Because Minds Matter: Collaborating to Strengthen Psychotropic Medication Management for

1. Psychotropic Medication Use and Management for Children in Foster CareKamala D. Allen Vice President and Director, Child Health Quality Because Minds Matter: Collaborating to Strengthen Psychotropic Medication Management for Children and Youth in Foster Care August 27-28, 2012 Washington, DC

2. Overview of the Session • Organizational Background • A Focus on Psychotropic Medication Use in Children in Foster Care • What we Know about the States’ Efforts:A snapshot based on 26 States • The CHCS Quality Improvement Collaborative: A Model for Improvement

3. CHCS Mission To improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care. Our Priorities Enhancing Access to and Coverage of Services Improving Quality and Reducing Racial and Ethnic Disparities Integrating Care for People with Complex and Special Needs Building Medicaid Leadership and Capacity

4. Premise for our Child Welfare Work • Children in child welfare - specifically those in foster care - have significantly high rates of physical, behavioral and oral health needs. • Children in foster care likely have legitimately higher rates of need, and consequently, use of behavioral health services. • Foster children are at high risk for the negative consequences of poor access and uncoordinated care. • Children in foster care require a tailored approach to care delivery involving all system partners.

5. Psychotropic Medication: Federal Focus and Legislative Opportunities • ACF’s April 2012 Information Memorandum • Child and Family Services Improvement and Innovation Act (2011) • Joint Dear State Officials Letter to Medicaid, Child Welfare, and Behavioral Health Directors (2011) • Fostering Connections Act (2008) • Patient Protection and Affordable Care Act (2010) • Child Health Insurance Program Reauthorization Act (2009)

6. Problem is multi-faceted • Lack of non-pharmacological interventions • Lack of behavioral health specialists • Use of medications to control difficult behaviors • Lack of knowledge regarding appropriate use of psychotropics among child welfare case workers • Lack of coordination across providers and between child-serving systems • Financial incentives to prescribe • Aggressive/effective pharmaceutical marketing • Need for “quick fixes”

7. What do the Data Say? • Faces of Medicaid: Child Behavioral Health Utilization and Expenditure Study, 2012 • 2005 MAX data (Medicaid Claims) for 29 million children and youth in Medicaid • 2.8M children received behavioral health care (services and psychotropic medication) = 9.6% penetration rate Source: Pires, Grimes, Allen, Gilmer, Mahadevan, Forthcoming 2012

8. What do the Data Say? • Special Analyses on Children in Foster Care • Represent 3.2 percent of children in Medicaid • Represent 12.6 percent of children in Medicaid receiving psychotropic medication • Represent 15 percent of children in Medicaid receiving behavioral health services • 32% of children in foster care receive behavioral health services • 23% of children in foster care receive psychotropic medication • 39.3% of children in foster care received behavioral health care (services and/or psychotropic meds) • Account for 28.6% of Medicaid child behavioral health exp. • Mean expenditures: $4,036 (PH), $8,094 (BH), Total: $12,130

9. What do the Data Say? • Of children in Medicaid prescribed psychotropic medications, children in foster care: • Were prescribed psychotropic medication at a rate 4 times their representation in Medicaid (TANF children at 2/3 their representation • Had Medicaid expenditures for behavioral health services 7 times that of the overall Medicaid child population • Of children who received psychotropic medications, we see concerning patterns: • 42% of children in foster care (and SSI) were prescribed antipsychotics versus 18% of TANF children • 19% of children in foster care were on 3 or more psychotropic medications within the year versus 10% of the overall Medicaid child population

10. What do the Data Say? • Special Analyses on Psychotropic Medication Use • 1.7M (5.8%) of all children in Medicaid (2005) received psychotropic medications with or without another Medicaid-covered behavioral health or physical health service. • Only 50 percent of the 1.7 million children on psychotropic medications also received identifiable behavioral health services. • Among children who used behavioral health services, psychotropic medication was among the top three categories of service use for children in Foster Care, those in SSI, and children with developmental disabilities.

11. How Will We Impact the Use of Psychotropic Medications among Children in Foster Care?

12. National Initiative on Psychotropicsin Foster Care Improving the Use of Psychotropic Medications among Children in Foster Care Quality Improvement Collaborative (PMQIC) 3-year initiative funded by the Annie E. Casey Foundation 32 letters of interest; 26 applications Multi-state effort New York Vermont Rhode Island** • Illinois • Oregon • New Jersey ** Casey Special Interest Site

13. Highlights of Existing Models • CONSENT • Centralized review and consent process • Partnership with academic research center • OVERSIGHT (at prescriber level) • Provider profiling • Second opinions • Prior authorizations/Preferred drug lists • MONITORING (at child level) • Quarterly reports • Targeted interventions

14. PMQIC State Efforts

15. Why use a State collaborative approach to improve psychotropic medication use? • State child welfare agencies are responsible for the safety and well-being of children in foster care. • Specific requirements re: psychotropic medications • Most children in foster care are Medicaid-eligible, and Medicaid pays for their psychotropic medications. • States have successes to build upon and peer exchange is fostered to facilitate spread. • CHCS has a quality improvement collaborative model that has been effective in reducing inappropriate psychotropic medication use among children in child welfare.

