Recommendations

August 2016 California’s Foster Care System The State and Counties Have Failed to Adequately Oversee the Prescription of Psychotropic Medications to Children in Foster Care Report 2015-131 COMMITMENT INTEGRITY LEADERSHIP CALIFORNIA STATE AUDITOR 621 Capitol Mall, Suite 1200 | Sacramento | CA | 95814 916.445.0255 | TTY 916.445.0033 For complaints of state employee misconduct, contact us through the Whistleblower Hotline: 1.800.952.5665 Don’t want to miss any of our reports? Subscribe to our email list at auditor.ca.gov For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Aff airs at 916.445.0255 This report is also available online at www.auditor.ca.gov | Alternate format reports available upon request | Permission is granted to reproduce reports Elaine M. Howle State Auditor Doug Cordiner Chief Deputy August 23, 2016 2015-131 Th e Governor of California President pro Tempore of the Senate Speaker of the Assembly State Capitol Sacramento, California 95814 Dear Governor and Legislative Leaders: As requested by the Joint Legislative Audit Committee, the California State Auditor presents this audit report concerning the oversight of psychotropic medications prescribed to California’s foster children. Th is report concludes that the State and counties have failed to adequately oversee the prescribing of these medications. Specifi cally, some counties have yet to adopt the State’s prescribing guidelines (state guidelines), a valuable tool that counties should use to ensure that foster children do not receive inappropriate or unnecessary psychotropic medications. Consequently, when we reviewed the case fi les for a total of 80 foster children at Los Angeles, Madera, Riverside, and Sonoma counties, we found that many foster children were authorized psychotropic medications in quantities and dosages that exceeded the state guidelines. Although exceeding the state guidelines may be medically appropriate in some cases, we found no evidence that the counties had followed up with the health care providers to ensure the safety and necessity of the medications. When counties do not follow up with providers about prescriptions that exceed the state guidelines, the counties cannot ensure that they are reducing foster children’s exposure to potentially inappropriate medication interventions. Further, the counties have not always ensured that they follow best practices relating to the health services that foster children should receive in conjunction with their psychotropic medications. Specifi cally, one-third of the foster children whose records we reviewed did not receive follow-up appointments with their prescribers or other healthcare providers within 30 days after they began taking new psychotropic medications, thus increasing the risk that any harmful side eff ects would go unaddressed. Further, our review of the 80 case fi les indicates that foster children did not always receive corresponding psychosocial services before or while they were taking psychotropic medications. Additionally, and in violation of state law, counties did not always obtain required court authorizations or parental consents before foster children received prescriptions for psychotropic medications. Finally, we found that the fragmented structure of the State’s child welfare system contributes to the problems we identifi ed. Oversight of psychotropic medications prescribed to foster children is vested among diff erent levels and branches of government, leaving us unable to identify a comprehensive plan that coordinates the various mechanisms in place. Although the diff erent public entities involved have made eff orts to collaborate, the State’s overall approach has exerted little system-level oversight to help ensure that these entities’ collective eff orts actually work as intended and produce desirable results. For instance, the fragmented oversight structure has contributed to the State’s failure to ensure it and other stakeholders have the reliable information necessary to monitor the prescription of psychotropic medications to foster children. Even when combined, the results from data systems operated by two state departments still contain inaccurate and incomplete data related to foster children who are prescribed psychotropic medications. Consequently, neither of the two departments can completely identify which foster children statewide are prescribed psychotropic medications or which medications those children are prescribed. We recommend that the State collaborate with counties and other stakeholders to develop and implement a reasonable oversight structure for psychotropic medications prescribed to foster children. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor 621 Capitol Mall, Suite 1200 Sacramento, CA 95814 916.445.0255 916.327.0019 fax www.auditor.ca.gov Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 v August 2016 Contents Summary 1 Introduction 7 Chapter 1 The Counties Have Not Always Provided Adequate Oversight to Ensure the Appropriateness of the Psychotropic Medications That Children in Foster Care Receive 21 Recommendations 48 Chapter 2 Fragmented Oversight and Poor Data Have Hampered State and County Eff orts to Ensure the Appropriate Prescribing of Psychotropic Medications to Children in Foster Care 51 Recommendations 74 Appendix Summary Tables Showing Statewide and County Data Regarding Psychotropic Medications Prescribed to Foster Children 79 Responses to the Audit California Department of Social Services 95 California State Auditor’s Comment on the Response From the California Department of Social Services 103 Department of Health Care Services 105 Medical Board of California 109 Los Angeles County 111 California State Auditor’s Comments on the Response From Los Angeles County 115 Riverside County 117 California State Auditor’s Comments on the Response From Riverside County 121 Sonoma County 123 California State Auditor’s Comments on the Response From Sonoma County 129 vi California State Auditor Report 2015-131 August 2016 Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 1 August 2016 Summary Results in Brief Audit Highlights . . . Psychotropic medications such as antidepressants, mood stabilizers, Our audit concerning the oversight of and antipsychotics can provide signifi cant benefi ts in the treatment psychotropic medications prescribed of psychiatric illnesses, but they can also cause serious adverse to California’s foster children revealed side eff ects. Although the American Psychological Association has the following: mentioned that studies since the 1970s have found that children in foster care (foster children) often have a greater need for mental health » Nearly 12 percent of California’s more treatment, public and private entities have expressed concerns about than 79,000 foster children were the higher prescription rates of psychotropic medication among foster prescribed psychotropic medications children than among nonfoster children. Th is issue is of particular during fi scal year 2014–15. importance to California, which has the largest population of foster children in the country. In fact, our analysis of the available state data » Some foster children were prescribed found that nearly 12 percent of California’s more than 79,000 foster psychotropic medications in amounts and children were prescribed psychotropic medications during fi scal dosages that exceeded state guidelines year 2014–15, whereas studies suggest that only about 4 to 10 percent and counties did not follow up with of nonfoster children are prescribed these medications. prescribers to ensure the appropriateness of these prescriptions. To examine the oversight of psychotropic medications prescribed to foster children, we reviewed case fi les for a total of 80 foster children » Many foster children did not receive in Los Angeles, Madera, Riverside, and Sonoma counties and follow-up visits or recommended analyzed available statewide data. We found that many foster children psychosocial services in conjunction had been authorized to receive psychotropic medications in amounts with their prescriptions for and dosages that exceeded the State’s recommended guidelines (state psychotropic medications. guidelines), circumstances that should have prompted the counties responsible for their care to follow up with the children’s prescribers. » Counties did not always obtain For example, 11 of the 80 children whose fi les we reviewed had been required court or parental approval for authorized to take multiple psychotropic medications within the psychotropic medications prescribed to same drug class. Further, 18 of the 80 children had been authorized foster children as required by law. to take psychotropic medications in dosages that exceeded the State’s recommended maximum limits. Medications that exceed the » The State’s fragmented oversight structure State’s recommended guidelines may be appropriate under some of its child welfare system has contributed circumstances, and we are not questioning prescribers’ medical to weaknesses in the monitoring of foster expertise. However, in the instances above, the counties did not children’s psychotropic medications. contact the prescribers to ensure the safety and necessity of the medications in question, as the state guidelines recommend. » The California Department of Social Services’ and the Department of Compounding these concerns is the fact that many of these children Health Care Services’ data systems do not appear to have received follow-up visits or recommended together cannot completely identify psychosocial services in conjunction with their prescriptions for which foster children are prescribed psychotropic medications. Th e American Academy of Child and psychotropic medications. Adolescent Psychiatry recommends that children should receive follow-up visits with their health care providers ideally within » Foster children’s Health and Education two weeks, but at least within a month, after they start psychotropic Passports—documents summarizing medications. Nonetheless, one-third of the 67 foster children who critical health and education started at least one psychotropic medication during our audit period information—contained inaccurate and did not receive follow-up appointments with their prescriber or incomplete mental health data. 2 California State Auditor Report 2015-131 August 2016 other health care provider within 30 days after they began taking new psychotropic medications, thus increasing the risk that any harmful side eff ects would go unaddressed. In addition, our review of the 80 case fi les indicates that foster children did not always receive corresponding psychosocial services before or while they were taking psychotropic medications, even though such services are critical components of most comprehensive treatment plans. In response to a recent state law, the Judicial Council of California adopted new and revised forms—which became eff ective in July 2016—to be used in the court authorization process for foster children’s psychotropic medications. Th e proper completion of these newly revised forms should provide county staff with additional information necessary to identify instances when foster children are prescribed psychotropic medications in amounts or dosages that exceed the state guidelines. Among other things, these revised forms require prescribers to explain for each foster child why they prescribed more than one psychotropic medication in a class or dosages that are outside the state guidelines. If these forms are not properly completed, county staff will need to follow up with prescribers to obtain information necessary to ensure that the prescriptions beyond the state guidelines are appropriate. We also found that, in violation of state law, counties did not always obtain required court or parental approval before foster children received prescriptions for psychotropic medications. Specifi cally, when we reviewed the case fi les for 67 foster children who should not have received psychotropic medications without authorization from a juvenile court, we found that 23 (34 percent) did not contain evidence of such authorization for at least one psychotropic medication. Similarly, when we reviewed the case fi les for 13 foster children who should not have received psychotropic medications without the consent of their parents, we found that fi ve (38 percent) did not contain evidence of such consent for at least one psychotropic medication. In eff ect, these children were prescribed