Psychotropic Medication Use Among Medicaid-Eligible Foster Children

In order to address DHS concerns surrounding the safety and efficacy of psychotropic medications prescribed to Medicaid-enrolled foster children, we asked PolicyLab to conduct an in-depth data analysis to identify trends and areas needing improvement in PA.

At both the state and federal levels, the prescribing of psychotropic medications to the foster care population has increasingly garnered critical attention over the past decade. Foster children in Pennsylvania enrolled in Medicaid are up to four times more likely to be prescribed psychotropic medications than other Pennsylvania children enrolled in Medicaid.

Over the last seven years, DHS was able to realize a 93.2 percent reduction in psychotropic medication use for children served through the Medicaid fee-for-service program administered by DHS. These decreases were achieved by requiring prior authorization from DHS prior to prescribing these powerful medications for children.  

With emerging themes identified from PolicyLab’s research and analysis, DHS and the Administrative Office of Pennsylvania Courts convened workgroups, including a Psychotropic Medication Subcommittee. The committee reviewed research findings, current policies, and procedures and developed recommendations regarding the appropriate use and monitoring of psychotropic medications for children in foster care. Click here to view recommendations.

In response to PolicyLab’s research and analysis, DHS and the Administrative Office of Pennsylvania Courts convened workgroups, including a Psychotropic Medication Subcommittee that offered a series of recommendations to DHS in June 2015.

DHS is taking the following additional steps to further reduce the use of psychotropic drugs among children
in the foster care system:

  • Implemented prior authorization for all physical-health managed care organizations (PH-MCOs). PH-MCOs serves nearly 98 percent of the children in the foster care system. DHS worked with all MCOs in the Medicaid system to implement consistent policies regarding the authorization and reauthorization of antipsychotic medications. The new prior authorization policies mirror the changes that proved to be a vital part of the policies that reduced the use of psychotropic drugs in the Medicaid fee-for service program by 93.2 percent over seven years. DHS will continue to monitor prescribing patterns of psychotropic medications by PH-MCOs every six months.
  • Developed best practice guidelines for primary care physicians and psychiatrists. Working in partnership with the Pennsylvania Chapter of the American Academy of Pediatrics and the Pennsylvania Psychiatric Society, DHS created best practice guidelines regarding comprehensive assessments of behavior and treatment interventions. The guidelines are as follows:
    • Guidance for Informed Consent for Children and Youth in CCYA Related to Psychotropic
      Medication Treatment
    • Guidelines for Psychotropic Medication Prescribing in Primary Care for Children and Adolescents
      in Foster Care
    • Psychotropic Medication Categories
    • Psychotropic Medication Resources

DHS also announced the following initiatives, which will be implemented in the next few months:

  • Creating a telephonic child psychiatric consultative service in April 2016. The new telephone hotline will assist prescribing physicians, physician assistants, and certified registered nurse practitioners to appropriately prescribe psychotropic medication for children. In August, the Department will add statistics about the use of the phone service to its electronic dashboard.
  • Deploying an electronic dashboard to improve care coordination for foster care children. The electronic dashboard will allow state and county child welfare officials to monitor progress in reducing the inappropriate use of anti-psychotic and psychotropic medications for foster children in out-of-home placements and ensure children’s medical needs are met. The electronic dashboard will be used to monitor the use of antipsychotics in children and adolescents and their associated physical and behavioral health care services.
  • Adopting a new psychotropic training module in July 2016. The Department is working with the University of Pittsburgh’s Child Welfare Resource Center to create a new training module regarding the appropriate use of psychotropic medication. When complete, the training will be offered to child welfare caseworkers, and birth, kinship, and foster parents.
     

Key Findings

  • For youth ages 6-18 years old in 2012, the use of psychotropic medications was nearly three times higher among youth in foster care than youth in Medicaid overall (prescribed at 43% versus 16%).
  • The use of antipsychotics was four times higher among youth in foster care (22%) than youth in Medicaid overall (5%). More than half of youth antipsychotic users in Medicaid had a diagnosis of ADHD. This is concerning, as the majority of these youth did not have another diagnosis that clinically indicated the use of antipsychotics, a medication class with significant side effects.
  • Polypharmacy, the use of multiple classes of medications in combination, occurred at a rate four times higher for youth in foster care than all youth in Medicaid (12% versus 3%).
  • Youth in foster care were more likely to have not received any visits within the year with a provider for their behavioral health concerns while on psychotropic medications.
     

Press Releases

DHS Resources

More Available Resources

The Department of Human Services Health Care Workgroup Subcommittee on Psychotropic Medication would like to ensure that stakeholders working with children and youth who are involved in the child welfare system are aware of available resources related to appropriate use and monitoring of psychotropic medication for children and youth in foster care.

  • The Administration for Children and Families (ACF) Children’s Bureau has released two guides on this topic. (1) Making Healthy Choices: A Guide on Psychotropic Medications for Youth in Foster Care and (2) Supporting Youth in Foster Care in Making Healthy Choices: A Guide for Caregivers and Caseworkers on Trauma, Treatment, and Psychotropic Medications.

    Making Healthy Choices: A Guide on Psychotropic Medications for Youth in Foster Care includes useful information, worksheets, and tips for empowering youth to understand their options and make healthy choices. The guide is available for free through the Child Welfare Information Gateway in English and Spanish.

A companion publication, Supporting Youth in Foster Care in Making Healthy Choices: A Guide for Caregivers and Caseworkers on Trauma, Treatment, and Psychotropic Medications, was released by ACF’s Children’s Bureau. This guide is intended to help caseworkers, foster parents, or other caring adults understand trauma and treatment and support youth in making decisions about their mental health and using Making Healthy Choices: A Guide on Psychotropic Medications for Youth in Foster Care. Free copies of Supporting Youth in Foster Care in Making Healthy Choices are available on the Child Welfare Information Gateway in English or Spanish.

  • The American Bar Association Center on Children and the Law Practice and Policy Brief issued a publication titled Psychotropic Medication and Children in Foster Care: Tips for Advocates and Judges. This publication addresses the role of medication in behavioral health treatment. The publication includes a list of psychotropic medications, their specific use, benefits, and side effects. Although the last section of the publication is titled “Questions that Judges and Attorneys Should Ask”, these questions can be used by caseworkers or caregivers when making decisions about appropriate medication use.
  • The National Institute of Mental Health issued the following guide titled Mental Health Medications. This guide provides information on the types of medications used to treat specific behavioral health diagnoses their side effects and the Food and Drug Administration approved age for consumption.
  • The Administrative Office of Pennsylvania Courts (AOPC), Office of Children and Families in the Courts, convened a workgroup to examine the use of psychotropic medication for children in foster care. The group created tools to assist counties in ensuring that foster children were receiving medication in the most appropriate manner. These tools include a Key Question card for use by dependency judges.
     

Questions to ask

The Workgroup also recommended that everyone involved in a dependent child’s life ask the following questions:

  • What is the child's diagnosis? Is it the correct diagnosis?
  • What is the medication's intended effect? Is it effective?
  • Are we monitoring for adverse effects?
  • If the child is doing well, have we thought about tapering the medication?
  • What is the opinion of the treating physician?
  • What treatment interventions are happening other than medication?