www.chcs.org

CHCS Center forHealth Care Strategies, Inc.Improving the cost-effectiveness of publicly financed

health care

Psychotropic Medication Use and Management for Children in Foster Care

Kamala D. Allen Vice President and Director, Child Health Quality

Because Minds Matter: Collaborating to Strengthen Psychotropic Medication Management for

Children and Youth in Foster Care August 27-28, 2012

Washington, DC

Overview of the Session

• Organizational Background

• A Focus on Psychotropic Medication Use in Children in Foster Care

• What we Know about the States’ Efforts:A snapshot based on 26 States

• The CHCS Quality Improvement Collaborative: A Model for Improvement

CHCS Mission

To improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care.

• Our Priorities► Enhancing Access to and Coverage of Services► Improving Quality and Reducing Racial and Ethnic Disparities► Integrating Care for People with Complex and Special Needs► Building Medicaid Leadership and Capacity

Premise for our Child Welfare Work

• Children in child welfare - specifically those in foster care - have significantly high rates of physical, behavioral and oral health needs.

• Children in foster care likely have legitimately higher rates of need, and consequently, use of behavioral health services.

• Foster children are at high risk for the negative consequences of poor access and uncoordinated care.

• Children in foster care require a tailored approach to care delivery involving all system partners.

Psychotropic Medication: Federal Focus and Legislative Opportunities

• ACF’s April 2012 Information Memorandum

• Child and Family Services Improvement and Innovation Act (2011)

• Joint Dear State Officials Letter to Medicaid, Child Welfare, and Behavioral Health Directors (2011)

• Fostering Connections Act (2008)

• Patient Protection and Affordable Care Act (2010)

• Child Health Insurance Program Reauthorization Act (2009)

Problem is multi-faceted

• Lack of non-pharmacological interventions• Lack of behavioral health specialists• Use of medications to control difficult behaviors• Lack of knowledge regarding appropriate use of

psychotropics among child welfare case workers• Lack of coordination across providers and

between child-serving systems• Financial incentives to prescribe• Aggressive/effective pharmaceutical marketing• Need for “quick fixes”

What do the Data Say?

Faces of Medicaid: Child Behavioral Health Utilization and Expenditure Study, 2012

• 2005 MAX data (Medicaid Claims) for 29 million children and youth in Medicaid

• 2.8M children received behavioral health care (services and psychotropic medication) = 9.6% penetration rate

Source: Pires, Grimes, Allen, Gilmer, Mahadevan, Forthcoming 2012

What do the Data Say?

• Special Analyses on Children in Foster Care► Represent 3.2 percent of children in Medicaid► Represent 12.6 percent of children in Medicaid receiving

psychotropic medication► Represent 15 percent of children in Medicaid receiving

behavioral health services

► 32% of children in foster care receive behavioral health services► 23% of children in foster care receive psychotropic medication► 39.3% of children in foster care received behavioral health care

(services and/or psychotropic meds)► Account for 28.6% of Medicaid child behavioral health exp.► Mean expenditures: $4,036 (PH), $8,094 (BH), Total: $12,130

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What do the Data Say?

• Of children in Medicaid prescribed psychotropic medications, children in foster care:

► Were prescribed psychotropic medication at a rate 4 times their representation in Medicaid (TANF children at 2/3 their representation

► Had Medicaid expenditures for behavioral health services 7 times that of the overall Medicaid child population

• Of children who received psychotropic medications, we see concerning patterns:

► 42% of children in foster care (and SSI) were prescribed antipsychotics versus 18% of TANF children

► 19% of children in foster care were on 3 or more psychotropic medications within the year versus 10% of the overall Medicaid child population

What do the Data Say?

• Special Analyses on Psychotropic Medication Use ► 1.7M (5.8%) of all children in Medicaid (2005) received

psychotropic medications with or without another Medicaid-covered behavioral health or physical health service.

► Only 50 percent of the 1.7 million children on psychotropic medications also received identifiable behavioral health services.

► Among children who used behavioral health services, psychotropic medication was among the top three categories of service use for children in Foster Care, those in SSI, and children with developmental disabilities.

How Will We Impact the Use of Psychotropic Medications

among Children in Foster Care?

