reducing the use of psychotropic medication in foster...
TRANSCRIPT
Reducing the Use of Psychotropic Medication in Foster Care
F. Scott McCown Clinical Professor
Director of the Children’s Rights Clinic The University of Texas School of Law
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What Is Psychotropic Medication? Texas Family Code: "Psychotropic medication" means a medication that is prescribed for the treatment of symptoms of psychosis or another mental, emotional, or behavioral disorder and that is used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state. The term includes the following categories when used as described by this subdivision: (A) psychomotor stimulants; (B) antidepressants; (C) antipsychotics or neuroleptics; (D) agents for control of mania or depression; (E) antianxiety agents; and (F) sedatives, hypnotics, or other sleep-promoting medications.
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Catalyst to Reduce Use • In 2004, the Texas Comptroller released a study, Forgotten Children,
reporting that “many foster children receive disturbing amounts of mind-altering psychotropic drugs with little or no accountability.”
• In 2011, the General Accounting Office released a study of 2008
data from five states, including Texas, showing that foster children more frequently received psychotropic drugs than non-foster children.
• In 2011 and again in 2013, stakeholders such as Texas CASA,
attorneys ad litem, and former foster youth themselves provided anecdotal evidence that too many foster children were on too much psychotropic medicine.
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Why Do We Care? • Adverse side effects of medicine can be
significant • It gives the false impression that we are
treating the problem so we don’t really treat the problem
• When used for sedation it may provide temporary control but not lasting treatment
• The costs of medicine and follow up are substantial
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What the GAO Found • In 2008, foster children were prescribed psychotropic
drugs at higher rates than non-foster children in Medicaid.
• Concomitant use of 5 or more drugs—which no evidence supports.
• Doses higher than maximum levels—which increases side effects without increasing efficacy.
• Use in children under 1 year old, which no evidence supports.
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GAO Digs Deeper Survey Data 2007-2009
• Noninstitutionalized children on one or more psychotropic medications: – 4.8% Privately Insured – 6.2% Medicaid – 18% Foster Care
• Noninstitutionalized children on an antipsychotic medication: – 0.5% Privately Insured – 1.3% Medicaid
• Foster Children – 18% on Psychotropic Medications
• 13% on 3 or More Psychotropic Medications • 6.4% on an Antipsychotic Medication
– 48% Group Home or RTC – 14% Nonrelative Foster Home – 12% Kinship Care
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National Standards and Federal Law
• American Academy of Child & Adolescent Psychiatry, A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents (Feb 2012)—General Guidelines
• Fostering Connections Act in 2008 requires states to provide ongoing oversight of medical services including psychotropic medication
• Child and Family Services Improvement and Innovation Act in 2011 requires states to establish protocols for use and monitoring of psychotropic medication
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What is the right number? • GAO recognized that higher rates “could be due in part
to foster children’s greater mental health needs, greater exposure to traumatic experiences and the challenges of coordinating their medical care.
• Better access to medical care and more focus on children’s needs might also account for higher rates.
• State’s removal rate may effect proportion on psychotropic medication. – California 6.8 per 1,000 (2010) – Texas 1.8 per 1,000 (2010)
• The “right number” is unknown.
