GETTING PRACTICAL: DEVELOPING YOUR STATE PLAN FOR PSYCHOTROPIC MEDICATION

MANAGEMENT – PART 2

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N E E D A S S I S TA N C E ? P L E A S E C A L L : 2 0 2 - 6 87 - 0 3 0 8 O R

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an intra-agency Agreement between ACF/ACYF and SAMHSA/CMHS.

L A U R E L K . L E S L I E , M D , M P H A s s o c i a t e P r o f e s s o r , T u f t s M e d i c a l C e n t e r

D i r e c t o r , A R C H , T u f t s C T S I

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Getting Practical: Your State Plan for Psychotropic Medication Management

Note. We have no financial conflicts to disclose

Presented for Administration on Children, Youth, and Families’ Q and A on Developing State Plans for Management of Psychotropic Use among Youth in Foster Care

Information Memorandum (5 Components)

1. Screening, evaluation and treatment planning.

2. Shared decision-making.

3. Medication monitoring.

4. Mental health expertise and consultation.

5. Information sharing.

Implementation Stage

For each component, where is your state?

Implementation Quality

Improvement Prioritizing

Assessing and

Planning

Component 1: Screening and Assessment

Initial Health Screen (24-72 hours) Comprehensive Assessment (30-60 days) Sensitive to the unique needs and experiences of

youth in child welfare custody Trauma related to maltreatment and trauma secondary to

removal from home and placement changes In-utero environmental drug exposure Genetic loading (AAP District II Task Force on Health Care for Children, 2001;

AACAP/CWLA, 2002; Jensen et al., 2009)

Component 1: State Approaches

Component 1: Self Reflection

What type of approach will we use ? e.g., as needed, screen/assessment, assessment

How will the approach address the unique needs for mental health evaluation of youth in child welfare custody, including trauma, in utero exposures, and potential genetic loading?

When will we conduct the screen (24-72 hours) and assessment (30-60 days)?

Who will conduct the evaluation?

What standardized “tool” will we use?

How will the cost be reimbursed to recruit appropriate clinicians? e.g., foster care-risk adjustment

Are there available services once needs are identified?

Can we track receipt of services?

e.g., information system

Resource: California Evidence Based Clearinghouse

Component 1: Resources

Sponsor/ Author Guideline

American Academy of Child and Adolescent Psychiatry (AACAP)

Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline

AACAP Policy Statement on Psychiatric Care of Children in the Foster Care System

AACAP; and Child Welfare League of America (CWLA)

Policy Statement on Mental Health and Use of Alcohol and Other Drugs, Screening and Assessment of Children in Foster Care

American Academy of Pediatrics

Fostering Health: Health Care for Children and Adolescents in Foster Care

Jensen PJ, Romanelli LH, Pecora PJ, Ortiz A.

Mental Health Practice Guidelines for Child Welfare

Component 2: Informed Consent and Assent

Informed Consent: The process of the clinician providing information, including benefits and risks, to the youth and caregiver about all possible treatments, and the caregiver making an informed decision regarding which treatments are in the best interest of the child.

Assent: A 3-part process that includes the youth understanding (to the best of his/her developmental abilities) treatment options, the youth voluntarily choosing to undergo treatment options, and the youth communicating this choice.

Component 2: State Approaches

Youth and biological parent engagement?

Component 2: Self Reflection

How can we ensure consenting authority can access mental health expenditure?

