Ensuring Appropriate and Informed Use of Psychotropic Medications With Children in Department Custod

1
Ensuring Appropriate and Informed Use of
Psychotropic Medications With Children in
Department Custody

• Department Of Children and Families
• Presentation to
• Senate Children Families Committee
• January 11, 2005

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Ensuring Appropriate and Informed Use of
Psychotropic Medications With Children in
Department Custody

• Child Welfare Current Situation
• Mental Health Perspective
• Behavior Pharmacy Management Program
• University of Florida Perspective
• Current Strategies

3
Case Flow Process for Child Welfare Mental
Health Interface
3
4

• For children in DCF custody care, prevalence of
  SED is almost 3 times greater than the percentage
  of children on psychotropic medication

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Mental Health Philosophy and Perspective

• Issue is one of APPROPRIATE USE
• Individualized
• Monitored
• Informed
• With other treatments and social supports
• Clinical Decision

6
Proportion of Medicaid-Eligible Children in State
Custody Receiving at least One Psychotropic
Medication
Specific Classes of Psychotropic
Medications

• Stimulants
• Mood Stabilizers

• Sedative Hypnotics
• Other

• Antipsychotics
• Antidepressants

7
Proportion of Medicaid-Eligible Children in State
Custody Care Receiving at least One
Psychotropic Medication
8
The Medicaid Behavioral Health Pharmacy
Management Program
9
Mental Health Exemption

• No requirements for prior authorization or
  other restrictions on medications used to treat
  such illnesses as schizophrenia, severe
  depression or bipolar disorder may be imposed on
  Medicaid recipients
• Section 409.912(39)(a)(11), F.S.

10
Growth In Expenditures on Mental Health Drugs

• FY 00-01 237,648,098
• FY 01-02 323,232,592
• FY 02-03 439,031,148
• FY 03-04 520,529,637
• FY 04-05 680,000,000

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Decision of the 2004 Legislature

• Improve quality
• Increase the extent to which prescribing is based
  on best practices
• Improve patient adherence to medication plans
• Reduce clinical risks
• Lower prescribed drug costs and save 34 million

12
Organizational Arrangements
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Working with DCF

• ID children in the child protection system who
  are on mental health drugs
• Improve the quality of prescribing services
  delivered to these children

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How will we do this?

• Corrective Actions
• Define quality prescribing practices
• ID children receiving prescriptions that are
  inconsistent with these practices
• ID prescribers who are writing these scripts
• Take action to change the practices of these
  prescribers when this is appropriate
• Preventive Actions
• Develop or refine best practice guidelines when
  they are not fully developed or up to date
• Educate and generate sustained support for the
  use of guidelines in the system

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Use of Behavioral Medication for Florida
Children in State Custody

• ALL AGES
• September 1, 2004 through November 30, 2004
• 42,043 Children in State custody were Medicaid
  eligible
• 5,641 Received at least one behavioral drug
  (13)
• 2,074 Received an atypical antipsychotic (5)
• 44 Received 2 or more atypicals from 53
  different prescribers

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Frequency of Drug Classes Used by the 5,641
Medicaid Children in State Custody

• Any antipsychotics 37
• Any antidepressants 33
• Any stimulants 59
• Any ADHD non-stimulants 10
• Any sedative/hypnotics 7
• Children receiving 3 or more
• behavioral drugs concurrently 8

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Outlier Practices

• 5,641 Children with a behavioral drug
• 1,273 Children with quality questions
• Quality questions include
• On gt2 atypicals
• On gt2 stimulants
• On high dose of atypicals
• On more than 3 drugs concurrently

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New Actions to Improve Quality

• Monthly review of behavioral medications to
  Children in Custody
• Notice to prescriber when quality is inconsistent
  with best practice
• Monitoring of change and if necessary a
  peer-to-peer consultation with prescriber
• Initial letters sent in December 2004 to over 500
  prescribers seeing children
• Next contact by January 27, 2005

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Strategies to Prevent Problems (Prospective)

• Adoption of best practices guidelines through
  expert conferences
• Educational efforts targeted to prescribers,
  community mental health providers, consumers and
  family members, advocates and community leaders
• Educational strategies newsletters, regional
  leadership conferences, teleconferences, provider
  meetings, academic detailing, national conference
• Encouragement of consumer/family education on
  best practices