National Initiative on Psychotropicsin Foster Care

• Improving the Use of Psychotropic Medications among Children in Foster Care Quality Improvement Collaborative (PMQIC)- 3-year initiative funded by the Annie E. Casey

Foundation- 32 letters of interest; 26 applications- Multi-state effort

» Illinois» Oregon» New Jersey

** Casey Special Interest Site

» New York» Vermont» Rhode Island**

Highlights of Existing Models

• CONSENT► Centralized review and consent process► Partnership with academic research center

• OVERSIGHT (at prescriber level)► Provider profiling► Second opinions► Prior authorizations/Preferred drug lists

• MONITORING (at child level)► Quarterly reports ► Targeted interventions

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PMQIC State Efforts

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State

Consent, Oversight, Monitoring

Quality

Framework

Data EBP/ Approp Use

Reform Practice Change

IL X X X

NJ X X X X

NY X X X X X

OR X X X X X

RI X X X X X X

VT X X X X X

Why use a State collaborative approach to improve psychotropic medication use?

• State child welfare agencies are responsible for the safety and well-being of children in foster care.

► Specific requirements re: psychotropic medications

• Most children in foster care are Medicaid-eligible, and Medicaid pays for their psychotropic medications.

• States have successes to build upon and peer exchange is fostered to facilitate spread.

• CHCS has a quality improvement collaborative model that has been effective in reducing inappropriate psychotropic medication use among children in child welfare.

Case Study: Child Welfare Quality Improvement Collaborative

Three-year quality improvement initiativefocused on improving three aspects of health care for children involved in child welfare:• Access to Care

- Connecticut Behavioral Health Partnership- Magellan Behavioral Health of Florida- Mid Rogue Health Plan- Priority Partners Managed Care Organization- UPMC for You

• Coordination of Care- Volunteer State Health Plan- Wraparound Milwaukee

• Appropriate use of Psychotropic Medications- CareOregon- Massachusetts Behavioral Health

Partnership

Participating MCO Project Goal Impact

Connecticut Behavioral Health Partnership

Improve access and reduce waiting times for needed behavioral health services for children entering the child welfare system.

• 60% increase in the number of children with BH needs who received services within 60 days.

• Decreased average time to an appointment for behavioral health services from 22.5 days to 6.5 days (71% improvement).

Magellan Florida Prevent kinship placement disruption due to behavioral health problems with the support of Kinship Navigators.

• Maintained kinship placements for 100% of kinship caregivers of children with BH needs.

Massachusetts Behavioral Health Partnership

Address outlier psychotropic provider prescribing patterns and simplify medication regimes for children who have been stable for at least six months.

• Reduced psychotropic polypharmacy among 84% of targeted DCF youth eligible for medication simplification within a pilot site provider practice.

Mid Rogue Provide and coordinate health assessments to support medical homes for children newly placed in out-of-home care.

• Established a medical home for 88% of children entering foster care.

Overview of Plans’ CW Initiatives

Overview of Plans’ CW InitiativesParticipating

MCO Project Goal Impact

UPMC for You Develop and send electronic health records to Allegheny County child welfare workers for all children in foster care. Improve rates of annual well child visits, annual preventive dental visits; and access to behavioral health services for children new to foster care by 10% over baseline.

• Increased well-child visit rate among children entering foster care from 53% to 78.5%.

• Increased annual dental visit rate for children entering foster care from 60% to 75%.

• Created and provided to county CYF an electronic Health Record for 100% of children entering foster care.

Volunteer State Health Plan

Increase provider use of electronic health records and review of the clinical health records of newly placed foster care children prior to the initial medical exam.

• Increased the rate at which children’s clinical health records were reviewed by a provider from a baseline of 27% of children to 52% of children.

Wraparound Milwaukee

Ensure that all CW-involved members who are on three or more psychotropic medications (PMs) and have not seen their PCP within the last year make and keep an appointment with their PCP.

• Decreased number of children on three or more PMs who had not seen their PCP within past year from 19% to 12%, and those on two or more PMs who had not seen PCP within past year from 35% to 19%.

Questions we will seek to answer…

• Can the data currently being collected inform targeting of improvement strategies?

• Can data be shared more effectively among Medicaid, child welfare and behavioral health agencies?

• Can provider practices be modified to reflect peer guidelines for prescribing psychotropics to children and youth?

• Can consent, oversight and monitoring policies and practices be coordinated and strengthened within child welfare and Medicaid systems?

Questions we will seek to answer…

• Can families and youth be more effectively engaged in care planning to avoid unnecessary use of psychotropics?

• Can financial incentives be changed to encourage the use of non-pharmacological interventions?

• Can we help states more effectively monitor and intervene to reduce inappropriate prescribing among children in foster care?

