Transcript Risk Assessment - Paltech - Planning and Learning

Consent for
Psychotropic
Medication
Connecticut’s Model for Children
and Youth in Foster Care
Lesley Siegel, MD
Chief of Psychiatry
CT Dept. of Children and Families
CT Department of Children and
Families (DCF):
A Multi-Mandate Agency
Abuse/Neglect
Mental Health
Juvenile
Justice
Foster
Care/Adoption
State-Wide Advisory
Committee began in 1999
O Psychotropic Medication Advisory Committee
(PMAC) meets monthly
O Members include private and public APRNs,
Child Psychiatrists, Pharmacists, Pediatricians,
Medicaid Agency Representatives, Parents
O Initially set-up by former DCF Chief of Psychiatry,
Dr. Pat Leebens
O Reviews “Best Practice” for evaluation and
treatment of foster care children and youth,
including all aspects of evidence-informed care
CT adapts Illinois Model
OFormer Chief of Psychiatry, Dr. Pat Leebens,
worked with Dr. Mike Naylor (from U of Illinois)
on AACAP Practice Standards for Prescribing in
Foster Care Population
OUsed Illinois state/university partnership when
proposing CT informed consent model and new
legislation
OGiven small size of state and multi-mandate
child welfare agency, decision made to develop
unit within DCF for consultations/consent
instead of partnership with a university
Connecticut Law passed 2004
Sec. 17a-21a. Guidelines for use and management of
psychotropic medications. Database established. The
Department of Children and Families shall, within available
resources and with the assistance of The University of
Connecticut Health Center, (1) establish guidelines for the use
and management of psychotropic medications with children and
youths in the care of the Department of Children and Families,
and (2) establish and maintain a database to track the use of
psychotropic medications with children and youths committed to
the care of the Department of Children and Families.
(P.A. 04-238, S. 2; P.A. 06-196, S. 112.)
Centralized Medication
Consent Unit (CMCU)
Chief of
Psychiatry
Child
Psychiatrist(s)
Advanced
Practice
Nurse(s)
Support Staff
Stakeholders in
Informed Consent
Youth
Worker
Foster
Family
PCP
CMCU
CT Guidelines for
Consent/Assent
Guardian
Consent
Required
under age
18
Patient
Assent:
Required by
age 14; Best
practice age
9 and over
Shared Decision-Making
O Shared decision-making is a description of the
process that should be happening regarding
psychotropic medication prescribing and has been
associated with better outcomes due to increased
youth and other stakeholder involvement and
compliance.
O Components include agreement with what is being
prescribed, knowledge about side effects and
necessary monitoring, and alternatives to
medication.
O Similar principles to team decision making which
child welfare staff in CT and many other states are
currently being trained on.
9
Consent Procedure
Prescriber completes 465
and emails or faxes it to
CMCU
Prescription filled
CMCU enters information in
SACWIS and emails worker,
regional nurse, and regional
clinical manager of details
CMCU Child Psychiatrist or
APRN reviews information,
checks SACWIS (electronic
data base) for past
prescribing info
**If after review request is
considered appropriate,
consent is given and
emailed/faxed to provider
Consent Decisions Based On:
Legal Status
Verified
Form
relatively
complete
Baseline
Monitoring
Done
Meds fit
Diagnosis
Consent Decisions, cont.
Med on
Approved
List
Dosing
appropriate
Number of
psych meds
overall
Generally only
one
antipsychotic
Other factors informing
decision:
O Past psychiatric history available in
O
O
O
O
LINK(SACWIS)
Child’s setting (PRNs and more than one change
at once might be approved for hospitals)
History with prescriber
Other ongoing treatment, especially traumainformed modalities
Over-arching goal of least number of meds longterm
Consent Process Practice Changes
2007-2010
2011/2012
•More likely to give consent
if within core guidelines
(approved med at approved
dose)
•More dialogue with
prescribers
•More discussion of traumainformed treatment
approaches
•Consents “modified” by
CMCU increased from 5% to
29%
Quarterly Consent Data
CMCU Website
O Readily available on CT DCF home page and
user-friendly, with frequent updates.
O Link to the website on all CMCU members’
electronic signatures.
O Information about meds, prescribing doses,
monitoring protocols, risk in pregnancy, links
to NIMH and NYU information on all
psychotropic medications, handbook written
for families and DCF workers by PMAC, etc.
17
18
18
Pros and Cons of Centralized
Process
O Pros: Standardized system; quick turn-
around; providers are happy; Medical team
enters note directly in LINK; Medical team
aware of need for medical information prior
to starting med; doses; monitoring.
Centralized unit can review past
psychotropic med history easily as available
in LINK notes since CMCU began in 2007.
19
Pros and Cons, cont.
O Cons: Area office CPS staff feel disconnected
from process; may have information from the
foster family or the child/adolescent that is
different from what the prescriber is told; may
feel they don’t have the authority or access to
question the APRN/Physician. Also, area office
staff may feel they can’t alter or undo the
official CMCU consent.
O Children/Youth may feel they don’t have a voice
in the process, may feel they have no choice
about taking prescribed medication.
20
“Crisis of Credibility”
O Training developed to address “crisis of
credibility” between CPS workers and
prescribers; includes Diane Sawyer’s 20/20
segment with foster children describing their
experiences on psychotropic medication.
O Purpose is to increase collaboration so that CPS
workers don’t feel prescribers just “overmedicate” foster kids and prescribers don’t feel
that child welfare is “black hole” of information
(i.e. multiple requirements to produce
documents with no information given out).
Next Steps
Complete
psychotropic med
training for all case
workers
Train Foster
Families
Develop training in
Spanish
Link trauma
treatment data with
medication data
Analyze data by
race/ethnicity
Consent data 2011
23
Examples:
Consent
Process
• 15 year old adolescent girl
newly admitted to a psych
hospital
• 8 year old boy in a foster
home
• 17 ½ year old boy in a
residential treatment setting
Questions?
Lesley Siegel, MD
DCF Chief of Psychiatry, State of Connecticut
[email protected]
860-560-5020 (w); 203-530-0351(c)
www.ct.gov/dcf/