CHCS. Session Overview 3/7/2014
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1 CHCS Center for Health Care Strategies, Inc. Improving the cost-effectiveness of publicly financed health care Session Overview Using Data and Clinical Expertise to Improve the Monitoring and Use of Psychotropic Medications for Children in Foster Care Children s Mental Health Research and Policy Conference Tampa, Florida March 2-5, 2014 Kamala D. Allen, Center for Health Care Strategies Sheila A. Pires, Human Service Collaborative Christopher Bellonci, MD, Tufts Medical Center Deborah Lancaster, NJ Department of Children and Families Mike Naylor, MD, University of Illinois at Chicago Context Setting for psychotropic medication use in the foster care population Key Findings from 50-state Medicaid data analysis Quality Metrics states are monitoring to provide better oversight State Spotlights on Illinois and New Jersey s statewide efforts Question and Answer 2 1
2 Improving the quality and cost-effectiveness of publicly financed health care Landmark Federal Communication Context Setting Kamala D. Allen Director of Child Health Quality, CHCS The Department of Health and Human Services (HHS) has become increasingly concerned about the safe, appropriate, and effective use of psychotropic medications among children in foster care. -- November 23,
3 CHCS Child Health Quality Team s Mantra CHCS Project Highlights Use Data to Drive Quality Faces of Medicaid: Examining Children s Behavioral Health Service Utilization and Expenditures (Children s Faces) Psychotropic Medication Quality Improvement (QI) Collaborative 6-state QI Initiative Measure development Psychotropic Medication Quality Improvement Virtual Learning Community 5 6 3
4 Faces of Medicaid: Children s Behavioral Health Illuminates patterns of use and expense Behavioral health services Physical health services Special analyses: foster care, developmental disabilities, psychotropic medication Establishes baseline for monitoring trends over time Serves as national benchmark for individual state analyses Provides context for undertaking quality improvement initiatives Improving the quality and cost-effectiveness of publicly financed health care Key Findings: Examining Children's Behavioral Health Service Utilization and Expenditures Sheila A. Pires Partner, Human Service Collaborative Senior Program Consultant, CHCS 7 4
5 Children s Faces Study Design Data source: 2005 Medicaid Analytic extract (MAX) personlevel data from all states were used for demographics and eligibility analyses Fee-for-service (FFS) claims and managed care encounters were used to capture utilization Mean expense/per child, for physical and behavioral health services, was based on FFS claims data (available on 60% of the study population) Total behavioral health expenditures represented children in FFS and children in managed care with non-ffs dollars imputed from FFS expense data Populations Identified in Children s Faces Children using any behavioral health care = 9.3% penetration 9 SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December
6 Children in Medicaid: Behavioral Health Penetration and Total Expense Children in Medicaid Using Behavioral Health Care Are an Expensive Population SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December
7 Highest Expenditure Services for Children in Medicaid Using Behavioral Health Services Children in Foster Care are a High-Cost Medicaid Population Represent 3.2% of children in Medicaid, but 15% of children using behavioral health services 32% of children in foster care use behavioral health services, compared to 26% of children on SSI, and 4.9% TANF Mean behavioral health expenditure is $8,094 per child in foster care, compared to $7,264 for children on SSI Have overall (physical and behavioral health care) mean expenditure of $12,130 per child costs are driven by behavioral health care Children in foster care who use behavioral health services have costs that are 7x higher than for Medicaid children in general SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December
