1. 2 many of the children i advocated for were taking some sort of psychotropic medication many of...
TRANSCRIPT
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Minds Matter: Improving the Appropriate Use of Psychotropic
Medication in Foster Youth
Psychotropic Medication Symposium September 17, 2015
Rick Smith, MD
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Many of the children I advocated for were taking some sort of psychotropic medication
Many of them were on multiple psychotropics
Many of them were on antipsychotics, often without a diagnosis that justified it
Once on these medications, it was hard to get them off
Things I’ve learned as a CASA/GAL . . .
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Over 80% of children in foster care have developmental, emotional, or behavioral problems1
Emotional problems in foster children are strongly related to their history of deprivation, neglect and abuse, and the lack of security and permanence in their lives1
• 1Child Welfare League of America
Mental Illness in Foster Children
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Children on Medicaid are prescribed antipsychotics at four times the rate of privately insured children1
Among Medicaid children, 12.4% of foster children received antipsychotics, compared to 1.4% of non-foster children1
Foster youth are prescribed psychotropic medications at nine times the rate of other Medicaid youth2
1Wall Street Journal, August 11, 20132Crystal, S; Olfson, M; Huang, C; Pincus, H; & Gerhard, T. (2009). Broadened use of atypical antipsychotics: Safety, effectiveness, and policy challenges. Health Affairs. 28(5):770.
National Trends
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Between 22-35% of foster youth are prescribed psychotropic medication1,2
Foster youth have a much higher rate of poly-pharmacy1
Foster youth have a much higher rate of being on 2 or more psychotropic medications from the same class1
1 Zito et al, Pediatrics 20082Crystal, S; Olfson, M; Huang, C; Pincus, H; & Gerhard, T. (2009). Broadened use of atypical antipsychotics: Safety, effectiveness, and policy challenges. Health Affairs. 28(5):770.
National Trends
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29% of Medicaid children treated for mental health conditions receive psychotropic medications.
• 5.4% received ≥ 4 psychotropic medications.
• Of those receiving AAPs, 4.2% receive ≥ 2 AAPs.
• 0.60% of preschool children between 2-5 years of age receive an AAP.
Polypharmacy rate is 2-3 times greater among children in foster care.
Ohio Trends
Source: Cynthia Fontanella, Clinical Profile of Children with SED (Ohio Medicaid Data 2006-2010.) Rates for
children continuously enrolled in Medicaid.
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Addressing the Problem in Ohio: Minds Matter
• $1 million investment by the Ohio Office of Health Transformation and Department of Medicaid
• Partnership with BEACON (Best Evidence for Advancing Childhealth in Ohio NOW!)
• The three-year goals:
• Increase timely access to safe and effective psychotropic medications and other treatments
• Improve pediatric health outcomes
• Reduce potential adverse effects
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BEACON Statewide Stakeholder Meetings/All Pilot Communities
Facilitators: QI Vendor and Clinical QI Leader
Schedule: June 2013, Sept 2014, Nov 2015
BEACON Statewide Stakeholder Meetings/All Pilot Communities
Facilitators: QI Vendor and Clinical QI Leader
Schedule: June 2013, Sept 2014, Nov 2015
State Steering Committee (N = 25)Clinical Advisory Panel (N= 17)Pilot Community Chairs (N =3)
Facilitator: QI Vendor and Clinical QI Leader
Meeting Schedule: Bi-Monthly, Quarterly
State Steering Committee (N = 25)Clinical Advisory Panel (N= 17)Pilot Community Chairs (N =3)
Facilitator: QI Vendor and Clinical QI Leader
Meeting Schedule: Bi-Monthly, Quarterly
Central Community Steering
Committee Clinical and QI
FacilitatorsMeeting Schedule: Quarterly
meetings beginning in August 2013
Chair: Dr. Jonathan Thackeray
Central Community Steering
Committee Clinical and QI
FacilitatorsMeeting Schedule: Quarterly
meetings beginning in August 2013
Chair: Dr. Jonathan Thackeray
Leadership Structure
Northeast Community Steering
Committee Clinical and QI
FacilitatorsMeeting Schedule: Quarterly
meetings beginning in August 2013
Chair: Dr. Steven Jewell
Northeast Community Steering
Committee Clinical and QI
FacilitatorsMeeting Schedule: Quarterly
meetings beginning in August 2013
Chair: Dr. Steven Jewell
SouthwestCommunity Steering
Committee Clinical and QI
FacilitatorsMeeting Schedule: Quarterly
meetings beginning in August 2013
Chair: Dr. Rick Smith
SouthwestCommunity Steering
Committee Clinical and QI
FacilitatorsMeeting Schedule: Quarterly
meetings beginning in August 2013
Chair: Dr. Rick Smith
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Psychotropic—Medication used in the treatment of mental illness
Atypical AntiPsychotic (AAP)—2nd generation of antipsychotic medications (e.g. Risperdal, Abilify) which have a lower incidence of serious side effects than 1st generation (e.g. Haldol, Thorazine). Approved for use in:• Adolescents with schizophrenia • Adolescents with Bipolar • Irritability associated with autism (school age
& above)
Definitions
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Antipsychotic medications in children less than 6 years of age
Two or more antipsychotics at the same time Four or more psychotropic medications in youth < 18
years of age
Measurement Targets
25% reduction
in the use of
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• Shared decision making toolkit
• Parent’s guide to youth mental health
• Psychotropic medication fact sheet
• Inattention, hyperactivity, and impulsivity fact sheets and resources
• Disruptive behavior and aggression fact sheets and resources
• Moodiness and irritability fact sheets and resources
Resources for Consumers, Workers and Schools
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‣ Tools to empower consumers to actively participate in the shared decision making process
‣ Preparing for Mental Health Visit Questions
‣ Personal Decision Guide
‣ Information Sharing Checklist
‣ Medication Side Effects Watch List
‣ Video for parents, caregiver and youth
Shared Decision Making Materials
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‣ Training module for workers in utilizing the tools with parents/caregivers/youth
