Transcript CHCS Core Slides

CHCS
Center for
Health Care Strategies, Inc.
Improving the cost-effectiveness of publicly financed health care
Psychotropic Medication Use and
Management for Children in Foster Care
Kamala D. Allen
Vice President and Director, Child Health Quality
Because Minds Matter: Collaborating to Strengthen
Psychotropic Medication Management for
Children and Youth in Foster Care
August 27-28, 2012
Washington, DC
www.chcs.org
Overview of the Session
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Organizational Background
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A Focus on Psychotropic Medication Use in
Children in Foster Care
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What we Know about the States’ Efforts:
A snapshot based on 26 States
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The CHCS Quality Improvement
Collaborative: A Model for Improvement
CHCS Mission
To improve health care quality for low-income children
and adults, people with chronic illnesses and disabilities,
frail elders, and racially and ethnically diverse
populations experiencing disparities in care.
• Our Priorities
Enhancing Access to and Coverage of Services
► Improving Quality and Reducing Racial and Ethnic Disparities
► Integrating Care for People with Complex and Special Needs
► Building Medicaid Leadership and Capacity
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Premise for our Child Welfare Work
• Children in child welfare - specifically those in
foster care - have significantly high rates of
physical, behavioral and oral health needs.
• Children in foster care likely have legitimately
higher rates of need, and consequently, use
of behavioral health services.
• Foster children are at high risk for the
negative consequences of poor access and
uncoordinated care.
• Children in foster care require a tailored
approach to care delivery involving all system
partners.
Psychotropic Medication: Federal
Focus and Legislative Opportunities
• ACF’s April 2012 Information Memorandum
• Child and Family Services Improvement and Innovation Act
(2011)
• Joint Dear State Officials Letter to Medicaid, Child Welfare,
and Behavioral Health Directors (2011)
• Fostering Connections Act (2008)
• Patient Protection and Affordable Care Act (2010)
• Child Health Insurance Program Reauthorization Act (2009)
Problem is multi-faceted
• Lack of non-pharmacological interventions
• Lack of behavioral health specialists
• Use of medications to control difficult behaviors
• Lack of knowledge regarding appropriate use of
psychotropics among child welfare case workers
• Lack of coordination across providers and between
child-serving systems
• Financial incentives to prescribe
• Aggressive/effective pharmaceutical marketing
• Need for “quick fixes”
What do the Data Say?
Faces of Medicaid: Child Behavioral Health Utilization
and Expenditure Study, 2012
• 2005 MAX data (Medicaid Claims) for 29 million children and
youth in Medicaid
• 2.8M children received behavioral health care (services and
psychotropic medication) = 9.6% penetration rate
Source: Pires, Grimes, Allen, Gilmer, Mahadevan, Forthcoming
2012
What do the Data Say?
• Special Analyses on Children in Foster Care
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Represent 3.2 percent of children in Medicaid
Represent 12.6 percent of children in Medicaid receiving
psychotropic medication
Represent 15 percent of children in Medicaid receiving
behavioral health services
32% of children in foster care receive behavioral health services
23% of children in foster care receive psychotropic medication
39.3% of children in foster care received behavioral health care
(services and/or psychotropic meds)
Account for 28.6% of Medicaid child behavioral health exp.
Mean expenditures: $4,036 (PH), $8,094 (BH), Total: $12,130
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What do the Data Say?
• Of children in Medicaid prescribed psychotropic medications,
children in foster care:
► Were prescribed psychotropic medication at a rate 4 times their
representation in Medicaid (TANF children at 2/3 their
representation
► Had Medicaid expenditures for behavioral health services 7
times that of the overall Medicaid child population
• Of children who received psychotropic medications, we see
concerning patterns:
► 42% of children in foster care (and SSI) were prescribed
antipsychotics versus 18% of TANF children
► 19% of children in foster care were on 3 or more psychotropic
medications within the year versus 10% of the overall Medicaid
child population
What do the Data Say?
• Special Analyses on Psychotropic Medication Use
► 1.7M (5.8%) of all children in Medicaid (2005) received
psychotropic medications with or without another Medicaidcovered behavioral health or physical health service.
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Only 50 percent of the 1.7 million children on psychotropic
medications also received identifiable behavioral health
services.
Among children who used behavioral health services,
psychotropic medication was among the top three categories
of service use for children in Foster Care, those in SSI, and
children with developmental disabilities.
How Will We Impact the Use of
Psychotropic Medications
among Children in Foster Care?
