Reducing the Use of Psychotropic
Medication in Foster Care
F. Scott McCown
Clinical Professor
Director of the Children’s Rights Clinic
The University of Texas School of Law
smccown@law.utexas.edu
1
What Is Psychotropic Medication?
Texas Family Code:
"Psychotropic medication" means a medication that is prescribed
for the treatment of symptoms of psychosis or another mental,
emotional, or behavioral disorder and that is used to exercise an
effect on the central nervous system to influence and modify
behavior, cognition, or affective state. The term includes the
following categories when used as described by this subdivision:
(A) psychomotor stimulants;
(B) antidepressants;
(C) antipsychotics or neuroleptics;
(D) agents for control of mania or depression;
(E) antianxiety agents; and
(F) sedatives, hypnotics, or other sleep-promoting medications.
2
Catalyst to Reduce Use
• In 2004, the Texas Comptroller released a study, Forgotten Children,
reporting that “many foster children receive disturbing amounts of
mind-altering psychotropic drugs with little or no accountability.”
• In 2011, the General Accounting Office released a study of 2008
data from five states, including Texas, showing that foster children
more frequently received psychotropic drugs than non-foster
children.
• In 2011 and again in 2013, stakeholders such as Texas CASA,
attorneys ad litem, and former foster youth themselves provided
anecdotal evidence that too many foster children were on too much
psychotropic medicine.
3
Why Do We Care?
• Adverse side effects of medicine can be
significant
• It gives the false impression that we are
treating the problem so we don’t really
treat the problem
• When used for sedation it may provide
temporary control but not lasting treatment
• The costs of medicine and follow up are
substantial
4
What the GAO Found
• In 2008, foster children were prescribed psychotropic
drugs at higher rates than non-foster children in
Medicaid.
• Concomitant use of 5 or more drugs—which no evidence
supports.
• Doses higher than maximum levels—which increases
side effects without increasing efficacy.
• Use in children under 1 year old, which no evidence
supports.
5
GAO Digs Deeper
Survey Data 2007-2009
• Noninstitutionalized children on one or more psychotropic
medications:
– 4.8% Privately Insured
– 6.2% Medicaid
– 18% Foster Care
• Noninstitutionalized children on an antipsychotic medication:
– 0.5% Privately Insured
– 1.3% Medicaid
• Foster Children
– 18% on Psychotropic Medications
• 13% on 3 or More Psychotropic Medications
• 6.4% on an Antipsychotic Medication
– 48% Group Home or RTC
– 14% Nonrelative Foster Home
– 12% Kinship Care
6
National Standards
and Federal Law
• American Academy of Child & Adolescent
Psychiatry, A Guide for Community Child Serving
Agencies on Psychotropic Medications for Children
and Adolescents (Feb 2012)—General Guidelines
• Fostering Connections Act in 2008 requires states to
provide ongoing oversight of medical services
including psychotropic medication
• Child and Family Services Improvement and
Innovation Act in 2011 requires states to establish
protocols for use and monitoring of psychotropic
medication
7
What is the right number?
• GAO recognized that higher rates “could be due in part
to foster children’s greater mental health needs, greater
exposure to traumatic experiences and the challenges of
coordinating their medical care.
• Better access to medical care and more focus on
children’s needs might also account for higher rates.
• State’s removal rate may effect proportion on
psychotropic medication.
– California 6.8 per 1,000 (2010)
– Texas 1.8 per 1,000 (2010)
• The “right number” is unknown.
8
Reasons for Overprescribing
• Want to do something!
– Same problem as antibiotics
• Trauma mimicking mental illness
– But medicine does no good
• Sedation
– Chemical restraint
• Drug Company Sales
9
Texas Legislation
• SB 6 in 2005
– http://www.capitol.state.tx.us/BillLookup/History.aspx?
LegSess=79R&Bill=SB6
• HB 915 in 2013
– http://www.capitol.state.tx.us/BillLookup/History.aspx?
