U.S. Department of Health and Human Services Office of Inspector General Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication OEI-07-15-00380 OEI-00-00-00000 Month 201Y2018 September Daniel R. Levinson Inspector General oig.hhs.gov Report in Brief U.S. Department of Health and Human Services September 2018 OEI-07-15-00380 Office of Inspector General Treatment Planning and Medication Monitoring Why OIG Did This Review Were Lacking for Children in Foster Care Up to 80 percent of children enter foster care with significant mental Receiving Psychotropic Medication health needs. For children with What OIG Found mental health needs, psychotropic In five States, one in three children in foster care who Key Takeaway medications (i.e., medication used were treated with psychotropic medications did not The five States we to treat clinical psychiatric receive treatment planning or medication monitoring as reviewed partially symptoms or mental disorders required by States. Additionally, the Administration for complied with their own such as depression, bipolar Children and Families (ACF) has suggested that States State requirements for disorder, and schizophrenia) may consider practice guidelines from professional treatment planning and be effective treatments. However, organizations, including the American Academy of Child medication monitoring for these medications can have serious and Adolescent Psychiatry, (AACAP) related to treatment children in foster care side effects and, as ACF suggests planning and medication monitoring. We found that receiving psychotropic and the five States in our sample State requirements for oversight of psychotropic medication. Improved require, should be used in medication did not always incorporate these professional conjunction with treatment compliance and stronger practice guidelines. planning mechanisms and effective State requirements will medication monitoring. Treatment planning is critical to enhancing continuity of help protect children who care; improving coordination of services between health are at risk for A 2015 OIG report found—based and child welfare professionals; and reducing the risk of inappropriate treatment on review of medical records— harmful side effects. Effective medication monitoring and inappropriate serious quality-of-care concerns in can reduce the risk of inappropriate dosing and prescribing practices. the treatment of children with inappropriate medication combinations. psychotropic medications. How OIG Did This Review We selected a sample of 625 children in foster care from the 5 States that had the highest utilization of psychotropic medications in their foster care populations. On the basis of foster care case file documentation and What OIG Recommends Medicaid claims data, we To ensure coordinated care for children in foster care who receive psychotropic determined the extent to which the medications, we recommend that ACF develop a comprehensive strategy to children in our sample were improve States’ compliance with requirements related to treatment planning and treated with psychotropic medication monitoring for psychotropic medications. ACF should assist States in medications in a manner consistent strengthening their requirements for oversight of psychotropic medications by with their respective States’ incorporating suggested professional practice guidelines for monitoring children requirements. Additionally, we at the individual level. ACF stated that it concurred with some of our compared the five States’ recommendations but not others; it did not specify which of the two formal requirements for psychotropic recommendations it agreed with, and which it did not. OIG continues to medication oversight with recommend additional action by ACF as actions to date have not led to the treatment planning and medication needed outcomes. monitoring practice guidelines from the American Academy of Full report can be found at oig.hhs.gov/oei/reports/oei-07-15-00380.asp Child and Adolescent Psychiatry. TABLE OF CONTENTS BACKGROUND 1 Objectives 1 Methodology 4 FINDINGS 6 One in three children in foster care who were treated with psychotropic medications did not 6 receive required treatment planning or medication monitoring State requirements for psychotropic medication oversight did not always incorporate 9 suggested professional practice guidelines for treatment planning and medication monitoring CONCLUSION AND RECOMMENDATIONS 12 Develop a comprehensive strategy to improve States’ compliance with requirements related to 12 treatment planning and medication monitoring for psychotropic medication Assist States in strengthening their requirements for oversight of psychotropic medication by 13 incorporating professional practice guidelines for monitoring children at the individual level Agency Comments and Office of Inspector General Response 14 APPENDICES A: Five Required Elements for Monitoring the Appropriate Use of Psychotropic Medications 16 B: Detailed Methodology 17 C: State-by-State Compliance With Psychotropic Medication Requirements 20 D: Statistical Estimates and Confidence Intervals 26 E: State Demographics Regarding Children in Foster Care Treated With Psychotropic 30 Medications F: Agency Comments 33 ACKNOWLEDGMENTS 35 ENDNOTES 37 BACKGROUND Objectives For the five States with the highest percentages of children in foster care treated with psychotropic medications: 1. to assess the extent to which children in foster care who were treated with psychotropic medications received treatment planning and medication monitoring consistent with States’ requirements; and 2. to assess the extent to which States incorporate suggested professional practice guidelines for treatment planning and medication monitoring into their requirements for treatment of children with psychotropic medications. In 2012, nearly 30 percent of the 400,000 children in foster care in the United States were taking at least one psychotropic medication.1 Psychotropic medications are often used to treat clinical psychiatric symptoms or mental health disorders such as depression, bipolar disorder, schizophrenia, attention deficit/hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and anxiety disorders.2, 3 Psychotropic medications can be effective treatments for children who have mental health needs, including children in foster care.4 However, these medications can have serious side effects, such as drowsiness, weight gain, nausea, headaches, involuntary movements, and tremors, among others.5 There is limited research to guide the use of psychotropic medications in children.6 Therefore, psychotropic medications are to be used with care and as part of a comprehensive treatment plan.7 Many factors related to foster care can complicate efforts to provide appropriate mental health treatment. Up to 80 percent of children in foster care enter State custody with significant mental health needs.8 Unlike children from intact families, children in foster care often do not have a consistent interested party to coordinate treatment planning or to provide continuous oversight of their mental health treatment.9 Further, responsibility for children in foster care is shared among multiple people— foster parents, birth parents, and caseworkers—which creates risk of miscommunication, conflict, and lack of followup.10 Children in foster care may also experience multiple changes in placement and in physicians, which can cause health information about these children to be incomplete and spread across many sources.11 Therefore, children in foster care may be at risk for inappropriate prescribing practices (e.g., too many medications, incorrect dosage, incorrect duration, incorrect indications for use, or inappropriate treatment).12 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 1 OEI-07-15-00380 Effective ongoing oversight of children’s care and monitoring of prescribing patterns has several potential benefits, such as enhanced continuity of care, increased placement stability, reduced need for psychiatric hospitalization, and decreased incidence of adverse drug reactions and dangerous drug-to-drug interactions.13 Ineffective monitoring may increase the risk for inappropriate dosing, frequent medication switches, or the use of inappropriate medication combinations.14 For example, if a prescriber is unaware that medications are not being taken as ordered, the prescriber may conclude that the existing medication regimen is inadequate and increase a dose or add another medication.15 A March 2015 Office of Inspector General (OIG) report found that children enrolled in Medicaid—including children in foster care—experienced quality-of-care issues related to their treatment with antipsychotic medications, which are a type of psychotropic medication. Two of the common quality-of-care issues that we identified through reviewing medical records were related to treatment and monitoring.16 