Models of Agency Consent for. Children and Youth in Child Welfare. PsychotropicMedications for. Care: Exploring the Issues Webinar Series

Transcription

1 Psychotropic Medications and Foster Care: Exploring the Issues Webinar Series Models of Agency Consent for PsychotropicMedications for Children and Youth in Child Welfare June 10, :00-2:30 PM EST Dial-In: // Passcode:

2 Questions? Ask a Question Online: Click the Q&A icon located in the hidden toolbar at the top of your screen. 2

3 Agenda Welcome and Overview Children in Foster Care: A Medicaid Snapshot Agency Consent: Setting the Context State Agency Consent Models New Jersey Connecticut Illinois Closing Comments 3

4 Improving the quality and cost-effectiveness of publicly financed health care Children in Foster Care: A Medicaid id Snapshot Kamala D. Allen Director, Child Health Quality Center for Health Care Strategies

5 Landmark Federal Communication The Department of Health and Human Services (HHS) has become increasingly i concerned about the safe, appropriate, and effective use of psychotropic medications among children in foster care. -- November 23,

6 BH Services for Children in Foster Care* Children in foster care account for: 3 % of the child Medicaid population 15 % of behavioral health services used 29 % of behavioral health service dollars * Findings from the forthcoming CHCS Medicaid Child Behavioral Health Utilization and Expenditure Study,

7 Children in Foster Care and Psychotropic Meds* Children in foster care were more likely to be prescribed psychotropic medications prescribed psychotropic medications 27% of children in foster care on psych medications vs.: 23% of children with SSI/disabled-eligibility 4% of children with TANF-eligibility More likely to receive multiple psychotropic medications 40% received 2 or more 20% received 3 or more More likely to be prescribed antipsychotics 42% of foster children and SSI children vs. 18% TANF * Findings from the forthcoming CHCS Medicaid Child Behavioral Health Utilization and Expenditure Study,

8 Children in Foster Care: How are States t Responding? Collaboration among Medicaid, child welfare and behavioral health agencies Specialized care management approaches Managed care carve-outs Specialty provider networks Special protocol for oversight and monitoring complex and high-cost services 8

9 Psychotropic Medication Quality Improvement Collaborative (PMQIC) Quality Improvement Collaborative (Casey Foundation) Six state teams (IL, NJ, NY, OR, RI, VT) Three-year system change initiative PMQIC Data Subgroup Impact measures Psychotropic Medication Virtual Learning Community (SAMHSA/ACF) Bi-monthly webinars Monthly technical assistance e-newsletter SharePoint Resource Center 9

10 Setting the Context Informed consent is essential to ensure that guardians of patients understand the medications prescribed. States vary in how they define and operationalize informed consent processes for children in foster care. Not all states have informed consent policies in place. 10

11 Setting the Context Policies vary along a number of dimensions: Consenting entity Consent review entity Length of informed consent Consent elements for approval/authorization Information provided d to patient/guardian t/ Youth consent/assent Prescribing without consent 11

12 Setting the Context Some states utilize medical expertise to review and inform consent decisions. Agency consent models: Decentralized consent review Centralized internal consent review Centralized external consent review Agency consent models: New Jersey, Connecticut and Illinois 12

13 Informed Consent for Psychotropic Medication in New Jersey June 10, 2013 Mary Beirne, MS, EdD, MD DCF Child/Adolescent Psychiatrist D b L t MLIR Debra Lancaster, MLIR Director, Office of Child and Family Health

14 State Context State-administered administered child welfare system 7,645 children were in out-of-home care as of May 2013 All children in out-of-home care enrolled in New Jersey Medicaid Children s System of Care 14

15 State Context Child Health Units (CHU) Co-located in Child Protection & Permanency (CP&P) Local Offices CHU Nurse Caseload is 1:50 DCF Child/Adolescent Psychiatrist 15

16 Establish the Fundamentals Reviewed our Case Practice Model Discussed our philosophy for caring for children in out-of-home care Biological parents should maintain responsibility for medical consent Preference for decentralized decision-making 16

17 Develop Policy: Research Reviewed AACAP, AAP, CWLA Guidelines Reviewed other states policies, including CT, FL, IL, TN, & TX Convened an internal workgroup 17

18 Develop Policy: Process Established policy components Psychiatric Evaluation Authorized Prescribers Treatment Plan Informed Consent Medication Guidelines Safety Monitoring i Guidelines Prescribing Parameters 18

19 Develop Policy: Process Convened a Psychotropic Medication Advisory Group to provide feedback and support the Department s efforts to implement the policy Issued in January