LegSess=83R&Bill=HB915
10
Percent of Children in Texas Foster Care prescribed Psychotropic
Medications by category: Change from Fiscal Years 2004-2013
35.0%
30.0%
29.6%
29.9%
28.0%
26.4%
25.0%
25.0%
24.7%
21.5%
21.2%
20.5%
19.8%
19.8%
20.0%
19.1%
36% decrease
15.0%
10.0%
5.0%
5.0%
0.0%
3.3%
4.0%
2.5%
0.7%
2002
3.4%
1.1%
2003
1.4%
2004
0.9%
2005
2.5%
0.7%
2006
2.0%
0.7%
2007
1.8%
0.6%
2008
1.8%
0.5%
2009
1.7%
0.5%
2010
1.7%
0.5%
2011
1.4%
0.4%
2012
71% decrease
0.4%
2013
74% decrease
Psychotropic Meds 60 days+
Class polypharmacy
Five or more Meds polypharmacy
DFPS Chart
11
Percent of Children in Texas Foster Care prescribed Psychotropic Medications for 60 days or more
by age groups: Change from Fiscal Years 2004 thru 2013
60.0%
51.5%
50.0%
51.8%
48.3%
47.8%
41.5%
43.4%
46.8%
47.0%
44.7%
44.4%
40.6%
38.3%
40.0%
41.2%
41.0%
33.4%
32.7%
41.9%
20.0%
10.0%
7.0%
16% decrease
32.3%
31.5%
29.8%
28.3%
36% decrease
22.5%
19.1%
17.6%
8.9%
43.7%
37.1%
30.0%
21.4%
45.3%
9.8%
8.6%
17.0%
17.7%
15.0%
6.5%
6.4%
5.0%
13.8%
14.2%
14.2%
12.9%
11.9%
4.1%
4.0%
3.8%
3.2%
3.6%
47% decrease
0.8%
1.0%
1.0%
0.8%
0.5%
0.7%
0.5%
0.5%
0.4%
0.4%
0.4%
0.9%
63% decrease
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
12% decrease
0.0%
0–2
3
4–5
6 – 12
13 – 17
12
DFPS Chart
Percent of Children in Texas Foster Care prescribed Class Polypharmacy by
age group:
Change from Fiscal Years 2004 thru 2013
12.0%
10.6%
10.0%
9.4%
8.2%
8.0%
7.8%
6.9%
6.1%
6.2%
5.8%
6.0%
5.0%
4.6%
4.0%
5.1%
5.1%
2.1%
2.3%
5.3%
5.3%
50% decrease
4.3%
3.8%
3.2%
3.2%
2.7%
2.1%
2.0%
1.0%
0.0%
0.7%
0.4%
0.1%
2002
1.3%
1.2%
0.5%
0.3%
2003
0.6%
0.4%
81% decrease
0.2%
0.2%
0.1%
0.1%
0.1%
0.2%
0.1%
0.1%
0.1%
0.1%
0.0%
0.0%
0.0%
0.0%
2005
2006
2007
2008
2009
2010
2011
2012
2013
0.3%
2004
1.8%
3
4–5
6 – 12
92% decrease
64% decrease
13 – 17
13
DFPS Chart
Percent of Children in Texas Foster Care prescribed Class Five or more meds
by age group:
Change from Fiscal Years 2004 thru 2013
3.0%
2.6%
2.5%
2.3%
2.0%
2.0%
2.0%
1.8%
1.7%
1.5%
1.5%
1.3%
1.3%
1.3%
1.3%
1.1%
1.1%
1.1%
1.3%
1.3%
1.2%
55% decrease
1.0%
1.0%
0.9%
0.8%
0.7%
0.7%
0.6%
0.5%
0.4%
0.4%
0.2%
83% decrease
0.2%
0.2%
0.0%
0.0%
2006
2007
0.1%
0.1%
0.1%
0.0%
0.0%
0.0%
2012
2013
0.0%
2002
2003
2004
2005
2008
4–5
2009
6 – 12
2010
2011
100% decrease
13 – 17
14
DFPS Chart
Steps Taken
• Medical Director - James A. Rogers, M.D.
• Managed Care – Star Health
– Parameters for Prescribing
– Retrospective Review
• Consent Process
• Health Passport
• Judicial Review
15
Managed Care/STAR Health
• HHSC entered into contract with Superior Health Plan
Network for a managed care system for foster children.
• Managed care medical home model with provider
network
• Richer reimbursement than fee-for-service Medicaid
• Superior Health Plan Network is responsible for physical
health services and subcontracts with other vendors for
behavioral health (Cenpatico), dental, vision, and
pharmacy services.
• Launched on April 1, 2008.
16
Prescribing Parameters
• In February 2005, HHSC, DSHS, and DFPS,
released the Psychotropic Medication Utilization
Parameters for Foster Children (updated June 2007,
December 2010, and September 2013).
• The current version can be found at:
http://www.dfps.state.tx.us/Child_Protection/Medical
_Services/guide-psychotropic.asp
• The parameters use nine criteria to trigger further
review of a child’s medication.
17
Review Criteria
1.
Absence of DSM-5 diagnosis.
2.
Four (4) or more psychotropic medications.
3.
Prescribing:
• Two (2) or more stimulants at the same time
• Two (2) or more alpha agonists
• Two (2) or more antidepressants at the same time
• Two (2) or more antipsychotics at the same time
• Three (3) or more mood stabilizers at the same time.
4.