psychotropic medications without proper oversight from the counties responsible for their care. Further, the fragmented structure of the State’s child welfare system contributed both to the specifi c problems we identifi ed in our review of the 80 case fi les and to larger oversight defi ciencies that we noted statewide. Specifi cally, oversight of the administration of psychotropic medications to foster children is spread among diff erent levels and branches of government, leaving us unable to identify a comprehensive plan that coordinates the various mechanisms currently in place to ensure that the foster children’s health care providers prescribe these medications appropriately. Although the diff erent public entities involved have made eff orts California State Auditor Report 2015-131 3 August 2016 to collaborate, the State’s overall approach has exerted little system-level oversight to help ensure that these entities’ collective eff orts actually work as intended and produce desirable results. Th e State’s fragmented oversight structure has also contributed to its failure to ensure it has the data necessary to monitor the prescription of psychotropic medications to foster children. Th e two state entities most directly involved in overseeing foster children’s mental health care are the California Department of Social Services (Social Services) and the Department of Health Care Services (Health Care Services). Even when combined, results from data systems these two departments operate still contain inaccurate and incomplete data related to foster children who are prescribed psychotropic medications. Consequently, neither agency can completely identify which foster children statewide are prescribed psychotropic medications or which medications those children are prescribed. Further, the inaccurate and incomplete information in Social Services’ data system is used to produce Health and Education Passports, which are critical documents that are meant to follow foster children should their placement change. We found that all 80 of the Health and Education Passports we reviewed contained instances of incorrect start dates for psychotropic medications. Moreover, 13 of these 80 Health and Education Passports did not identify all the psychotropic medications that the courts authorized, and all 80 were missing information about the corresponding psychosocial services the foster children should have received for at least one psychotropic medication. Th ese errors and omissions appear to have been caused in large part by a lack of county staff to enter foster children’s health information into Social Services’ data system and an unwillingness of some county departments to share foster children’s information with each other. However, caretakers, health care providers, social workers, and others rely on the Health and Education Passports to make decisions about foster children’s care; without accurate information, they may inadvertently make decisions that do not refl ect the children’s best interests. Also, the State has missed opportunities to ensure that the counties have reasonable processes for overseeing the prescription of psychotropic medications to foster children. For example, Social Services’ California Child and Family Services Reviews of the counties only recently began examining in more depth psychotropic medications prescribed to foster children. Because Social Services and Health Care Services have not historically examined the prescription of psychotropic medications to foster children in their periodic reviews, they have missed opportunities for in-depth, county-by-county reviews of this issue. However, as of March 2016, both departments had begun collecting from the counties certain information about these medications. 4 California State Auditor Report 2015-131 August 2016 Finally, rather than publishing this audit report in June 2016 as originally intended, we had to delay publication by two months to allow us time to obtain and analyze additional data from Health Care Services and to revise the report’s text and graphics accordingly. In November 2015, our offi ce began analyzing data originally provided by Health Care Services in response to our request for all Medi-Cal data related to the provision of psychotropic medications and related psychosocial services to foster children. Th ese data provided the basis for the audit report we intended to publish in June 2016. However, about one week before we were to originally publish our audit report, Health Care Services confi rmed that it had not provided all the medical services data that we originally requested. Although it had provided us data for medications, treatment authorizations, and services provided by specialty mental health plans, it had not given us services data for managed care plans or fee-for-service providers.1 Our review showed that the additional June 22, 2016, data consisted of approximately 617 million medical service records. Th e related text and graphics in our audit report refl ect a consolidation of the original more than 46 million medical service records provided by Health Care Services in November 2015 and the additional 617 million medical service records it subsequently provided on June 22, 2016, for a total of more than 663 million claims for medical services. Because the results from the consolidated data did not substantively aff ect the conclusions we reached originally or the recommendations we made, we did not ask the auditees to resubmit their written responses to our June 2016 draft report. Recommendations Legislature Th e Legislature should require Social Services to collaborate with its county partners and other relevant stakeholders to develop and implement a reasonable oversight structure that addresses, at a minimum, the insuffi ciencies in oversight and monitoring of psychotropic medications prescribed to foster children highlighted in this report. California Department of Social Services To improve the oversight of psychotropic medications prescribed to foster children, Social Services should collaborate with counties and other relevant stakeholders to develop and implement a 1 Please see Figure 2 on page 11 for a depiction of the types of Medi-Cal providers. California State Auditor Report 2015-131 5 August 2016 reasonable oversight structure that addresses, at a minimum, the monitoring and oversight weaknesses highlighted in this report and that ensures the accuracy and completeness of Social Services’ data system and the resulting Health and Education Passports. Counties To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should take the following actions: • Implement procedures to more closely monitor requests for authorizations for psychotropic medications for foster children that exceed the state guidelines for multiple prescriptions or excessive dosages. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with the prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up in the foster children’s case fi les. In instances in which counties do not believe that prescribers have adequate justifi cation for exceeding the state guidelines, counties should relay their concerns and related recommendations to the courts or the children’s parents. • Ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication. • Implement a process to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications. • Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications. Agency Comments Th e state entities and the counties agreed with our recommendations. Further, Madera County told us that because it agreed with our report’s recommendations, it did not intend to submit a written response. We look forward to assessing Madera County’s implementation of our recommendations when it provides updates to us at 60 days, 6 months, and one year following the issuance of our report. 6 California State Auditor Report 2015-131 August 2016 Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 7 August 2016 Introduction Background In the last decade, both public and private entities have expressed concerns about the higher prescription rates for psychotropic medications for children in foster care (foster children) than for nonfoster children.2 In the context of foster care, state law defi nes psychotropic medications as those medications administered for the purpose of aff ecting the central nervous system to treat psychiatric disorders or illnesses. Such illnesses may include anxiety disorders, Classifi cations of Psychotropic Medications attention-defi cit/hyperactivity disorder, bipolar • Antianxiety medications disorder, post-traumatic stress disorder, as well as others. As the text box shows, psychotropic • Antidepressants medications can fall into several categories, • Antipsychotics depending on the types of affl ictions they treat.3 • Mood stabilizers Although some circumstances warrant the use of psychotropic medications, these medications can • Stimulants have serious side eff ects, including weight gain or Sources: California State Auditor’s review of websites for loss, depression, movement disorders, pain, and organizations such as the National Institute of Mental Health, sleep disturbance. Also, journal articles have linked the National Alliance on Mental Illness, and the Stanford University School of Medicine. antipsychotics to the increased risk of sudden cardiac death. Studies have shown that foster children are prescribed psychotropic medications more frequently than nonfoster children, raising questions about whether foster children are receiving these medications appropriately. For example, in a 2010 multistate study on psychotropic medication oversight in foster care, the Tufts Clinical and Translational Science Institute cited research showing that the use of psychotropic medication in the general child population was only 4 percent while the use of psychotropic medication for foster children ranged from 13 percent to 52 percent. Additionally, a 2011 Government Accountability Offi ce report found that 21 percent to 39 percent of foster children received prescriptions for psychotropic medications in 2008, compared with only 5 percent to 10 percent of nonfoster children. According to the American Psychological Association, studies since the 1970s have found that children in foster care often have greater need for mental health treatment than children in the general population. However, given the potential risks associated with psychotropic medications, the higher rates at which they are prescribed to foster children is a cause for concern. 2 Throughout this report, we use the term foster children to refer to children ages zero to 17 in the foster care system. 3 Examples of psychotropic medications include the following brand names: Abilify, Ativan, Cymbalta, Haldol, Prozac, Ritalin, Seroquel, Wellbutrin, Xanax, and Zoloft. 8 California State Auditor Report 2015-131 August 2016 The Prescription of Psychotropic Medications to Children in California’s Foster Care System Questions regarding the prescription of psychotropic medications to foster children are of particular importance to California, which has the largest population of foster children in the country. To determine how many of the State’s more than 79,000 foster children were prescribed psychotropic medications, we used statewide data (state data) from the California Department of Social Services (Social Services) and the Department of Health Care Services (Health Care Services), two key state agencies that work with foster children. As we discuss in Chapter 2, we have concerns about the accuracy and comprehensiveness of the state data; nonetheless, they represent the best information available regarding the number of foster children statewide who were prescribed these medications. As shown in Figure 1, the state data show that nearly 12 percent of California’s foster children received nearly 96,000 prescriptions for psychotropic medications paid by Medi-Cal in fi scal year 2014–15, or an average of about 10 prescriptions per child per year.4 Th e state data show the number of foster children prescribed psychotropic medications paid through Medi-Cal decreased by more than 7 percent from fi scal year 2012–13 to fi scal year 2014–15. At the same time, the number of paid prescriptions for psychotropic medications for these children decreased by nearly 13 percent. Further, our analysis of the state data shows that older foster children were more likely to have paid prescriptions for psychotropic medications than younger ones. Nearly three quarters (74 percent) of the foster children with paid prescriptions for psychotropic medications in fi scal year 2014–15 were aged 12 to 17, compared to less than 2.5 percent aged 5 years or less. Despite the decrease in the overall number of foster children receiving psychotropic medications, state data show that nearly half of these foster children had paid antipsychotic medication prescriptions in fi scal year 2014–15. Antipsychotics pose a particular risk for children because they have a high risk of severe side eff ects. Nevertheless, the state data show that antipsychotics made up nearly 35 percent of all paid prescriptions for psychotropic medications for foster children, as Figure 1 shows. We provide summary data about foster children prescribed psychotropic medications in the Appendix beginning on page 79. 