Medicaid pays for a majority of the healthcare services that children in foster care receive, including psychotropic medications.17 In 2013, State Medicaid programs paid approximately $366 million for psychotropic medications for nearly 240,000 children in foster care up to age 21.18 The Administration for Children and Families’ (ACF) Oversight of State Foster Care Program Requirements ACF is responsible for awarding Federal funding to States’ child welfare programs and for overseeing those programs. ACF Requirements for State Plans. ACF requires the State agency that administers the State’s child welfare program to submit a State plan every 5 years, which outlines how it will comply with Federal requirements. As part of its State plan submission, each State must include a healthcare coordination and oversight plan. The State child welfare agency develops this plan with the State Medicaid agency, pediatricians, other healthcare experts, child welfare service experts, and recipients of these services. The plan addresses the oversight of prescription medicines, including requirements for monitoring the appropriate use of psychotropic medications.19, 20 The plan must address five elements (listed in Appendix A).21 Annually, ACF requires each State child welfare agency to describe in its Annual Progress and Service Report its protocols (official procedures used to accomplish the State plan) related to each of the five elements and provide additional information on how the child welfare workforce and providers are trained with regard to these requirements.22 Hereinafter, we refer to State agency as State and protocols as State requirements. As noted earlier, previous OIG work has identified (through review of medical records) issues with children receiving inappropriate treatment and monitoring. Two of the five elements ACF requires to be part of a State’s Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 2 OEI-07-15-00380 plan include: (1) screening, assessment, and treatment planning mechanisms to identify children’s mental health needs and trauma-treatment needs, including a psychiatric evaluation, as necessary, to identify whether children need psychotropic medications; and (2) effective medication monitoring at both the client level and agency level.23 Client-level monitoring—in this case, child-level monitoring—refers to monitoring an individual who receives medication. Child-level monitoring can include practices such as employing nurses to ensure that individual children receive necessary services or requiring review of individual prescriptions.24 Agency-level monitoring—in this case, State-level monitoring—refers to activities that support and inform decisions for all clients of an agency. State-level monitoring could involve a State’s monitoring the rate at which children in foster care receive psychotropic medication, monitoring the types of psychotropic medications children receive, or establishing an advisory committee to oversee its medication formulary.25 ACF Oversight of State Compliance. ACF oversight includes periodic reviews of each State’s child welfare system, known as Child and Family Services Reviews, to assess whether a State complies with its State plan requirements.26 In this report, we refer to these reviews as compliance reviews. ACF determines compliance (i.e., substantial conformity) based on a number of factors, including the State’s ability to meet criteria related to outcomes for children and families.27 In making its assessment, ACF uses a compliance review instrument that assesses particular criteria and makes a determination based on the entirety of the review. If ACF finds that a State is not in substantial conformity with its State plan, it requires that the State develop a program improvement plan.28, 29 If the State fails to successfully complete a program improvement plan, ACF has the authority to withhold a certain amount of Federal funding.30 The mental/behavioral health section of the compliance review instrument includes an assessment of needs, and services that the State provided to meet those needs, for a sample of children in foster care. The instrument includes criteria such as (1) ensuring the child was seen regularly by the physician to monitor the effectiveness of medication, assess side effects, and consider any changes needed in dosage; (2) regularly following up with foster parents/caregivers about administering medications appropriately and outcomes and side effects.31 Guidance on Oversight of Psychotropic Medications for Children in Foster Care ACF’s instruction to States regarding development of requirements related to screening, assessment, treatment planning, and effective medication monitoring is broad. For example, ACF has not established requirements defining the periodicity of the screening, the assessment tools that should be used, or the details that should be included in the treatment plan. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 3 OEI-07-15-00380 ACF has suggested that States consider practice guidelines from professional organizations related to treatment planning and medication monitoring in efforts to improve their monitoring and oversight requirements of psychotropic medications. These organizations include the American Academy of Child and Adolescent Psychiatry (AACAP), the American Academy of Pediatrics, and prescription parameters developed by the State of Texas, which detail mechanisms that may be used to accomplish the broad requirements.32 ACF highlighted the AACAP guidelines as particularly relevant to States when developing their psychotropic medication oversight and monitoring requirements. However, ACF instruction acknowledges that States are unique and does not mandate States to incorporate professional practice guidelines in their requirements. Professional practice guidelines highlight the importance of treatment planning and medication monitoring for children prescribed psychotropic medications.33 Treatment planning should include collaboration among caregivers to discuss symptoms, behaviors, and potential benefits and side effects of treatment options.34 This allows all parties to understand why medication is being used and the plan for followup.35 Medication monitoring visits should occur regularly to enhance patient and guardian confidence in the treatment, and to promote effective management of longer term treatment and safety issues.36 Specifically, medication monitoring enables prescribing professionals, patients, and guardians to establish a plan for followup and reduce the risk for an unidentified relapse or recurrence of symptoms.37 Methodology Scope For five States, we determined whether children in foster care were treated with psychotropic medications consistent with their States’ requirements related to: (1) screening, assessment, and treatment planning mechanisms, including (as necessary) psychiatric evaluations; and (2) medication monitoring. This study focuses on these two elements because of the quality-of-care concerns that we identified in previous OIG work. We also determined the extent to which these State requirements were consistent with suggested professional practice guidelines focused on treatment of children with psychotropic medications. In the States we reviewed, requirements related to screening and assessment applied only to children entering foster care. There was not a significant number of sampled children who entered foster care during the review period. Therefore, we were not able to project results related to screening and assessment requirements in the study. Further, according to the States’ requirements, psychiatric evaluations are required only “as necessary,” or “if recommended.” Because case files did not consistently document the need for psychiatric evaluation, we could not Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 4 OEI-07-15-00380 assess compliance with this conditional requirement. Therefore, we were not able to project results related to psychiatric evaluation requirements. State and Sample Selection We selected the five States with the highest percentages of children in foster care who were treated with psychotropic medications in FY 2013, the most recent year for which there was complete data available in the Medicaid Statistical Information System (MSIS).38 They were Iowa, Maine, New Hampshire, North Dakota, and Virginia. We combined foster care eligibility data and Medicaid claims data obtained from the five States to determine the population of children in foster care treated with psychotropic medication during the review period, October 1, 2014, through March 31, 2015. From that population, we selected a simple random sample of 125 children from each of the 5 States, for a total of 625 children. We excluded 36 children for various reasons, such as the child’s not having been in foster care for a sufficient time (see Appendix B). Collection and