Kathy Teutsch, RN, LMSW-MSSW: CPS Division Administrator for Medical Services

1. 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

2. 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

3. 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.

4. Psychotropic Medication for Texas Foster Children Fiscal Years 2002-2012 There's been a 34% decrease since 2004 in Psychotropic Med use that lasts longer than 60 days for Texas Foster Children. There has been a 66% decrease since 2004 in Class Polypharmacy and 69% decrease in five or more Meds Polypharmacy.

5. 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.

6. 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 non-pharmacological 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.

7. 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.

8. 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.

9. 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.

10. 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 pre-service 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.

11. 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.

12. 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

13. 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.

14. 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.

15. 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.

16. 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

17. 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.