Michael W. Naylor, M.D. University of Illinois at Chicago Director, Clinical Services in Psychopharmacology

Historical context –DCFS challenged by federal courts, DOJ and ACLU inadequate casework chaotic and dangerous placements substandard care –Illinois violating constitutional rights of children

Historical context –Chicago Tribune 1995 editorial series: DCFS called “the worst child welfare system in America…” and “a cruel, indifferent bureaucracy that harms kids.” “system of shame”

Historical context –Federal court-approved consent decree (B.H. v Suter, 1991) DCFS and ACLU agree to collaborate on system reform plan

Psychotropic medication consent –DCFS Rule 325 –Clinicians wishing to start a foster child on a psychotropic medication must obtain consent from the DCFS Guardian

DCFS Psychotropic Medication Consent Program –Two components: Centralized Psychotropic Medication Consent Line –Office of the DCFS Guardian Clinical Services in Psychopharmacology –University of Illinois at Chicago

Centralized Psychotropic Medication Consent Line –Office of the DCFS Guardian legal guardian for children committed to the Department responsible for providing consent for medical, surgical, and psychiatric treatment

Clinical Services in Psychopharmacology –provide independent review for all psychotropic medication requests –monitor utilization of psychotropic medications –provide consultation on particularly complicated cases

Clinical Services in Psychopharmacology –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

Prescribing Clinician UIC Research Team UIC Psychiatric Nurse UIC Psychiatric Consultant MD UIC Psychiatric Nurse DCFS Authorized Agent

–name –DCFS ID Number –date of birth –sex –race –weight and height –placement –physician’s name and specialty Demographic information

Clinical information –diagnosis –current medications and dosage –symptoms/rationale –requested medication dosage and frequency

Three main providers of consultation for clinicians treating foster children: –Clinical Services in Psychopharmacology –DocAssist –Consult for Kids

CSP ConsentOversightClinical Prior Authorization Systemic Monitoring/ QI

Consultation –consent process independent review of the appropriateness of the psychotropic medication consent request recommend action to DCFS –approve –deny –modify

Consultation –oversight formal –high risk prescribers –emergency medication utilization informal –feedback from Administrative Case Reviews –concerns expressed by caseworkers, regional nurses, guardian ad litem, Court Appointed Special Advocates, judges, Office of the DCFS Guardian

Consultation –clinical clinical concerns that arise in the course of the independent medication review MD:MD review of consent history chart review face-to-face

Consultation –prior authorization provided consultation to HFS vis-à-vis prior authorization for antipsychotic medications and stimulants for children DCFS consent for a medication serves as prior authorization for foster children

Consultation –systemic consult on development of policies, best practice guidelines re: mental health care for foster children co-write legislation

Consultation –monitoring/QI medication utilization patterns –rate of copharmacy with two or more antipsychotics –rate of polypharmacy by age group timeliness of consent process compliance with Rule 325

Illinois DocAssist –established through the joint efforts of the Department of Healthcare and Family Services, the Department of Human Services – Mental Health, and the University of Illinois at Chicago –funding support by the Illinois Children’s Mental Health Partnership

Illinois DocAssist –clinical quality of treatment for Medicaid funded children with mental illness in the primary care setting –client – Medicaid funded providers with a focus on primary care –purpose – improve the identification, diagnosis and treatment of children and youth with mental health issues through consultation, education and referral services

Consult for Kids Program –established by DCFS to provide primary care clinicians participating in HealthWorks with resources to evaluate foster children in their care for mental health and behavioral concerns

Consult for Kids Program –clinical address questions and concerns about a foster child’s emotional, interpersonal, behavioral or cognitive problems –client – primary care providers –purpose – help primary care providers navigate a challenging child through the child welfare system

Challenges to effective consultation –“silo-ization” duplication of services lack of coordination –informing stakeholders of the services –meeting demand for services

“The Curse of Unwelcome Oversight and Unrequested Consultation.”