Psychiatric Consultation in a Psychotropic Medication

Oversight Program for Foster Children: The Illinois Model

Michael W. Naylor, M.D.University of Illinois at Chicago

Director, Clinical Services in Psychopharmacology

Background

• Historical context– DCFS challenged by federal courts, DOJ

and ACLU• inadequate casework• chaotic and dangerous placements• substandard care

– Illinois violating constitutional rights of children

Background

• Historical context– Chicago Tribune 1995 editorial series:

• DCFS called “the worst child welfare system in America…” and “a cruel, indifferent bureaucracy that harms kids.”

• “system of shame”

Background

• Historical context– Federal court-approved consent decree

(B.H. v Suter, 1991)• DCFS and ACLU agree to collaborate on

system reform plan

State Context

• Psychotropic medication consent– DCFS Rule 325– Clinicians wishing to start a foster child on

a psychotropic medication must obtain consent from the DCFS Guardian

State Context

• DCFS Psychotropic Medication Consent Program– Two components:

• Centralized Psychotropic Medication Consent Line

– Office of the DCFS Guardian• Clinical Services in Psychopharmacology

– University of Illinois at Chicago

State Context

• Centralized Psychotropic Medication Consent Line– Office of the DCFS Guardian

• legal guardian for children committed to the Department

• responsible for providing consent for medical, surgical, and psychiatric treatment

State Context

• Clinical Services in Psychopharmacology– provide independent review for all

psychotropic medication requests– monitor utilization of psychotropic

medications– provide consultation on particularly

complicated cases

State Context

• Clinical Services in Psychopharmacology– notify the Guardian where provider patterns

warrant review– conduct training for DCFS, foster parents and

childcare providers on psychotropic medications

– disseminate information regarding new pharmaceutical developments and alerts

Consent ProcessPrescribing

Clinician

UIC Research Team

UIC Psychiatric Nurse

UIC Psychiatric Consultant MD

UIC Psychiatric Nurse

DCFS Authorized

Agent

Psychotropic MedicationRequest Form

– name– DCFS ID

Number– date of birth– sex

– race– weight and

height– placement – physician’s

name and specialty

• Demographic information

Psychotropic MedicationRequest Form

• Clinical information– diagnosis– current medications and dosage– symptoms/rationale– requested medication

• dosage and frequency

Consultation

• Three main providers of consultation for clinicians treating foster children:– Clinical Services in Psychopharmacology– DocAssist– Consult for Kids

CSP

Consent

Oversight

Clinical

Prior Authorization

Systemic

Monitoring/QI

Clinical Services in Psychopharmacology

• Consultation– consent process

• independent review of the appropriateness of the psychotropic medication consent request

• recommend action to DCFS– approve– deny– modify

Clinical Services in Psychopharmacology

• Consultation– oversight

• formal– high risk prescribers– emergency medication utilization

• informal– feedback from Administrative Case Reviews– concerns expressed by caseworkers, regional nurses,

guardian ad litem, Court Appointed Special Advocates, judges, Office of the DCFS Guardian

Clinical Services in Psychopharmacology

• Consultation– clinical

• clinical concerns that arise in the course of the independent medication review

• MD:MD• review of consent history• chart review• face-to-face

Clinical Services in Psychopharmacology

• Consultation– prior authorization

• provided consultation to HFS vis-à-vis prior authorization for antipsychotic medications and stimulants for children

• DCFS consent for a medication serves as prior authorization for foster children

Clinical Services in Psychopharmacology

• Consultation– systemic

• consult on development of policies, best practice guidelines re: mental health care for foster children

• co-write legislation

Clinical Services in Psychopharmacology

• Consultation– monitoring/QI

• medication utilization patterns– rate of copharmacy with two or more antipsychotics– rate of polypharmacy by age group

• timeliness of consent process• compliance with Rule 325

Impact of Consultation

0 20 40 60 80 100

0.00

0.05

0.10

0.15

0.20

Months

% R

eque

sts

ParoxetineFluoxetineOther SSRIs

Paroxetine WarningCSP InterventionBlack Box Warning

Consultation

• Illinois DocAssist– established through the joint efforts of the

Department of Healthcare and Family Services, the Department of Human Services – Mental Health, and the University of Illinois at Chicago

– funding support by the Illinois Children’s Mental Health Partnership

Consultation

• Illinois DocAssist– clinical

• quality of treatment for Medicaid funded children with mental illness in the primary care setting

– client – Medicaid funded providers with a focus on primary care

– purpose – improve the identification, diagnosis and treatment of children and youth with mental health issues through consultation, education and referral services

Consultation

• Consult for Kids Program– established by DCFS to provide primary

care clinicians participating in HealthWorks with resources to evaluate foster children in their care for mental health and behavioral concerns

Consultation

• Consult for Kids Program– clinical

• address questions and concerns about a foster child’s emotional, interpersonal, behavioral or cognitive problems

– client – primary care providers– purpose – help primary care providers navigate a

challenging child through the child welfare system

Consultation

• Challenges to effective consultation– “silo-ization”

• duplication of services• lack of coordination

– informing stakeholders of the services– meeting demand for services

Consultation

“The Curse of Unwelcome Oversight

and Unrequested Consultation.”