National Initiative on Psychotropics
in Foster Care
• Improving the Use of Psychotropic Medications
among Children in Foster Care Quality Improvement
Collaborative (PMQIC)
- 3-year initiative funded by the Annie E. Casey
Foundation
- 32 letters of interest; 26 applications
- Multi-state effort
» Illinois
» New York
» Oregon
» Vermont
» New Jersey » Rhode Island**
** Casey Special Interest Site
Highlights of Existing Models
• CONSENT
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Centralized review and consent process
Partnership with academic research center
• OVERSIGHT (at prescriber level)
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Provider profiling
Second opinions
Prior authorizations/Preferred drug lists
• MONITORING (at child level)
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Quarterly reports
Targeted interventions
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Consent,
Oversight,
Monitoring
IL
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NJ
X
NY
X
OR
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RI
X
VT
X
EBP/
Approp Use
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Practice
Change
Reform
Data
Quality
Framework
State
PMQIC State Efforts
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Why use a State collaborative approach to
improve psychotropic medication use?
• State child welfare agencies are responsible for the
safety and well-being of children in foster care.
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Specific requirements re: psychotropic medications
• Most children in foster care are Medicaid-eligible, and
Medicaid pays for their psychotropic medications.
• States have successes to build upon and peer exchange
is fostered to facilitate spread.
• CHCS has a quality improvement collaborative model
that has been effective in reducing inappropriate
psychotropic medication use among children in child
welfare.
Case Study: Child Welfare Quality
Improvement Collaborative
Three-year quality improvement initiative
focused on improving three aspects of health
care for children involved in child welfare:
• Access to Care
- Connecticut Behavioral Health Partnership
- Magellan Behavioral Health of Florida
- Mid Rogue Health Plan
- Priority Partners Managed Care
Organization
- UPMC for You
• Coordination of Care
- Volunteer State Health Plan
- Wraparound Milwaukee
• Appropriate use of Psychotropic Medications
- CareOregon
- Massachusetts Behavioral Health
Partnership
Overview of Plans’ CW Initiatives
Participating
MCO
Project Goal
Impact
Connecticut Behavioral
Health Partnership
Improve access and reduce waiting times for
needed behavioral health services for children
entering the child welfare system.
• 60% increase in the number of children with BH
needs who received services within 60 days.
• Decreased average time to an appointment for
behavioral health services from 22.5 days to 6.5
days (71% improvement).
Magellan Florida
Prevent kinship placement disruption due to
behavioral health problems with the support of
Kinship Navigators.
• Maintained kinship placements for 100% of kinship
caregivers of children with BH needs.
Massachusetts
Behavioral Health
Partnership
Address outlier psychotropic provider prescribing
patterns and simplify medication regimes for
children who have been stable for at least six
months.
• Reduced psychotropic polypharmacy among 84% of
targeted DCF youth eligible for medication
simplification within a pilot site provider practice.
Mid Rogue
Provide and coordinate health assessments to
support medical homes for children newly placed
in out-of-home care.
• Established a medical home for 88% of children
entering foster care.
Overview of Plans’ CW Initiatives
Participating
MCO
Project Goal
Impact
UPMC for You
Develop and send electronic health records to
Allegheny County child welfare workers for all
children in foster care. Improve rates of annual well
child visits, annual preventive dental visits; and
access to behavioral health services for children new
to foster care by 10% over baseline.
• Increased well-child visit rate among children
entering foster care from 53% to 78.5%.
• Increased annual dental visit rate for children
entering foster care from 60% to 75%.
• Created and provided to county CYF an
electronic Health Record for 100% of children
entering foster care.
Volunteer State
Health Plan
Increase provider use of electronic health records
and review of the clinical health records of newly
placed foster care children prior to the initial medical
exam.
• Increased the rate at which children’s clinical
health records were reviewed by a provider from
a baseline of 27% of children to 52% of children.
Wraparound
Milwaukee
Ensure that all CW-involved members who are on
three or more psychotropic medications (PMs) and
have not seen their PCP within the last year make
and keep an appointment with their PCP.
• Decreased number of children on three or more
PMs who had not seen their PCP within past year
from 19% to 12%, and those on two or more PMs
who had not seen PCP within past year from 35%
to 19%.
Questions we will seek to answer…
• Can the data currently being collected
inform targeting of improvement strategies?
• Can data be shared more effectively among
Medicaid, child welfare and behavioral
health agencies?
• Can provider practices be modified to reflect
peer guidelines for prescribing psychotropics
to children and youth?
• Can consent, oversight and monitoring
policies and practices be coordinated and
strengthened within child welfare and
Medicaid systems?
Questions we will seek to answer…
• Can families and youth be more effectively
engaged in care planning to avoid
unnecessary use of psychotropics?
• Can financial incentives be changed to
encourage the use of non-pharmacological
interventions?