The prescribed psychotropic medication is not consistent with appropriate
care for the patient’s diagnosed mental disorder or with documented target
symptoms.
5.
Psychotropic polypharmacy (2 or more medications) for a given mental
disorder is prescribed before utilizing a single medication.
6.
The psychotropic medication dose exceeds usual recommended doses
(FDA and /or literature based maximum dosages).
Adapted from DFPS Slide
18
Review Criteria (continued)
7.
Psychotropic medications are prescribed for children of very young age,
including children receiving the following medications with an age of:
• Stimulants:
Less than three (3) years of age
• Alpha Agonists:
Less than four (4) years of age
• Antidepressants: Less than four (4) years of age
• Antipsychotics:
Less than four (4) years of age
• Mood Stabilizers: Less than four (4) years of age
8.
Prescribing by a primary care provider for a diagnosis other than the
following (unless recommended by a psychiatrist consultant):
• Attention Deficit Hyperactive Disorder (ADHD)
• Uncomplicated anxiety disorders
• Uncomplicated depression
9.
Antipsychotic medication(s) prescribed continuously without appropriate
monitoring of glucose and lipids at least every 6 months.
Adapted from DFPS Slide
19
Review Process
•
Health screenings – STAR Health Service Managers conduct phone
interviews with caretakers to identify those children who have medication
regimens which appear to be outside of the Psychotropic Medication
Utilization Parameters prescribing criteria.
•
Automated pharmacy claims screening – STAR Health also conducts a
real time automated screening program utilizing pharmacy claims
information from vendor drug to identify foster children who have medication
regimens which may fall outside the prescribing criteria.
•
External request – CPS Nurse specialists, CPS caseworkers, CASA
volunteers, foster parents, attorneys or Child Placing Agencies can request
a medication review.
•
Court request – Family court judges can request a review to answer
questions about a foster child’s medication regimen.
Adapted from DFPS Slide
20
Review Process (continued)
• Psychotropic Medication Utilization Review (PMUR) – process
by which all the children's psychotropic medication regimens
"outside of Parameters" are reviewed and managed through STAR
Health child psychiatrist consultations to the prescribing physicians.
The written PMUR report is uploaded to the Health Passport.
• Quality of Care Review (QOC) – physicians with practice patterns
of concern (identified through the PMUR process or by complaints
by parties involved in the child's care) are thoroughly reviewed and
may, if warranted, be referred to the STAR Health Credentialing
Committee for further investigation and disciplinary action including
termination from the network. (In 2011, 28 QOC reviews with 6
corrective action plans.)
Adapted from DFPS Slide
21
Medical Consent
•
•
•
Court authorizes DFPS or an individual to consent to medical care
If DFPS is authorized, DFPS must designate a particular individual
– Live-in caregivers, emergency shelter staff, cottage parents; or
– CPS staff in facilities with shift staff
Medical consenter must complete training on informed consent:
– http://www.dfps.state.tx.us/Training/PsychotropicMedication/default.asp
•
•
Medical consenter must participate in each medical appointment of child
DFPS and attorneys ad litem must notify youth of their right to ask court to
authorize them to consent to some or all of their own medical care before at
16
– Court considers capacity of youth
– DFPS may file petition if youth refuses needed treatment
– DFPS must include training on informed consent in Preparation for Adult
Living Life Skills Training
– Youth must complete training if taking psychotropic medications
22
Health Passport
• Secure, web-based electronic health record (EHR) system
• Access by state staff, network providers, and medical consenters
• Provides access by authorized users according to their role
• Accessed at www.fostercaretx.com
• Initially populated with two years of Medicaid and CHIP claims
history and pharmacy data
• When the child leaves foster care, the passport is available in
electronic or printed formats to:
– child’s legal guardian, managing conservator, or parent
– child if at least 18 years of age or an emancipated minor
23
Judicial Review
•
•
DFPS
– Must provide information about medications in court report
Judges
– Must review child’s medical care
– Must ensure the child has had an opportunity to express an opinion
on medical care and must review child’s opinion
– If child is receiving psychotropic medication, must determine
whether:
• Child has been provided appropriate psychosocial therapies, behavior strategies,
and other non-pharmacological interventions;
• Child has been seen by the prescribing physician or PA or APN at least once
every 90 days
•
Attorneys ad litem
– Must review medical care provided to the child
– Elicit child’s opinion on medical care
– Advise child who is at least 16 years of right to request the court to authorize the child
to consent to the child’s own medical care.
•
Notification to parents
24
Alternatives
• Non-Pharmacological Interventions:
trauma-informed, evidence-based
psychosocial therapies.
• Stronger Foster Homes—better trained
foster parents and fewer children and
youth.
• Alternatives for teenagers—alternative
education and supervised independent
living.
25