8 Medicaid Behavioral Health Spending Per Enrollee* Children in Foster Care Use More Restrictive, More Expensive Services in Medicaid More likely to use: Inpatient psychiatric services Residential treatment/therapeutic group care Emergency room services Psychotropic medications Children in foster care were only one-fifth the size of the TANF population, but: Represented nearly the same amount of dollars for residential and group care and emergency room visits Represented 3.5 times more of the dollars for therapeutic foster care SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December
9 Distribution of Psychiatric Diagnoses among Children in Medicaid Diagnosis % N ADHD 54.9% 654,863 Mood 26.2% 312,642 Anxiety 22.7% 270,721 COD 22.8% 272,288 DD 5.8% 69,541 Psychosis 4.3% 51,323 Other DX 1.4% 16,259 No Dx 766,325 Notes: 1) N s are not unduplicated counts (children may have more than one diagnosis); overall, only 60% of children with BH care had a diagnosis 2) Percentages are among children with at least one psychiatric diagnosis Distribution of Psychotropic Medication Type by Psychiatric Diagnosis ADHD Mood Anxiety COD DD Psychosis Other DX No DX Antipsychotics 24.6% 60.9% 41.0% 51.6% 63.5% 81.1% 53.6% 28.5% Mood Stabilizers 6.3% 23.3% 11.1% 15.6% 13.1% 21.7% 12.9% 8.0% Lithium 1.4% 8.0% 3.3% 4.1% 3.2% 8.6% 4.9% 1.3% Antidepressants 23.0% 62.9% 67.2% 42.1% 40.5% 52.1% 51.5% 49.4% ADHD/ stimulants 93.3% 48.0% 47.0% 65.3% 54.9% 42.8% 55.8% 49.4% Anxiety 1.8% 5.1% 9.1% 4.0% 9.4% 7.0% 6.5% 6.4% N = 1,686,387 (Medicaid enrolled children in 2005 with claims for psychotropic medication) SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December
10 Children in Foster Care Have High Rates of Psychotropic Medication Use 23% of children in foster care are prescribed psychotropic medications vs. SSI (27%) and TANF (4%) Children in foster care are more likely to receive 2 or more concurrent psychotropic medications than any other aid category (49%) vs. SSI (46%) and TANF (26%) Among children receiving anti-psychotics, 42% are in foster care Children in foster care represent 13% of all children prescribed psychotropic medication (but only 3% of all children in Medicaid) Patterns of Psychotropic Medication Use by Age and Aid Category Patterns of Psychotropic Medication Use by Age and Aid Category among Children in Medicaid, 2005* Age Range Medication Type** Overall Age 0-5 Age 6-12 Age TANF Aid Category Foster Care SSI/Disabled Antipsychotics 26.3% 22.7% 22.5% 30.9% 18.1% 42.1% 42.4% Anticonvulsants/Mood Stabilizers 8.1% 6.2% 5.8% 10.9% 5.9% 12.1% 12.8% Lithium 1.8% 0.3% 1.0% 2.9% 1.1% 3.5% 3.2% Anti-depressants 34.7% 15.1% 22.3% 50.6% 33.1% 43.5% 34.3% ADHD Medications 69.3% 64.4% 84.0% 53.4% 70.4% 68.0% 66.6% Anxiety Medications 6.0% 16.0% 3.9% 7.3% 5.5% 3.5% 8.9% *N = 1,686,387. Convenience sample of all enrollees with psychotropic claims; continuous enrollment not required. ** Do not sum to 100% since children may take multiple medications. 19 SOURCE: S. Pires, K. Grimes, et al. Identifying Opportunities to Improve Children s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, December
11 Medicaid Expenditure for Children Receiving Psychotropic Medication Total Medicaid expense for child and adolescent psychotropic medication use in 2005 was $1.6 billion With 42% of expense represented by antipsychotic use Mean expense by aid category $934 per child, in foster care $916 per child, for those with SSI $475 per child, for children covered by TANF $85 million spent in 2005 on psychotropic medications for children with no psychiatric diagnosis Questions?