4 The average number of paid prescriptions per foster child may refl ect that some foster children received more than one type of psychotropic medication. Alternatively, it may indicate that some foster children had paid prescriptions of a single medication fi lled a number of times during the year (perhaps on a monthly or bimonthly basis). California State Auditor Report 2015-131 9 August 2016 Figure 1 Statewide Number and Proportion of Children in Foster Care With Prescriptions for Psychotropic Medications Paid for by Medi-Cal During Fiscal Year 2014–15 Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. Foster Children and Health Care Foster care is a social welfare program funded and administered by federal, state, and county governments. Children enter foster care through one of two channels: the child welfare system or the probation system. Within the child welfare system, state law authorizes a juvenile court to declare a child to be a dependent of the court for certain specifi ed reasons that generally involve the parents’ or caregivers’ unwillingness or inability to provide adequate care, including protecting children from physical or sexual abuse. Within the probation system, state law authorizes the juvenile court 10 California State Auditor Report 2015-131 August 2016 to declare a child to be a ward of the court because the child is beyond the control of his or her parent, guardian, or custodian; fails to comply with curfews or attend school; or has committed a crime. State data show that from fi scal years 2012–13 through 2014–15 about 80 percent of California’s foster children with paid prescriptions for psychotropic medications were in the child welfare system, compared to about 20 percent in the probation system. Th e federal Social Security Act requires that, in order to be eligible for federal payment, a state must have a plan for child welfare services that provides foster children with health care, including mental health care services. In addition, Medicaid requires—and helps pay for— the provision of necessary health services, including psychosocial services, to children covered by Medicaid, which includes foster children up to age 21. In response to these requirements, the State provides basic health care to foster children that includes health screenings within 30 days of the children entering foster care; periodic screenings and mental health assessments thereafter; and services, treatments, and medications, as needed. Medicaid funding covers part of the health care costs of foster children, including those related to mental health care services. Its reimbursement levels vary depending upon the type of cost. For example, Medicaid will reimburse 50 percent for the costs of health care services provided to foster children. It will also reimburse 75 percent of the costs for skilled professional medical personnel— such as public health nurses—and their support staff who provide services to the foster care program. Th e State and counties generally provide or acquire the remainder of the necessary funding for foster children’s health care. State funding for psychosocial services for foster children can come from a variety of sources, including state public safety realignment funding from sales taxes, vehicle taxes, and fees. In addition, the Mental Health Services Act imposes a 1 percent tax on income in excess of 1 million to expand mental health services. Counties also provide their own funding and may acquire additional funding through grants. Counties are responsible for ensuring the provision of health care services to foster children. Specifi cally, state law enacted in 2012 moved programmatic responsibility for child welfare services, including the support and care of foster children, from the State to the counties (child welfare services realignment). However, Social Services—which under state law is jointly responsible with the counties for establishing and supporting the child welfare services system—is still responsible for providing oversight and technical assistance to the counties. Under child welfare services realignment, the counties provide psychosocial services through diff erent types of health care systems, as shown in Figure 2. California State Auditor Report 2015-131 11 August 2016 Figure 2 A Child in Foster Care’s Path to Mental Health Services in California Child enters the foster care system through one of two channels. Child Welfare Department Probation Department Actions of adult(s) in child’s life Actions of child result in placement. result in placement. Child placed in out-of-home care: • Foster family home • Group home • Kin/relative home Organizations or individuals offering mental health care services to foster children Medi-Cal Medi-Cal Medi-Cal Medi-Cal State Plan Mental Health Plans Managed Care Plans (fee-for-service) Other: Administered by county Administered by health Providers enrolled and paid • Community health centers. behavioral/mental health plans through contracts by the Department of • Community-based departments through with the Department of Health Care Services. organizations. contracts with the Health Care Services, Department of Health Care providing mental health • Free clinics. Services, providing “specialty services described in • Individual providers mental health” services the contracts. paid by county child described in the contracts. welfare departments. Serving children with Serving children with Serving children with Serving children with various “moderate to severe” mental “mild to moderate” mental “mild to moderate” mental mental health needs. health needs based on health needs based on health needs based on medical-necessity criteria. medical-necessity criteria. medical-necessity criteria. Sources: California laws, state and county agency documents, and the California State Auditor’s review of other information. 12 California State Auditor Report 2015-131 August 2016 Oversight of the Provision of Psychotropic Medications to Foster Children Diff erent levels and branches of government are responsible for overseeing the provision of psychotropic medications to foster children in California. As shown in Table 1, executive branch entities at the federal, state, and county levels oversee foster children who receive psychotropic medications. Further, the judicial branch at the state and county levels also has an oversight role for these foster children. Th e federal government provides oversight of the prescription of psychotropic medications through the U.S. Department of Health and Human Services (Health and Human Services). Before 2011, Health and Human Services provided general guidance to states regarding psychotropic medications and Medicaid benefi ciaries but did not require the states to take any specifi c actions. However, in response to a change in federal law in September 2011, Health and Human Services established certain requirements with which states must now comply. For example, states must now include an outline of their protocols for ensuring the appropriate use and monitoring of psychotropic medications in their Child and Family Services Plans, which set forth the states’ strategic plans for strengthening their overall child welfare systems. Health and Human Services requires states to submit these plans every fi ve years and to submit annual progress and services reports related to their plans in the interim. Health and Human Services then uses information from the Child and Family Services Plans as well as the states’ annual reports as part of the statewide assessment component of the federal child and family services review (federal review), which assesses each state’s child welfare system. Since Health and Human Services’ implementation of the federal review in 1997, it has twice reviewed all the states and is currently reviewing them for the third time. Although California’s past federal reviews have included little discussion of foster children who received psychotropic medications, its third review is likely to more directly address this issue. Specifi cally, California’s most recent federal review, for which Health and Human Services published a report in 2008, included just two references to psychotropic medications: it acknowledged that stakeholders had expressed concerns that foster children had been prescribed psychotropic medications rather than being given adequate psychosocial services, and it mentioned the role of public health nurses in monitoring psychotropic medications. However, California’s upcoming 2016 federal review will include information from its 2015–2019 Child and Family Services Plan, which describes California’s protocols for the appropriate use and monitoring of psychotropic medications. In particular, the protocols address fi ve key components specifi ed by Health and Human Services’ guidance: screening, assessment, and treatment plans; informed and shared decision making; medication monitoring; mental health expertise and consultation; and mechanisms for sharing accurate and up-to-date information. We discuss the State’s and counties’ oversight mechanisms in more detail in Chapter 2 of our report. California State Auditor Report 2015-131 13 August 2016 Table 1 Key Entities and Mechanisms for the Oversight of Psychotropic Medications Prescribed to Children in Foster Care PUBLIC ENTITY OVERSIGHT ROLE FOR FOSTER CHILDREN PRESCRIBED PSYCHOTROPIC MEDICATIONS FEDERAL Executive Branch U.S. Department of Health and Human Services— Provides guidance and instructions to states regarding foster children and Administration for Children and Families & psychotropic medications. Centers for Medicare and Medicaid Services STATE Judicial Branch Judicial Council Provides guidance and instruction—through court rules, template forms, trainings, and some technical support—to county superior courts related to approving psychotropic medications for foster children. Executive Branch California Department of Social Services Oversees and administers programs serving California’s most vulnerable residents. (Social Services) Child and Family Services Division Provides assistance in adoptions, foster care, children’s programs, and child welfare services. In collaboration with the Department of Health Care Services (Health Care Services), Social Services maintains the Health Care Program for Children in Foster Care, a public health nursing program administered by local public health departments to provide public health nursing expertise to ensure the health care needs of children in out-of-home placement or foster care. Community Care Licensing Division Administers the Children’s Residential Licensing Program, which issues licenses to homes and facilities that house foster children. Health Care Services Administers the Medi-Cal program, which includes specialty mental health, managed care, and fee-for-service programs. Clinical Assurance and Reviews and adjudicates treatment authorization requests for medications under Administrative Support Division the Medi-Cal fee-for-service program. Mental Health Services Division Administers, oversees, and monitors community mental health program service delivery and compliance for the Medi-Cal Specialty Mental Health Services program and the Mental Health Services Act. Managed Care Quality and Monitors and oversees California’s Medi-Cal managed care health plans and Monitoring Division Medi-Cal managed care policy development. Pharmacy Benefi ts Division Administers Health Care Services’ Medi-Cal fee-for-service drug program and responsible for the management of the Medi-Cal managed care pharmacy program. Provider Enrollment Division Reviews applications for providers seeking to participate directly or indirectly in the fee-for-service Medi-Cal program. Medical Board of California Licenses and oversees medical doctors, with the authority to investigate and discipline any physicians alleged to have committed acts of wrongdoing. It is currently in the process of acquiring Medi-Cal pharmacy claims data related to foster children and psychotropic medications to review and identify physicians who may have inappropriately prescribed psychotropic medications to foster children. LOCAL—ALL COUNTIES Judicial Branch Superior Court Administers the court authorization review process, which adjudicates requests to administer psychotropic medications to foster children. Executive Branch Child Welfare Department/Divisions Oversees dependents of the court and administers the counties’ foster care programs. Probation Department Oversees wards of the court, including those who are placed into foster care. Mental Health/Behavioral Health Administers county Medi-Cal mental health plans that provide mental health services, Department/Divisions including case management, psychosocial therapies, and psychiatric medication support to Medi-Cal benefi ciaries, including foster children and wards of the court. Sources: California State Auditor’s review of federal and state laws and various agency documents. 