SHARED DECISION-MAKING PANEL
Informed Consent and Monitoring of
Psychotropic Medications in Texas
Kathy Teutsch, RN, LMSW-MSSW:
CPS Division Administrator for Medical Services
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Psychotropic Medication for Texas Foster Children
History of Medical Consent and
Monitoring of Psychotropic Medication
• In February 2005, released the Psychotropic Medication Utilization
Parameters for Foster Children
• In September 2005, Senate Bill 6 (authored by Senator Jane Nelson)
became effective implementing reforms for DFPS, including the
development of a comprehensive health care system for children in
foster care and specific requirements related to medical consent (Texas
Family Code Chapter 266)
• In April 2008, STAR Health began for all Texas foster
children and young adults
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Psychotropic Medication for Texas Foster Children
Who Provides Informed Consent?
• Texas law requires court to authorize:
– DFPS or an individual to consent to medical care for a child, or
– A 16 or 17 year old youth to consent to their own medical care
• If DFPS is authorized (most cases), DFPS must designate an
individual to consent and notify court:
– Emergency shelter staff or live-in caregiver in home-like setting
– DFPS staff in residential facility with shift staff
– Other appropriate individual, such as a relative or birth parent
• When DFPS is authorized, DFPS also designates a back-up
medical consenter
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Psychotropic Medication for Texas Foster Children
Responsibilities of Medical Consenter
• Complete training on informed consent
• Participate in each medical appointment of child
• Become knowledgeable of child’s medical
condition and needs
• Consent to all medical care--each psych med
and any change
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Psychotropic Medication for Texas Foster Children
Responsibilities of Medical Consenter
• Involve child in decisions about medical care
• Inform DFPS by the next business day of any
psychotropic medications prescribed for a child
• Keep foster care agency and DFPS apprised of all
medical care
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Psychotropic Medication for Texas Foster Children
Responsibilities of Foster Care
Agencies*
• Ensure compliance with DFPS policies, rules and licensing
requirements
• Provide pre-service and annual training on psych meds
• Ensure children have minimum of quarterly visits with prescriber to
assess child’s progress and presence of side effects
• Ensure monitoring of child, documentation and contacts with
prescriber about side effects or adverse reactions
* Residential Child Care Licensing Minimum Standards were revised in 2007 to add heightened
requirements for foster care providers concerning psychotropic medications:
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Psychotropic Medication for Texas Foster Children
Responsibilities of DFPS
• Act as “parent” and oversee all medical care
• If authorized to consent, designate medical consenter
and monitor performance
• Provide written Summary of Medical Care at each court
hearing (condition, diagnosis, symptoms, child’s
progress, adverse reactions and side effects)
• Employ regional nurse consultants to support CPS staff
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Psychotropic Medication for Texas Foster Children
Responsibilities of DFPS
• Inform children about to turn 16 about option to petition
court for right to consent to own medical care
• Offer training on Informed Consent to youth in
Preparation for Adult Living Life Skills training
• Consult with other parties in the case about psych meds
as needed (foster care agencies, birth parents, health
care providers, attorneys, Court Appointed Special
Advocates, etc.)
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Psychotropic Medication for Texas Foster Children
Responsibilities of Judiciary
• Authorize a medical consenter for each child
• Provide opportunity for each child to express their views on medical
care being provided
• Review Summary of Medical Care provided by DFPS at status,
placement and permanency hearings
• Can issue orders related to medical care that in the child’s best
interests
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Psychotropic Medication for Texas Foster Children
Responsibilities of STAR Health
• Credential and contract with providers for STAR Health
network
• Answer general questions from judges
• Screen all children re: psych med use
•
•
•
Telephonic health screenings when child enters foster care,
changes placement or has significant changes in medical condition
Automated pharmacy claims screening
External requests—CPS nurse consultants. DFPS staff, foster
parents, attorneys, foster care agencies, Court Appointed Special
Advocates
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Psychotropic Medication for Texas Foster Children
Responsibilities of STAR Health
Conduct Psychotropic Medication Utilization Review
(PMUR) when:
• Telephonic health screening indicates outside Parameters
• Pharmacy fills psych med prescription for:
– Any child under age 4
– 2 or more meds in same class (3 or more mood stabilizers)
– 5 or more psych meds for more than 60 days
• Court requests review
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Psychotropic Medication for Texas Foster Children
Responsibilities of STAR Health
Once PMUR triggered
• Gather information from caregiver and available documentation
• Submit information to child and adolescent psychiatrist for formal
review:
– Outreaches to prescriber
– Issues a formal report with a finding
• Conduct Quality of Care review for prescribers with persistent
prescribing patterns of concern
• Can require corrective action from prescribers or terminate them
from network
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Psychotropic Medication for Texas Foster Children
Opportunities to Express Concerns
• Medical consenter/child/DFPS staff may talk to prescriber about
concerns
• Interested parties may express concerns to DFPS
• Interested parties may request a PMUR through STAR Health
• Court hearings provide venues for child and interested parties to
express concerns
• Youth may request court to authorize them as their own medical
consenters
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Psychotropic Medication for Texas Foster Children
Challenges to This Approach
• Medical consenter reluctant to question physician
• Caregiver/medical consenter may be overwhelmed with
multiple children and resort to psych med use as a
means of control
• PMUR is a retrospective process after child taking psych
meds
• Communication challenges between judiciary and
medical community
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Psychotropic Medication for Texas Foster Children
What Works Well
• One health care network statewide
• Each child has medical consenter knowledgeable about
their medical condition and needs
• Multi-tiered oversight and monitoring process with shared
decision-making
• All children’s psych meds regimens are screened
• Processes for raising concerns
• Method to outreach to prescribers to enhance practices
• Reduction in psych med use of 36% between 2002 and
2011
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Psychotropic Medication for Texas Foster Children
Update on the Use of Psychotropic Medications in
Texas Foster Children: Fiscal Years 2002-2011
35.0%
Percentage of Children in Foster Care
30.0%
28.0%
29.6%
29.9%
26.4%
25.0%
24.7%
25.0%
21.5%
21.2%
20.5%
20.0%
19.3%
36% Decrease
since 2004
15.0%
10.0%
5.0%
5.0%
3.3%
4.0%
0.7%
1.1%
1.4%
FY2002
FY2003
FY2004
68% Decrease
since 2004
3.4%
2.5%
2.5%
0.9%
0.7%
0.7%
FY2005
FY2006
FY2007
0.0%
Psychotropic Meds 60 days+
2.0%
1.8%
1.8%
1.6%
0.6%
0.5%
0.5%
0.4%
FY2008
FY2009
FY2010
FY2011
Class polypharmacy
70% Decrease
since 2004
Five or more Meds polypharmacy
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Psychotropic Medication for Texas Foster Children
Efforts to Improve Process
• Trauma Informed Care initiative to provide evidence-based
non-pharmacological interventions as an alternative to
psych meds
• Third-party review of Parameters to enhance Parameters
• Judge’s round-table to improve communication and
processes
• Efforts to strengthen informed consent processes with
training and written process
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