1. QI Initiatives for Psychotropic Use in Foster Youth in Maine Lindsey Tweed MD MPH Office of Child & Family Services; Maine DHHS Lindsey.Tweed@Maine.gov

2. Sixteen State Collaborative Antipsychotic Study This study occurred before the more recent focus on all psychotropics in foster youth Focus was on all Medicaid beneficiaries; not just foster youth Data analysis covered 2004-2007

3. 16 State Antipsychotic Study: Part II Rate for of antipsychotic use for all MaineCare members 0-18: 3.1 % Rate for MaineCare members 12-18 varied between 5 and 6% Maine was above the median Rate for foster youth: 20% Nobody knows what the rates should be; but these seemed high

4. Rationale for More Intense Focus on Antipsychotics Although psychotropics should never be used inappropriately, stimulants and antidepressants are relatively safe Medically important side effects are very common with antipsychotics Majority of psychotropic side effect burden would seem to be due to antipsychotics Other less prevalent meds that commonly have medically important side effects…

5. Handling Antipsychotic Outliers More than one; high dose; very young Pharmacy benefit manager had implemented Prior Authorization process; mainly as a cost saving tool PA requirement added for two AP’s or for doses over FDA approved PA for AP use in children under 5 later added; requires a chart review

6. Reaction to Initial Prior Authorization Requirements PA approved by committee including community psychiatrists Still, there was a very strong reaction against the PA M.D. at benefit manager: We should have had a conference, other means of input and education, before implementing. We may now be in a different era

7. But Non-Outliers Are Majority of the Problem Most AP prescription is to youth 5 and over; one antipsychotic; and at FDA approved doses These youth commonly/usually experience medically important side effects The majority of foster youth side effect burden would appear to come from non- outlier use of AP’s

8. Goals and Members of AP Use in Foster Youth Workgroup Goal: Ensure that Foster Youth are prescribed antipsychotics only when clinically indicated Members: Foster Youth, Foster Parents, Residential Treatment Providers, Child Psychiatrists, DHHS We began in September 2009 and met for about one year

9. Strategies Chosen Strengthen teen consent process –Tool developed to empower youth Strengthen caseworker consent process; be the best parent you can Worksheet for caseworkers

10. Worksheet for Caseworkers/Supervisors Use in psychosis and for Bipolar Disorder Use for aggression as a target symptom In context of Autism Spectrum In context of Disruptive Behavior Disorders (CD, ADHD with aggression) Maximize good casework Maximize psychosocial interventions –EBT’s Maximize treatment of primary disorders (e.g., ADHD, depression) with safer meds

11. Worksheet (cont.) Monitoring therapeutic effects Monitoring side effects –Ask specifically about weight, BMI, BMI percentile, glucose and lipids When aggression is target symptom, and when youth has done well for 6 months, expectation is to taper All good med decisions are risk vs benefit

12. Additional Strategies Additional Support for Caseworkers –By clinicians who work within OCFS Education on Guidelines: Youth, Caseworkers, Prescribers, Foster Parents, Residential Providers Monitoring Our Progress –Both via MACWIS and via MaineCare claims –Proportion of youth on each category of med; by district, supervisor, caseworker –How to measure if process followed?

13. AP Use Rate 0-18 Years Minimum one month MaineCare eligibility Year% of AP Users 20043.1% 20053.1% 20063.2% 20073.1% 20083.1% 20093.0% 20102.8% 20112.6% Maine DRAFT 8/8/2012

14. Foster/Non-Foster AP Use Rate 0-18 Years One month MaineCare eligibility virtually all atypical anti-psychotics AP Use Demographics YearFoster Care Non- Foster 200410.9%3.0% 20059.2%3.0% 20068.5%3.0% 20079.5%3.0% 200817.2%2.8% 200916.8%2.7% 201016.7%2.5% 201114.6%2.4% DRAFT 8/8/2012

15. Recent Initiatives for All MaineCare Members Legislator introduced a bill to regulate AP prescription in youth –Compromise was a DHHS report –Similar stakeholder group made similar recs for all prescribers –Method for monitoring agencies’ QI being devised New PA: required monitoring of metabolic side effects within first 20 weeks of use

16. Role of Evidence Based Treatments Most youth started on AP’s have significant mental health symptoms EBT’s have not been widely disseminated Overuse of AP’s may be a logical consequence of non-dissemination of EBT’s Significant prevalence of disruptive behavior, anxiety, depression, and post- traumatic stress in foster youth