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QI Initiatives for Psychotropic Use in Foster Youth in Maine

QI Initiatives for Psychotropic Use in Foster Youth in Maine. Lindsey Tweed MD MPH Office of Child & Family Services; Maine DHHS Lindsey.Tweed@Maine.gov. Sixteen State Collaborative Antipsychotic Study. This study occurred before the more recent focus on all psychotropics in foster youth

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QI Initiatives for Psychotropic Use in Foster Youth in Maine

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  1. QI Initiatives for Psychotropic Use in Foster Youth in Maine Lindsey Tweed MD MPH Office of Child & Family Services; Maine DHHS Lindsey.Tweed@Maine.gov

  2. Sixteen State Collaborative Antipsychotic Study • This study occurred before the more recent focus on all psychotropics in foster youth • Focus was on all Medicaid beneficiaries; not just foster youth • Data analysis covered 2004-2007

  3. 16 State Antipsychotic Study: Part II • Rate for of antipsychotic use for all MaineCare members 0-18: 3.1 % • Rate for MaineCare members 12-18 varied between 5 and 6% • Maine was above the median • Rate for foster youth: 20% • Nobody knows what the rates should be; but these seemed high

  4. Rationale for More Intense Focus on Antipsychotics • Although psychotropics should never be used inappropriately, stimulants and antidepressants are relatively safe • Medically important side effects are very common with antipsychotics • Majority of psychotropic side effect burden would seem to be due to antipsychotics • Other less prevalent meds that commonly have medically important side effects…

  5. Handling Antipsychotic Outliers • More than one; high dose; very young • Pharmacy benefit manager had implemented Prior Authorization process; mainly as a cost saving tool • PA requirement added for two AP’s or for doses over FDA approved • PA for AP use in children under 5 later added; requires a chart review

  6. Reaction to Initial Prior Authorization Requirements • PA approved by committee including community psychiatrists • Still, there was a very strong reaction against the PA • M.D. at benefit manager: We should have had a conference, other means of input and education, before implementing. • We may now be in a different era

  7. But Non-Outliers Are Majority of the Problem • Most AP prescription is to youth 5 and over; one antipsychotic; and at FDA approved doses • These youth commonly/usually experience medically important side effects • The majority of foster youth side effect burden would appear to come from non-outlier use of AP’s

  8. Goals and Members of AP Use in Foster Youth Workgroup • Goal: Ensure that Foster Youth are prescribed antipsychotics only when clinically indicated • Members: Foster Youth, Foster Parents, Residential Treatment Providers, Child Psychiatrists, DHHS • We began in September 2009 and met for about one year

  9. Strategies Chosen • Strengthen teen consent process • Tool developed to empower youth • Strengthen caseworker consent process; be the best parent you can • Worksheet for caseworkers

  10. Worksheet for Caseworkers/Supervisors • Use in psychosis and for Bipolar Disorder • Use for aggression as a target symptom • In context of Autism Spectrum • In context of Disruptive Behavior Disorders (CD, ADHD with aggression) • Maximize good casework • Maximize psychosocial interventions • EBT’s • Maximize treatment of primary disorders (e.g., ADHD, depression) with safer meds

  11. Worksheet (cont.) • Monitoring therapeutic effects • Monitoring side effects • Ask specifically about weight, BMI, BMI percentile, glucose and lipids • When aggression is target symptom, and when youth has done well for 6 months, expectation is to taper • All good med decisions are risk vs benefit

  12. Additional Strategies • Additional Support for Caseworkers • By clinicians who work within OCFS • Education on Guidelines: Youth, Caseworkers, Prescribers, Foster Parents, Residential Providers • Monitoring Our Progress • Both via MACWIS and via MaineCare claims • Proportion of youth on each category of med; by district, supervisor, caseworker • How to measure if process followed?

  13. AP Use Rate 0-18 YearsMinimum one month MaineCare eligibility Maine DRAFT 8/8/2012

  14. Foster/Non-Foster AP Use Rate 0-18 YearsOne month MaineCare eligibilityvirtually all atypical anti-psychotics AP Use Demographics DRAFT 8/8/2012

  15. Recent Initiatives for All MaineCare Members • Legislator introduced a bill to regulate AP prescription in youth • Compromise was a DHHS report • Similar stakeholder group made similar recs for all prescribers • Method for monitoring agencies’ QI being devised • New PA: required monitoring of metabolic side effects within first 20 weeks of use

  16. Role of Evidence Based Treatments • Most youth started on AP’s have significant mental health symptoms • EBT’s have not been widely disseminated • Overuse of AP’s may be a logical consequence of non-dissemination of EBT’s • Significant prevalence of disruptive behavior, anxiety, depression, and post-traumatic stress in foster youth

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