20 Implement Policy: Internal Held workshops with child welfare leadership and supervisors to provide a basic understanding of psychiatric illness in child population and the role of medication in treatment Held workshops with Child Health Unit nurses to provide in-depth information about psychiatric illness and medications 20

21 Implement Policy: External Presented to mental health community Held a Provider Forum Presented at Grand Rounds Attended on site meetings with providers Participated in treatment team meetings 21

22 Policy in Action: Informed Consent Basic Principles i Medical treatment for children who are in CP&P custody requires consent, which varies for routine and non-routine care Psychotropic medication is non-routine care and requires written consent Our Case Practice Model recognizes the role of parents in the child s ongoing care and requires their consent whenever possible 22

23 Consenting Authority CP&P staff first seek consent from the child s parents. If the parents are unavailable or uncooperative, CP&P--preferably the Local Office Manager--may provide consent under certain scenarios such as: When parental rights have been terminated A court has provided specific authority to CP&P In an emergency and the parents are unavailable 23

24 Consultation: Child Health Units CP&P and CHU staff work with the child s provider to gather all relevant health care information that will help the child s parent/cp&p to make the most informed decision Information necessary to make an informed decision is provided by the treating professional CHU Nurses are available to answer general questions about psychotropic medications 24

25 Consultation: Psychiatrist When there are additional questions or concerns, consultation ti with DCF s Child/Adolescent l Psychiatrist i t may be appropriate Cases typically referred for consultation include: Child under 6 years of age and the medication is not recommended per Policy Prescribing Parameters Three or more psychotropic medications Child has complicating medical illness Medication not approved for child s diagnosisi Responses may include a conference call or requesting a treatment t t team meeting 25

26 Successes Developed a policy that reflects the values of our case practice model De-centralized and family-focused CHU nurses track and report psychotropic medication utilization and policy compliance Improved rate of informed consent in record Quarterly quality assurance reviews of specific at-risk cohorts 26

27 Challenges Developing and integrating ti and assent process into the current informed consent policy and practice Ongoing challenges with implementation 27

28 Questions? Ask a Question Online: Click the Q&A icon located in the hidden toolbar at the top of your screen. 28

29 Consent for Psychotropic Medication Connecticut s Model for Children and Youth in Foster Care

30 CT Department of Children and Families (DCF): A Multi Multi Mandate Mandate Agency Child Welfare Behavioral Health Juvenile Justice Education and Prevention

31 State Wide S Wid Ad Advisory i Committee began g in Psychotropic Medication Advisory Committee (PMAC) meets monthly Members include private and public APRNs, Child P hi i Psychiatrists, Ph Pharmacists, i P Pediatricians, di i i M Medicaid di id agency representatives Headed by DCF Chief of Psychiatry, Dr. Pat Leebens Reviews Best Practice for evaluation and treatment of foster care children and youth, including all aspects of evidence-informed care and informed consent. Dr. Leebens, works with Dr. Mike Naylor, on AACAP Practice Standards for Prescribingg in Foster Care Population, and introduces legislation for similar model in Connecticut in 2003

32 Connecticut Law passed 2004 Sec. 17a-21a. Guidelines for use and management of psychotropic medications. Database established. The Department of Children and Families shall, within available resources and d with i h the h assistance i off Th The U University i i off Connecticut Health Center, (1) establish guidelines for the use and management of psychotropic medications with children and youths in the care of the Department of Children and Families, Families and (2) establish and maintain a database to track the use of psychotropic medications with children and youths committed to the care of the Department of Children and Families. Families (P.A , S. 2; P.A , S. 112.)

33 CT adapts Illinois Model Given small size of state and multi multi-mandate mandate child welfare agency, decision made to develop unit within DCF for consultations/consent lt ti / t iinstead t d off partnership with a university Internal model possibly more cost cost-effective effective as it relies on only a few dedicated positions plus other existing state resources In I design, d i staff ff to be b used d not only l for f consent but for state-specific consultations

34 Centralized C li d Medication M di i Consent Unit (CMCU) ( ) Chief of Psychiatry Child P hi tri t( ) Psychiatrist(s) Advanced act ce Practice Nurse(s) Supportt Sta Suppo Staff

35 Stakeholders in Informed Consent Youth Worker Foster Family PCP CMCU

36 CT Guidelines G id li for f Consent/Assent Guardian Consent Required under age 18 Patient Assent: Required by age 14; Best practice age 9 and over

37 Shared Decision Making Associated with better outcomes partly due to increased involvement and compliance. Components C t include i l d agreement g t with ith what h t is being prescribed, knowledge about side effects and necessary monitoring, and alternatives to medication. Similar principles to team decision making which child welfare staff in CT and many other states are currently being trained on. 37