How will we… Engage youth

Consent/Assent Handbook

Engage foster and kin caregivers

Engage biological parents,

whenever appropriate

Use information systems to support decision-making

Resource: NRCPFC: Handbooks for Youth in Foster Care

Handbook under review, Children’s Bureau/ ACF

Component 2: Resources

Sponsor/ Author Resource

California Foster Youth Help

Maine Youth in Care Bill of Rights

New York A Medical Guide for Youth in Foster Care

Oregon Foster Care Questions

National Resource Center for Permanency and Family Connections

Resources to Promote Stakeholder Involvement

Child Welfare Information Gateway

Use of Psychotropic Medications

Patient Information Handouts

e.g., Dulcan, MK & Lizarralde, C. Helping Parents, Youth and Teachers Understand Medications for Behavioral and Emotional Problems: A Resource Book of Medication Information Handouts (3rd Edition)

Component 3: Medication Monitoring State Approaches

Prospective Retrospective

Consultation Court Hearings

Prior Authorization Drug Utilization Review

Mandatory Second Opinion Data Trends

Component 4: Mental Health Expertise

Mental health expertise may be available as: Hired staff within the Agency;

Staff at partnering State Agencies; or

Consultants external to the State system (e.g. academic medical center).

Medical Director (8.5%)

Mental Health

Director(25.5%)

Both(25.5%)

Neither(40.4%)

Medical & Mental Health Directorin State Child Welfare Agencies

n=47

Component 4: Self-Reflection

What skill set do we need in our system?

Will we house expertise within child welfare, other public sector systems, or “contract-out”?

How will we provide mental health expertise at the individual child level? As-needed basis?

PRN consultation available?

Routine, required reviews? Selected psychotropic medications/populations

All psychotropic medication/populations

Component 5: Information Sharing

Information Sharing: As stated in the information memorandum, disseminating

accurate and up-to-date information and educational materials related to mental health and trauma-related interventions (including information about psychotropics) to clinicians, child welfare staff, and consumers (e.g., youth, family members, foster parents, and advocates)

Component 5: Self Reflection

Where can we get accurate, up-to-date information? Consult available professional guidelines

Example: AACAP Policy Statement on Psychiatric Care of Children in the Foster Care System. See Appendix in Tufts Study Report.

Acquire additional expertise in child welfare agency

Component 5: Resources

Sponsor/Author Publication

NIMH Mental Health Medications

NIMH Treatment of Children with Mental Illness

NIMH Treatment of Children with Mental Disorders

NAMI NAMI Policy Research Institute Task Force Report: Children and Psychotropic Medications

AACAP Psychiatric Medications for Children and Adolescents: Part I – How Medications are Used

AACAP Psychiatric Medications for Children and Adolescents: Part II – Types of Medications

Questions?

For more information on the Multi-State Study on Psychotropic Medication Oversight in Foster Care, please link here.

For additional information about our work, including our current study, please contact:

Laurel K. Leslie (lleslie@tuftsmedicalcenter.org)

Tom Mackie (tmackie@tuftsmedicalcenter.org).

References

AAP District II Task Force on Health Care for Children in Foster Care,. (2001). District II Fostering Health: Health Care for Children in Foster Care—A Resource Manual . Lake Success, NY: American Academy of Pediatrics

Administration for Children and Families, (2012). ACF Information Memorandum ACYF-CB-IM-12-03.

American Academy of Child and Adolescent Psychiatry and Child Welfare League of America. (2003). AACAP/CWLA policy statement on mental health and substance use screening and assessment of children in foster care. Retrieved October 1, 2008, from www.aacap.org.

American Academy of Child and Adolescent Psychiatry.

(2001). Psychiatric Care of Children in the Foster Care System. Available at: http://www.aacap.org/cs/root/policy_statements/psychiatric_care_of_children_in_the_foster_care_system

Jensen, P. J., Hunter Romanelli, L., Pecora, P. J., & Ortiz, A. (2009). Special Issue: Mental Health Practice Guidelines for Reform. Child Welfare, 88(1). Retrieved online from http://www.thereachinstitute.org/files/documents/cwmh-guidelines-03-09.pdf

Leslie, L K., Raghavan, R, Hurley, M, Zhang, J,

Landsverk, J, Aarons, G. (2011) Investigating geographic variation in use of psychotropic medications among youth in child welfare. Child Abuse & Neglect, 35(5):333-42.

