Psychotropic Medication Use by
Children in Texas Foster Care:
HB 915 Update
Stakeholder Meeting
March 7, 2014
Kathy Teutsch, RN, LMSW-MSSW:
CPS Division Administrator for Medical Services
1
Collaboration to Improve Health Care
Since 2004, Texas stakeholders have collaborated to improve the health care
and oversight of psychotropic medication use by children in DFPS
conservatorship:
•
Passage of SB 6 of the 77th Legislature which added Chapter 266 to the
Texas Family Code with a goal of improving healthcare for children in DFPS
conservatorship
•
Release of the Psychotropic Medication Utilization Review Parameters for
Foster Children in 2005 (“the Parameters”) with most recent update in 2013
•
Implementation of STAR Health in April 2008
•
Passage of HB 915 of the 83rd Legislature
2
Accomplishments
• Between FY 2004 and FY 2012 there has been a 34%
reduction in the use of psychotropic medications for 60
days or more (following slide).
• The progress in Texas has largely resulted from
collaboration among multiple stakeholders with diverse
views coming together with the goal of ensuring that
psychotropic medications are prescribed appropriately
and only when needed.
3
Psychotropic Medication for Texas Foster Children
Fiscal Years 2002-2012
35.0%
Percentage of Children in Texas Foster Care
There's been
decrease since 2004 in Psychotropic
29.9%
29.6%a 34%
30.0%
28.0%
Med use
that lasts longer
than 60 days for Texas Foster
26.4%
25.0%
24.7%
Children.
There
has
been
a 66%
decrease since 2004 in34% decrease
25.0%
21.5%
since 2004
21.2% in five or more Meds
Class Polypharmacy and 69% decrease
20.5%
19.8%
19.8%
20.0%
Polypharmacy.
15.0%
10.0%
5.0%
4.0%
3.3%
0.7%
66% decrease
since 2004
5.0%
3.4%
1.1%
1.4%
0.9%
0.7%
0.0%
FY2002
FY2003
FY2004
FY2005
2.5%
2.5%
FY2006
Psychotropic Meds 60 days+
2.0%
0.7%
FY2007
1.8%
0.6%
FY2008
Class polypharmacy
1.8%
0.5%
FY2009
FY2010
1.7%
1.7%
0.5%
0.5%
FY2011
0.4%
FY2012
Five or more Meds polypharmacy
69% decrease
since 2004
4
Implementation of HB 915
•
In general, implementing the provisions of HB 915 has involved the revision
of CPS policy, training, forms, court reports and the Residential Contract.
•
DFPS set up Medical Consent Mailbox in September 2013.
•
DFPS sent preliminary policy memos to CPS staff (Sep 2013) and
residential providers (Oct 2013) instructing them to implement the
requirements.
– CPS Handbook policy is finalized and expected to be published in the CPS
Handbook in May.
– Basic requirements of HB 915 were included in FY 2014 Residential
Contract (September 2013-August 2014).
– Residential Contract amendment addressing additional procedures is
expected to be released this Spring.
•
The following slides provide more detailed information about DFPS actions
to implement the requirements.
5
Strengthen Training
•
Online Medical Consent and Psychotropic Medication trainings were revised
to add requirements for informed consent for psychotropic medications,
information about trauma informed care and the appropriate use of nonpharmacological interventions.
•
All new and existing medical consenters are now required to complete the
new Medical Consent training initially and annually, sign the
Acknowledgement and Certificate of Completion of Medical Consent
Training form and provide a copy to CPS caseworkers at time of placement.
•
DFPS is providing a classroom training, in addition to the online training, for
CPS staff who attend psychotropic medication appointments at residential
operations– 3 out of 6 classroom training sessions have been completed.
•
After classroom training has been completed around the state, DFPS will
hold monthly calls with CPS medical consenters for about 6 months to allow
them to ask questions.
6
Strengthen Informed Consent Practices
• Medical consenters are now required to attend psychotropic
medication appointments in person and complete the “Psychotropic
Medication Consent Form” for each new medication.
• CPS staff who are medical consenters are attending psychotropic
medication appointments at RTCs and other facilities.
• The brochure, “Making Decisions About Psychotropic Medications,”
is posted on the DFPS website and information about the brochure
has been distributed to CPS staff and residential providers.