12 Children in Foster Care: How are states responding to their behavioral health needs? Specialized care management approaches Managed care carve-outs Specialty provider networks Special protocol for oversight and monitoring complex and high-cost services Collaboration and data sharing among Medicaid, child welfare and behavioral health agencies Psychotropic Medication Quality Improvement Collaborative (PMQIC) Six state teams (IL, NJ, NY, OR, RI, VT) Three-year system change initiative PMQIC Data Subgroup QI project planning and impact measurement Technical assistance (TA) Monthly TA calls Monthly TA e-newsletter Bi-monthly webinars SharePoint resource center 23 Project funded by the Annie E. Casey Foundation 24 12
13 Improving the quality and cost-effectiveness of publicly financed health care Data Definitions and Common Measures in Support of Psychotropic Medication Oversight and Monitoring Christopher Bellonci, MD Associate Professor, Tufts University Clinical Consultant, CHCS Best Practices Comprehensive and coordinated screening, assessment, and treatment planning mechanisms to identify children s mental health and trauma-treatment needs Informed and shared decision-making and methods for on-going communication Effective medication monitoring at both the client and agency level Availability of mental health expertise and consultation regarding both consent and monitoring issues Mechanisms for accessing and sharing accurate and up-to-date information and educational materials related to mental health and trauma-related interventions 26 13
14 PMQIC Data Subgroup PMQIC Data Definitions Comprised of representatives from each of the six participating states (IL, NJ, NY, OR, RI, VT) Goal: Identify and agree upon common definitions and measures that each state could implement to address the inappropriate use of psychotropic medications Foster youth: children placed away from their parents or guardians in 24-hour substitute care and for whom the state agency has placement and care responsibility (federal definition) Young children: all children under age 6 (5 years and 364 days old) Consent: defined by individual state laws or regulations (if they exist)
15 PMQIC Data Definitions cont. Psychotropic medications: medications being used for an emotional or behavioral condition Medications automatically assumed to be for a psychiatric indication and included in this definition: Antipsychotics Stimulants Antidepressants Benzodiazepines Anti-anxiety medications (incl. Buspar) Mood stabilizers (e.g., Lithium) PMQIC Data Definitions cont. Medications used for a psychiatric purpose, but not typically classified as psychiatric medication, require cross-referencing with their diagnosis in the Medicaid system; includes: Alpha-agonists (e.g., Clonidine and Guanfacine and their long-term analogs); use of these medications for hypertension in children is so rare that it could be assumed they are being used for a behavior indication Anti-convulsants, if absence of a seizure disorder diagnosis, then assumed for mood stabilization
16 PMQIC Data Definitions cont. Dosage Guidelines Polypharmacy: children taking more than one psychiatric medication or more than one medication within the same class (e.g., 2+ more antipsychotic medications) or co-pharmacy Child would need to be taking the medications simultaneously for 90+ days to be considered poly- or co-pharmacy FDA approval for use in a pediatric population Multiple indications in youth No FDA indication for the pediatric population Use the associated/extrapolated dose for children under 13 years and those 13 to 18 as the Physicians Desk Reference suggests Use the maximum dose for the psychiatric indication (PDR) Use the guidelines proposed by the Texas report regarding the care of children in foster care* No FDA indication or guidance from the Texas report Use dosing parameters set forth in Appendix 1 of Pediatric Psychopharmacology: Principles and Practice (Editors Andres Martin, Lawrence Scahill, Dennis S. Charney, and James F. Leckman Oxford University Press, 2003) None of the above sources set forth any guidance Use the adult PDR maximum 31 ercareparameters-december2010.pdf 32 16
17 Baseline Measures for Metabolic Monitoring Minimum Metabolic Monitoring Protocol for Second Generations Antipsychotics (SGAs) Baseline measures for monitoring second generation antipsychotics (SGAs) following the ADA/APA adult consensus guidelines Exception: lipids checked annually, rather than every five years States can set their own protocols requiring more frequent measures, but this list = minimum standard States may monitor other meds metabolic or other labs (i.e., Valproic acid, Lithium, etc.) can define themselves Personal and family history Waist circumference Weight and BMI Blood pressure Fasting plasma glucose Fasting lipid profile Baseline and annually Baseline and annually Baseline, every 4 weeks up to 12 weeks, and then quarterly Baseline, 12 weeks and annually Baseline, 12 weeks and annually Baseline, 12 weeks and annually