14 California State Auditor Report 2015-131 August 2016 Guidelines for the Safe and Appropriate Use of Psychotropic Medications in the Treatment of Foster Children A number of diff erent entities have developed or established guidelines that can help to ensure the appropriate use of psychotropic medications in the treatment of foster children. For example, in 2009 the American Academy of Child and Adolescent Psychiatry (Academy) developed a document titled Practice Parameter on the Use of Psychotropic Medication in Children and Adolescents. Th e purpose of the document was to promote the appropriate and safe use of psychotropic medications in children and adolescents with psychiatric disorders by emphasizing best practice principles that underlie Select Recommendations from the American medication prescribing. Further, in 2012 the Academy of Child and Adolescent Psychiatry Academy developed another document titled A Guide for Community Child Serving Agencies on • Health providers should follow up within at least a month Psychotropic Medications for Children and of a child starting a psychotropic medication. Adolescents. Th e purpose of this document was to • Generally, a child should receive nonpharmaceutical provide entities that serve children, including psychosocial services before starting a psychotropic child welfare and juvenile justice agencies, with medication, and should receive such services when information regarding the role of psychotropic receiving a psychotropic medication. medications in treatment plans for children. Sources: California State Auditor’s review of the American Th roughout our report, we refer to these Academy of Child and Adolescent Psychiatry’s 2009 Practice two documents collectively as academy guidelines. Parameter on the Use of Psychotropic Medication in Children and Adolescents, and its 2012 A Guide for Community Child We summarize the academy guidelines in the Serving Agencies on Psychotropic Medications for Children text box and discuss them in more detail in and Adolescents. applicable sections of our report. Th e State also recently developed its own guidelines for the safe administration of psychotropic medications to foster children. In 2012, Social Services and Health Care Services initiated a statewide quality improvement project to improve techniques for monitoring psychotropic medication use among children in foster care. Th is project included the creation of a clinical workgroup to develop statewide guidelines for the ongoing oversight and coordination of health care services for children in foster care, including protocols and strategies to improve the appropriate use and monitoring of psychotropic medication for these children. In March 2015, as part of this quality improvement project, Social Services and Health Care Services jointly released a document titled California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care (state guidelines), which they consider to be a summary of the best practices for the treatment of children who are placed in foster care. Th e state guidelines represent the fi rst comprehensive eff ort at the state level to address the use of psychotropic medication by children in out-of-home care who are being served by the child welfare and/or probation system. California State Auditor Report 2015-131 15 August 2016 In developing these guidelines, Social Services and Health Care Services reviewed the Academy’s publications, the American Academy of Pediatrics’ policies, California county child welfare and behavioral health policies and practices, and the policies of child welfare and mental health agencies in other states. Th e state guidelines include prescribing standards that counties can, but are not required to, use when Key Standards Within the State’s Guidelines reviewing applications to courts for authorization for Prescribing Psychotropic Medications to prescribe psychotropic medications to foster to Foster Children children. According to Social Services and Health • A foster child should generally not take multiple Care Services, these prescribing standards psychotropic medications within the same represent the current best practices and incorporate class concurrently. evidence-based support. Th e departments do • A foster child should generally be limited to taking a total not intend these prescribing standards to stifl e number of psychotropic medications, regardless of class, independent treatment or care by providers but that is appropriate for his or her age: rather to form a foundation for review, with the goal to ensure that children receive the minimum number FOR CHILDREN AGED: NO MORE THAN: of psychotropic medications necessary in the lowest 0–5 years one psychotropic medication therapeutic doses that are appropriate for their ages. 6–11 years two psychotropic medications 12–17 years three psychotropic medications As shown in the text box, these prescribing standards recommend limiting the number of • A foster child should generally only take psychotropic concurrent psychotropic medications by class that medications within recommended dosage parameters, foster children should take. Th ey also recommend as outlined in the Los Angeles County Department of limiting psychotropic medications by dosage Mental Health’s Parameters 3.8: For Use of Psychotropic and by a child's age. According to the prescribing Medication in Children and Adolescents. standards, counties should identify prescriptions Source: California State Auditor’s review of the California that exceed these limitations and ask prescribers to Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care. submit additional information to justify or explain the prescriptions. Scope and Methodology Th e Joint Legislative Audit Committee (audit committee) directed the California State Auditor to examine state and county agencies’ monitoring and oversight of foster children who have been prescribed psychotropic medications. It also directed us to review the availability and adequacy of other supportive services for foster children, such as mental health and substance abuse counseling. Table 2, beginning on the following page, lists the audit committee’s objectives and the methods we used to address them. Also, rather than publishing this audit report in June 2016 as originally intended, we had to delay publication by two months to allow us time to obtain and analyze additional data from Health Care Services and to revise the report’s text and graphics accordingly. In November 2015, our offi ce began analyzing data originally 16 California State Auditor Report 2015-131 August 2016 provided by Health Care Services in response to our request for all Medi-Cal data related to the provision of psychotropic medications and related psychosocial services to foster children. Th ese data provided the basis for the audit report we intended to publish in June 2016. However, about one week before we were to originally publish our audit report, Health Care Services confi rmed that it had not provided all medical services data that we originally requested. Although it had provided us data for medications, treatment authorizations, and services provided by specialty mental health plans, it had not given us services data for managed care plans or fee-for-service providers.5 Our review showed that the additional June 22, 2016, data consisted of approximately 617 million medical service records. Th e related text and graphics in our audit report refl ect a consolidation of the original more than 46 million medical service records provided by Health Care Services in November 2015 and the additional 617 million medical service records it subsequently provided on June 22, 2016, for a total of more than 663 million claims for medical services. Because the results from the consolidated data did not substantively aff ect the conclusions we reached originally or the recommendations we made, we did not ask the auditees to resubmit their written responses to our June 2016 draft report. Table 2 Audit Objectives and the Methods Used to Address Them AUDIT OBJECTIVE METHOD 1 Review and evaluate the laws, rules, and regulations • We reviewed relevant laws, rules, regulations, and guidelines related to children signifi cant to the audit objectives. in foster care (foster children) and psychotropic medications. • We interviewed key staff at state and county agencies that oversee the administration and approval of psychotropic medications prescribed to foster children. 2 Identify the respective roles in overseeing the mental • We interviewed staff and reviewed relevant documents to identify the health care of foster children of the California Department responsible state entities and the processes they use to oversee psychotropic of Social Services (Social Services), the Department of medications prescribed to foster children. Health Care Services (Health Care Services), county child • For each of the four counties we visited (Los Angeles, Madera, Riverside, and welfare service agencies and probation agencies, as well Sonoma), we interviewed staff and reviewed relevant documents to identify the as the county mental or behavioral health departments county agencies involved and the processes they use to oversee psychotropic that oversee the specialty mental health services that medications prescribed to foster children. foster children receive. Specifi cally identify which agencies are responsible for ensuring that foster children eligible for Medi-Cal are receiving the mental and behavioral health services to which they are entitled under federal and state laws. 5 Please see Figure 2 on page 11 for a depiction of the types of Medi-Cal providers. California State Auditor Report 2015-131 17 August 2016 AUDIT OBJECTIVE METHOD 3 Examine the adequacy and accuracy of data tracked • For our review, we selected 20 foster children overseen by the child welfare by these agencies on whether foster children who are services and probation agencies at each of the four counties we visited, for a being prescribed psychotropic medications also receive total of 80 children. For each of these 80 children, we examined the following: other appropriate nonpharmacological supportive - Hard-copy case fi les and electronic records, if available, at the counties. services, such as counseling. In particular, evaluate - Electronic case fi le information from Social Services’ Child Welfare Services/ whether these data are suffi cient to determine the Case Management System (Social Services’ data system). extent to which foster children are receiving mental health, psychosocial, behavioral health, and substance - Electronic claims information from Health Care Services for psychosocial abuse services. services, psychotropic medications, follow-up visits, and treatment authorization requests. a. Evaluate how the above data are tracked and used, how their accuracy is ensured, and whether • To assess the adequacy and accuracy of the data tracked by Social Services’ data opportunities exist to better gather and use this system, we compared information from all three of these sources. We summarize information. To the extent that barriers exist the results of our review in Table 3 and provide more