qi initiatives for psychotropic use in foster youth in maine lindsey tweed md mph office of child...
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QI Initiatives for Psychotropic Use in Foster Youth in Maine
Lindsey Tweed MD MPH
Office of Child & Family Services; Maine DHHS
Sixteen State Collaborative Antipsychotic Study
• This study occurred before the more recent focus on all psychotropics in foster youth
• Focus was on all Medicaid beneficiaries; not just foster youth
• Data analysis covered 2004-2007
16 State Antipsychotic Study: Part II
• Rate for of antipsychotic use for all MaineCare members 0-18: 3.1 %
• Rate for MaineCare members 12-18 varied between 5 and 6%
• Maine was above the median
• Rate for foster youth: 20%
• Nobody knows what the rates should be; but these seemed high
Rationale for More Intense Focus on Antipsychotics
• Although psychotropics should never be used inappropriately, stimulants and antidepressants are relatively safe
• Medically important side effects are very common with antipsychotics
• Majority of psychotropic side effect burden would seem to be due to antipsychotics
• Other less prevalent meds that commonly have medically important side effects…
Handling Antipsychotic Outliers
• More than one; high dose; very young
• Pharmacy benefit manager had implemented Prior Authorization process; mainly as a cost saving tool
• PA requirement added for two AP’s or for doses over FDA approved
• PA for AP use in children under 5 later added; requires a chart review
Reaction to Initial Prior Authorization Requirements
• PA approved by committee including community psychiatrists
• Still, there was a very strong reaction against the PA
• M.D. at benefit manager: We should have had a conference, other means of input and education, before implementing.
• We may now be in a different era
But Non-Outliers Are Majority of the Problem
• Most AP prescription is to youth 5 and over; one antipsychotic; and at FDA approved doses
• These youth commonly/usually experience medically important side effects
• The majority of foster youth side effect burden would appear to come from non-outlier use of AP’s
Goals and Members of AP Use in Foster Youth Workgroup
• Goal: Ensure that Foster Youth are prescribed antipsychotics only when clinically indicated
• Members: Foster Youth, Foster Parents, Residential Treatment Providers, Child Psychiatrists, DHHS
• We began in September 2009 and met for about one year
Strategies Chosen
• Strengthen teen consent process– Tool developed to empower youth
• Strengthen caseworker consent process; be the best parent you can
• Worksheet for caseworkers
Worksheet for Caseworkers/Supervisors
• Use in psychosis and for Bipolar Disorder
• Use for aggression as a target symptom• In context of Autism Spectrum• In context of Disruptive Behavior Disorders (CD,
ADHD with aggression)• Maximize good casework• Maximize psychosocial interventions
– EBT’s
• Maximize treatment of primary disorders (e.g., ADHD, depression) with safer meds
Worksheet (cont.)
• Monitoring therapeutic effects
• Monitoring side effects– Ask specifically about weight, BMI, BMI
percentile, glucose and lipids
• When aggression is target symptom, and when youth has done well for 6 months, expectation is to taper
• All good med decisions are risk vs benefit
Additional Strategies
• Additional Support for Caseworkers– By clinicians who work within OCFS
• Education on Guidelines: Youth, Caseworkers, Prescribers, Foster Parents, Residential Providers
• Monitoring Our Progress– Both via MACWIS and via MaineCare claims– Proportion of youth on each category of med; by
district, supervisor, caseworker– How to measure if process followed?
AP Use Rate 0-18 YearsMinimum one month MaineCare eligibility
AP Use in MaineCare Members Under 19Maine 2004-2011
Other States 2004-2007
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
4.5%
2004 2005 2006 2007 2008 2009 2010 2011
Maine Maximum Median Minimum
Year % of AP
Users
2004 3.1%
2005 3.1%
2006 3.2%
2007 3.1%
2008 3.1%
2009 3.0%
2010 2.8%
2011 2.6%
Maine
DRAFT 8/8/2012
Foster/Non-Foster AP Use Rate 0-18 Years
One month MaineCare eligibilityvirtually all atypical anti-psychotics
AP Use in Children/ Youth 0-18Maine 2004-2011
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
2004 2005 2006 2007 2008 2009 2010 2011
Foster Care Non-Foster Care
AP Use Demographics
Year Foster Care
Non-Foster
2004 10.9% 3.0%
2005 9.2% 3.0%
2006 8.5% 3.0%
2007 9.5% 3.0%
2008 17.2% 2.8%
2009 16.8% 2.7%
2010 16.7% 2.5%
2011 14.6% 2.4%DRAFT 8/8/2012
Recent Initiatives for All MaineCare Members
• Legislator introduced a bill to regulate AP prescription in youth– Compromise was a DHHS report– Similar stakeholder group made similar recs
for all prescribers– Method for monitoring agencies’ QI being
devised
• New PA: required monitoring of metabolic side effects within first 20 weeks of use
Role of Evidence Based Treatments
• Most youth started on AP’s have significant mental health symptoms
• EBT’s have not been widely disseminated• Overuse of AP’s may be a logical
consequence of non-dissemination of EBT’s• Significant prevalence of disruptive
behavior, anxiety, depression, and post-traumatic stress in foster youth