18
19 Common Measures Data gathered at baseline, and over the course of the 3-year initiative, will measure the percentage of children in foster care: On any psychotropic medication On specific classes of medications (e.g., antidepressants, stimulants, mood stabilizers, antianxietals) On more than 1 medication from the same class (co-pharmacy) On 2, 3, and 4+ psychotropic medications < 6 years old on any psychotropic medication < 6 years old on 2, 3, and 4+ psychotropic medications <6 years old on antipsychotics Common Measures cont. Will also measure: Implementation of evidence-based or promising interventions for sleep disorders and/or aggression Development of an informed consent process or increased adherence to the state s informed consent process
20 Improving the quality and cost-effectiveness of publicly financed health care Questions? Using Clinical Expertise to Inform the Medication Consent Process Deborah Lancaster NJ Department of Children and Families Mike Naylor, MD University of Illinois, Chicago
21 Types of Consent Agency Consent Models Terminology Informed consent: Responsibility conferred onto the provider to ensure that guardians of patients and youth themselves understand the medications prescribed Agency consent: Responsibility conferred onto the child welfare agency to act as the parent and in the best interest of the child States medication consent policies vary in how they define and operationalize consent processes for children in foster care Some states utilize medical expertise to review and inform consent decisions Centralized internal consent review Decentralized internal consent review (e.g., NJ) Centralized external consent review (e.g., IL) Decentralized consent review Centralized external consent review
22 Department of Children and Families The New Jersey Child Health Unit: Psychotropic Medication Oversight and Monitoring New Jersey Department of Children and Families Commissioner Debra Lancaster Director, Child Health Unit NJ Department of Children and Families Division of Children s System of Care (formerly DCBHS) Division of Child Protection & Permanency (formerly DYFS) Division of Family & Community Partnerships (formerly DPCP) Division on Women Office of Adolescent Services
23 Well Being: DCF Child Health Values Access Continuity Child/Family Centered Quality Integration Partnership Structure of the Child Health Units 46 Child Health Units across the state Staffed with nurses, nurse practitioner s and staff assistants 50/50 state/federal match through Medicaid administrative claiming
24 Role of the Child Health Units Access to health care Timely follow-up A healthcare plan is developed specific to the child s health needs Coordination of healthcare services Executing agencies and services to ensure effective and frequent communication between: CP&P Child Health Program Resource Families Birth Families Child/Adolescent 47 Mental Health Screening Follow Up Care Semi-Annual Dental EPSDTs: 25+ months EPSDTs: months Comprehensive Medical Exams (30 PrePlacement Assessments Child Health Indicators for Children in Out-of-Home Placement July 1, March 31, % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 85% 85% 95% 93% 93% 48 99% 99% 24
25 Mental Health Ongoing mental health screening Refer for mental health assessment if indicated Ensure receipt of mental health services if indicated Monitoring services Monitoring psychotropic medication utilization and policy compliance Policy Development Process Reviewed American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Child Welfare League of America Guidelines Reviewed other states policies Convened an internal workgroup Developed policy components Convened a Psychotropic Medication Advisory Group Issued policy in January
26 Key Policy Components Psychiatric evaluation Authorized prescribers Treatment plan Informed consent Medication guidelines Safety monitoring guidelines Prescribing parameters Informed Consent Must address risks and benefits of pharmacological treatment Consultation with Child Health Unit RN Requires the informed consent of the child/youth s parent Local Office Manager consents when parents cannot
27 Monitoring and Oversight Requires written informed consent On-going health monitoring by Child Health Unit Nurse Quarterly review Case consultation at any time for any child/youth with full time clinical team Quarterly Review Review the number and percentage of: Children/youth (0-21) prescribed psychotropics Psychotropics prescribed per child/youth (1, 2, 3, 4, 5+) Children/youth by age group (0-5; 6-10, 11-17, 18+) Children/youth with uncomplicated ADHD Various types of prescribers Psychotropics with a consent (any & up to-date) Children/youth with a treatment plan (any & up to-date) Children/youth with a psychiatric evaluation (any & up to-date) Children/youth receiving non-pharmacological interventions Conduct Quality Assurance review on children ages 0-5 and children/youth prescribed 4+ meds Analyze data based on set of common measures established through the Center for Health Care Strategies PMQIC