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Strategies to Prevent Quality Problems
(Concurrent)

• Identify prescribers who are significant
  providers of service to children in the child
  protection system.
• Equip them with Personal Data Assistants (PDAs)
• Access to all medication histories of the
  children they serve
• Up to date information about drugs, indicators,
  side effects, interactions
• Electronic prescription writing capacity
• Programmed quality edits
• Programmed medication guidelines
• Training and monitoring of PDA use

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Use of Psychotropic Medications Among Children in
State Custody

• Context of Practice
• Childrens Mental Health Issues (General)
• Mental Health Issues in Child Welfare Kids
• Information and Use of Psychotropic Medications
• Solutions
• Provide Clinical Rigor to the Legal Process of
  Informed Consent
• Make Expertise Accessible to Clinicians and
  Public at Large
• Focus attention on Childrens Mental Health

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Mental Disorders and Serious Emotional
Disturbances in Children

• High prevalence of undiagnosed and untreated
  serious emotional disturbances in children
• Children are extremely vulnerable to effects of
  emotional disturbances that can interfere with
  their development
• Early identification of emotional problems in
  children and their effective treatment is a very
  high priority
• Surgeon Generals Report, 2000
• Presidents New Freedom Commission Report, 2003

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Reasons for Greater Use of Psychotropic
Medications Among Child-Welfare Children

• Greater occurrence of Serious Emotional Disorders
• Family situation is not conducive to non
  pharmacologic treatment
• Children expelled from day care
• Behavioral treatment takes time and effort
• Psycho social treatments are not available or are
  not sufficient

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Our Assessment

• Met with providers, guardians, judges, and DCF
  administration in all of the districts in the
  State.
• Provided general education and saw need for
  continued consultation both local and state wide.
• Conducted several reviews
• Care is generally good but some significant
  outliers

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Improving Current Practice

• Educate the Prescriber
• Provide consultation to Prescriber
• STRENGTHEN INFORMED CONSENT PROCESS
• Educate the general public, case-workers,
  guardians, and judges

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Make Expertise Accessible to Prescribing
CliniciansCONSULTATION

• Develop state-level consultation network to
  provide expert guidance to local prescribers
• Consortium of Child Psychopharmacology Experts at
  District-level
• Medication consultation line for prescribers
• Formation of a State Center for Child
  Psychopharmacology at University of Florida

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Make Expertise Accessible to Prescribing
Clinicians- and Custodians CONSULTATION Experience

• University of Florida Medication Helpline
• Since January 2004 has provided consultation
  services via telephone appointments
• Most with guardian ad litem and child care
  workers
• Aid in formulating appropriate clinical questions

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Provide Good Information to the General Public

• Awareness Programs for Childrens Mental Health
• Public Media
• Schools
• Strengthen Screening Programs for emotional and
  mental disorders in children
• Develop single web-based repository of
  information for media, mental health
  professionals, and public on serious emotional
  disturbances in children

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Initiatives to Ensure Appropriate and Informed
Use of Psychotropic Medications With Children in
Departmental Custody

• Monitoring Practice Quality Assurance
• Strengthen Process of Informed Consent
• Defining and Implementing Practice Standards

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Monitor Practice Quality Assurance

• Apply Behavior Pharmacy Management System to
  child welfare settings
• HomeSafenet database being updated to add
  information about use of psychotropic medications
• Targeted reviews of child-welfare settings across
  state to assess appropriateness of current
  practices

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Strengthen Process of Informed Consent

• University of Florida Med-Consult Line
• Institute pre-informed consent review, prior to
  obtaining court authorization, for children under
  the age of five by March 15
• Handbook on Use of Psychotropic Medications in
  Children (2003, updated 12/04)
• Training program for new caseworkers and
  supervisors about use of psychotropics in
  children (Web-based Live)

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Define and Implement Practice Standards

• Adopt administrative rule on Behavioral Health
  Services for Children in Out-of-Home Care
• Target completion by April 15
• State expert panel to develop practice standards
• First meeting January 21-23, Tampa
• Regional Conferences to educate prescribers
• February 15 Tampa
• February 16 - Orlando

• February 17 Miami
• February 18 - Jacksonville