‣ Fact sheets for parents/caregivers/youth
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Personal Decision Guide
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Customized for youth in Foster Care
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Interactive Training Module
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Issues beyond the scope of Minds Matter
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Medicating for behavior problems that stem from abuse, neglect or other trauma
Insufficient knowledge of child’s traumatic social history
Demands by foster parents, schools and other stakeholders
Reimbursement, time pressures and shortages of healthcare providers
Factors leading to overmedication of foster youth
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Medication “quick fix” for problems more suited for psychosocial treatments
No clearly designated adult to monitor and consent to treatment
Reluctance to question a doctor’s medication recommendations
Large pharmaceutical companies encouraging off-label prescribing
Factors leading to overmedication of foster youth
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Is child on an excessive number of medications?• Four or more psychotropics• Two or more antipsychotics
Are medications being prescribed “off-label”?• Antipsychotics for other than psychosis,
bipolar or autism• Antipsychotics under age of 6 years• Child’s diagnoses do not warrant medication
Are antipsychotics being prescribed by other than a child psychiatrist?
What should caregivers watch out for?
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Is child exhibiting side effects? Is child being medicated for behaviors
attributable to trauma, neglect, abuse, bad placement
Does older child know risks & benefits, and assent to taking medications?
Is noncompliance likely (e.g. due to lack of knowledge or assent; side effects; older child making decisions based on peers or internet research)?
What should caregivers watch out for?
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Make sure the prescribing provider knows the child’s psychosocial history, especially trauma, neglect, abuse, placement problems/changes
Have a general knowledge of medications, i.e. names, classes, approved uses (see handout)
Don’t be afraid to question why a child is on a medication
Engage other stakeholders in the shared decision-making process (provider, foster parents, child, etc.)
Utilize the Minds Matter toolkit!
What can caregivers do?
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Creating a “portable medical record” that follows the foster child intact through changes in placements, doctors, schools, etc
Creating a system of monitoring that “red flags” a foster child who is either inappropriately or over-medicated
Ensuring that all foster children receive a thorough mental health evaluation and behavioral therapy before they are medicated
Systemic Challenges
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“What would you do if this was your child?”
What my patient’s parents would always ask me . . .
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Fairfield County Protective Services
& Minds Matter
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Custodial Agency
Court Orders
Voluntary Cases
Kinship, Foster and Adoptive Families
Emancipated youth/young adults
Post Adoption Services (PASSS)
Identifying PCSA role
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Piloted Minds Matter with Permanency Team (adoption and permanency workers)
Presented information to county cluster, area public mental health agencies, and Juvenile Court staff
Trained agency foster families Trained all agency caseworkers, supervisors
and managers Developed policy related to informed
consent and authorization of psychotropic medications as required by ODJFS
Fairfield Co. PCSA experience:
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Custodial Agency Role Great feedback from pilot participants Concern from foster parents, probation
officers and treatment providers regarding youth voice and choice
Role of youth Be alert for developmental functioning,
cognitive abilities and other factors Provider Engagement
Lessons Learned – Youth Toolkit
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Custodial agency must provide authorization and consent for medications for children/youth
Engaging birth parents/caregivers Importance of Informed consent Use of www.ohiomindsmatter.org for
support for medication authorization and documentation
Custodial Agency Role
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Content is accessible to most youth, ages 14+
Engaging youth to be informed consumers Role modeling interactions Preparation for appointments Independent living services Enhancing value of face to face visits “It’s not about you, without you.” Fact versus Fantasy
Youth Feedback
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Lack of consistent provider/placement/sharing of information
Adults uncomfortable with informed consent with youth
Provider shift in practice Youth fear of side effects Lack of education for caregivers and others
related to impact of trauma on children in substitute care
Provider capacity
Challenges
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Enhance understanding of medication and reasons for medication
Provide resources Prepare for appointments Feedback has been very positive Need support to do the “work” Love the resource sheets Monitor for worries that need addressed
with providers SUPPORT, SUPPORT, SUPPORT
Parents and Consumers
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Education and Information
Advocacy
Normalize Informed Consent
Making good use of time
Obtaining needed information for consent/authorization
Working with Providers
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Getting buy-in
Education and Information
Importance of informed consent
Informing of process/procedure
Working with other stakeholders
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Spread the word!
Use advocacy, education and information when working with PCSA, consumers and birth families
Download forms/tools and provide web address
Next Steps
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Thanks for your commitment to children and their families!
Johanna [email protected]
Questions
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