analysis of documentation and data. For each child in our sample, we requested documentation from foster care case files and Medicaid claims data representing services received during the review period. We determined whether any services represented evidence that a required element—screening, assessment, treatment planning, psychiatric evaluation, and/or medication monitoring—occurred. For each instance of a requirement that the State appeared to have not met, we invited the State to provide additional evidence. Comparing States’ Requirements to Practice Guidelines Recommended by AACAP ACF suggested States consider professional practice guidelines for improving their monitoring and oversight of psychotropic medications.39 We selected professional practice guidelines from AACAP guidance documents for comparison with the five States’ requirements for oversight regarding psychotropic medication.40 See Appendix B for a detailed description of our methodology. Limitations Our estimates cannot be generalized beyond the five selected States. It is possible that some children in our sample received healthcare services that were not paid for by Medicaid or were not included in the data submitted; therefore, this study may have underestimated the provision of required health services for these children.41 Standards This study was conducted in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 5 OEI-07-15-00380 FINDINGS One in three Thirty-four percent of children in foster care who were treated with psychotropic medications, in the five States we reviewed, did not receive children in foster either treatment planning or medication monitoring (see Exhibit 1). Eight care who were percent of these children received neither treatment planning nor treated with medication monitoring. Treatment planning and effective medication psychotropic monitoring are imperative because of the risks of inappropriate treatment and inappropriate prescribing practices (e.g., too many medications, medications did not incorrect dosage, incorrect duration, incorrect indications for use). See receive required Appendix C for more information regarding States’ compliance with each treatment planning requirement we reviewed. or medication Exhibit 1: One in three children in foster care who were treated with monitoring psychotropic medications did not receive required treatment planning or medication monitoring See Appendix D for all point estimates and corresponding 95-percent confidence intervals. Twenty percent of children in foster care did not receive treatment planning In the five States reviewed, 20 percent of children did not receive treatment planning, as States required. Effective treatment planning provides a mechanism for caseworkers, foster parents, and prescribers to be aware of medications the child is receiving. For children in foster care, effective treatment planning is critical to enhancing continuity of care, improving coordination of services between health and child welfare professionals, and reducing the risk of harmful side effects. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 6 OEI-07-15-00380 In the following example, there was no evidence that a treatment plan was developed before starting the medication of a child in foster care. However, the child did receive a retrospective review of the four psychotropic medications prescribed. This review indicated concerns regarding the medical necessity of the child’s drug regimen that should have been considered and documented in a treatment plan. Without a treatment plan, there is no evidence that the child’s caregivers understood important concerns before medicating this child, such as (1) the rationale for each medication, (2) the potential benefits and side effects of each medication, and (3) the plan for followup. Child Description—6-year-old child diagnosed with ADHD, behavior disorder, learning disability, tic disorder, dysarthria (speech disorder), oppositional defiant disorder, PTSD, trichotillomania (hair-pulling disorder). Prescribed four psychotropic medications. Case Narrative—The State-employed nurse coordinator noted her opinion that the medications “were quite a bit for a child of his age,” and initiated a referral for a medication review. The medication review indicated that the psychiatrist reviewer had questions regarding two of the four medications prescribed to this child. He acknowledged that current medication use could have been within the standard of care. However, there were questions concerning the following: (1) medical necessity for one of the medications; (2) side effects of one medication that could be exacerbating one of the child’s conditions; and (3) a dosage increase in one medication that could have negated the need for the fourth medication. The medical review resulted in correspondence with the prescribing professional regarding the medical necessity for two of the child’s four medications. Subsequent to this review, the child’s drug regimen was changed. In three of five States, over half of the children who received treatment planning did not have a complete treatment plan. Three of the five States have specific criteria for treatment plans. In those States, 52 percent of children who received treatment planning had plans that did not meet all State criteria. See Appendix C for each of the States’ specific criteria for treatment plans, as well as the percentage of children for whom treatment plans did not meet all State-required criteria. Examples of State criteria for treatment plans in those three States include documentation of: diagnoses, assessment summaries, interventions, treatment progress, information about prescribed medications, and evidence of collaboration by a multidisciplinary team. Including these criteria in treatment plans helps caregivers to understand why medication is being used and the plan for followup. Further, treatment planning provides a mechanism for caregivers Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 7 OEI-07-15-00380 to collaborate to assess target symptoms, behaviors, potential benefits, and adverse effects of treatment. Twenty-three percent of children in foster care did not receive medication monitoring In the five states we reviewed, 23 percent of children did not receive medication monitoring during the review period. Effective medication monitoring can reduce the risk of inappropriate dosing or inappropriate combinations of medications. For example, if a prescriber is unaware that medications are not provided as planned, the prescriber may unknowingly increase a dose or add another medication. Medication monitoring is essential for children in foster care to promote communication among prescribing professionals, patients, and guardians, and to establish a plan for followup. Further, medication monitoring can reduce the risk for an unidentified recurrence of symptoms and promote effective management of longer term treatment and safety issues. States acknowledged challenges in providing required services related to oversight of psychotropic medication for children in foster care In the five States we reviewed, officials reported challenges in State plan implementation that can pose barriers to providing required services for children in foster care. These challenges included a lack of data for measuring outcomes and limited access to mental health services. Additionally, States noted that some gaps in meeting their requirements are related to transitions in the case-management workforce, developing effective accountability measures for caseworkers, and appropriate training for new caseworkers. Officials reported a need for additional guidance and technical assistance from ACF related to oversight of psychotropic medications prescribed to children in foster care. States proposed some guidance and assistance that would be helpful to mitigate barriers to providing required services, including:  national data for States to use as benchmarks in measuring their progress toward meeting the requirements;  successful policy and practice strategies that have been used by other States to meet requirements; and  assistance in improving communication between Medicaid and child welfare systems to facilitate the tracking of services provided to children in foster care and measure progress in meeting requirements. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 8 OEI-07-15-00380 State requirements In the five States we reviewed, State requirements did not always incorporate professional practice guidelines regarding oversight of for psychotropic psychotropic medications for children in foster care, as suggested by ACF. medication Although ACF requires State plans to protect children by including oversight did not treatment planning mechanisms and effective medication monitoring, it always incorporate allows States flexibility in implementation. ACF suggests that States consider practice guidelines from professional organizations, including suggested AACAP, to improve their treatment planning and medication monitoring professional requirements. practice guidelines The five States' requirements did not consistently incorporate for treatment professional practice guidelines for child-level monitoring planning and Our review of five States found that State requirements did not always medication incorporate these recommendations related to child-level treatment monitoring planning and medication monitoring (see Exhibit 2). For example, none of the five States we reviewed included requirements to document medication dosages or potential adverse effects of medications within children’s foster care case files. Exhibit 2: States’ requirements did not consistently incorporate elements of suggested professional practice guidelines for child-level oversight of psychotropic medication Among five States, number that included suggested case file documentation requirements for child-level monitoring of psychotropic medications: Specifically, State child-level requirements did not include elements such as information on potential adverse effects or assessment of risk for nonadherence to the treatment plan. These elements provide essential information to accomplish effective oversight, to monitor prescribing, and Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 9 OEI-07-15-00380 to enhance continuity of care. Without these child-level requirements, there is no mechanism to ensure that caregivers are consistently collaborating to assess target symptoms, behaviors, potential benefits, and adverse effects of treatment. Child-level practice guidelines promote a coordinated strategy in oversight of individual children’s psychotropic medication use. This guidance is critical due to known concerns in the foster care population, such as complex mental healthcare needs and changes in foster home placement. These concerns increase the risk of miscommunication among caregivers and ineffective and inappropriate medications or medication combinations. Additionally, previous work by the Government Accountability Office (GAO) concluded that States that do not incorporate AACAP’s recommended elements limit their ability to identify potentially risky prescribing practices.42 The following example highlights the importance of State child-level requirements. In this State, there is no requirement for caseworkers to follow up with foster parents about medication and the child’s outcomes or assess the risk for medication nonadherence. The child was without prescribed medication for a time and experienced adverse effects. There was no evidence in the case file that the caseworker was aware of the nonadherence and the impact on the child’s outcome. Child Description—11-year-old child diagnosed with reactive attachment disorder, conduct disorder, anxiety, and ADHD. Prescribed two psychotropic medications. Case Narrative—The child experienced a 3-month period during which the foster mother stated she had difficulties obtaining medication refills for the child. Two prescribing professionals said the child needed to be seen first by a psychiatrist. One prescriber agreed to provide a refill because the child was unmanageable without medications. The child was seen by a psychiatrist during the fourth month, at which time the notes indicated the child was without medications, had lost the ability to maintain normal psychological function, and had experienced a decline of his overall situation. The decline included increased stealing, lying, bullying, poor interactions with other children, and in-school suspension. The five States' requirements generally incorporated suggested professional practice guidelines for State-level monitoring Unlike States’ child-level requirements, States’ State-level requirements generally incorporated suggested professional practice guidelines (see Exhibit 3, on the next page). For example, States included a requirement to monitor the rates and types of psychotropic medication usage and rates of adverse reactions. These aggregate mechanisms can improve States’ ability Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 10 OEI-07-15-00380 to identify potentially risky prescribing practices and to improve oversight of psychotropic medications for children in foster care. Exhibit 3: States’ requirements generally incorporated suggested professional practice guidelines for State-level oversight of psychotropic medication Among five States, number that included suggested practice guidelines within their requirements for State-level monitoring of psychotropic medications: Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 11 OEI-07-15-00380 CONCLUSION AND RECOMMENDATIONS The five States that we reviewed partially complied with their own State-established requirements for treatment planning and medication monitoring for children in foster care receiving psychotropic medications; further, State requirements did not always include suggested professional practice guidelines designed to protect these children. Specifically, 34 percent of children in foster care who were treated with psychotropic medications did not receive treatment planning or medication monitoring as required. Additionally, States’ requirements did not consistently incorporate suggested professional practice guidelines, such as requiring assessment strategies and documenting information on potential adverse effects. Improved compliance and strengthened State requirements are imperative to provide protections for children who are at risk for inappropriate treatment and inappropriate prescribing practices. To ensure coordinated care for children in foster care receiving psychotropic medications, we recommend that ACF: Develop a comprehensive strategy to improve States’ compliance with requirements related to treatment planning and medication monitoring for psychotropic medication ACF must ensure that States coordinate care for children in foster care with regard to oversight of psychotropic medication. To do this, ACF should develop a comprehensive strategy that identifies methods for States to improve compliance with requirements for treatment planning and medication monitoring. The strategy should guide ACF in strengthening compliance and identifying gaps that need to be addressed. This will improve transparency and accountability, and assist States in doing the same. The strategy should include, at a minimum:  providing enhanced training and technical assistance, through collaboration with professional provider organizations, for States related to implementing treatment-planning mechanisms and effective medication monitoring (e.g., continued education for caseworkers and supervisors). Also, ACF may consider:  helping States develop effective accountability measures and mechanisms for internal quality review;  requesting that States report data on treatment planning and medication monitoring to the extent they can provide reliable and consistent data, and then providing the compiled national data to States to use as a benchmark for their progress in meeting requirements; and Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 12 OEI-07-15-00380  placing increased weight on treatment planning and medication monitoring when determining a State’s substantial conformity with plan requirements, changing the assessment instrument as necessary, and following up with enforcement actions when appropriate (e.g., mandating program improvement plans, and, where appropriate, withholding Federal funds). Assist States in strengthening their requirements for oversight of psychotropic medication by incorporating professional practice guidelines for monitoring children at the individual level ACF must help States strengthen their requirements by incorporating child- level protections for children in foster care who are treated with psychotropic medications. To do this, ACF should:  strengthen its annual review of States’ protocols to confirm that State requirements incorporate professional practice guidelines related to treatment planning and medication monitoring,  publish an Information Memorandum regarding specific mechanisms for child-level treatment planning and methods to achieve effective medication monitoring, and  provide enhanced training and technical assistance for States related to incorporating professional practice guidelines in State protocols through collaboration with professional provider organizations. Also, ACF may consider:  providing standardized protocols or templates that include child-level recommendations and implementation strategies that States could adapt to meet local needs. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 13 OEI-07-15-00380 AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ACF stated that it concurred with some of our recommendations but not others; it did not specify which of the two formal recommendations it agreed with, and which it did not. ACF comments addressed various subsections of each of these recommendations. We ask that ACF clarify in its Final Management Decision its concurrence or non-concurrence for each formal recommendation. OIG recommended that ACF develop a comprehensive strategy to improve States’ compliance with requirements related to treatment planning and medication monitoring for psychotropic medication. In response, ACF noted that it already has a well-established approach to program implementation that includes a regulated mechanism to identify and correct compliance issues. However, OIG found that one in three children were not receiving treatment planning or medication monitoring, as required in their respective States, which suggests the current approach to identifying and correcting compliance issues is insufficient and more needs to be done. ACF did agree to assess opportunities to continue to provide technical assistance in this area as well as ensure States are reporting on this requirement through Child and Family Services Plans and annual updates. If ACF does conduct such technical assistance and training activities, in collaboration with professional organizations, this would fulfill the intent of our first recommendation. However, we encourage ACF to further consider our additional suggestions toward improving States’ treatment planning and medication monitoring for children in foster care. We note that ACF disagreed with one of these suggestions related to reporting data on treatment planning and medication monitoring. ACF views this data reporting to be outside the scope of what can be reliably and consistently reported to an administrative data set. ACF notes that, by law, its administrative data set must be both reliable and consistent across the reporting population. OIG agrees that data reporting must be reliable and consistent. We continue to encourage ACF to consider innovative approaches to promote State reporting of basic information on treatment planning and medication monitoring that will be reliable and consistent. Likewise, ACF could actively assist States to develop effective accountability measures and mechanisms for internal quality review and consider placing increased weight in its review of treatment planning and medication monitoring during its compliance reviews of States. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 14 OEI-07-15-00380 With respect to the second recommendation, OIG recommended that ACF assist States in strengthening their requirements for oversight of psychotropic medication. In response, ACF stated that it is amenable to assessing what additional technical assistance and best practice guidance to provide to States regarding the monitoring of psychotropic medication. ACF described the mechanisms through which it makes technical assistance available to States and noted that, to date, no States have reached out around this area of need. ACF also stated that the Child Welfare Information Gateway will include a new article on improving the use of psychotropic medication for children in foster care. This article may represent a step toward providing technical assistance for States related to incorporating professional practice guidelines in State protocols, one aspect of OIG’s recommendation. However, overall, ACF’s response did not address the substance of OIG’s recommendation. OIG continues to recommend that ACF actively engage with States through various actions. In addition to providing technical assistance, these actions should include strengthening its annual review of States’ protocols to confirm that State requirements incorporate professional practice guidelines related to treatment planning and medication monitoring for children at the individual level. The full text of ACF’s comments can be found in Appendix F. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 15 OEI-07-15-00380 APPENDIX A: Five Required Elements for Monitoring the Appropriate Use of Psychotropic Medications ACF program instruction directs States to include the following elements in their protocols: 1. 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 medications; and 2. informed and shared decision making and methods for ongoing communication between the prescriber, the child, the child’s caregivers, and other stakeholders (e.g., healthcare providers and child welfare worker); 3. effective medication monitoring at both the client level and agency level; 4. availability of mental health expertise and consultation regarding both consent and monitoring issues by a board-certified child and adolescent psychiatrist; and 5. mechanisms for sharing accurate and up-to-date information related to psychotropics with clinicians, child welfare staff, and consumers (e.g., children and caregivers), including both data sharing mechanisms (e.g., integrated information systems) and methods for sharing educational materials.43 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 16 OEI-07-15-00380 APPENDIX B: Detailed Methodology State Selection We selected the five States with the highest percentages of children in foster care who were treated with psychotropic medications in FY 2013. Our assessment of Medicaid eligibility and claims data determined they were Iowa, Maine, New Hampshire, North Dakota, and Virginia. Appendix E contains further details on demographics and Medicaid fee-for-service (FFS) expenditures in all States. Exhibit B-1: State Demographics Regarding Children in Foster Care Treated with Psychotropic Medications and Related Medicaid Expenditures Number of Percentage of Total Medicaid Children in Children in FFS Expenditures Population of Foster Care Foster Care for Psychotropic State Children in Treated with Treated with Medications for Foster Care Psychotropic Psychotropic Children in Foster Medications Medications Care Iowa 13,951 4,981 35.7% $7,135,849 Maine 3,527 1,155 32.7% $1,600,692 New Hampshire 2,614 944 36.1% $1,741,581 North Dakota 2,734 1,021 37.3% $1,184,934 Virginia 14,999 5,584 37.2% $11,959,404 Source: OIG analysis of MSIS eligibility and prescription drug claims data, 2016. Collection of States’ Data and Requirements We sent a letter to the administrator of each selected State’s foster care agency and to each Medicaid director to request a point of contact to respond to our requests for information. From the points of contact, we requested: (1) foster care eligibility data representing all children enrolled in foster care at any time during the review period; (2) a copy of the State’s selected foster care requirements; (3) any supporting documentation accompanying those requirements (such as State policies or required forms); (4) State responses to questions that the team developed regarding how the State has implemented the requirements and any related guidance and technical assistance ACF has provided; and (5) all Medicaid-paid claims for psychotropic medications prescribed to children up to 21 years old between October 1, 2014, and March 31, 2015, from the States’ Medicaid Management Information Systems (MMIS). Sample Selection We selected a simple random sample of 125 children from each State for a total of 625 children. A total of 36 children were determined to be ineligible Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 17 OEI-07-15-00380 for the sample for one of the following reasons: the child was not in foster care during the review period, the child did not receive a Medicaid-paid psychotropic drug claim during their foster care eligibility or during our review period, the child was not in foster care for at least 30 days of our review period, or other limitations prevented review of the case file. Therefore, the overall weighted response rate was 92 percent. In total, 589 children were analyzed for this review. See Exhibit B-2 below regarding the population and sample sizes for the five States. Exhibit B-2: Population of Children in Foster Care Enrolled in Medicaid Treated with Psychotropic Medications at Any Time Between October 1, 2014, and March 31, 2015 Ineligible Final Analyzed Population State Sample Size Sampled Sampled Size Children Children Iowa 2,166 125 9 116 Maine 566 125 5 120 New Hampshire 244 125 1 124 North Dakota 280 125 7 118 Virginia 2,156 125 14 111 Total 5,412 625 36 589 Source: OIG analysis of State foster care case files and Medicaid claims for children in foster care, 2017. Case File Documentation and Medicaid Claims Data Review We developed criteria based on the State’s selected requirements related to screening, assessment, treatment planning, medication monitoring, and psychiatric evaluation. Using the foster care case file documentation and Medicaid claims data, we reviewed each child’s treatment with psychotropic medications according to the State’s requirements. For our study period, October 1, 2014 to March 31, 2015, we identified the case file documentation and