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Psychotropic Quality

Improvement (PQI)

CollaborativeTennessee Stakeholder Meeting

October 25, 2019

Poonam Juneja, Carrie Mason & Sarah Pauter

National Center for Youth Law

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Agenda

I. Introduction and Group Agreements

II. Overview of the PQI Collaborative & Psych Meds

III. Research Review on Issues and Best Practices

IV. Tennessee SummaryStakeholder Update

V. Lunch

VI. Brainstorming Activity

VII. Action Items and Next Steps

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Meeting Objectives

During today’s meeting, stakeholders will:

I. Learn about the PQI Collaborative, including goals, timelines, and deliverables

II. Begin building relationships with key stakeholders, including lived experts with firsthand experience in the child welfare, juvenile justice, and mental health systems

III. Explore the research related to psychotropic medication prescribing patterns and best practices

IV. Determine what information/resources will be most helpful for key stakeholders to ensure psychotropic medications are only prescribed when in a child/youth’s best interest

V. Develop next steps, including outreach to additional stakeholder to join the PQI Collaborative

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Introductions

Please share your:

1. Name

2. Agency affiliation

or role as a

member of the PQI

Collaborative

3. The last show you

binge-watched

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Group Agreements

“How would we like to work together?”

• Be present, both mentally and

physically

• Be mindful of technology use and other

potential distractions

• Maintain confidentiality and privacy-

what is said here, stays here

• Be respectful- all ideas are valid and

everyone’s voice matters

• Others?

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Overview of the PQI

Collaborative & Psych Meds

“Ensuring foster youth are only prescribed

psychotropic medications when in their best interest”

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7Overview of the PQI

Collaborative

“Ensuring foster youth are only prescribed

psychotropic medications when in their best interest”

Goals of the project:

• To increase the number of states that adopt research-

informed policies aimed at ensuring foster youth are only

prescribed psychotropic medications when in their best interest.

• To increase awareness of promising policies and practices

identified by researchers and increase the capacity of foster youth,

line-level stakeholders, and policymakers to improve state policy.

• To discuss and disseminate information to stakeholders to assist in

efforts to address psychotropic medication overuse and misuse

with children and youth in foster care.

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8Overview of the PQI

Collaborative (cont.)“Ensuring foster youth are only prescribed

psychotropic medications when in their best interest”

Deliverables of the project:

• Creation of research-informed resources created with guidance and

input from stakeholders for the following audiences:

• Foster Youth• Foster Parents• Court Appointed Special Advocates (CASAs)• Judges• Policymakers

• These deliverables will be accomplished through quarterly

stakeholder meetings, foster youth learning community calls, and

ongoing communication

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Psychotropic Medications

Psychotropic medicines are taken for the purpose of improving the emotional and behavioral health of a child or adolescent diagnosed with a mental health condition.*

They may include, but are not limited to, anxiolytic agents, antidepressants, mood stabilizers, antipsychotic medications, anti-Parkinson agents, hypnotics, medications for dementia, and psychostimulants.

*AACAP (2007) A Guide for Community Child Serving Agencies on Psychotropic Medications for Children and Adolescents.

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10Psychotropic Medication

TennesseeDCS policy:

• “Medication that exercises a direct effect

upon the central nervous system and which

is capable of influencing and modifying

behavior and mental activity. Psychotropic

medications include, but are not limited to

anti-psychotics; antidepressants; agents for

control of mania and depression; anti-anxiety

agents; psychomotor stimulants and

hypnotics.” Tenn. Code § 49-2-124 (2)

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Psychotropic Medications

Examples*

ADHD: Dexedrine, Adderall, Vyvanse, Concerta, Daytrana,, Ritalin, Focalin, Strattera, Tenex, Intuniv;

Antidepressant and Anti-Anxiety: Prozac, Zoloft, Paxil, Lexapro, Effexor, Cymbalta, Wellbutrin;

Anti-Anxiety Medications (Rarely used in children): Xanax, Ativan, Valium, Klonopin, BuSpar.

Antipsychotic Medications: Thorazine, Mellaril, Prolixin, Haldol, Abilify, Risperdal;

Mood Stabilizers and Anticonvulsant Medications: Lithium, Tegretol, Valproic Acid (Depakote, Depakene);

Sleep Medications: Desyrel, Ambien, Sonata, Lunesta, and Benadryl.*AACAP (2017) Psychiatric Medication For Children And Adolescents: Part II - Types Of Medications

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Psychotropic Medications

Can…

• Help when used as a part

of a larger treatment plan

• Benefit some individuals

who have already tried

other evidence-based

treatment options and

medical rule-outs

• Be prescribed with a

child’s safety, overall

interests, medical history,

and risks in mind

Are Not…

• First line treatments for mental health

• To be used alone (med-only treatment)

• Curative

• To be used for behavioral control

• To be used to mask side effects of a different medication

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Too Long

No Risk/

Benefit Profile

Too Many

Adverse Effects

No Informed Consent

Too Soon

Off-label

Misdiagnoses,

Overdiagnoses,

Inaccurate Diagnoses

Too Much

No Monitoring

Untested

No Other Mental

Health Services

Psychotropic Medication

Concerns

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Youth Voice

https://youtu.be/L7lHeosq-FY?t=104

https://youtu.be/L7lHeosq-FY?t=106

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Research Review: Issues and

Best Practices

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16Issues Identified OIG

Report: Five Target States

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Inspector General Report 2018

Recommendations for ACF:

1. Develop a comprehensive strategy to improve States’ compliance with

requirements related to treatment planning and medication monitoring for

psychotropic medication.