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Reasons for Overprescribing
• Want to do something! – Same problem as antibiotics
• Trauma mimicking mental illness – But medicine does no good
• Sedation – Chemical restraint
• Drug Company Sales
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Texas Legislation • SB 6 in 2005
– http://www.capitol.state.tx.us/BillLookup/History.aspx?LegSess=79R&Bill=SB6
• HB 915 in 2013
– http://www.capitol.state.tx.us/BillLookup/History.aspx?LegSess=83R&Bill=HB915
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28.0% 29.6% 29.9%
26.4% 25.0% 24.7%
21.5% 21.2% 20.5%
19.8% 19.8% 19.1%
3.3% 4.0%
5.0%
3.4% 2.5% 2.5% 2.0% 1.8% 1.8% 1.7% 1.7% 1.4%
0.7% 1.1% 1.4% 0.9% 0.7% 0.7% 0.6% 0.5% 0.5% 0.5% 0.4% 0.4% 0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Percent of Children in Texas Foster Care prescribed Psychotropic Medications by category: Change from Fiscal Years 2004-2013
Psychotropic Meds 60 days+ Class polypharmacy Five or more Meds polypharmacy
36% decrease
71% decrease
74% decrease
DFPS Chart 11
0.8% 1.0% 1.0% 0.8% 0.5% 0.7% 0.5% 0.5% 0.4% 0.4% 0.4% 0.9%
7.0% 8.9% 9.8%
8.6% 6.4% 6.5%
5.0% 4.1% 4.0% 3.8% 3.2% 3.6%
17.6%
21.4% 22.5%
19.1% 17.0% 17.7%
15.0% 13.8% 14.2% 14.2%
12.9% 11.9%
41.5% 43.4% 44.4%
40.6% 38.3%
37.1%
33.4% 32.7% 32.3% 31.5% 29.8%
28.3%
47.8%
51.5% 51.8%
48.3% 46.8% 47.0%
41.2% 41.0% 41.9% 44.7% 45.3%
43.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Percent of Children in Texas Foster Care prescribed Psychotropic Medications for 60 days or more by age groups: Change from Fiscal Years 2004 thru 2013
0 – 2 3 4 – 5 6 – 12 13 – 17
16% decrease
36% decrease
47% decrease
63% decrease
12% decrease
DFPS Chart 12
0.1% 0.3% 0.3% 0.0% 0.1% 0.2% 0.1% 0.0% 0.1% 0.0% 0.0% 0.1%
0.5%
1.0% 1.2% 0.7%
0.4% 0.6% 0.4% 0.1% 0.2% 0.2% 0.1% 0.1%
3.8%
4.6%
6.9%
4.3%
3.2% 3.2% 2.7%
2.1% 2.3% 2.1% 1.8%
1.3%
7.8%
9.4%
10.6%
8.2%
6.1% 6.2%
5.0% 5.1% 5.1% 5.3% 5.8%
5.3%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Percent of Children in Texas Foster Care prescribed Class Polypharmacy by age group:
Change from Fiscal Years 2004 thru 2013
3 4 – 5 6 – 12 13 – 17
50% decrease
92% decrease
81% decrease
64% decrease
DFPS Chart 13
0.2%
0.4%
0.2% 0.2% 0.0% 0.0%
0.1% 0.0%
0.1% 0.1% 0.0% 0.0%
1.1%
1.8%
2.3%
1.3%
1.0% 1.1%
0.9%
0.8% 0.7% 0.7%
0.6%
0.4%
1.3%
2.0%
2.6%
2.0%
1.5%
1.7%
1.3% 1.3% 1.1%
1.3% 1.3% 1.2%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Percent of Children in Texas Foster Care prescribed Class Five or more meds by age group:
Change from Fiscal Years 2004 thru 2013
4 – 5 6 – 12 13 – 17
55% decrease
83% decrease
100% decrease
DFPS Chart 14
Steps Taken
• Medical Director - James A. Rogers, M.D. • Managed Care – Star Health
– Parameters for Prescribing – Retrospective Review
• Consent Process • Health Passport • Judicial Review
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Managed Care/STAR Health • HHSC entered into contract with Superior Health Plan
Network for a managed care system for foster children. • Managed care medical home model with provider
network • Richer reimbursement than fee-for-service Medicaid • Superior Health Plan Network is responsible for physical
health services and subcontracts with other vendors for behavioral health (Cenpatico), dental, vision, and pharmacy services.
• Launched on April 1, 2008.
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Prescribing Parameters
• In February 2005, HHSC, DSHS, and DFPS, released the Psychotropic Medication Utilization Parameters for Foster Children (updated June 2007, December 2010, and September 2013).
• The current version can be found at: http://www.dfps.state.tx.us/Child_Protection/Medical
_Services/guide-psychotropic.asp • The parameters use nine criteria to trigger further
review of a child’s medication.
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Review Criteria
1. Absence of DSM-5 diagnosis.
2. Four (4) or more psychotropic medications.
3. Prescribing: • Two (2) or more stimulants at the same time • Two (2) or more alpha agonists • Two (2) or more antidepressants at the same time • Two (2) or more antipsychotics at the same time
• Three (3) or more mood stabilizers at the same time.
4. The prescribed psychotropic medication is not consistent with appropriate care for the patient’s diagnosed mental disorder or with documented target symptoms.
5. Psychotropic polypharmacy (2 or more medications) for a given mental disorder is prescribed before utilizing a single medication.