28 Questions? Michael W. Naylor, M.D. University of Illinois at Chicago Director, Clinical Services in Psychopharmacology
29 Source US GAO CHCS Research Funding Advisor/ Consultant x Employee Speakers Bureau Books, Intellectual Property In-kind Services (Example: travel) x Stock or Equity Honorarium or expenses for presentation Honorarium or expenses for this presentation or meeting Administration of psychotropic medications to children for whom DCFS is legally responsible
30 Challenge Provide informed consent Provide safe and effective care Delivered in timely manner Protect rights of foster children Provide longitudinal oversight Two components Centralized Psychotropic Medication Consent Line DCFS Authorized Agent Clinical Services in Psychopharmacology University of Illinois at Chicago
31 Concept DCFS is the legal guardian for ~ 15,300 youth The Office of the Guardian is responsible for providing consent for medical and psychiatric treatment Objectives: Provide independent review for all psychotropic medication requests Monitor utilization of psychotropic medications Provide consultation on particularly complicated cases
32 Objectives: 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 Screening, evaluation and treatment planning Shared decision-making Medication monitoring Mental health expertise & consultation Information sharing
33 Screening, Evaluation and Treatment Planning Integrated Assessment Revised DCFS Rule 325 Guidelines for the Utilization of Psychotropic Medications for Children in Foster Care
34 The prescription of psychotropic medications is just one component of a comprehensive treatment plan that includes psychosocial and behavioral interventions All children must receive a diagnostic assessment prior to starting a psychotropic medication Consent
35 Prescribing Clinician DCFS Authorized Agent UIC Psychiatric Nurse Univ. of IL Chicago (UIC) Research Team UIC Psychiatric Nurse Consultant recommendations: Approved Denied Modified Reviewed (emergency medications only) UIC Psychiatric Consultant MD
36 Oversight Procedure
37 Informal oversight Feeds back through the Office of the Guardian or to the CSP program Administrative Case Reviews GAL, Office of the Public Guardian Regional nurse Formal oversight Case-specific Independent medication review Watch list high risk children Record review
38 Formal oversight System-wide CSP consent database (1998 present) Medicaid payment database ( ) Watch list high risk prescribers Emergency medication use
39 Formal oversight (cont.) System-wide Quarterly reports Timeliness» Error rates Medications without consent Denials Formal oversight System-wide Quarterly reports Children < 4 years Polypharmacy Co-pharmacy High-risk preschoolers Weekly reports Emergency medications
40
41 Consultation Consultations Clinician requested Caseworker Regional nurse Guardian Guardian ad Litem, judges CSP requested
42 Consultations MD: MD Review of consent history Chart review Face to face Information Sharing
43 Information sharing Clinical Medication history Educational Foster parents Care providers, authorized agents Caseworkers Post-adoption workers Information sharing DCFS Prescribers Listserv FDA warnings Policy changes Website Clinicians Foster parents, care providers Educational materials Clinical resources
44 % Requests Paroxetine Warning CSP Intervention Black Box Warning Paroxetine Fluoxetine Other SSRIs Projects Months
45
46 The CSP can: Assess statewide diagnostic patterns Monitor rate of utilization of psychotropic medications Identify adverse effects of medications Implement evidence-informed consent strategies Assess impact of changes in consent strategies on prescriber behaviors
47 Psychotropic Medication Quality Improvement Virtual Learning Community (PMVLC) All 44 states not included in PMQIC are represented Extension of the PMQIC work Technical assistance Monthly technical assistance e-newsletter Bi-monthly webinars SharePoint resource center Contact Information Kamala Allen Sheila Pires Christopher Bellonci Mike Naylor Deborah Lancaster - debra.lancaster@dcf.state.nj.us Visit for all resources related to the six-state quality improvement initiative to reduce inappropriate prescribing of psychotropic medications to children in foster care. Project funded with support from the Annie E. Casey Foundation
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