Leslie, L.K., Mackie, T.I., Dawson, E.H., Bellonci, C., Schoonover, D.R., Rodday, A.M., Hayek, M., Hyde, J. (2010). Multi-State Study on Psychotropic Medication Oversight in Foster Care. Study Report.

Multi-State Study on Psychotropic Medication Oversight in Foster Care

47 States and District of Columbia (48/51)

Thank you!

Currently in field to update findings

For more information, contact project manager: tmackie@tuftsmedicalcenter.org

© 2010 GEORGETOWN UNIVERSITY

Q & A

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Getting Practical: Developing Your State Plan

for Psychotropic Medication Management

Stephen Crystal Director, Center for Education and Research On Mental Health Therapeutics, Rutgers U.

scrystal@rci.rutgers.edu

Presented for Administration On Children, Youth and Families Q and A on

Developing State Plans for Management Of Psychotropic Use in Foster Care Youth

4/24/2012

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Key Areas for Plan Development (see ACYF-CB-IM-12-03)

• Comprehensive and coordinated screening, assessment, and treatment planning mechanisms to identify children’s mental health and trauma-treatment needs (including a psychiatric evaluation, as necessary, to identify needs for psychotropic medication).

• Informed and shared decision-making (consent and assent) and methods for on-going communication between the prescriber, the child, his/her caregivers, other healthcare providers, the child welfare worker, and other key stakeholders.

• Effective medication monitoring at both the client and agency level.

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Key Areas for Plan Development

• Availability of MH expertise and consultation by child and adolescent psychiatrist.

• Mechanisms for accessing and sharing up-to-date information and educational materials related to MH and trauma-related interventions (including information about psychotropics) to clinicians, child welfare staff, consumers.

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Developing Effective Plans for Medication Monitoring and for Acting on Results to Improve

Quality

• MEDNET and MMDLN initiatives provide relevant experience and methods.

• Key questions for states to consider in developing plans: –What metrics do we want to monitor and how will we use the

results? –What data sources will be utilized and what data linkages

will be necessary? (Relevant data are often “siloed”). –What information do we want to distribute to what users?

(State leadership? Case managers? Clinicians? Parents?) Do legal/policy barriers exist to merging, distributing data?

–Relationship to consent/assent process.

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Developing Effective Plans for Medication Monitoring and for Acting on Results to Improve

Quality –Monitoring in comparison to what

criteria/expectations/goals? Do monitoring plans need to be supported by guidelines, treatment parameters, explicit review flags?

–How can key stakeholders be engaged in developing monitoring plans? How can we achieve buy-in?

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Monitoring of Mental Health Evaluation, Psychosocial Treatment, and Followup

• Medication monitoring is not an island. • Need for monitoring includes multiple aspects of treatment,

including access/use of comprehensive psychiatric evaluation and psychosocial treatment, including supply of and access to evidence-based psychosocial interventions.

• Particularly for antipsychotic-treated youth, elements of appropriate management of concern may include: – Adequate initial psychiatric evaluation; – Utilization of appropriate psychosocial services prior to or

concurrent with pharmacological treatment; – Appropriate followup contacts for treatment management and

monitoring, and management of metabolic risks.

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Multiple Levels of Monitoring • Monitoring is a multipurpose tool that can be used at

multiple levels and for multiple purposes: –Aggregate level: Needs assessment, policy planning,

monitoring problems and trends. –Provider level: Quality measurement at agency or clinician

level; provider feedback as a QI tool. –Client level: Care coordination (e.g. treatment from multiple

prescribers); making information available to responsible actors; identifying and acting on “review flags” (e.g., too many, too much, too young).

• Metrics can support use at multiple levels, but needs for each level should be considered. –For care coordination and clinical management, current status

(as close to real-time as possible) is key; for other purposes, measurement over longer timeframes may meet needs.

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Selected Issues to Consider for Monitoring • Consistency of treatment with diagnosis. • Polypharmacy (between and within class)—”too many”. • Dosage – “too much”. • Management of metabolic risk. • Treatment rates by age – “too young”.

