1. OVERVIEW OF STATE APPROACHES TO OVERSIGHT AND MONITORING OF PSYCHOTROPIC MEDICATIONS Joyce Pfennig, Ph.D. Kate Stepleton, MSW

2. Annual Progress and Services Reports (APSRs) Since 1994, agencies receiving funding from title IV-B have been required to submit Child and Family Services Plans (CFSPs) to the Children’s Bureau (HHS) The CFSP is a five-year strategic plan that sets forth the vision and goals to be accomplished to strengthen each agency’s overall child welfare system The APSR provides annual updates on progress made towards accomplishing the goals and objectives of the CFSP

3. Child and Family Services Improvement and Innovation Act of 2011

4. Required Components of Psychotropic Oversight and Monitoring Plan Comprehensive and coordinated screening, assessment, and treatment planning Mechanisms to identify children’s mental health and trauma-treatment needs Including a psychiatric evaluation, as necessary, to identify needs for psychotropic medication Program Instruction ACYF-CB-PI-12-05: http://www.acf.hhs.gov/programs/cb/laws_policies/policy/pi/2012/pi1205.pdf

5. Required Components of Psychotropic Oversight and Monitoring Plan Informed and shared decision-making (consent and assent) Methods for ongoing communication between the prescriber, the child, his/her caregivers, other healthcare providers, the child welfare worker, and other key stakeholders

6. Required Components of Psychotropic Oversight and Monitoring Plan Effective medication monitoring both the client and agency level

7. Required Components of Psychotropic Oversight and Monitoring Plan Availability of mental health expertise and consultation regarding: Both consent and monitoring issues by a board-certified or board-eligible Child and Adolescent Psychiatrist (at both the agency and individual case level)

8. Required Components of Psychotropic Oversight and Monitoring Plan Mechanisms for sharing accurate and up-to-date information related to psychotropics to clinicians, child welfare staff, and consumers This should include both data sharing mechanisms (e.g., integrated information systems) and methods for sharing educational materials

9. Synthesis of State Plans

10. Caveats APSRs may not be fully reflective of policies and procedures that are in place Other information may be found in CFSP Health Care Services Plan or elsewhere in APSR Five components are not always distinct (e.g., overlap between ensuring informed consent and information sharing)

11. Screening, Assessment and Treatment

12. Informed and Shared Decision-Making

13. Medication Monitoring

14. Mental Health Expertise and Consultation

15. Mechanisms for Sharing Accurate and Up-To-Date Information

16. Common Approaches and Innovative Ideas

17. General Observations  There is significant variation in approaches across States  States describe a mix of current and proposed approaches  States rarely addressed both client- AND agency- level protocols  Few States described procedures related to ALL FIVE components  Widespread adoption of AACAP guidelines

18. Screening, Assessment and Treatment  Many States are using EPSDT as screening and assessment mechanism  Several States ensure that a trauma-informed assessment is completed  At entry  Within 30 days of placement  Within 45 days of placement  Integration with other screening and assessment activities  Innovative: Use of telemedicine – required initial screening completed over the phone using validated screening tools

19. Informed Consent and Shared Decision- Making  Approaches emphasized assent as well as consent – youth involvement in decision-making  Several States give birth parent decision-making authority until parental rights have been terminated  Some States describe protocols for contesting decisions

20. Medication Monitoring  Mix of retrospective and prospective approaches  Many States are using red flags to trigger reviews  Prescription of antipsychotic to child under 6  Prescription of 2 or more antipsychotics for more than 60 days  Many States use Drug Utilization Review (DUR) Programs to monitor psychotropic medication use  Feedback reports to providers to address prescribing that does not align with best practices  Direct links between SACWIS and Medicaid information system facilitate monitoring

21. Mental Health Expertise and Consultation  Innovative: Trauma consultation in complex cases  Trauma specialist as part of review team for consultation in cases where multiple medication changes have not resulted in improvements in symptoms  Trauma-informed technical assistance hotlines for providers  Innovative: Creative solutions to deal with shortage areas (provider consultation lines)

22. Mechanisms for Sharing Accurate and Up-To-Date Information  Several States described use of medical passports or use of electronic health records that incorporate behavioral health  Use of interagency linkages – such as MOUs for the development of shared records  Tools to ensure informed consent  Guide and tools for youth  Resources for foster parents  Trainings for caseworkers