healthcare services received by each child during the child’s foster care eligibility. We then determined whether any of those services represented a required element. For medication monitoring with a prescribing professional, any Medicaid claim for an evaluation and management visit with a mental health diagnosis was considered to fulfill this requirement.44 Any documentation in the case file stating that an appointment occurred was considered to have fulfilled this requirement so long as we could determine it was with a prescribing professional or the child’s psychotropic medication(s) were discussed. Caseworker notes, narrative, or emails that summarized changes in medication were also considered medication monitoring. Because States gave minimal definition of treatment plans, we considered any case file documentation that was labeled “treatment plan,” “case plan,” or “care plan” to have fulfilled the treatment plan requirement.45 Plans developed by prescribing professionals and/or by foster care caseworkers Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 18 OEI-07-15-00380 were considered to have fulfilled this requirement. Documents developed by schools were not considered to have fulfilled treatment plan requirements. Analysis of Results We reviewed foster care case file documentation and Medicaid claims data for each sampled child. If either foster care case file documentation or the Medicaid claims demonstrated receipt of a particular required element by a sampled child, that element was counted as received. If neither the foster care case file documentation nor the Medicaid claims demonstrated receipt of a particular required element by a sampled child, that element was counted as not received. We followed up with foster care program officials in the five States regarding every child for whom we determined at least one required element was missing. State officials either provided additional documentation showing that the child did receive the element(s) in question, or declined to submit additional documentation. If additional documentation showed that the element(s) were received, we counted those element(s) as received. Comparing States’ Protocols to Professional Practice Guidelines We selected professional practice guidelines from AACAP guidance documents for comparison with the five States’ requirements for oversight regarding psychotropic medication. Specifically, we selected professional practice guidelines related to (1) screening, assessment, psychiatric evaluations, and treatment planning; and (2) medication monitoring. We then assessed the extent to which State requirements incorporated these professional practice guidelines. For example, regarding treatment planning and medication monitoring, we assessed whether States’ protocols required inclusion of elements such as assessment for risk of nonadherence, information on adverse effects, assessment strategies, starting dose and timing of dose changes in the medication list. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 19 OEI-07-15-00380 APPENDIX C: State-by-State Compliance With Psychotropic Medication Requirements This appendix contains five State-by-State summaries of compliance for selected foster care requirements regarding psychotropic medications. We reviewed foster care case file documentation and Medicaid claims data representing healthcare services and mental health services received by the sampled children during the review period. We determined whether any of those documents or claims represented evidence that a State-required criteria of treatment planning and medication monitoring was provided. Each State establishes its own foster care requirements (i.e., protocols) for oversight of psychotropic medications. Each State’s requirements are unique; therefore, the criteria that we used to assess consistency with the requirements in each selected State is unique to that State. Additionally, we included a determination for each State of whether each sampled child received medication monitoring by a prescribing professional. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 20 OEI-07-15-00380 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 21 OEI-07-15-00380 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 22 OEI-07-15-00380 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 23 OEI-07-15-00380 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 24 OEI-07-15-00380 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 25 OEI-07-15-00380 APPENDIX D: Statistical Estimates and Confidence Intervals Exhibit D-1 contains:  sample sizes (the number of sample children where we obtained useable outcomes);  point estimates (made using the outcomes determined on the basis of the number of sample children reviewed, or the sample size); and  95-percent confidence intervals (estimates of the error in the point estimates; 95 percent is a strong level of confidence). Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals Sample Point 95-Percent Estimate Description Size Estimate Confidence Interval Five States combined statistics Percent of children in foster care treated with psychotropic medications that did not receive 589 33.9% 29.8%–38.3% treatment planning or medication monitoring Percent of children who did not receive a 589 19.5% 15.9%–23.6% treatment plan Percent of children who did not receive 589 22.9% 19.2%–27.0% medication monitoring Percent of children who did not receive 589 8.4% 6.0%–11.7% treatment planning and medication monitoring In States with specific treatment plan requirements, percent of children who received 308 52.0% 44.4%–59.6% a treatment plan that did not receive all State- required treatment planning criteria Iowa’s specific requirements Percent of children who did not receive a 116 30.2% 22.7%–38.9% treatment plan Percent of children who did not have evidence that the caseworker documented whether the 116 40.5% 32.2%–49.5% child was receiving necessary medical care in their case files Percent of children who did not have evidence that the caseworker documented whether the 116 32.8% 25.0%–41.6% program plan was providing appropriate and sufficient services in their case files continued on next page Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 26 OEI-07-15-00380 Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals (continued) 95-Percent Sample Point Estimate Description Confidence Size Estimate Interval Iowa’s specific requirements Percent of children who did not have evidence that the caseworker inquired of the foster family 116 82.8% 75.0%–88.5% the effectiveness of the medications in their case files Percent of children who did not have evidence that the caseworker documented the reason the 116 83.6% 76.0%–89.2% medication was prescribed Percent of children who did not have evidence that the caseworker documented whether the 116 72.4% 63.8%–79.6% medication was meeting the child’s needs Percent of children who did not receive medication monitoring by a prescribing 116 48.3% 39.5%–57.1% professional Maine’s specific requirements Percent of children who did not receive a 120 27.5% 21.0%–35.1% treatment plan Percent of children who did not have their medication plan reviewed quarterly by their 120 25.8% 19.5%–33.4% treatment provider Percent of children prescribed antipsychotic medication who had no evidence that the caseworker participated in medical or psychiatric appointments where medications were initially 39 59.0% 44.9%–71.7% discussed and a determination is made to proceed or not, and then at least every 3 months following* Percent of children who did not receive medication monitoring by a prescribing 120 10.8% 6.8%–16.8% professional New Hampshire’s specific requirements Percent of children who did not receive a 124 23.4% 18.6%–29.0% treatment plan Percent of children who did not receive all 95 75.8% 69.2%–81.3% State-required treatment planning criteria Percent of children who did not have an 95 6.3% 3.6%–10.8% assessment summary in their treatment plan Percent of children who did not have a diagnosis 95 37.9% 31.3%–44.9% in their treatment plan Percent of children who did not have goals or 95 3.2% 1.4%–6.8% desired outcomes in their treatment plan continued on next page Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 27 OEI-07-15-00380 Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals (continued) 95-Percent Sample Point Estimate Description Confidence Size Estimate Interval New Hampshire’s specific requirements Percent of children who did not have incremental 95 7.4% 4.4%–12.0% steps to goal achievement in their treatment plan Percent of children who did not have 95 6.3% 3.6%–10.8% interventions in their treatment plan Percent of children who did not have the evaluator’s name/signature/date in their 95 56.8% 49.8%–63.7% treatment plan Percent of children who did not receive medication monitoring by a prescribing 124 21.8% 17.1%–27.3% professional. North