lessons Learned from Individual Case Reviews
Important to stress consultative nature of committee so that it encourages referrals
Individuals referred to committee typically present with multiple issues in addition to poly-pharmacy which may be “tip of the iceberg”
Individuals facing declining health status; outcomes may focus on quality of life issues
Individuals often present with effects of long term utilization of psychotropic medications, which affects individuals with ID differently than general population
Physicians, however well meaning, tend to add medications when an individual is experiencing behavioral or other issues
Physicians try to be responsive to family and or direct support staff who may be having significant challenges with supporting an individual which sometimes leads to increasing medications
Extremely productive to have clinicians from multiple disciplines; enables better coordination and problem solving
Massachusetts Dept. of Developmental Services Next Steps
Further refinement of referral package Broader outreach to DDS community to encourage
more referrals Change of name of committee More in-depth analysis of prescriber practices utilizing
Medicaid data Development of more systemic outreach efforts to
community clinicians Initiation of evaluation component of both process
and outcomes of Medication Committee Reviews
Georgia Dept. of Behavioral Health andDevelopmental Disabilities
Psychotropic & Anti-epileptic Medications Study Purpose of study Olmstead Plan Study participants Data collected and points in time Analysis plan Anticipated action from study findings
Missouri Division of DevelopmentalDisabilities
Identification of Concerns and Development of Strategies NCI data – ensure accuracy Cross –analysis with Medicaid Claims Cross- analysis with HIPS Established threshold for local identifiers as a
result of discussion with Medical Director and Chief Behavior Analyst.
Missouri Division of DevelopmentalDisabilities
Educating and Implementing Strategies Used national and regional
data to present at each Regional Office/ SOP to further educate staff and stakeholders of identified concerns.
Region specific data was prepared for each question related to medication and behavior supports.
Missouri Division of DevelopmentalDisabilities
Next Steps: Using established threshold, continue to identify individuals quarterly
and forward to respective Regional Office teams for individualized review.
Statewide data will be compiled to establish benchmarks for comparison of improvement with current strategies.
Continue to monitor data through current systems and share findings with stakeholders for continued improvement.
Currently working to develop a standardized Developmental Disabilities Medication Administration curriculum, with a component specifically addressing psychotropic medications.
Development of a best practice guide regarding the use of psychotropic medications –currently in development
For more information
NCI website: http://www.nationalcoreindicators.org
NASDDDS: Mary Lee Fay, Director of NCI, [email protected]
Charles Moseley, Associate Executive Director, [email protected]
HSRI:Val Bradley, President, [email protected]
Sarah Taub, Director of NCI, [email protected]
Julie Bershadsky, Research Associate, [email protected]
Josh Engler, NCI Project Coordinator, [email protected]