psychotropic quality improvement (pqi) collaborative...stakeholder update v. lunch vi. brainstorming...
TRANSCRIPT
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Psychotropic Quality
Improvement (PQI)
CollaborativeTennessee Stakeholder Meeting
October 25, 2019
Poonam Juneja, Carrie Mason & Sarah Pauter
National Center for Youth Law
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Agenda
I. Introduction and Group Agreements
II. Overview of the PQI Collaborative & Psych Meds
III. Research Review on Issues and Best Practices
IV. Tennessee SummaryStakeholder Update
V. Lunch
VI. Brainstorming Activity
VII. Action Items and Next Steps
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Meeting Objectives
During today’s meeting, stakeholders will:
I. Learn about the PQI Collaborative, including goals, timelines, and deliverables
II. Begin building relationships with key stakeholders, including lived experts with firsthand experience in the child welfare, juvenile justice, and mental health systems
III. Explore the research related to psychotropic medication prescribing patterns and best practices
IV. Determine what information/resources will be most helpful for key stakeholders to ensure psychotropic medications are only prescribed when in a child/youth’s best interest
V. Develop next steps, including outreach to additional stakeholder to join the PQI Collaborative
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Introductions
Please share your:
1. Name
2. Agency affiliation
or role as a
member of the PQI
Collaborative
3. The last show you
binge-watched
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Group Agreements
“How would we like to work together?”
• Be present, both mentally and
physically
• Be mindful of technology use and other
potential distractions
• Maintain confidentiality and privacy-
what is said here, stays here
• Be respectful- all ideas are valid and
everyone’s voice matters
• Others?
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Overview of the PQI
Collaborative & Psych Meds
“Ensuring foster youth are only prescribed
psychotropic medications when in their best interest”
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7Overview of the PQI
Collaborative
“Ensuring foster youth are only prescribed
psychotropic medications when in their best interest”
Goals of the project:
• To increase the number of states that adopt research-
informed policies aimed at ensuring foster youth are only
prescribed psychotropic medications when in their best interest.
• To increase awareness of promising policies and practices
identified by researchers and increase the capacity of foster youth,
line-level stakeholders, and policymakers to improve state policy.
• To discuss and disseminate information to stakeholders to assist in
efforts to address psychotropic medication overuse and misuse
with children and youth in foster care.
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8Overview of the PQI
Collaborative (cont.)“Ensuring foster youth are only prescribed
psychotropic medications when in their best interest”
Deliverables of the project:
• Creation of research-informed resources created with guidance and
input from stakeholders for the following audiences:
• Foster Youth• Foster Parents• Court Appointed Special Advocates (CASAs)• Judges• Policymakers
• These deliverables will be accomplished through quarterly
stakeholder meetings, foster youth learning community calls, and
ongoing communication
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Psychotropic Medications
Psychotropic medicines are taken for the purpose of improving the emotional and behavioral health of a child or adolescent diagnosed with a mental health condition.*
They may include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants.
*AACAP (2007) A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents.
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10Psychotropic Medication
TennesseeDCS policy:
• “Medication that exercises a direct effect
upon the central nervous system and which
is capable of influencing and modifying
behavior and mental activity. Psychotropic
medications include, but are not limited to
anti-psychotics; antidepressants; agents for
control of mania and depression; anti-anxiety
agents; psychomotor stimulants and
hypnotics.” Tenn. Code § 49-2-124 (2)
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Psychotropic Medications
Examples*
ADHD: Dexedrine, Adderall, Vyvanse, Concerta, Daytrana,, Ritalin, Focalin, Strattera, Tenex, Intuniv;
Antidepressant and Anti-Anxiety: Prozac, Zoloft, Paxil, Lexapro, Effexor, Cymbalta, Wellbutrin;
Anti-Anxiety Medications (Rarely used in children): Xanax, Ativan, Valium, Klonopin, BuSpar.
Antipsychotic Medications: Thorazine, Mellaril, Prolixin, Haldol, Abilify, Risperdal;
Mood Stabilizers and Anticonvulsant Medications: Lithium, Tegretol, Valproic Acid (Depakote, Depakene);
Sleep Medications: Desyrel, Ambien, Sonata, Lunesta, and Benadryl.*AACAP (2017) Psychiatric Medication For Children And Adolescents: Part II - Types Of Medications
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Psychotropic Medications
Can…
• Help when used as a part
of a larger treatment plan
• Benefit some individuals
who have already tried
other evidence-based
treatment options and
medical rule-outs
• Be prescribed with a
child’s safety, overall
interests, medical history,
and risks in mind
Are Not…
• First line treatments for mental health
• To be used alone (med-only treatment)
• Curative
• To be used for behavioral control
• To be used to mask side effects of a different medication
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Too Long
No Risk/
Benefit Profile
Too Many
Adverse Effects
No Informed Consent
Too Soon
Off-label
Misdiagnoses,
Overdiagnoses,
Inaccurate Diagnoses
Too Much
No Monitoring
Untested
No Other Mental
Health Services
Psychotropic Medication
Concerns
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Youth Voice
https://youtu.be/L7lHeosq-FY?t=104
https://youtu.be/L7lHeosq-FY?t=106
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Research Review: Issues and
Best Practices
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16Issues Identified OIG
Report: Five Target States
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Inspector General Report 2018
Recommendations for ACF:
1. Develop a comprehensive strategy to improve States’ compliance with
requirements related to treatment planning and medication monitoring for
psychotropic medication.