• Can we help states more effectively monitor
and intervene to reduce inappropriate
prescribing among children in foster care?
What about all of the other states?
• Learning Community of States supported by
Substance Abuse and Mental Health Services
Administration (SAMHSA) in partnership with the
Administration for Children and Families (ACF)
• “Low touch” technical assistance to other 44 states
► Quarterly how-to webinars
► Dissemination of resources developed under
PMQIC
► Fostering sharing of resources, effective practices
and “lessons learned” among states
• Coordination with other national initiatives on reducing
inappropriate psychotropic medication use as they
emerge
What do we Know?
Lessons from a 26-State Sample
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States’ Profile
• Foster care census across the states ranged from just
under 1,000 to nearly 58,000 children/youth.
• Most states have state-administered/locally-operated
child welfare systems.
• Most states are enrolling children in foster care in
Medicaid managed care.
• Most states were not effectively leveraging the data
available through Medicaid claims systems.
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Consent Process
• 7 states have no consent policy for psychotropic
medication for children in foster care.
• Among states with a policy, there are varying
approaches to consent.
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Parent/Guardian
Child Welfare Guardian
Child Welfare Caseworker or Supervisor
Child Welfare Health Unit
Centralized Consent Unit
Judicial/Juvenile Court Officer
• Existence of youth assent policies was less clear.
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Cross-Agency Collaboration
• Several states have interagency agreements in
place to allow for the exchange/integration of
data between/among agencies.
• Some states use Medicaid prior authorization
and/or preferred drug list mechanisms to control
access to certain classes of psychotropics or for
specific populations.
• A number of states have psychiatric consultation
lines to provide support to primary care
providers.
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Data Capacity
• Just under half of the 26 states are able to monitor
psychotropic medications at the child level.
• All states recognize ability to get critical information from
Medicaid claims data and follow post-permanency assuming
continued Medicaid eligibility.
• Several states are currently utilizing Medicaid claims data to
monitor concerning prescribing trends.
• Many SACWIS states have augmented their data systems
with robust health components, though many do not contain
medication or prescriber data.
• Some states rely on case workers to enter medical
information; others, health professionals.
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Provider Engagement
• All states recognized the importance of engaging
prescribers.
• A few states focus particularly on key role played by
inpatient psychiatric hospitals, residential and group care
providers; more focus on primary care providers.
• Strategies ranged from individual outreach to identify
physician champions to engagement of professional
societies.
• Provider detailing education and training are common
models proposed for facilitating changes in prescribing
patterns.
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Youth and Family Engagement
• Most states were aware of foster care alumni
organizations, but were not actively partnering.
• Most states were aware of foster parent associations,
with which they seemed to be more active.
• Many states have task forces and/or standing
committees looking at psychotropic medication use that
include foster care alumni.
• Many states acknowledged that the involvement of birth
families is challenging.
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Availability of Psychosocial Alternatives
• Most states identified the lack of psychosocial therapies as a
cause of potential over-reliance among prescribers on
psychotropics.
• The lack of specialists and individuals trained to deliver
psychosocial therapies also cited as a challenge.
• Access in rural areas of particular concern.
• Few states had clear strategies to increase the availability of
alternatives to psychotropics, but should consider importance of:
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Medicaid and behavioral health financing
Adoption of evidence-based practices and evidence-informed
approaches
Provision of trauma-informed assessments
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In summary…
• There is tremendous variation across the states
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Rates of Use
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Approaches to Oversight and Monitoring
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Infrastructure
 Data capacity/availability
 Human Resources
 Professional Resources
• Cross-agency collaboration is critical
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In summary…
• States need to:
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Leverage and build on what exists
Engage providers to adopt practice guidelines
Engage youth and families, meaningfully
Pursue technical assistance offerings
Understand that there is no one-size-fits-all solution
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Recommendations: REAL Collaboration
• Child Welfare Agencies
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Create a consent policy.
Look at the data, regularly.
Partner to provide access to broader range of services and supports.
Ensure case workers have roles that they are trained to effectively
carry out.
• Medicaid Agencies
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Partner to provide data related to use and expense.
Reimburse trauma-informed approaches.
• Behavioral Health Agencies
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Be at the table with data related to use and expense.
Partner to provide access to broader range of services and supports.
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Recommendations: Leverage
• Existing mandates
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Federal and State legislation and regulations
Agency policies and guidance
• Existing infrastructure
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Data Systems
Human resources
Financial resources
Standing committees
Community-based organizations
Provider associations
Memoranda of Understanding among agencies
Contractual arrangements (e.g. with MCOs/BHOs and/or
provider networks.)
Contact Information
Kamala D. Allen
Director, Child Health Quality
[email protected]
www.chcs.org
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