– Antipsychotic and other psychotropic treatment for children under 6 has been a focus of attention in several states. Authorization and review criteria for very young children merits attention.

• Mental health evaluation. • Psychosocial treatment prior to/concurrent with pharmacological

treatment.

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Utilizing Metrics for QI • Review flags for individual cases (see, for example, Texas foster care

prescribing parameters). Raises issue, in developing state plans, of use of second opinions and availability of “second opinion” review resources. Texas, Massachusetts and Washington are among states that offer models of second-opinion/clinical consultation approaches.

• Feedback of metrics to providers can be an important quality tool. Provider reports can compare providers to peer norms.

• Clinic-level QI initiatives represent another use of metrics. • Identification of outlier providers. • Geographic variation without apparent clinical rationale is common;

understanding these patterns can help to inform policy development and serve as a useful tool in working with provider communities.

• Linkage of monitoring with provision of provider education, engagement of provider communities.

• A continuous quality improvement program utilizing the metrics may offer the most effective strategy to improve treatment and outcomes, in collaboration with key stakeholders.

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Collaborative Development of Monitoring and QI Plans • Collaborative planning, engaging multiple state agencies as

well as other key stakeholders, can be an effective tool in achieving buy-in, engagement, and coordination across systems. A state QI collaborative can serve as a vehicle both for planning and for implementation of the state plan.

• Baseline data on current utilization patterns/quality metrics (optimally utilizing graphic presentations, mapping, etc.) can be a constructive means of engaging stakeholders in planning.

• IM-12-03 provides links to numerous resource materials. • For appropriate psychotropic use in management of

aggression, the CERTs T-MAY (Treatment of Maladaptive Aggression in Youth) guidelines provide an additional resource (currently incorporated in T-MAY clinician toolkit and in in-press papers in Pediatrics).

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ACP Report/Resource Guide and other materials at: http://chsr.rutgers.edu/MMDLNAPKIDS.html (or google Rutgers MMDLN Resource Guide)

Clinician’s Toolkit for Management of Atypical Aggression in Youth

http://www.chainonline.org/content.cfm?menu_id=232

Email: scrystal@rci.rutgers.edu

© 2010 GEORGETOWN UNIVERSITY

Q & A

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POLLING QUESTIONS 1

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POLLING QUESTIONS 2

© 2010 GEORGETOWN UNIVERSITY

CHILD WELFARE SHAREPOINT SITE http://gucchd.collaborationhost.net/ChildWelfare/

• This web site is designed to help you share information related to a particular subjects in the development of the psychotropic medication oversight and monitoring components of your state plan in the form of text, images, links, and other media such as video.

• Your posts can be used as team sites, news sites, journals, diaries, and more.

• Posts usually consist of frequent short postings and are typically displayed in reverse chronological order (newest entries first). Entries encourage site visitors to interact with one another by leaving comments on posts.

© 2010 GEORGETOWN UNIVERSITY

CHILD WELFARE SHAREPOINT SITE http://gucchd.collaborationhost.net/ChildWelfare/

• This post can also be used as a team communication tool. Keep team members informed by providing a central place for links and relevant news.

• Username and password will be provided in an email notification from mn344@georgetown.edu.

• Please contact 202.687.0308 if you are unable to access the site.

INFORMATION MEMORANDUMS AND IMPORTANT DATES

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• Overview of the Psychotropic Medications and Well-being

Information Memorandums (IM)s - http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/im00index.htm#2012

• Webinar Part 3: (June 5, 2012: 3:00pm – 4:30pm), Psychotropic Meds/Well-being IMs and pre-planning for the Summit with representatives of ACYF

• Because Minds Matter: Collaborating to Strengthen Management of Psychotropic Medications for Children and Youth in Foster Care Summit (August 27 & 28, 2012) at the Hyatt Regency Washington on Capitol Hill