Dakota’s specific requirements Percent of children who did not receive a 118 6.8% 4.1%–11.1% treatment plan Percent of children who did not receive all 110 38.2% 31.7%–45.2% State-required treatment planning criteria Percent of children who did not receive goals or 110 1.8% 0.6%–5.0% objectives in their treatment plan Percent of children who did not receive action steps for meeting specified goals in their 110 8.2% 5.1%–12.9% treatment plan Percent of children who did not receive information about prescribed medications in their 110 10.9% 7.3%–16.1% treatment plan Percent of children who did not receive documentation of treatment progress in their 110 10.9% 7.3%–16.1% treatment plan Percent of children who did not receive a treatment plan developed by a multidisciplinary 110 27.3% 21.5%–33.9% team Percent of children who did not receive medication monitoring by a prescribing 118 1.7% 0.6%–4.7% professional continued on next page Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 28 OEI-07-15-00380 Exhibit D-1: Point Estimates, Sample Sizes, and Confidence Intervals (continued) 95-Percent Sample Point Estimate Description Confidence Size Estimate Interval Virginia’s specific requirements Percent of children who did not receive a 111 7.2% 3.7%–13.6% treatment plan Percent of children who did not receive all 103 51.5% 42.1%–60.7% State-required treatment planning criteria Percent of children who did not receive strengths 103 11.7% 6.8%–19.2% or needs of the child in their treatment plan Percent of children who did not receive a health status, including any allergies or health 103 25.2% 17.9%–34.3% conditions in their treatment plan Percent of children who did not receive the names and addresses of child's medical and 103 41.7% 32.8%–51.2% mental health providers in their treatment plan Percent of children who did not receive a list of the child's medications including psychotropic 103 29.1% 21.3%-38.4% drugs in their treatment plan Percent of children who did not receive medication monitoring by a prescribing 111 2.7% 0.9%–7.8% professional Source: OIG analysis of State foster care case files and Medicaid claims for children in foster care, 2017. *We are unable to reliably project the frequency estimates for this item because of the small number of sample occurrences. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 29 OEI-07-15-00380 APPENDIX E: State Demographics Regarding Children in Foster Care Treated With Psychotropic Medications For each State, Exhibit E-1 represents the population of children in foster care,46 the number and percentage of children in foster care who were treated with psychotropic medications,47 and total Medicaid FFS expenditures for psychotropic medications for children in foster care in FY 2013. These figures are based on MSIS eligibility and prescription drug claims data. For States that cover medications through managed care, the exhibit does not reflect the amounts the managed care organizations (MCOs) paid for psychotropic medications for children in foster care.48 States such as Arizona and Hawaii do not have FFS expenditures for these drugs because they were all covered through managed care. Exhibit E-1: State Demographics Regarding Children in Foster Care Treated with Psychotropic Medications and Related Medicaid Expenditures* Total Medicaid FFS Number of Children Percentage of Expenditures for Population of in Foster Care Children in Foster Psychotropic State Children in Treated with Care Treated with Medications for Foster Care Psychotropic Psychotropic Children in Medications Medications Foster Care Alabama 11,709 2,897 24.7% $4,851,356 Alaska 4,175 672 16.1% $1,204,665 Arizona 24,731 4,257 17.2% $0 Arkansas 9,857 2,470 25.1% $3,415,546 California 147,806 20,064 13.6% $44,581,405 Colorado 21,155 4,871 23.0% $9,116,770 Connecticut 5,674 1,532 27.0% $3,345,982 Delaware 2,254 719 31.9% $1,465,037 District of Columbia 4,671 613 13.1% $1,026,092 Florida 65,198 11,228 17.2% $16,510,753 Georgia 33,033 9,408 28.5% $12,021,956 Hawaii 5,912 571 9.7% $0 Idaho** 5,024 1,102 21.9% $1,515,443 Illinois 53,898 10,109 18.8% $10,733,426 Indiana 23,912 6,844 28.6% $14,371,841 Iowa 13,951 4,981 35.7% $7,135,849 continued on next page Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 30 OEI-07-15-00380 Exhibit E-1: State Demographics Regarding Children in Foster Care Treated with Psychotropic Medications and Related Medicaid Expenditures* (continued) Number of Children Percentage of Total Medicaid FFS Population of in Foster Care Children in Foster Expenditures for State Children in Treated with Care Treated with Psychotropic Foster Care Psychotropic Psychotropic Medications for Medications Medications Foster Children Kansas 18,319 4,292 23.4% $3,230,278 Kentucky 18,257 5,657 31.0% $494,659 Louisiana 13,407 4,017 30.0% $5,584,262 Maine 3,527 1,155 32.7% $1,600,692 Maryland 16,030 4,450 27.8% $9,441,087 Michigan 18,884 4,190 22.2% $10,193,641 Minnesota 12,446 3,597 28.9% $4,094,907 Mississippi 7,294 1,891 25.9% $3,187,730 Missouri 34,817 9,847 28.3% $26,130,684 Montana 4,861 1,249 25.7% $2,336,576 Nebraska 13,606 3,882 28.5% $7,118,577 Nevada 12,100 1,829 15.1% $3,431,784 New Hampshire 2,614 944 36.1% $1,741,581 New Jersey 27,856 3,871 13.9% $387,902 New Mexico 6,450 1,189 18.4% $53,857 New York 54,099 9,068 16.8% $9,671,915 North Carolina 23,121 7,004 30.3% $16,393,851 North Dakota 2,734 1,021 37.3% $1,184,934 Ohio 35,029 9,196 26.3% $23,575,138 Oklahoma 11,120 2,267 20.4% $3,150,116 Oregon 23,331 4,468 19.2% $4,812,840 Pennsylvania 54,349 11,387 21.0% $1,377,212 Rhode Island** 4,875 979 20.1% $178,257 South Carolina 14,087 3,630 25.8% $3,794,339 South Dakota 4,709 1,304 27.7% $2,480,728 Tennessee 24,455 6,418 26.2% $11,017,546 Texas 88,609 23,991 27.1% $35,762,195 Utah 10,862 3,212 29.6% $7,954,880 Vermont 2,950 933 31.6% $1,915,196 continued on next page Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 31 OEI-07-15-00380 Exhibit E-1: State Demographics Regarding Children in Foster Care Treated with Psychotropic Medications and Related Medicaid Expenditures* (continued) Number of Children Percentage of Total Medicaid FFS Population of in Foster Care Children in Foster Expenditures for State Children in Treated with Care Treated with Psychotropic Foster Care Psychotropic Psychotropic Medications for Medications Medications Foster Children Virginia 14,999 5,584 37.2% $11,959,404 Washington 27,538 5,035 18.3% $7,008,379 West Virginia 10,950 3,138 28.7% $4,163,156 Wisconsin 18,290 4,557 24.9% $7,289,062 Wyoming 3,805 875 23.0% $1,542,474 Total: 1,073,340 238,465 22.2% $365,555,960 Source: OIG analysis of MSIS eligibility and prescription drug claims data, 2016. *Massachusetts is not included in this exhibit because its MSIS eligibility files for FY 2013 were incomplete. The Massachusetts eligibility data included only approximately 1,500 unique identifiers for children in foster care. The population of children in foster care in Massachusetts is known to be significantly higher than 1,500. **Indicates that complete FY 2013 data was not available in MSIS at the time of data collection; therefore, FY 2012 data was used. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 32 OEI-07-15-00380 APPENDIX F: Agency Comments Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 33 OEI-07-15-00380 Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 34 OEI-07-15-00380 ACKNOWLEDGMENTS Jamila Murga served as the team leader for this study, and Dana Squires and Abbi Warmker served as lead analysts. Others in the Office of Evaluation and Inspections who conducted the study include Cody Johnson, Katie Fry, Lesta Newberry, Anna Pechenina, and Andrea Staples. Office of Evaluation and Inspections central office staff who provided support include Althea Hosein and Seta Hovagimian. This report was prepared under the direction of Brian T. Whitley, Regional Inspector General for Evaluation and Inspections in the Kansas City regional office, and Jennifer E. King, Deputy Regional Inspector General. To obtain additional information concerning this report or to obtain copies, contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov. Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication 35 OEI-07-15-00380 ABOUT THE OFFICE OF INSPECTOR GENERAL The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components: Office of Audit The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit Services work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. Office of Evaluation The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable and Inspections information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations. Office of The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, Investigations operations, and beneficiaries. With investigators working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. Office of Counsel to The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and the Inspector operations and providing all legal support for OIG’s internal operations. General OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the healthcare industry concerning the anti-kickback statute and other OIG enforcement authorities. 