• A new memo was released to caseworkers on March 3 requiring
them to provide the brochure, “Making Decisions About
Psychotropic Medications” to each medical consenter for them to
use as a guide at psychotropic medication appointments.
7
11 New Specialized HST Positions
• Eleven positions for Human Services technicians (HST)
were hired.
• HST positions are supporting I See You (ISY) caseworkers
with other tasks (transportation, parental visits, etc.) to free
up more ISY caseworker time to attend appointments with
children.
• Guiding Principles/policy are in place for HST participation
in appointments only as a last resort.
• HSTs are taking the online and classroom trainings.
8
Non-pharmacological Interventions
• Definition in the DFPS Medical Consent training is:
“Options that don't include medicines. They include any
psychological and social therapies and behavior strategies
provided to the child or youth. Non-medication interventions are
specific methods a caregiver can use to help a child or youth
manage behavior. In other words, non-pharmacological
interventions are methods to manage behavior without the use
of medicines. This may include therapy and counseling.”
• Policy/Residential Contract directs medical consenters to
consider non-pharmacological interventions before or
concurrently with the use of psychotropic medications.
9
Non-Pharmacological Interventions
•
STAR Health is working on building clinical capacity within STAR Health to
provide trauma-informed, evidence-based psychosocial therapies.
•
Residential contractors are required to ensure that foster parents and direct
caregivers complete the online Trauma Informed Care Training during preservice training and annually thereafter.
•
Service plans/treatment plans developed by residential contractors and
CPS staff address psychosocial therapy and behavior strategies (i.e.,
strategies to help children learn to cope with stress, manage their emotions
and impulses and function successfully at home, in school and other social
situations).
•
DFPS is collaborating with experts and exploring ways to enhance caregiver
practices that address the impact of trauma and how caregivers can help
children recover and attain social and emotional well being.
10
Ensure 90 Day Visits with Health Care Provider
• DFPS has addressed the 90 Day Visit requirement in:
– The Residential Contract
– Policy
– Training
– “Making Decisions About Psychotropic Medications”
brochure
• Preliminary reports shows 88% of children had a follow
up visit within 90 days in 2013. DFPS is researching the
12% of children without 90 days visit to identify any
trends.
11
Enhance Judicial Review of Medical Care
DFPS has revised the “Summary of Medical Care” section
in court reports for permanency and placement hearings to
require caseworkers to address:
• Behavior strategies and psychosocial therapies considered before
or used concurrently with psychotropic medications
• The expected timeframe the child will need to take the medications
and other medications tried
• The expected benefits of the any psychotropic medication the child
is taking
• Dates of appointments
• That the youth 16 and over was notified about their right to request
the court to authorize them to consent to some or all of their own
medical care and the youth’s response
12
Notification to Parents
DFPS has revised policy to require caseworkers to
notify parents of the initial prescription of
psychotropic medications and any dosage
changes at the next scheduled meeting with the
caseworker after the prescription.
13
Transition Planning
• DFPS revised the youth Transition Plan to address
physical/mental health care and resources that may assist
the youth.
• As of January 2014 caseworkers were trained on the new
Transition Planning form.
14
Youth Training
This Spring, DFPS will release new requirements concerning
completion of online Medical Consent Training (and online
Psychotropic Medication Training if the youth takes psychotropic
medications) by youth who are authorized to consent to their own
medical care or who are aging out of DFPS conservatorship.
• The Residential Contract amendment will require contractors to
ensure that youth complete the online trainings.
• At the same time, CPS will release a policy memo requiring CPS
caseworkers to ensure that these youth complete the online training
and is incorporating this requirement in the May publication of the
CPS Handbook policy revisions.
15
Monitoring for Children Who Are Dually Eligible or in
ICPC
Processes are in place:
• For quarterly psychotropic medication
monitoring by the HHSC Medicaid Vendor Drug
Program Pharmacy Utilization Review contractor
• To notify the home state of any child placed in
Texas under ICPC when the medication regimen
is outside the parameters
16
Screenings, Evaluations and Assessments
• Work is underway to better understand what is needed to
update the assessment process to ensure that children in
foster care have appropriate, quality and timely services.
• Clinical staff at HHSC, DFPS, Medicaid staff and CPS
program have been working together to develop proposal
options.
17