16. Case Study: Child Welfare Quality Improvement Collaborative • Three-year quality improvement initiative • focused on improving three aspects of health care for children involved in child welfare: • Access to Care • Connecticut Behavioral Health Partnership • Magellan Behavioral Health of Florida • Mid Rogue Health Plan • Priority Partners Managed Care Organization • UPMC for You • Coordination of Care • Volunteer State Health Plan • Wraparound Milwaukee • Appropriate use of Psychotropic Medications • CareOregon • Massachusetts Behavioral Health Partnership

17. Overview of Plans’ CW Initiatives

18. Overview of Plans’ CW Initiatives

19. Questions we will seek to answer… • Can the data currently being collected inform targeting of improvement strategies? • Can data be shared more effectively among Medicaid, child welfare and behavioral health agencies? • Can provider practices be modified to reflect peer guidelines for prescribing psychotropics to children and youth? • Can consent, oversight and monitoring policies and practices be coordinated and strengthened within child welfare and Medicaid systems?

20. Questions we will seek to answer… • Can families and youth be more effectively engaged in care planning to avoid unnecessary use of psychotropics? • Can financial incentives be changed to encourage the use of non-pharmacological interventions? • Can we help states more effectively monitor and intervene to reduce inappropriate prescribing among children in foster care?

21. What about all of the other states? • Learning Community of States supported by Substance Abuse and Mental Health Services Administration (SAMHSA) in partnership with the Administration for Children and Families (ACF) • “Low touch” technical assistance to other 44 states • Quarterly how-to webinars • Dissemination of resources developed under PMQIC • Fostering sharing of resources, effective practices and “lessons learned” among states • Coordination with other national initiatives on reducing inappropriate psychotropic medication use as they emerge

22. What do we Know? Lessons from a 26-State Sample

23. States’ Profile • Foster care census across the states ranged from just under 1,000 to nearly 58,000 children/youth. • Most states have state-administered/locally-operated child welfare systems. • Most states are enrolling children in foster care in Medicaid managed care. • Most states were not effectively leveraging the data available through Medicaid claims systems.

24. Consent Process • 7 states have no consent policy for psychotropic medication for children in foster care. • Among states with a policy, there are varying approaches to consent. • Parent/Guardian • Child Welfare Guardian • Child Welfare Caseworker or Supervisor • Child Welfare Health Unit • Centralized Consent Unit • Judicial/Juvenile Court Officer • Existence of youth assent policies was less clear.

25. Cross-Agency Collaboration • Several states have interagency agreements in place to allow for the exchange/integration of data between/among agencies. • Some states use Medicaid prior authorization and/or preferred drug list mechanisms to control access to certain classes of psychotropics or for specific populations. • A number of states have psychiatric consultation lines to provide support to primary care providers.

26. Data Capacity • Just under half of the 26 states are able to monitor psychotropic medications at the child level. • All states recognize ability to get critical information from Medicaid claims data and follow post-permanency assuming continued Medicaid eligibility. • Several states are currently utilizing Medicaid claims data to monitor concerning prescribing trends. • Many SACWIS states have augmented their data systems with robust health components, though many do not contain medication or prescriber data. • Some states rely on case workers to enter medical information; others, health professionals.

27. Provider Engagement • All states recognized the importance of engaging prescribers. • A few states focus particularly on key role played by inpatient psychiatric hospitals, residential and group care providers; more focus on primary care providers. • Strategies ranged from individual outreach to identify physician champions to engagement of professional societies. • Provider detailing education and training are common models proposed for facilitating changes in prescribing patterns.

28. Youth and Family Engagement • Most states were aware of foster care alumni organizations, but were not actively partnering. • Most states were aware of foster parent associations, with which they seemed to be more active. • Many states have task forces and/or standing committees looking at psychotropic medication use that include foster care alumni. • Many states acknowledged that the involvement of birth families is challenging.

29. Availability of Psychosocial Alternatives • Most states identified the lack of psychosocial therapies as a cause of potential over-reliance among prescribers on psychotropics. • The lack of specialists and individuals trained to deliver psychosocial therapies also cited as a challenge. • Access in rural areas of particular concern. • Few states had clear strategies to increase the availability of alternatives to psychotropics, but should consider importance of: • Medicaid and behavioral health financing • Adoption of evidence-based practices and evidence-informed approaches • Provision of trauma-informed assessments

30. In summary… • There is tremendous variation across the states • Rates of Use • Approaches to Oversight and Monitoring • Infrastructure • Data capacity/availability • Human Resources • Professional Resources • Cross-agency collaboration is critical

31. In summary… • States need to: • Leverage and build on what exists • Engage providers to adopt practice guidelines • Engage youth and families, meaningfully • Pursue technical assistance offerings • Understand that there is no one-size-fits-all solution

32. Recommendations: REAL Collaboration • Child Welfare Agencies • Create a consent policy. • Look at the data, regularly. • Partner to provide access to broader range of services and supports. • Ensure case workers have roles that they are trained to effectively carry out. • Medicaid Agencies • Partner to provide data related to use and expense. • Reimburse trauma-informed approaches. • Behavioral Health Agencies • Be at the table with data related to use and expense. • Partner to provide access to broader range of services and supports.

33. Recommendations: Leverage • Existing mandates • Federal and State legislation and regulations • Agency policies and guidance • Existing infrastructure • Data Systems • Human resources • Financial resources • Standing committees • Community-based organizations • Provider associations • Memoranda of Understanding among agencies • Contractual arrangements (e.g. with MCOs/BHOs and/or provider networks.)

34. Contact Information Kamala D. Allen Director, Child Health Quality kallen@chcs.org www.chcs.org