6. The psychotropic medication dose exceeds usual recommended doses (FDA and /or literature based maximum dosages).
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Adapted from DFPS Slide
Review Criteria (continued)
7. Psychotropic medications are prescribed for children of very young age, including children receiving the following medications with an age of:
• Stimulants: Less than three (3) years of age • Alpha Agonists: Less than four (4) years of age • Antidepressants: Less than four (4) years of age • Antipsychotics: Less than four (4) years of age • Mood Stabilizers: Less than four (4) years of age
8. Prescribing by a primary care provider for a diagnosis other than the
following (unless recommended by a psychiatrist consultant): • Attention Deficit Hyperactive Disorder (ADHD) • Uncomplicated anxiety disorders • Uncomplicated depression
9. Antipsychotic medication(s) prescribed continuously without appropriate monitoring of glucose and lipids at least every 6 months.
19 Adapted from DFPS Slide
Review Process
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• Health screenings – STAR Health Service Managers conduct phone interviews with caretakers to identify those children who have medication regimens which appear to be outside of the Psychotropic Medication Utilization Parameters prescribing criteria.
• Automated pharmacy claims screening – STAR Health also conducts a real time automated screening program utilizing pharmacy claims information from vendor drug to identify foster children who have medication regimens which may fall outside the prescribing criteria.
• External request – CPS Nurse specialists, CPS caseworkers, CASA volunteers, foster parents, attorneys or Child Placing Agencies can request a medication review.
• Court request – Family court judges can request a review to answer questions about a foster child’s medication regimen.
Adapted from DFPS Slide
Review Process (continued)
• Psychotropic Medication Utilization Review (PMUR) – process
by which all the children's psychotropic medication regimens "outside of Parameters" are reviewed and managed through STAR Health child psychiatrist consultations to the prescribing physicians. The written PMUR report is uploaded to the Health Passport.
• Quality of Care Review (QOC) – physicians with practice patterns of concern (identified through the PMUR process or by complaints by parties involved in the child's care) are thoroughly reviewed and may, if warranted, be referred to the STAR Health Credentialing Committee for further investigation and disciplinary action including termination from the network. (In 2011, 28 QOC reviews with 6 corrective action plans.)
21 Adapted from DFPS Slide
Medical Consent
• Court authorizes DFPS or an individual to consent to medical care • If DFPS is authorized, DFPS must designate a particular individual
– Live-in caregivers, emergency shelter staff, cottage parents; or – CPS staff in facilities with shift staff
• Medical consenter must complete training on informed consent: – http://www.dfps.state.tx.us/Training/PsychotropicMedication/default.asp
• Medical consenter must participate in each medical appointment of child • DFPS and attorneys ad litem must notify youth of their right to ask court to
authorize them to consent to some or all of their own medical care before at 16 – Court considers capacity of youth – DFPS may file petition if youth refuses needed treatment – DFPS must include training on informed consent in Preparation for Adult
Living Life Skills Training – Youth must complete training if taking psychotropic medications
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Health Passport
• Secure, web-based electronic health record (EHR) system
• Access by state staff, network providers, and medical consenters
• Provides access by authorized users according to their role
• Accessed at www.fostercaretx.com
• Initially populated with two years of Medicaid and CHIP claims history and pharmacy data
• When the child leaves foster care, the passport is available in electronic or printed formats to:
– child’s legal guardian, managing conservator, or parent – child if at least 18 years of age or an emancipated minor
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Judicial Review • DFPS
– Must provide information about medications in court report • Judges
– Must review child’s medical care – Must ensure the child has had an opportunity to express an opinion
on medical care and must review child’s opinion – If child is receiving psychotropic medication, must determine
whether: • Child has been provided appropriate psychosocial therapies, behavior strategies,
and other non-pharmacological interventions; • Child has been seen by the prescribing physician or PA or APN at least once
every 90 days • Attorneys ad litem
– Must review medical care provided to the child – Elicit child’s opinion on medical care – Advise child who is at least 16 years of right to request the court to authorize the child
to consent to the child’s own medical care. • Notification to parents
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Alternatives • Non-Pharmacological Interventions:
trauma-informed, evidence-based psychosocial therapies.
• Stronger Foster Homes—better trained foster parents and fewer children and youth.
• Alternatives for teenagers—alternative education and supervised independent living.
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