36 ENDNOTES 1 ACF, Managing Psychotropic Medications for Children and Youth in Foster Care, 2012. Accessed at http://www.acf.hhs.gov/blog/2012/08/managing-psychotropic-medications-for-children-and-youth-in-foster-care on April 1, 2016. 2 Centers for Disease Control, Psychotropic Medication Use Among Adolescents: United States, 2005-2010, 2013. Accessed at https://www.cdc.gov/nchs/data/databriefs/db135.pdf on July 5, 2017. 3 National Institute of Mental Health, Mental Health Medications, 2016. Accessed at http://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml on March 31, 2016. 4 ACF, Information Memorandum ACYF-CB-IM-12-03, 2012. Accessed at https://www.acf.hhs.gov/sites/default/files/cb/im1203.pdf on August 24, 2017. 5 National Institute of Mental Health, Mental Health Medications, 2016. Accessed at http://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml on March 31, 2016. 6 ACF, Managing Psychotropic Medications for Children and Youth in Foster Care, 2012. Accessed at http://www.acf.hhs.gov/blog/2012/08/managing-psychotropic-medications-for-children-and-youth-in-foster-care on April 1, 2016. 7 Ibid. 8 American Academy of Pediatrics (AAP), “Health Care Issues for Children and Adolescents in Foster Care and Kinship Care,” Pediatrics, Vol. 136, No. 4, 2015. Accessed at http://pediatrics.aappublications.org/content/136/4/e1142 on October 26, 2017. 9 Michael Naylor, et al, “Psychotropic Medication Management for Youth in State Care: Consent, Oversight, and Policy Considerations,” Child Welfare, Vol. 86, No. 5, 2007, pp. 175-192. 10 AAP, Fostering Health: Health Care for Children and Adolescents in Foster Care 2nd Edition, 2005. Accessed at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Fostering-Health.aspx on September 15, 2017. 11 Ibid. 12 ACF, Information Memorandum ACYF-CB-IM-12-03, 2012. Accessed at https://www.acf.hhs.gov/sites/default/files/cb/im1203.pdf on August 24, 2017. 13 Michael Naylor, et al, “Psychotropic Medication Management for Youth in State Care: Consent, Oversight, and Policy Considerations,” Child Welfare Vol. 86, No. 5, 2007, pp. 175-192. 14 AACAP, “Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents,” J. Am. Acad. Child Adolesc. Psychiatry, Vol. 48, No. 9, 2009, pp. 961-973. Accessed at http://www.jaacap.com/article/S0890-8567(09)60156-8/pdf on March 9, 2016. 15 Ibid. 16 OIG, Second-Generation Antipsychotic Drug Use Among Medicaid-Enrolled Children: Quality-of-Care Concerns (OEI-07-12-00320), March 2015. Accessed at https://oig.hhs.gov/oei/reports/oei-07-12-00320.pdf on October 31, 2017. 17 In all States, nearly all children in foster care are eligible for Medicaid services. According to section 1902(a)(10)(A)(i)(I) of the Social Security Act (the Act), children in foster care who are eligible for assistance payments through Title IV-E of the Act are mandatorily eligible for Medicaid. Children in foster care who are not eligible under Title IV-E usually qualify for Medicaid through other eligibility categories established by each State. Because most children in foster care are eligible for Medicaid, Medicaid pays for healthcare services for almost all children in foster care. 18 These expenditures only reflect fee-for-service (FFS) Medicaid payments reflected in Medicaid Statistical Information System (MSIS) data for fiscal year (FY) 2013. This was the most recent complete data available at the time of State selection. 19 The Act, § 422(b)(15)(A)(1)(v). 20 Each State is required to submit its health services oversight and coordination plan as part of its CFSP to ACF every 5 years (45 CFR § 1357.15). The most recent plans available during the period of our review cover FYs 2015 through 2019. 21 ACF, Program Instruction ACYF-CB-PI-12-05, 2012. Accessed at http://www.acf.hhs.gov/sites/default/files/cb/pi1205.pdf on July 30, 2015. 22 Ibid. 23 Ibid. 24 Michael Naylor, et al, “Psychotropic Medication Management for Youth in State Care: Consent, Oversight, and Policy Considerations,” Child Welfare Vol. 86, No. 5, 2007, pp. 175-192. 25 Ibid. 37 26 The compliance reviews assess State compliance with Federal requirements and the outcomes of the child welfare system. These reviews do not specifically determine whether children in foster care received treatment consistent with States’ requirements. ACF, Child and Family Service Reviews Fact Sheet. Accessed at https://www.acf.hhs.gov/sites/ default/files/cb/cfsr_general_factsheet.pdf on September 15, 2017. 27 “Substantial conformity” is determined by the State agency’s ability to meet various standards and criteria, including its capacity to deliver services leading to improved outcomes for children and families. 45 CFR § 1355.34. 28 45 CFR § 1355.34. 29 45 CFR § 1355.35(a). 30 If the State fails to successfully complete a program improvement plan, ACF has the authority to withhold a certain amount of Federal funding for the year under review and each subsequent year until the State either successfully completes a program improvement plan or is found to be operating in substantial conformity. 45 CFR § 1355.33 – 1355.36. 31 ACF, CFSR Round 3 Onsite Review Instrument and Instructions, 2016. Accessed at https://www.acf.hhs.gov/sites/default/files/cb/cfsr_r3_osri.pdf on November 14, 2017. 32 ACF, Information Memorandum ACYF-CB-IM-12-03, 2012. Accessed at https://www.acf.hhs.gov/sites/default/files/cb/im1203.pdf on August 24, 2017. 33 The recommendations described in this evaluation are not an exhaustive list of all professional recommendations. We have selected recommendations that are relevant to the scope of this study. 34 AACAP, A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents, 2012. Accessed at http://www.aacap.org/app_themes/aacap/docs/press/guide_for_community_child_serving_agencies_on_ psychotropic_medications_for_children_and_adolescents_2012.pdf on October 30, 2017. 35 Ibid. 36 AACAP, “Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents,” J. Am. Acad. Child Adolesc. Psychiatry, Vol. 48, No. 9, 2009, pp. 961-973. 37 Ibid. 38 We used eligibility and prescription drug files from the MSIS to calculate the total children enrolled in foster care in each State, and the total children who had at least one Medicaid-paid claim for a psychotropic medication in FY 2013. We used FY 2012 data for Idaho and Rhode Island because complete FY 2013 files were not available. 39 ACF, Program Instruction (ACYF-CB-PI-12-05), April 11, 2012, p. 13. Accessed at http://www.acf.hhs.gov/sites/default/files/cb/pi1205.pdf on July 30, 2015. 40 States are not mandated to establish requirements consistent with AACAP guidance. Therefore, our analysis does not conclude that States are in error, or have failed to meet requirements, where their requirements are not consistent with AACAP guidance. 41 Children may receive healthcare from sources such as schools, free health clinics, or a parent’s private insurance. Additionally, some of the Medicaid claims data provided for our review included Medicaid Managed Care capitated payments, which did not consistently provide detail regarding the services received by those children. 42 GAO, HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions (GAO-12-270T), 2011. Accessed at http://www.gao.gov/new.items/d12270t.pdf on October 31, 2017. 43 ACF, Program Instruction (ACYF-CB-PI-12-05), April 11, 2012, p. 13. Accessed at http://www.acf.hhs.gov/sites/default/files/cb/pi1205.pdf on July 30, 2015. 44 We define evaluation and management services as office visits, hospital visits, and consultations provided by qualified healthcare professionals authorized to perform such services within the scope of their practice. 45 States are required to develop a case plan for each child in foster care. The case plan must include information such as the child’s health records, medical problems, and medications. The Act, § 422(a)(8)(A)(ii), § 475(5), and § 475(1)(C). 46 The figures for the population of children in foster care in each State represent the total unique children that were eligible for Medicaid because of their foster care status at any point during FY 2013. 47 We considered any child who had at least one Medicaid-paid claim for a psychotropic medication while in foster care to have been treated with psychotropic medications. 48 Medicaid managed care is a type of healthcare delivery system that provides Medicaid health benefits and services to enrollees through contracted arrangements between State Medicaid agencies and MCOs. MCOs receive a set payment per member per month from the State Medicaid agency for these services. FFS is a type of healthcare delivery system in which healthcare providers are paid for each service provided to Medicaid enrollees. 38