detailed information in to eff ective data collection and use, identify Chapters 1 and 2, including Table 15 on page 57, of our audit report. potential solutions. • For the purposes of our audit, we limited our review to foster children b. For a selection of foster children at the aged zero through 17. four counties visited, determine how well the • Using relevant criteria and oversight processes identifi ed in Objectives 1 and 2, entities listed in Objective 2 have carried out their we reviewed available documents for the 80 selected foster children to identify applicable responsibilities. Using these results, information related to their fi lled prescriptions for psychotropic medications, if applicable, identify ways in which oversight of their court authorizations or parental consents for psychotropic medications, the these practices could be improved. psychosocial services they were provided, and the follow-up visits they received. • We reviewed the Health and Education Passports for the 80 selected foster children and determined the accuracy and completeness of the information within them. • Using Health Care Services’ data for Medi-Cal claims and treatment authorization requests and documentation from the case fi les, we determined whether Health Care Services received and reviewed treatment authorization requests according to its regulations and policies related to psychotropic medications. • We reviewed data reports identifying potential discrepancies regarding court authorizations and the prescription of psychotropic medications for foster children in the four counties we visited to assess how the State and counties help assure accuracy of the information within Social Services’ data system. • We calculated the number of foster children without a Medi-Cal claim for at least one follow-up medication service within 30 days after fi lling a new psychotropic medication prescription. To do so, we adapted the National Committee for Quality Assurance’s methodology for follow-up care for children with newly prescribed attention-defi cit/hyperactivity disorder (ADHD) medication. Specifi cally, at the recommendation of Health Care Services, we applied this methodology to foster children of all ages who had any new psychotropic medication—not just for children aged six to twelve with a new ADHD medication—and counted follow-up medication services if the prescriber recorded a mental health diagnosis in the Medi-Cal service data. 4 Determine whether any structural defi ciencies, network Using results from our case fi le review described under Objective 3, we identifi ed inadequacies, or adverse incentives exist within the defi ciencies in the oversight process. To identify the causes for these defi ciencies, county child welfare services, behavioral health, or we examined relevant documents and interviewed state and county staff . Medi-Cal systems that may be leading to the overuse of psychotropic medications among foster children. Specifi cally, evaluate whether viable alternatives to these medications are being underutilized because of funding defi ciencies, disincentives, or other identifi able reasons. continued on next page . . . 18 California State Auditor Report 2015-131 August 2016 AUDIT OBJECTIVE METHOD 5 Examine the existing level of oversight of doctors To determine the extent of their involvement in the oversight of prescribing prescribing psychotropic medications to foster children, physicians, we interviewed staff at the Medical Board of California and staff in evaluate whether this oversight is suffi cient to identify ombudsman offi ces within Social Services and Health Care Services and examined and remedy noncompliance with accepted standards relevant documents. of practice, and if appropriate, identify opportunities to strengthen this oversight. 6 Evaluate existing processes used by the courts, the We included the work associated with this objective—examining physician follow up— county child welfare services system, and mental health as part of Objective 3. plans and providers to ensure that ongoing use of psychotropic medication by foster children is monitored for negative reactions, side eff ects, or overdoses. 7 Identify whether county child welfare services agencies We included the work associated with this objective—examining Health and are ensuring that necessary health documentation Education Passports—as part of Objective 3. is being transmitted to caregivers, prescribers, and other stakeholders when foster children receiving psychotropic medication change placement. 8 Determine whether any other states have implemented • We identifi ed and reviewed documents, including bulletins issued by the innovations or oversight systems that have successfully U.S. Department of Health and Human Services, reports, studies, and reduced the use of psychotropic medications journal/media articles regarding practices states have in place for the oversight in foster children or improved their access to of psychotropic medications. nonpharmacological supports, and evaluate whether • We maintained awareness for potential best practices during our review of California could benefi t from some of these policies county oversight processes as part of Objectives 2 and 3. or practices. • Other than certain county practices we describe in Chapter 1, we identifi ed no innovations or oversight practices used by other entities that we would recommend for use in California. 9 Review and assess any other issues that are signifi cant We did not identify any other signifi cant issues. to the audit. Sources: California State Auditor’s analysis of state law, federal law, planning documents, and information and documentation identifi ed in the table column titled Method. Assessment of Data Reliability In performing this audit, we obtained electronic data fi les extracted from the information systems listed in Table 3. Th e U.S. Government Accountability Offi ce, whose standards we are statutorily required to follow, requires us to assess the suffi ciency and appropriateness of computer-processed information that we use to support fi ndings, conclusions, or recommendations. Table 3 describes the analyses we conducted using data from these information systems, our methods for testing, and the results of our assessments. Although these determinations may aff ect the precision of the numbers we present, there is suffi cient evidence in total to support our audit fi ndings, conclusions, and recommendations. California State Auditor Report 2015-131 19 August 2016 Table 3 Methods Used to Assess Data Reliability INFORMATION SYSTEM PURPOSE METHOD AND RESULT CONCLUSION Department of To identify psychosocial and We performed data-set verifi cation procedures and Undetermined reliability Health Care Services medication services through electronic testing of key data elements and did not for these audit purposes. (Health Care Services) Medi-Cal for children in foster identify signifi cant issues. Although this care (foster children) who had determination may We did not perform accuracy or completeness Paid Claims and Encounters paid psychotropic medication testing on these data because the source aff ect the precision of System (PCES), prescriptions fi lled during fi scal documentation is located at various locations the numbers we present, as of November 2015 year 2013–14. throughout the State, making such testing there is suffi cient evidence in total to Health Care Services To identify foster children who cost-prohibitive. support our audit had multiple psychotropic fi ndings, conclusions, California Medicaid medication prescriptions fi lled In our review of the more than 663 million claims and recommendations. Management Information in the same medication class, for Medi Cal services, we found that more System (CA-MMIS), or who had more psychotropic than 2.7 million of these claims—or less than as of November 2015 medication prescriptions fi lled half a percent—did not have suffi cient identifying than recommended by the information for us to determine if the claim was State’s guidelines during fi scal for a child in foster care. We determined that year 2014–15. none of these more than 2.7 million claims were for psychosocial services for children and only 6,155 were for follow-up medication services provided to children between July 1, 2013, and July 31, 2014. Because these claims did not have suffi cient identifying information, such as a social security number, we were not able to determine whether the claim was for a child in foster care. Therefore, we excluded them from our analyses. Health Care Services To identify whether a selection of We performed data-set verifi cation procedures and 80 foster children’s psychotropic electronic testing of key data elements and did not Service Utilization Review, medication prescriptions had identify signifi cant issues. Guidance, and Evaluation approved Treatment Authorization We did not perform accuracy and completeness (SURGE) system, Requests from July 2013 through testing on these data because the SURGE system is as of March 2016 December 2015. a mostly paperless system. Alternatively, we could have reviewed the adequacy of selected application controls, but we determined that this level of review was cost-prohibitive. California Department • To identify foster children in the We performed data-set verifi cation procedures and Not suffi ciently reliable. of Social Services State and in each county for electronic testing of key data elements and did not Although this (Social Services) each fi scal year from 2012–13 identify signifi cant issues. determination may through 2014–15. aff ect the precision of We reviewed existing information to determine Child Welfare Services/ • To calculate various statistics what is already known about the data and found the numbers we present, Case Management related to foster children who that prior audit results indicate there are pervasive there is suffi cient System (CWS/CMS), had psychotropic medication weaknesses in Social Services’ general controls over evidence in total to as of November 2015, prescriptions fi lled during fi scal its information systems. Further, as discussed in support our audit and matched Medi-Cal years 2012–13 through 2014–15. Chapter 2, we observed inaccurate and incomplete fi ndings, conclusions, pharmacy data, • To identify foster children who medical information in CWS/CMS. and recommendations. as of December 2015 had psychotropic medication prescriptions fi lled during fi scal year 2014–15 and who had court authorizations or parental consents to receive medication recorded in CWS/CMS. • To choose a selection of cases for foster children who had psychotropic medication prescriptions fi lled from April 2014 through March 2015. Sources: California State Auditor’s analysis of various documents, interviews, and data from Health Care Services and Social Services. 20 California State Auditor Report 2015-131 August 2016 Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 21 August 2016 Chapter 1 THE COUNTIES HAVE NOT ALWAYS PROVIDED ADEQUATE OVERSIGHT TO ENSURE THE APPROPRIATENESS OF THE PSYCHOTROPIC MEDICATIONS THAT CHILDREN IN FOSTER CARE RECEIVE Chapter Summary In 2015, the California Department of Social Services (Social Services) and the Department of Health Care Services (Health Care Services) adopted guidelines (state guidelines) for the safe administration of psychotropic medications to children in foster care (foster children). Although the state guidelines are a valuable tool that counties should use to ensure that foster children do not receive inappropriate or unnecessary psychotropic medications, some counties have yet to adopt them. Consequently, when we reviewed the case fi les for 80 foster children at the four counties we visited—Los Angeles, Madera, Riverside, and Sonoma—we found that many foster children had been authorized to receive psychotropic medications in quantities and dosages that exceeded the state guidelines. Although exceeding the state guidelines may be medically appropriate in some circumstances, we found no evidence that the counties had followed up with the health care providers in these cases. When counties do not follow up regarding prescriptions that exceed state guidelines, they cannot ensure that they are reducing foster children’s exposure to potentially inappropriate medication interventions. Further, the counties have not always ensured that they followed best practices relating to the health services that foster children should receive in addition to their psychotropic medications. Guidelines from the American Academy of Child and Adolescent Psychiatry (academy guidelines) state that follow-up visits and corresponding psychosocial services are important aspects of mental health treatment. However, the State’s data show that in fi scal year 2013–14, more than 29 percent of the State’s foster children who had a fi lled prescription for a new psychotropic medication did not have a corresponding Medi-Cal claim for a follow-up medication service within 30 days after the prescription was fi lled, thus increasing the risk that any harmful side eff ects would go unaddressed. In addition, a signifi cant number of foster children do not appear to have received psychosocial services around the time of their prescriptions for new psychotropic medications; therefore, the children may not have received the services needed to treat their conditions. 