1. Assist States in strengthening their requirements for oversight of

psychotropic medication by incorporating professional practice guidelines

for monitoring children at the individual level.

source: https://oig.hhs.gov/oei/reports/oei-07-15-00380.asp

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Psychotropic Medications

Red Flags• 2 or more medications

of any class

• 2 medications in the

same class of drugs

• High/Adult dosages

for children

• Antipsychotics + Stimulant

• Long-term use

without attempts to taper

off

• Abruptly stopping meds

• No

monitoring, documentation,

noticeable impact

Safest Practices• All baseline monitoring,

lab testing completed

• Start with one medication

only

• Start with a low dose

that accounts for the child’s

height, weight, personal and

family history

• Discussion of risks and

benefits

• Contact numbers for any

issues or side effects

• Visits weekly and then

monthly to monitor impact

and effect on the child

• Close watch on weight,

heart, suicidal ideation and

sleeping patterns

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Tennessee

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Tennessee Turnaround

• Brian A v. Haslam (2000)

• Settlement addressed issues including

psychotropic medication prescription

among children in out of home care.

• Medical Director• Centers of Excellence

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21Tennessee DCS Policy

20.18• Psychotropic medication for youth in care are

prescribed and administered “in accordance

with all applicable state and federal laws and in

keeping with best clinical practices.”

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Tennessee

Administrative

Policy 20.18

Only a licensed physician or nurse practitioner is qualified to prescribe

psychotropic medications.

Consultation with a board-certified child and adolescent psychiatrist should be sought in complex cases.:

A thorough examination should precede initial prescription.

Prescription must be accompanied “by an explanation that includes the need related to the child’s mental health diagnosis, potential side effects.

Tennessee Prescription Parameters

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23Tennessee Psychotropic

Medication Monitoring • DCS tracks psychotropic medication

prescription to children in state’s custody

through a Regional Nurse or Youth

Development Center nursing staff.

• DCS also keeps an electronic record with

prescription data and informed consent data

(TFACTS).

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24Psychotropic Medication Utilization

Parameters

• Provides guidelines and rationale for policy

as well as additional protections for the

children in state’s custody.

• Policy 20.18 indicates that cases that fall

outside of the guidelines in the Parameters

are assessed by the Regional Nurse and the

DCS Chief Medical Officer or the Officer’s

designee.

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25Policy 20.18 Clinical

Review

No DSM-IV diagnosis in the child’s medical record.

4 or more psychotropic medications prescribed together.

2 or more of the same type of med prescribed together.

Off-label use or dose.

2 meds prescribed for a given disorder before 1 is tried first.

Child under 5.

Some PCP prescriptions.

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Tennessee

Administrative

Policy 20.24

Parent(s) are part of medical decision making, unless rights have been

terminated, or the youth is 16 or older.

Youth over 16 have decide whether their parents will be involved in psychiatric appointments and psychotropic medication decisions.

Consent documented DCS Form CS-0627, Informed Consent for Psychotropic Medication

Refusal: Individuals refusing treatment are to be counseled and asked to sign DCS Form CS-0093- Release from Medical Responsibility.

Tennessee Informed Consent

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• Exception to Consent

• Emergency dose of psychotropic medication can be given without consent, but must be authorized by a licensed provider or a physician’s order, and is only allowable for a child that is hospitalized or placed in a Psychiatric Residential Treatment Facility (PRTF).

• Emergency psychotropic medication can only be authorized for a one-time dose.

• Emergency monitoring, documentation and notification is required.

Tennessee Informed

Consent: Policy 20.24

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Tennessee Practice

• The Center for State Child Welfare Data,

Tennessee Accountability Center Report

• Technical Assistance Committee, Monitoring

Report of the Technical Assistance Committee

In The Case Of Brian A. v. Haslam

• Prevalence• Informed Consent• Training and Oversight• Centers of Excellence

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• Stakeholder Report:

• What have you seen happening?

Tennessee

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Lunch Break!

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32Where do we go

from here?

• We believe that by supporting and

connecting organizations across the

states of California, New Mexico, North

Carolina and Tennessee who are

invested in psychotropic quality

improvement, we can improve

outcomes for children and youth

through the provision of individualized

trauma-focused and evidence-based

services and supports.

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Brainstorming Activity

Key question: What essential information

do the following audiences need to know

to ensure that foster youth are only

prescribed psychotropic medication when

in their best interest?

• Foster Youth

• Foster Parents

• CASAs

• Judges

• Policymakers

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Action Items & Next Steps

I. Large group discussion: what

stakeholder groups might be missing?

II. Meeting date for November/December

III. Exit Survey:

https://www.surveymonkey.com/r/GKS

MR9Y

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Email Follow-Ups

• Email Sarah.Pauter@phenomenalfamilies.org or

CarrieQMason@gmail.com with

• Your Name,

• County or City,

• Agency and Position.

• Ask Sarah or Carrie a question or tell us about

an issue you are currently trying to address

related to psychotropics.

• We will respond as a follow up and provide any data,

materials, or local connections that may be helpful to

you.

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Questions?