Transcript Presentation to the Texas CASA Chapter??

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
1
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.
2
Psychotropic Medication Monitoring in Texas Foster Care
Psychotropic Medication Parameters
• Current version dated December, 2010 of the Parameters,
earlier versions, and the 2006 report can be found at:
http://www.dfps.state.tx.us/Child_Protection/Medical_Servic
es/guide-psychotropic.asp
• These Parameters use eight criteria to indicate a need for
further review of the child’s medication regimen.
3
Psychotropic Medication Monitoring in Texas Foster Care
Criteria for Review of the Medication Regimen
1.
2.
3.
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
4
Psychotropic Medication Monitoring in Texas Foster Care
Review Criteria
(Continued)
4.
The prescribed psychotropic medication is not consistent with
appropriate care for the patient’s diagnosed mental disorder or with
documented target symptoms.
5.
Multiple psychotropic medications for a given mental disorder are
prescribed before utilizing a single medication.
6.
The psychotropic medication dose exceeds usually recommended
doses.
5
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
6
Psychotropic Medication Monitoring in Texas Foster Care
Use of Review Criteria with Data in Monitoring
•
Sources of data
–
–
–
–
•
Development of algorithms to sort claims data
–
–
•
Medicaid office visit claims for physician services for foster children
Pharmacy claims
The medical record
The Health Passport (since April, 2008)
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)
7
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
8
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
9
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
10
Psychotropic Medication Monitoring in Texas Foster Care
Psychotropic Medication Utilization
Review (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
11
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
12
Psychotropic Medication for Children in Texas Foster Care
Fiscal Years 2002-2011
Percentage of Children in Foster Care
35.0%
29.6%
30.0%
29.9%
28.0%
26.4%
25.0%
24.7%
25.0%
21.5%
21.2%
20.5%
20.0%
19.3%
36% Decrease
since 2004
15.0%
10.0%
5.0%
3.3%
0.7%
0.0%
4.0%
1.1%
68% Decrease
since 2004
5.0%
3.4%
1.4%
0.9%
2.5%
0.7%
2.5%
0.7%
2.0%
0.6%
1.8%
0.5%
1.8%
0.5%
1.6%
0.4%
FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011
Psychotropic Meds 60 days+
70% Decrease
since 2004
Class polypharmacy
Five or more Meds polypharmacy
13
Psychotropic Medication Monitoring in Texas Foster Care
Texas Foster Care SFY04 to SFY11:
Psychotropic Prescriptions Greater than 60 days by Drug Class
14
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)
15