22 California State Auditor Report 2015-131 August 2016 Finally, we found that a signifi cant number of foster children had at least one paid prescription for psychotropic medications without required court approval or parental consent, which is a violation of state law. Specifi cally, 28 of the 80 foster children in our case fi le review had at least one prescription for psychotropic medications without court or parental authorization. Further, when we looked at the state data, we found 65 percent of the foster children statewide with paid prescriptions for psychotropic medications were prescribed at least one psychotropic medication without the appropriate authorization recorded. By Failing to Adopt the State Guidelines, Some Counties May Be Missing an Opportunity to Better Protect Foster Children From the Risks of Inappropriate or Unnecessary Psychotropic Medications As we discuss in the Introduction, Social Services and Health Care Services developed recommended state guidelines in 2015 for the safe administration of psychotropic medications to foster children. By following these guidelines when reviewing health care providers’ requests to prescribe psychotropic medications, counties can better ensure the appropriateness and necessity of the psychotropic medications foster children receive. However, we found that some counties have yet to adopt the state guidelines and thus may be missing an opportunity to better protect the foster children under their care. In developing the state guidelines, Social Services and Health Care Services intended to create a tool that prescribers, pharmacists, and courts could use when reviewing foster children’s prescriptions According to state law, a foster for psychotropic medications. According to state law, a foster child child cannot receive psychotropic cannot receive psychotropic medications without the authorization of medications without the either a juvenile court or the child's parents, depending upon whether authorization of either a juvenile the court has delegated the ability to make such decisions to the child’s court or the child's parents. parents. To receive court authorization, a health care provider must fi ll out an application requesting approval to prescribe the medication. Th e county then reviews these applications and should determine whether the prescription complies with the state guidelines. To the extent that a prescription exceeds the guidelines, the county should follow up with the provider to inquire about the prescription’s medical necessity, if the prescriber did not thoroughly explain this in the application. If the county does not believe a provider has adequate justifi cation for exceeding the state guidelines, the county should recommend to the court that it not authorize the prescription. However, only two of the four counties that we reviewed have adopted either the 2015 state guidelines or very similar guidelines. For example, Los Angeles County adopted guidelines that are very similar to the state guidelines. Like the state guidelines, Los Angeles County’s guidelines generally only allow foster children to be concurrently California State Auditor Report 2015-131 23 August 2016 prescribed one psychotropic medication per class.6 Furthermore, the State adopted Los Angeles County’s dosage parameters as part of its guidelines. Th e only signifi cant diff erence between the two sets of guidelines is that Los Angeles’ guidelines allow three psychotropic Los Angeles’ guidelines allow medications for children nine years and older rather than for children three psychotropic medications who are 12 and older, as the state guidelines recommend. According to for children nine years and older the medical director of Los Angeles County’s Juvenile Court Mental rather than for children who Health Services (LA Juvenile Court Services), Los Angeles’ guidelines are 12 and older, as the state for children aged 9 to 11 diff er from the state guidelines because anxiety guidelines recommend. disorders often manifest in children around the age of nine. In part to ensure that health care providers comply with its guidelines, Los Angeles County established the LA Juvenile Court Services, a unit within its Department of Mental Health. LA Juvenile Court Services assists the juvenile court in making decisions to approve or deny prescribers’ requests to initiate or continue psychotropic medications for foster children. LA Juvenile Court Services’ staff includes a child psychiatrist and a pharmacist, both of whom review each request to ensure its adherence to the county’s guidelines. If a request for medication is outside these parameters, the LA Juvenile Court Services reviewers will generally follow up with the prescriber to determine if the prescription in question is medically necessary. If the reviewers determine that the request is not safe and appropriate, they will recommend that the court either deny the request or approve it for only 45 days, with the expectation that the child’s medication regimen will be changed after that time. Similarly, Madera County relies upon the state guidelines when reviewing prescriptions for psychotropic medications for foster children. For example, the policies of Madera County’s Child Welfare Services Division (Madera Child Services) require the county’s public health nurse to review all requests for court authorizations to identify proposed psychotropic medications that are outside Los Angeles County’s dosage parameters (which are also the parameters the State adopted). In addition, the public health nurse also determines whether prescribers are seeking court approval to prescribe multiple psychotropic medications within the same class or more psychotropic medications than foster children should take based on their age according to the state guidelines. Th e public health nurse documents her review of these and other risk factors on a psychotropic medication monitoring review form. If the public health nurse has concerns about the proposed medications based on the risk factors she has identifi ed, the nurse and the child’s assigned social worker will contact the health care provider. If county staff are unable to resolve their concerns with the provider, they will document their opposition to the prescription authorization request with the court. 6 We describe the classifi cations for psychotropic medications in the Introduction. 24 California State Auditor Report 2015-131 August 2016 In contrast, Sonoma County uses its own standards, which are less specifi c than the state guidelines, when reviewing requests for psychotropic medications. Specifi cally, in May 2015 the Sonoma County Department of Health Services, Behavioral Health Division (Behavioral Health Division) entered into an intracounty memorandum of understanding with the Sonoma County Department of Human Services, Family, Youth and Children’s Division (Children’s Division) to provide pediatric psychiatrists to review requests for court authorization for prescriptions for psychotropic medications for foster children. However, according to the Behavioral Health Division’s Medical Director, the reviewing psychiatrists are expected to ensure that proposed prescriptions adhere to a 1999 county policy rather than to the state guidelines. Although this county policy is consistent with the state guidelines in certain areas, it references another document that contains dosage restrictions based on Los Angeles County’s 1997 dosage parameters rather than the State’s current dosage standards. In addition, the policy does not contain any specifi c age-related restrictions on psychotropic medications. Behavioral Health Divisions’ medical director acknowledged that Sonoma County’s internal policies are outdated, and he stated that the county is in the process of updating its policies to refl ect the guidelines that Social Services and Health Care Services released in 2015. Riverside County also uses its own, less specifi c guidelines when reviewing foster children’s psychotropic medication prescriptions. According to Riverside County’s policies, a Riverside University Health System—Behavioral Health (Riverside Behavioral Health) child and adolescent psychiatrist reviews all requests for court authorization for foster children’s psychotropic medications. However, according to Riverside Behavioral Health’s medical director, the psychiatrist ensures that the prescriptions adhere to a 2011 county policy that diff ers signifi cantly from the state Riverside County’s policy allows guidelines. For example, Riverside’s policy allows the concurrent the concurrent prescriptions prescriptions of two medications within the same class without of two medications within requiring documentation; however, the state guidelines recommend the same class, and the policy that children receive no more than one medication within the does not contain any specifi c same class without justifi cation. Further, unlike the state guidelines, age-related restrictions on Riverside County’s policy does not contain any specifi c age-related psychotropic medications. restrictions on psychotropic medications. Finally, Riverside County’s policy contains specifi c maximum dosage limitations for antipsychotic medications only; it requires all other prescriptions for psychotropic medications to comply with the U.S. Food and Drug Administration’s recommended maximum dosages unless the providers document their reasons for exceeding these limits. According to Riverside Behavioral Health’s mental health services administrator, Riverside County has been working to implement the state guidelines. Riverside County’s Public Health, Behavioral California State Auditor Report 2015-131 25 August 2016 Health, and Public Social Services departments have met and agreed to develop a memorandum of understanding that will adhere to the state guidelines. Riverside County’s Public Social Services department has developed a draft of this memorandum, and Riverside Behavioral Health will off er an amended draft for all three county departments’ consideration after our audit report is released. When counties such as Sonoma and Riverside do not use state guidelines, they miss a valuable opportunity to improve their oversight practices. Not surprisingly, we generally found more instances in Sonoma and Riverside County of authorizations of prescriptions for foster children that exceeded the state guidelines State guidelines are a valuable than we did for Los Angeles and Madera counties. We believe that tool that counties should leverage the state guidelines are a valuable tool that counties should leverage to improve their oversight of to improve their oversight of foster children who are prescribed foster children who are prescribed psychotropic medications. psychotropic medications. Foster Children Throughout the State Have Been Authorized to Receive Amounts of Psychotropic Medications That Exceed the State Guidelines As previously discussed, the state guidelines include maximum amounts and dosages of psychotropic medications that foster children should receive. Nonetheless, when we reviewed the case fi les for 80 foster children at the counties we visited, we found that many had been prescribed psychotropic medications in amounts and dosages that exceeded the state guidelines. Although prescriptions that exceed the state guidelines may be appropriate under some circumstances, we often found little indication that the counties had followed up with the providers in question to ensure the appropriateness of the medications. Further, our review of statewide data (state data) from Social Services