Michael W. Naylor, M.D. University of Illinois at Chicago Director, Clinical Services in Psychopharmacology • Historical context – DCFS challenged by federal courts, DOJ and ACLU • inadequate casework • chaotic and dangerous placements • substandard care – Illinois violating constitutional rights of children • 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” • Historical context – Federal court-approved consent decree (B.H. v Suter, 1991) • DCFS and ACLU agree to collaborate on system reform plan • Psychotropic medication consent – DCFS Rule 325 – Clinicians wishing to start a foster child on a psychotropic medication must obtain consent from the DCFS Guardian • DCFS Psychotropic Medication Consent Program – Two components: • Centralized Psychotropic Medication Consent Line – Office of the DCFS Guardian • Clinical Services in Psychopharmacology – University of Illinois at Chicago • Centralized Psychotropic Medication Consent Line – Office of the DCFS Guardian • legal guardian for children committed to the Department • responsible for providing consent for medical, surgical, and psychiatric treatment • Clinical Services in Psychopharmacology – provide independent review for all psychotropic medication requests – monitor utilization of psychotropic medications – provide consultation on particularly complicated cases • Clinical Services in Psychopharmacology – notify the Guardian where provider patterns warrant review – conduct training for DCFS, foster parents and childcare providers on psychotropic medications – disseminate information regarding new pharmaceutical developments and alerts Prescribing Clinician DCFS Authorized Agent UIC Research Team UIC Psychiatric Nurse UIC Psychiatric Nurse UIC Psychiatric Consultant MD • Demographic information – name – DCFS ID Number – date of birth – sex – race – weight and height – placement – physician’s name and specialty • Clinical information – diagnosis – current medications and dosage – symptoms/rationale – requested medication • dosage and frequency • Three main providers of consultation for clinicians treating foster children: – Clinical Services in Psychopharmacology – DocAssist – Consult for Kids Consent Monitoring/ Oversight QI CSP Systemic Clinical Prior Authorization • Consultation – consent process • independent review of the appropriateness of the psychotropic medication consent request • recommend action to DCFS – approve – deny – modify • Consultation – oversight • formal – high risk prescribers – emergency medication utilization • informal – feedback from Administrative Case Reviews – concerns expressed by caseworkers, regional nurses, guardian ad litem, Court Appointed Special Advocates, judges, Office of the DCFS Guardian • Consultation – clinical • clinical concerns that arise in the course of the independent medication review • MD:MD • review of consent history • chart review • face-to-face • Consultation – prior authorization • provided consultation to HFS vis-à-vis prior authorization for antipsychotic medications and stimulants for children • DCFS consent for a medication serves as prior authorization for foster children • Consultation – systemic • consult on development of policies, best practice guidelines re: mental health care for foster children • co-write legislation • Consultation – monitoring/QI • medication utilization patterns – rate of copharmacy with two or more antipsychotics – rate of polypharmacy by age group • timeliness of consent process • compliance with Rule 325 0.20 Paroxetine Warning CSP Intervention Black Box Warning 0.10 0.05 0.00 % Requests 0.15 Paroxetine Fluoxetine Other SSRIs 0 20 40 60 Months 80 100 • Illinois DocAssist – established through the joint efforts of the Department of Healthcare and Family Services, the Department of Human Services – Mental Health, and the University of Illinois at Chicago – funding support by the Illinois Children’s Mental Health Partnership • Illinois DocAssist – clinical • quality of treatment for Medicaid funded children with mental illness in the primary care setting – client – Medicaid funded providers with a focus on primary care – purpose – improve the identification, diagnosis and treatment of children and youth with mental health issues through consultation, education and referral services • Consult for Kids Program – established by DCFS to provide primary care clinicians participating in HealthWorks with resources to evaluate foster children in their care for mental health and behavioral concerns • Consult for Kids Program – clinical • address questions and concerns about a foster child’s emotional, interpersonal, behavioral or cognitive problems – client – primary care providers – purpose – help primary care providers navigate a challenging child through the child welfare system • Challenges to effective consultation – “silo-ization” • duplication of services • lack of coordination – informing stakeholders of the services – meeting demand for services “The Curse of Unwelcome Oversight and Unrequested Consultation.”