38 Consent Procedure Prescriber completes state consent form (465) and s or faxes it to CMCU Prescription filled CMCU enters information in SACWIS and s worker, regional nurse, and regional clinical manager of details CMCU Child Psychiatrist y or APRN reviews information, checks SACWIS (electronic data base) for past prescribing info, treatment hx, etc. If after review request is considered appropriate, consent is given and ed/faxed to provider

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40 Consent Decisions Based On: Legal status verified Form relatively complete Baseline monitoring done Meds fit diagnosis

41 Consent Decisions, cont. Med on Approved List Dosing appropriate Number of psych meds overall Generally only one antipsychotic

42 O h ffactors informing Other i f i decision: Past psychiatric history available in LINK ((SACWIS)) Child s setting (PRNs and more than one change at once might be approved for hospitals) History with prescriber (outlier?) Other treatment received, especially traumainformed modalities Over-arching Over arching goal of least number of meds longlong term

43 More likely to give consent if within core guidelines (approved med at approved dose) More dialogue with prescribers More discussion of trauma-informed treatment approaches Consents modified by CMCU increased from 5% to 29%

44 CMCU Requests Quarterly Report

45 CMCU Website Readily available on CT DCF home page and user-friendly There s a link to the website on all CMCU members electronic signatures Information abo aboutt meds meds, prescribing doses, doses monitoring protocols, risk in pregnancy, links to NIMH and NYU information on all psychotropic medications, handbook written for families and DCF workers by PMAC, etc. 45

46 46 46

47 Pros of Centralized Process Standardized system; Quick turn-around; Providers are happy; Medical team enters note directly in LINK; Medical team aware of need for medical information prior to starting med; Centralized unit can scan past psychotropic med hx q quicklyy as available in LINK notes since CMCU began in

48 Cons of Centralized Process Child welfare staff may feel disconnected from process; Worker may have information from the foster family or the child/adolescent that is different from what the prescriber is told; Worker (or foster family) may feel they don t have the authority or access to question the Prescriber; Area office staff may feel they can can tt alter or undo the official CMCU consent; Patient assent is not documented in this process, although prescribers are informed that we expect this will be in their notes. As a result, Children/Youth may feel they don t have a voice in the process, may feel they have no choice about taking medication. 48

49 Crisis of Credibility Training given to child welfare staff to address crisis of credibility between CPS workers and Child Psychiatry; includes Diane Sawyer Sawyer ss 20/20 segment with foster children describing their experiences on psychotropic medication. Purpose is to increase collaboration so that workers don t feel prescribers just overmedicate foster kids and prescribers don t feel that child welfare is black hole of information (i.e. multiple requirements to produce documents with no information given out).

50 Next Steps Complete psychotropic med training for all case workers Train Foster Families Develop training in Spanish Link trauma treatment data with medication data Analyze data by race/ethnicity

51 Consent Data Children without ith t Consent Form Legal g Status 6-12 Children with ith Consent Form 6-12 Children without ith t Consent Form Children with ith Consent Form 13- Children 17 without ith t Consent Form % % % % 961 C it t Dual Commitment D l 0 0 0% 0 0% 0 0 0% 0 0% 25 Commitment Mental Health 0 0 0% 0 0% 0 0 0% 0 0% 1 Total Children with Total Children C Consent t FForm without ith t Consent Form Children with C Consent t FForm Total Count %age Count %age Total Count %age Count %age Total Count %age Count %age Total Count %age Count %age Commitment 800 Abuse/Neglect/Uncared For Statutory Parent Total % % 20 0% 0 0% % 6 2.8% % % % % % % % % % % % 80 0% % % 20 0% % 80 0% 0% % % % % % % % % 51

52 Questions? LLesley l Siegel, Si l MD DCF Chief of Psychiatry, State of Connecticut Lesley siegel@ct gov Lesley.siegel@ct.gov (w) (c) g / /

53 Questions? Ask a Question Online: Click the Q&A icon located in the hidden toolbar at the top of your screen. 53

54 Michael W. Naylor, M.D. University it of Illinois i at Chicago Director, Clinical Services in Psychopharmacology

55 Historical context DCFS challenged by federal courts, DOJ & ACLU Inadequate casework Chaotic and dangerous placements Substandard d care Illinois violating constitutional rights of children

56 Historical context Chicago Tribune 1995 editorial series: DCFS called the worst child welfare system in America and a cruel, indifferent bureaucracy that harms kids. System of shame

57 Historical context Historical context Federal court-approved consent decree (B.H. v Suter, 1991) DCFS & ACLU agree to collaborate on system reform plan