and Health Care Services indicates that many foster children prescribed psychotropic medications statewide may have received these medications in excess of the state guidelines. As discussed in the Introduction as well as in Chapter 2, we have concerns about the accuracy and comprehensiveness of the state data. Nevertheless, we used them in our analysis because they are currently the best data available that speak to the number of foster children prescribed psychotropic medications statewide. In response to a recent state law, the Judicial Council of California (Judicial Council) adopted new and revised forms—which became eff ective in July 2016—to be used in the court authorization process for foster children’s psychotropic medications. Th e proper completion of these newly revised forms should provide county staff with additional information necessary to identify instances when foster children are prescribed psychotropic medications 26 California State Auditor Report 2015-131 August 2016 in amounts or dosages that exceed the state guidelines. Among other things, these revised forms require prescribers to explain for each foster child why they prescribed more than one psychotropic medication in a class and dosages that are outside the state guidelines. If these forms are not properly completed, county staff will need to follow up with prescribers to obtain information necessary to ensure that the prescriptions beyond the state guidelines are appropriate. Fourteen Percent of the Foster Children We Reviewed Were Authorized to Receive Multiple Psychotropic Medications From the Same Drug Class Th e state guidelines recommend that a foster child should take no more than one psychotropic medication at a time from each medication class. Common classes of psychotropic medications include antipsychotics, antidepressants, mood stabilizers, stimulants, and antianxiety medications. Th e concurrent use of multiple psychotropic medications from the same class can lead to extremely harmful side eff ects. For example, a foster child taking multiple antidepressants could experience serotonin syndrome, which can be life-threatening and can cause symptoms including high fever, seizures, irregular heartbeat, and unconsciousness. When we reviewed the case fi les for Nevertheless, when we reviewed the case fi les for 80 foster children, 80 foster children, we found that we found that 11 (14 percent) were authorized to simultaneously 11 (14 percent) were authorized take multiple psychotropic medications within the same drug class to simultaneously take multiple during our audit period. As shown in Table 4, fi ve of the foster psychotropic medications within children whose cases fi les we reviewed were authorized by the the same drug class during our courts or their parents to simultaneously take multiple psychotropic audit period. medications within the same class even after the State released its guidelines. All fi ve of these cases were from Riverside and Sonoma counties, which have yet to adopt the state guidelines. Further, none of these fi ve case fi les contained any documentation demonstrating that the counties followed up with providers to question the need for simultaneously prescribing multiple psychotropic medications from the same class. Th e juvenile court in Riverside County authorized the prescriptions in three of these cases, while parents consented to prescriptions for Sonoma County foster children in the other two cases. In one of these cases, a teenaged foster child in Riverside County was prescribed three psychotropic medications at the same time: two antidepressants and a mood stabilizer. In another case, a teenaged foster child in Sonoma County was prescribed two antipsychotics concurrently, which studies have called out as a potentially dangerous combination that should generally be avoided. California State Auditor Report 2015-131 27 August 2016 Table 4 Cases in Which Counties Did Not Have Records That They Questioned Prescriptions That Exceeded the State’s Recommended Guidelines Related to Classes of Psychotropic Medications AT LEAST ONE INSTANCE WHERE PRESCRIPTIONS EXCEEDED GUIDELINES FOR NUMBER OF PSYCHOTROPIC MEDICATIONS WITHIN SAME CLASS BEFORE THE STATE AFTER THE STATE COUNTY PUBLISHED GUIDELINES PUBLISHED GUIDELINES Los Angeles 0/20 cases 0/20 cases Madera 1/20 0/20 Riverside 2/20 3/20 Sonoma 7/20 2/20 Totals 10/80 cases 5/80 cases* 13% 6% Sources: California State Auditor’s analysis of records at county welfare services and behavioral health departments. * We identifi ed four cases in which foster children were prescribed numbers of psychotropic medications that exceeded the State’s recommended guidelines both before and after the State adopted those guidelines. Therefore, a total of 11 (14 percent) of the 80 foster children whose case fi les we reviewed were authorized to simultaneously take multiple medications within the same drug classifi cation during our audit period. Four of these fi ve children had also been authorized to take multiple medications before the State adopted its guidelines. Including these four children, we found a total of 10 foster children who were authorized to take multiple medications before the state guidelines took eff ect. Seven of these children lived in Sonoma County. For three of these children, we did not see any evidence that Sonoma county staff followed up with providers to verify that the concurrent medications were medically necessary before they forwarded the requests to the Superior Court of California, County of Sonoma (Sonoma County Court) for approval. For example, in one of these cases, a foster child was prescribed fi ve diff erent psychotropic medications at the same time, two of which were antipsychotics, yet we did not see any evidence that the county questioned the prescriber on the need to prescribe two antipsychotic medications simultaneously. In the other four instances, the Sonoma County Court delegated to the children’s parent(s) the authority to approve their psychotropic medications. Since Sonoma County does not have a process for reviewing prescriptions that parents authorize, it did not follow up with the prescribers in these cases. According to a program manager in the Children’s Division, Sonoma County plans to expand its current review process—which we described previously—to include prescriptions authorized by parental consent in the future. In addition, similar to the county’s current process for advising the court about the appropriateness of proposed psychotropic medications, the reviewing psychiatrist 28 California State Auditor Report 2015-131 August 2016 should provide these parent(s) an opinion on the effi cacy and appropriateness of proposed medications so that they are able to make a more informed decision about whether to approve these medications for their children. It is imperative that Sonoma County make this change as soon as possible because the state data for fi scal year 2014–15 indicates that more than 20 percent of Sonoma County’s foster children receive parental consent to take psychotropic medications. In contrast, less than 1 percent of Los Angeles, Madera, and Riverside counties’ foster children receive parental consent to take these medications. Further, a deputy director at Social Services stated that foster children should receive the same level of oversight from the county with regard to their psychotropic medications whether a court or parent authorizes the medication. As discussed previously, LA Juvenile Court Services’ staff use guidelines that are nearly identical to the state guidelines to oversee proposed psychotropic medications that require court authorization. Th is is the likely reason that we did not note any instances in the cases we reviewed in which Los Angeles County did not follow up with providers who prescribed foster children multiple medications in the same class. Similarly, we only noted one instance in which a court authorized a Madera County foster child to take multiple medications in the same classifi cation without evidence that the county followed up with the provider, and this instance occurred before the State issued its guidelines, which Madera subsequently adopted. As shown in Table 5, the state data indicate that of the 9,317 foster children with fi lled psychotropic medication prescriptions statewide in fi scal year 2014–15, 851 were prescribed multiple antidepressants at the same time; 330 were prescribed multiple antipsychotics at the same time; and 193 were prescribed multiple stimulants at the same time.7 Th e state data show that a lower percentage of foster children in Los Angeles County who were prescribed psychotropic medications received multiple medications from the same class than the statewide average, likely refl ecting the fact that this county adopted the state guidelines. Conversely, the statewide data indicate that a greater proportion of Sonoma and Riverside county’s foster children who were prescribed psychotropic medications were concurrently prescribed multiple antidepressants compared to the statewide average. For example, nearly 18 percent of Sonoma County’s foster children prescribed psychotropic medications received multiple antidepressants at the same time, which is nearly double the statewide average of 9 percent. Similarly, Riverside County’s percentage of foster 7 The state guidelines state that the antidepressant trazodone is excepted when prescribed as a hypnotic. Because the state data did not identify when trazodone was prescribed as a hypnotic, we did not exclude it. California State Auditor Report 2015-131 29 August 2016 children with fi lled prescriptions for more than one antidepressant at the same time was nearly 12 percent, which is also greater than the statewide average. As discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications for foster children. Th ese forms now require physicians to describe why they prescribed more than one psychotropic medication in a class for the child. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications. Table 5 Number and Proportion of Children in Foster Care With Filled Prescriptions for Multiple Psychotropic Medications in the Same Class, Statewide and for Four Counties, Fiscal Year 2014–15 FOSTER CHILDREN WITH FOSTER CHILDREN WITH FOSTER CHILDREN WITH TOTAL NUMBER OF FOSTER MORE THAN ONE FILLED MORE THAN ONE FILLED MORE THAN ONE FILLED CHILDREN WITH FILLED ANTIDEPRESSANT PRESCRIPTION* ANTIPSYCHOTIC PRESCRIPTION* STIMULANT PRESCRIPTION* PSYCHOTROPIC MEDICATION PRESCRIPTIONS NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT Statewide 9,317 851 9.1% 330 3.5% 193 2.1% Counties We Visited Los Angeles 3,194 267 8.4% 69 2.2% 42 1.3% Madera 21 † † † † † † Riverside 595 71 11.9 26 4.4 † † Sonoma 140 25 17.9 † † † † Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ California Medicaid Management Information System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Note: The term foster children refers to children aged zero to 17 in the foster care system. * For our analysis, we considered foster children to be on more than one psychotropic medication only if they had fi lled prescriptions for more than one psychotropic medication within the same medication classifi cation for more than 30 consecutive days. † To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. Ten Percent of Foster Children We Reviewed Were Authorized to Receive More Psychotropic Medications Than State Guidelines Recommend for Children Their Ages Our review also found that some counties did not follow up with prescribers to ensure that foster children only received psychotropic medications that were appropriate for children of their ages. As explained in the Introduction, state guidelines recommend that children fi ve years old or younger take no more than one psychotropic medication at a time, children aged 6 to 11 take no more than two medications, and children aged 12 to 17 take no more than three medications. 