1. 1 Informed Consent and Monitoring of Psychotropic Medications in Texas Kathy Teutsch, RN, LMSW-MSSW: CPS Division Administrator for Medical Services SHARED DECISION-MAKING PANEL

2. 2 Psychotropic Medication for Texas Foster Children History of Medical Consent and Monitoring of Psychotropic Medication In February 2005, released the Psychotropic Medication Utilization Parameters for Foster Children In September 2005, Senate Bill 6 (authored by Senator Jane Nelson) became effective implementing reforms for DFPS, including the development of a comprehensive health care system for children in foster care and specific requirements related to medical consent (Texas Family Code Chapter 266) In April 2008, STAR Health began for all Texas foster children and young adults

3. 3 Psychotropic Medication for Texas Foster Children Who Provides Informed Consent? Texas law requires court to authorize: –DFPS or an individual to consent to medical care for a child, or –A 16 or 17 year old youth to consent to their own medical care If DFPS is authorized (most cases), DFPS must designate an individual to consent and notify court: –Emergency shelter staff or live-in caregiver in home-like setting –DFPS staff in residential facility with shift staff –Other appropriate individual, such as a relative or birth parent When DFPS is authorized, DFPS also designates a back-up medical consenter

4. Psychotropic Medication for Texas Foster Children Responsibilities of Medical Consenter Complete training on informed consent Participate in each medical appointment of child Become knowledgeable of child’s medical condition and needs Consent to all medical care--each psych med and any change 4

5. Psychotropic Medication for Texas Foster Children Responsibilities of Medical Consenter Involve child in decisions about medical care Inform DFPS by the next business day of any psychotropic medications prescribed for a child Keep foster care agency and DFPS apprised of all medical care 5

6. Psychotropic Medication for Texas Foster Children Responsibilities of Foster Care Agencies* Ensure compliance with DFPS policies, rules and licensing requirements Provide pre-service and annual training on psych meds Ensure children have minimum of quarterly visits with prescriber to assess child’s progress and presence of side effects Ensure monitoring of child, documentation and contacts with prescriber about side effects or adverse reactions * Residential Child Care Licensing Minimum Standards were revised in 2007 to add heightened requirements for foster care providers concerning psychotropic medications : 6

7. Psychotropic Medication for Texas Foster Children Responsibilities of DFPS Act as “parent” and oversee all medical care If authorized to consent, designate medical consenter and monitor performance Provide written Summary of Medical Care at each court hearing (condition, diagnosis, symptoms, child’s progress, adverse reactions and side effects) Employ regional nurse consultants to support CPS staff 7

8. Psychotropic Medication for Texas Foster Children Responsibilities of DFPS Inform children about to turn 16 about option to petition court for right to consent to own medical care Offer training on Informed Consent to youth in Preparation for Adult Living Life Skills training Consult with other parties in the case about psych meds as needed (foster care agencies, birth parents, health care providers, attorneys, Court Appointed Special Advocates, etc.) 8

9. 9 Psychotropic Medication for Texas Foster Children Responsibilities of Judiciary Authorize a medical consenter for each child Provide opportunity for each child to express their views on medical care being provided Review Summary of Medical Care provided by DFPS at status, placement and permanency hearings Can issue orders related to medical care that in the child’s best interests

10. Psychotropic Medication for Texas Foster Children Responsibilities of STAR Health Credential and contract with providers for STAR Health network Answer general questions from judges Screen all children re: psych med use Telephonic health screenings when child enters foster care, changes placement or has significant changes in medical condition Automated pharmacy claims screening External requests—CPS nurse consultants. DFPS staff, foster parents, attorneys, foster care agencies, Court Appointed Special Advocates 10

11. Psychotropic Medication for Texas Foster Children Responsibilities of STAR Health Conduct Psychotropic Medication Utilization Review (PMUR) when: Telephonic health screening indicates outside Parameters Pharmacy fills psych med prescription for: –Any child under age 4 –2 or more meds in same class (3 or more mood stabilizers) –5 or more psych meds for more than 60 days Court requests review 11

12. Psychotropic Medication for Texas Foster Children Responsibilities of STAR Health Once PMUR triggered Gather information from caregiver and available documentation Submit information to child and adolescent psychiatrist for formal review: –Outreaches to prescriber –Issues a formal report with a finding Conduct Quality of Care review for prescribers with persistent prescribing patterns of concern Can require corrective action from prescribers or terminate them from network 12

13. Psychotropic Medication for Texas Foster Children Opportunities to Express Concerns Medical consenter/child/DFPS staff may talk to prescriber about concerns Interested parties may express concerns to DFPS Interested parties may request a PMUR through STAR Health Court hearings provide venues for child and interested parties to express concerns Youth may request court to authorize them as their own medical consenters 13

14. Psychotropic Medication for Texas Foster Children Challenges to This Approach Medical consenter reluctant to question physician Caregiver/medical consenter may be overwhelmed with multiple children and resort to psych med use as a means of control PMUR is a retrospective process after child taking psych meds Communication challenges between judiciary and medical community 14

15. Psychotropic Medication for Texas Foster Children What Works Well One health care network statewide Each child has medical consenter knowledgeable about their medical condition and needs Multi-tiered oversight and monitoring process with shared decision-making All children’s psych meds regimens are screened Processes for raising concerns Method to outreach to prescribers to enhance practices Reduction in psych med use of 36% between 2002 and 2011 15

16. 16 Psychotropic Medication for Texas Foster Children

17. Efforts to Improve Process Trauma Informed Care initiative to provide evidence-based non-pharmacological interventions as an alternative to psych meds Third-party review of Parameters to enhance Parameters Judge’s round-table to improve communication and processes Efforts to strengthen informed consent processes with training and written process 17