58 DCFS recognized need for quality assurance vis-a-vis psychotropic medications Contracted with UIC in 1992 to provide independent medication review

59 Revised DCFS Rule 325 Administration of Psychotropic Medications to Children for whom DCFS is Legally Responsible Guidelines for the Utilization of Psychotropic Medications for Children in Foster Care

60 Challenge Provide informed consent Provide safe and effective care Delivered in timely manner Protect rights of foster children Provide longitudinal oversight

61 Two components Centralized Psychotropic Medication Consent Line DCFS Clinical Services in Psychopharmacology University of Illinois at Chicago

62 DCFS is the legal guardian for ~15,100 g g, youth The Office of the DCFS Guardian is responsible for providing consent for medical and psychiatric treatment Authorized Agents

63 Established by contract between DCFS and the UIC Department of Psychiatry Personnel Child psychiatrist (~ 1.0 FTE) Psychiatric nurses (2.5 FTE) Research assistants (6.0 FTE) MPH (1.0 FTE) Programmer (1.0 FTE)

64 Objectives: Provide independent review for all psychotropic medication requests Monitor utilization of psychotropic medications Notify the Guardian where provider patterns warrant review

65 Prescribing Clinician DCFS Authorized Agent UIC Research Team UIC Psychiatric Nurse UIC Psychiatric Nurse UIC Psychiatric Consultant MD

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67 Demographic information Name DCFS ID Number Date of birth Sex Race Weight and height Placement Physician s name and specialty

68 Clinical information Diagnosis, medical and psychiatric Current medications and dosage Laboratory tests Requested medication Dosage and frequency Symptoms/rationale

69 Medication request Type of request; i.e. new medication, medication renewal, emergency medication Medication requested including dose, range and duration Symptoms supporting medication request Rationale for polypharmacy and non-first-line medications

70 Consultant recommendations: Consultant recommendations: Approved Denied Modified Reviewed (emergency medications only)

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72 DCFS Psychotropic Consultation Requests Mont hly Total Nov-94 Nov-95 Nov-96 Nov-97 Nov-98 Nov-99 Nov-00 Nov-01 Nov-93 Nov-02 Nov-03 Nov-04 Nov-05 Nov-06

73 Formal oversight Formal oversight Case-specific Independent medication review Watch list high risk children Record review

74 Formal oversight (cont.) System-wide CSP consent database (1998 present) Medicaid payment database ( ) Watch list high risk prescribers Emergency medication use

75 Formal oversight (cont.) Formal oversight (cont.) System-wide Quarterly reports Timeliness» Error rates Medications without consent Denials

76 Formal oversight Formal oversight System-wide Quarterly reports Children < 4 years Polypharmacy Co-pharmacy High-risk preschoolers

77 Informal oversight Feeds back through the Office of the Guardian or to the CSP program Administrative Case Reviews GAL, Office of the Public Guardian Regional nurse

78 Diagnosis of bipolar disorder in foster children Impact of consultation on utilization of fluoxetine Second generation antipsychotics (SGA) and weight gain in foster children Identification of high risk preschoolers

79 The CSP can: Assess statewide diagnostic patterns Monitor rate of utilization of psychotropic medications Identify adverse effects of medications Implement evidence-informed consent strategies Assess impact of changes in consent strategies on prescriber behaviors

80 How to: have clear policy re: consent issues who how have clear sense of purpose of consent program oversight decrease utilization cost containment

81 How to: elicit partnership with and cooperation of professional organizations in the state expert panel community consultants implement program in its entirety ( nibbled to death by guppies ) COMMUNICATE WITH PROVIDERS!!!!!!!!!!!

82 Questions? Ask a Question Online: Click the Q&A icon located in the hidden toolbar at the top of your screen. 82

83 In the Centers of Excellence Pipeline: Measurement Activities Related to Children in Foster Care Identification of children with special health care needs Quality transitions from pediatric to adult-focused care Identification of social complexity for care coordination Care coordination for children with special health care needs in the context of a medical home Follow up care for children with ADHD (dx, tx, and management) Medication reconciliation mental health Mental health ED quality 83

84 National Collaborative for Innovation in Quality Measurement (NCINQ) Center of Excellence Led by the National Committee for Quality Assurance Measurement Development Topics Assigned by CMS and AHRQ Adolescent well-care Well care for children under age 12 Depression management Antipsychotic over-use Alcohol/drug screening and follow up Care for children in foster care Measure Concepts Under Consideration by NCINQ Related to Care Children in Foster Care Comprehensive intake assessment Routine preventive health care Behavioral health care Trauma-related specialty care Comprehensive re-assessment Care coordination 84

85 Thank you! 85