Nina Jo Muse, MD, Psychiatric Advisor State Hospital Section, Mental Health Substance Abuse Division Texas Department o

1. Psychotropic Medication Monitoring in Texas Foster Care Presentation to Because Minds Matter: Collaborating to Strengthen Management of Psychotropic Medications for Children and Youth in Foster Care Washington, DC July 20, 2012 Nina Jo Muse, MD, Psychiatric Advisor State Hospital Section, Mental Health Substance Abuse Division Texas Department of State Health Services

2. Psychotropic Medication Monitoring in Texas Foster Care Significant Events Leading to Monitoring • In April 2004, the state Comptroller released a report critical of foster care in Texas. • In February 2005, DFPS released the best practice guidelines: Psychotropic Medication Utilization Parameters for Foster Children. • In September 2005, Senate Bill 6 created a single managed care organization for foster children with requirements for consent and monitoring of psychotropic medications. • In 2006, DFPS released its first report of data on use of psychotropic medications in foster children in Texas in response to the Comptroller report. • In April 2008, the single MCO (STAR Health) began for 27,000 children and young adults in foster care in Texas.

3. Psychotropic Medication Monitoring in Texas Foster Care Psychotropic Medication Parameters • Current version dated December, 2010 of the Parameters, earlier versions, and the 2006 reportcan be found at: http://www.dfps.state.tx.us/Child_Protection/Medical_Services/guide-psychotropic.asp • These Parameters use eight criteria to indicate a need for further review of the child’s medication regimen.

4. Psychotropic Medication Monitoring in Texas Foster Care Criteria for Review of the Medication Regimen • Absence of a thorough assessment of DSM-IV diagnosis in the child’s medical record. • Five (5) or more psychotropic medications prescribed concomitantly. • Prescribing of: • Two (2) or more antidepressants at the same time • Two (2) or more antipsychotic medications at the same time • Two (2) or more stimulant medications at the same time • Three (3) or more mood stabilizer medications at the same time

5. Psychotropic Medication Monitoring in Texas Foster Care Review Criteria(Continued) • The prescribed psychotropic medication is not consistent with appropriate care for the patient’s diagnosed mental disorder or with documented target symptoms. • Multiple psychotropic medications for a given mental disorder are prescribed before utilizing a single medication. • The psychotropic medication dose exceeds usually recommended doses.

6. Psychotropic Medication Monitoring in Texas Foster Care Review Criteria(Continued) 7.Psychotropic medications are prescribed for children of very young age, including children receiving the following medications with an age of: • Antidepressants: Less than four (4) years of age • Antipsychotics: Less than four (4) years of age • Psychostimulants: Less than three (3) 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

7. Psychotropic Medication Monitoring in Texas Foster Care Use of Review Criteria with Data in Monitoring • Sources of data • Medicaid office visit claims for physician services for foster children • Pharmacy claims • The medical record • The Health Passport (since April, 2008) • Development of algorithms to sort claims data • Definitions of psychotropic, medication classes, “on the medication,” polypharmacy, concurrent • Techniques to handle the passage of time, fiscal years, and age • Uses and interpretation of claims data for monitoring • 10,000 foot view vs. on-the-ground view • Policy-making vs. clinical oversight • Retrospective vs. concurrent (vs. prospective reviews)

8. Psychotropic Medication Monitoring in Texas Foster Care Limitations in the Use of Claims Data • Limitations due to the sources of the data • Reconciliation of physician services claims with pharmacy claims • Claims data is NOT clinical data • Service claims do not capture all diagnoses nor all services rendered • Pharmacy fill data does not tell you who is taking what, how much, for how long, or for what purpose • A million ways to slice the data cake: Limitations in the sort algorithms • “What’s in a name?” Definitions of psychotropic, medication classes, “on the medication,” polypharmacy, all skew the data one way or another • Time flies or “What age is this kid really?” • Misuses and misinterpretation of data • Claims data only tell you trends and/or where to look next • Make no decisions based solely upon the surface of the data

9. Psychotropic Medication Monitoring in Texas Foster Care Features of STAR Health MCO • Medical home model (PCP) • Expedited enrollment • Coordination of physical and behavioral health (Service Management Teams) • Provision of preventive care (Texas Health Steps) • Broad network of providers • 24/7 nursing and behavioral help-line • Medical advisory committees to monitor the provision of the healthcare • Health Passport for continuity of care

10. Psychotropic Medication Monitoring in Texas Foster Care Health Passport • Operational on April 1, 2008 for access by state staff, network providers and medical consenters • Secure, web-based electronic health record (EHR) system • Accessed at www.fostercaretx.com (follow the link to “sign-up”) • Provides access by authorized users according to their role • 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

11. Psychotropic Medication Monitoring in Texas Foster Care Psychotropic Medication UtilizationReview (PMUR) 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. Update on the Use of Psychoactive Medication in Texas Foster Children Fiscal Year 2002-2011 can be found at: http://www.hhsc.state.tx.us/medicaid/OCC/Psychoactive_Medications.html

12. Psychotropic Medication Monitoring in Texas Foster Care PMUR 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 • 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

13. Psychotropic Medication for Children in Texas Foster Care Fiscal Years 2002-2011

14. Psychotropic Medication Monitoring in Texas Foster Care Texas Foster Care SFY04 to SFY11: Psychotropic Prescriptions Greater than 60 days by Drug Class

15. Psychotropic Medication Monitoring in Texas Foster Care The Future of Monitoring in Texas • Revising the Parameters review criteria and improved monitoring • Revision of indications, dosing, and age guidelines to reflect latest research • Decrease total number of meds that trigger polypharmacy review • Decrease ages that trigger review • Improve review of dosages • Improve feedback to physicians • Other entities adopting the Parameters and review criteria • Regular Medicaid for children • State Hospital system • Outpatient public mental health system • Private practitioners (spillover from their Medicaid work) • (National use—iPad App developed independently available)