What about all of the other states?• Learning Community of States supported by

Substance Abuse and Mental Health Services Administration (SAMHSA) in partnership with the Administration for Children and Families (ACF)

• “Low touch” technical assistance to other 44 states► Quarterly how-to webinars► Dissemination of resources developed under

PMQIC► Fostering sharing of resources, effective practices

and “lessons learned” among states

• Coordination with other national initiatives on reducing inappropriate psychotropic medication use as they emerge

What do we Know?Lessons from a 26-State Sample

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States’ Profile

• Foster care census across the states ranged from just under 1,000 to nearly 58,000 children/youth.

• Most states have state-administered/locally-operated child welfare systems.

• Most states are enrolling children in foster care in Medicaid managed care.

• Most states were not effectively leveraging the data available through Medicaid claims systems.

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Consent Process

• 7 states have no consent policy for psychotropic medication for children in foster care.

• Among states with a policy, there are varying approaches to consent.

► Parent/Guardian► Child Welfare Guardian► Child Welfare Caseworker or Supervisor► Child Welfare Health Unit► Centralized Consent Unit► Judicial/Juvenile Court Officer

• Existence of youth assent policies was less clear.

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Cross-Agency Collaboration

• Several states have interagency agreements in place to allow for the exchange/integration of data between/among agencies.

• Some states use Medicaid prior authorization and/or preferred drug list mechanisms to control access to certain classes of psychotropics or for specific populations.

• A number of states have psychiatric consultation lines to provide support to primary care providers.

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Data Capacity• Just under half of the 26 states are able to monitor

psychotropic medications at the child level.• All states recognize ability to get critical information from

Medicaid claims data and follow post-permanency assuming continued Medicaid eligibility.

• Several states are currently utilizing Medicaid claims data to monitor concerning prescribing trends.

• Many SACWIS states have augmented their data systems with robust health components, though many do not contain medication or prescriber data.

• Some states rely on case workers to enter medical information; others, health professionals.

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Provider Engagement

• All states recognized the importance of engaging prescribers.

• A few states focus particularly on key role played by inpatient psychiatric hospitals, residential and group care providers; more focus on primary care providers.

• Strategies ranged from individual outreach to identify physician champions to engagement of professional societies.

• Provider detailing education and training are common models proposed for facilitating changes in prescribing patterns.

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Youth and Family Engagement

• Most states were aware of foster care alumni organizations, but were not actively partnering.

• Most states were aware of foster parent associations, with which they seemed to be more active.

• Many states have task forces and/or standing committees looking at psychotropic medication use that include foster care alumni.

• Many states acknowledged that the involvement of birth families is challenging.

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Availability of Psychosocial Alternatives

• Most states identified the lack of psychosocial therapies as a cause of potential over-reliance among prescribers on psychotropics.

• The lack of specialists and individuals trained to deliver psychosocial therapies also cited as a challenge.

• Access in rural areas of particular concern.

• Few states had clear strategies to increase the availability of alternatives to psychotropics, but should consider importance of:• Medicaid and behavioral health financing• Adoption of evidence-based practices and evidence-informed

approaches• Provision of trauma-informed assessments

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In summary…

• There is tremendous variation across the states► Rates of Use

► Approaches to Oversight and Monitoring

► Infrastructure Data capacity/availability Human Resources Professional Resources

• Cross-agency collaboration is critical

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In summary…

• States need to:► Leverage and build on what exists► Engage providers to adopt practice guidelines► Engage youth and families, meaningfully► Pursue technical assistance offerings► Understand that there is no one-size-fits-all solution

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Recommendations: REAL Collaboration

• Child Welfare Agencies► Create a consent policy.► Look at the data, regularly.► Partner to provide access to broader range of services and supports.► Ensure case workers have roles that they are trained to effectively

carry out.

• Medicaid Agencies► Partner to provide data related to use and expense.► Reimburse trauma-informed approaches.

• Behavioral Health Agencies► Be at the table with data related to use and expense.► Partner to provide access to broader range of services and supports.

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Recommendations: Leverage• Existing mandates

► Federal and State legislation and regulations► Agency policies and guidance

• Existing infrastructure► Data Systems► Human resources► Financial resources► Standing committees► Community-based organizations► Provider associations► Memoranda of Understanding among agencies► Contractual arrangements (e.g. with MCOs/BHOs and/or

provider networks.)

Contact Information

Kamala D. AllenDirector, Child Health Quality

kallen@chcs.orgwww.chcs.org

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