1. Assist States in strengthening their requirements for oversight of
psychotropic medication by incorporating professional practice guidelines
for monitoring children at the individual level.
source: https://oig.hhs.gov/oei/reports/oei-07-15-00380.asp
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Psychotropic Medications
Red Flags• 2 or more medications
of any class
• 2 medications in the
same class of drugs
• High/Adult dosages
for children
• Antipsychotics + Stimulant
• Long-term use
without attempts to taper
off
• Abruptly stopping meds
• No
monitoring, documentation,
noticeable impact
Safest Practices• All baseline monitoring,
lab testing completed
• Start with one medication
only
• Start with a low dose
that accounts for the child’s
height, weight, personal and
family history
• Discussion of risks and
benefits
• Contact numbers for any
issues or side effects
• Visits weekly and then
monthly to monitor impact
and effect on the child
• Close watch on weight,
heart, suicidal ideation and
sleeping patterns
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Tennessee
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Tennessee Turnaround
• Brian A v. Haslam (2000)
• Settlement addressed issues including
psychotropic medication prescription
among children in out of home care.
• Medical Director• Centers of Excellence
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21Tennessee DCS Policy
20.18• Psychotropic medication for youth in care are
prescribed and administered “in accordance
with all applicable state and federal laws and in
keeping with best clinical practices.”
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Tennessee
Administrative
Policy 20.18
Only a licensed physician or nurse practitioner is qualified to prescribe
psychotropic medications.
Consultation with a board-certified child and adolescent psychiatrist should be sought in complex cases.:
A thorough examination should precede initial prescription.
Prescription must be accompanied “by an explanation that includes the need related to the child’s mental health diagnosis, potential side effects.
Tennessee Prescription Parameters
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23Tennessee Psychotropic
Medication Monitoring • DCS tracks psychotropic medication
prescription to children in state’s custody
through a Regional Nurse or Youth
Development Center nursing staff.
• DCS also keeps an electronic record with
prescription data and informed consent data
(TFACTS).
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24Psychotropic Medication Utilization
Parameters
• Provides guidelines and rationale for policy
as well as additional protections for the
children in state’s custody.
• Policy 20.18 indicates that cases that fall
outside of the guidelines in the Parameters
are assessed by the Regional Nurse and the
DCS Chief Medical Officer or the Officer’s
designee.
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25Policy 20.18 Clinical
Review
No DSM-IV diagnosis in the child’s medical record.
4 or more psychotropic medications prescribed together.
2 or more of the same type of med prescribed together.
Off-label use or dose.
2 meds prescribed for a given disorder before 1 is tried first.
Child under 5.
Some PCP prescriptions.
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Tennessee
Administrative
Policy 20.24
Parent(s) are part of medical decision making, unless rights have been
terminated, or the youth is 16 or older.
Youth over 16 have decide whether their parents will be involved in psychiatric appointments and psychotropic medication decisions.
Consent documented DCS Form CS-0627, Informed Consent for Psychotropic Medication
Refusal: Individuals refusing treatment are to be counseled and asked to sign DCS Form CS-0093- Release from Medical Responsibility.
Tennessee Informed Consent
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• Exception to Consent
• Emergency dose of psychotropic medication can be given without consent, but must be authorized by a licensed provider or a physician’s order, and is only allowable for a child that is hospitalized or placed in a Psychiatric Residential Treatment Facility (PRTF).
• Emergency psychotropic medication can only be authorized for a one-time dose.
• Emergency monitoring, documentation and notification is required.
Tennessee Informed
Consent: Policy 20.24
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Tennessee Practice
• The Center for State Child Welfare Data,
Tennessee Accountability Center Report
• Technical Assistance Committee, Monitoring
Report of the Technical Assistance Committee
In The Case Of Brian A. v. Haslam
• Prevalence• Informed Consent• Training and Oversight• Centers of Excellence
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• Stakeholder Report:
• What have you seen happening?
Tennessee
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Lunch Break!
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from here?
• We believe that by supporting and
connecting organizations across the
states of California, New Mexico, North
Carolina and Tennessee who are
invested in psychotropic quality
improvement, we can improve
outcomes for children and youth
through the provision of individualized
trauma-focused and evidence-based
services and supports.
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Brainstorming Activity
Key question: What essential information
do the following audiences need to know
to ensure that foster youth are only
prescribed psychotropic medication when
in their best interest?
• Foster Youth
• Foster Parents
• CASAs
• Judges
• Policymakers
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Action Items & Next Steps
I. Large group discussion: what
stakeholder groups might be missing?
II. Meeting date for November/December
III. Exit Survey:
https://www.surveymonkey.com/r/GKS
MR9Y
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Email Follow-Ups
• Email [email protected] or
[email protected] with
• Your Name,
• County or City,
• Agency and Position.
• Ask Sarah or Carrie a question or tell us about
an issue you are currently trying to address
related to psychotropics.
• We will respond as a follow up and provide any data,
materials, or local connections that may be helpful to
you.
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Questions?