30 California State Auditor Report 2015-131 August 2016 However, as shown in Table 6, eight (10 percent) of the 80 foster children whose case fi les we reviewed had been authorized to take more psychotropic medications than the state guidelines recommended for their ages, yet the counties did not appear to have sought additional justifi cation from the prescribers. By not questioning providers requesting psychotropic medications beyond the guidelines, counties cannot ensure that foster children are taking a number of psychotropic medications that are safe and appropriate for their age. Table 6 Cases in Which Counties Did Not Have Records That They Questioned Prescriptions of Psychotropic Medications That Exceeded the State’s Guidelines for Foster Children’s Ages AT LEAST ONE INSTANCE WHERE PRESCRIPTIONS EXCEEDED GUIDELINES FOR TOTAL NUMBER OF PSYCHOTROPIC MEDICATIONS BY AGE BEFORE THE STATE AFTER THE STATE COUNTY PUBLISHED GUIDELINES PUBLISHED GUIDELINES Los Angeles 2/20 cases 0/20 cases Madera 0/20 0/20 Riverside 2/20 0/20 Sonoma 4/20 1/20 Totals 8/80 cases 1/80 cases* 10% 1% Sources: California State Auditor’s analysis of records at county welfare services and behavioral health departments. * We identifi ed one case in which a child was prescribed psychotropic medications that exceeded the State’s recommended guidelines both before and after the State adopted those guidelines. Therefore, eight (10 percent) of the 80 children whose case fi les we reviewed were authorized to take more psychotropic medications than state guidelines recommend for their ages. Th ese eight cases all occurred before the issuance of the state guidelines. Four of these eight cases were Sonoma County foster children, three of whom received their parents’ approval to take these medications. In fact, one of these Sonoma County foster children had parental authorization to take these medications both before and after the State issued its guidelines. After the State issued its guidelines, the parents authorized this teenaged foster child to take fi ve psychotropic medications at the same time, although state guidelines recommend children that age should receive no more than three. In two of the eight cases, Los Angeles County courts authorized foster children to take a number of psychotropic medications that exceeded the state guidelines for their ages. However, these two instances occurred before the State released its guidelines, and neither involved prescriptions that exceeded Los Angeles County’s guidelines. In one of these cases, a young foster child was prescribed three psychotropic medications at the same California State Auditor Report 2015-131 31 August 2016 time. Although the state guidelines would later recommend that foster children aged 6 to 11 only receive up to two psychotropic medications concurrently, Los Angeles County’s guidelines allow children aged 9 to 17 to receive up to three of these medications. In the second case, a teenaged Los Angeles foster child was prescribed four psychotropic medications concurrently. However, one of the four medications was Cogentin, which Los Angeles County’s guidelines do not count toward the maximum number of psychotropic medications.8 Th e state data show that a signifi cant number of children statewide also had fi lled psychotropic medication prescriptions that exceeded the recommendations in the state guidelines for their ages. As shown In fi scal year 2014–15, 159 children in Table 7 on the following page, the state data indicate that 29 foster in foster care aged 6 to 11 received children aged zero to 5 received more than one fi lled psychotropic more than two fi lled psychotropic medication prescription at the same time during fi scal year 2014–15. medication prescriptions at the Furthermore, the state data show that 159 foster children aged 6 to 11 same time and 90 foster children received more than two fi lled psychotropic medication prescriptions aged 12 to 17 received more than and that 90 foster children aged 12 to 17 received more than three fi lled psychotropic medication three fi lled psychotropic medication prescriptions at the same time. prescriptions at the same time. Los Angeles County’s statistics, shown in Table 7 on the following page, were lower than the corresponding statewide averages while Riverside County’s statistics were higher. Specifi cally, less than half a percent of Los Angeles County’s foster children aged 12 to 17 receiving psychotropic medication prescriptions had more than three of these medications. Conversely, the rate in Riverside County for foster children the same age was 1.8 percent, or nearly double the statewide average. As discussed previously, Los Angeles County uses guidelines that include age-based restrictions on psychotropic medications that are very similar to the state guidelines, while Riverside County does not. Th is likely explains why Los Angeles County’s statistics compare more favorably than Riverside County’s statistics to the statewide average. 8 According to the medical director of Los Angeles County’s Juvenile Court Mental Health Services, the county excluded Cogentin from its standards because it is primarily used to counteract side eff ects of antipsychotics, not to treat symptoms of a mental or behavioral disorder. The state guidelines do not make an exception for Cogentin in determining the maximum number of medications a child may receive. 32 California State Auditor Report 2015-131 August 2016 Table 7 Number and Proportion of Children in Foster Care With Filled Prescriptions for Psychotropic Medications That Exceeded the State’s Recommended Guidelines for Age Groups, Statewide and for Four Counties, Fiscal Year 2014–15 FOSTER CHILDREN AGE 611 FOSTER CHILDREN AGE 1217 WITH MORE THAN TWO WITH MORE THAN THREE TOTAL NUMBER OF FOSTER CHILDREN AGE 05 FILLED PSYCHOTROPIC FILLED PSYCHOTROPIC FOSTER CHILDREN WITH WITH MORE THAN ONE MEDICATION PRESCRIPTIONS* MEDICATION PRESCRIPTIONS* FILLED PSYCHOTROPIC FILLED PSYCHOTROPIC MEDICATION PRESCRIPTIONS MEDICATION PRESCRIPTION* NUMBER PERCENT NUMBER PERCENT Statewide 9,317 29 159 1.7% 90 1.0% Counties We Visited Los Angeles 3,194 † 34 1.1% 14 0.4% Madera 21 † † † † † Riverside 595 † † † 11 1.8 Sonoma 140 † † † † † Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ California Medicaid Management Information System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Notes: State guidelines recommend that children aged zero to 5 take no more than one psychotropic medication, children aged 6 to 11 take no more than two psychotropics medications, and children aged 12 to 17 take no more than three psychotropic medications. The term foster children refers to children aged zero to 17 in the foster care system. * For our analysis, we considered foster children to be on more than one psychotropic medication only if they had fi lled prescriptions for more than one psychotropic medication for more than 30 consecutive days. † To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. Nearly a Quarter of the Foster Children We Reviewed Were Authorized to Take Larger Dosages of Psychotropic Medications Than State Guidelines Recommend Our review of 80 case fi les found that many foster children were authorized to take psychotropic medications in dosages that exceeded the state guidelines without the counties’ adequately documenting that they had contacted the prescribers. As described previously, when Social Services and Health Care Services created the state guidelines, they adopted Los Angeles County’s dosage parameters. Th ese dosage parameters established maximum daily dosages for commonly prescribed psychotropic medications. However, as shown in Table 8, our review of the case fi les for 80 foster children identifi ed 18 foster children (23 percent) for whom the courts or their parents approved at least one psychotropic medication with a maximum daily dosage that exceeded the state guidelines. Ten of these children were authorized to take these medications before the State issued its guidelines. One of these 10 children, along with eight more children, were all authorized to take these medications after the State released its guidelines. We found no evidence in any of these cases that the counties identifi ed these prescriptions as potential problems and questioned the prescribers about the dosages. California State Auditor Report 2015-131 33 August 2016 Table 8 Cases in Which Counties Did Not Have Documentation That They Questioned Providers When Prescriptions Went Beyond the State’s Recommended Guidelines for Dosages AT LEAST ONE PRESCRIPTION EXCEEDED GUIDELINES FOR MAXIMUM DAILY DOSAGE BEFORE THE STATE AFTER THE STATE COUNTY PUBLISHED GUIDELINES PUBLISHED GUIDELINES Los Angeles 0/20 cases 6/20 cases* Madera 1/20 1/20 Riverside 5/20 0/20 Sonoma 4/20 2/20 Totals 10/80 cases 9/80 cases† 13% 11% Sources: California State Auditor’s analysis of county records at welfare services and behavioral health departments. * Because Los Angeles County used the same parameters before the State adopted them, we consider all Los Angeles County dosage exceptions as post-guidelines regardless of when they happened. † Of these nine cases that exceeded the State’s recommended guidelines (state guidelines), one case also occurred before the state guidelines. Therefore, 18 (23 percent) of the 80 foster children whose case fi les we reviewed were authorized to take psychotropic medications with maximum daily dosages that exceeded the state guidelines. Although Social Services and Health Care Services consider the state guidelines to be best practices, they are of little value if counties do not use them. For example, six of the nine cases that occurred after the issuance of the state guidelines involved foster children in Los Angeles County. We fi nd this surprising since the State adopted Los Angeles County’s preexisting dosage standards as part of the state guidelines. In one of these instances, a physician prescribed an antidepressant medication for a foster child with a maximum daily dosage of 30 milligrams, which is 50 percent higher than the state guidelines’ maximum recommended dosage of 20 milligrams. When we asked the medical director of LA Juvenile Court Services in Los Angeles’ County’s Department of Mental Health why county staff did not follow up with this provider, he explained that the county’s practice has been to only review the actual daily dosage rather than the maximum daily dosage. However, he stated that county staff plan to monitor each prescription’s maximum daily dosage moving forward. Because a prescriber may include both an actual daily dosage and a maximum daily dosage when seeking court or parental authorization for a prescription, we are aware that some of the foster children we identifi ed in our review may not have taken psychotropic medications in dosages that exceeded the state guidelines. However, we believe counties should question prescribers when they request maximum daily dosages that exceed the state guidelines because they may then choose to increase the children’s dosage amounts up to the authorized maximum amounts without receiving additional review from the counties, the courts, or the children’s parents. 34 California State Auditor Report 2015-131 August 2016 Neither we nor the State can determine the extent statewide to which foster children’s maximum daily dosages may exceed the state guidelines because the State does not capture data related to the maximum daily dosages of psychotropic medications that foster children are authorized to take. However, we believe it would be benefi cial for the State to capture such information and compare it to the state guidelines. For example, such an analysis would allow the State to identify counties in which high proportions of foster children are being prescribed psychotropic medications in maximum daily dosages that exceed the state guidelines. Th is information would also allow the State to identify potentially problematic prescribing patterns so that it could follow up with the relevant counties. As discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications for foster children. Th ese forms now require physicians to describe why they prescribed dosages that were outside the approved range. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications Because the State lacks data on foster children’s maximum authorized daily dosages of psychotropic medications, we compared the statewide data on prescribed daily dosages to the state guidelines’ maximum dosage parameters. Th e state data show that in fi scal year 2014–15, 523 foster children had 2,389 prescriptions for psychotropic medications with prescribed daily dosages that exceeded the maximum allowable dosages in the state guidelines. Th ese prescriptions represent nearly 2.5 percent of the 95,748 psychotropic medication prescriptions for that year. Although these numbers are fairly small, they indicate that some foster children received psychotropic medications in doses that exceeded the State’s recommended maximum daily dosages, which put these children at higher risk of potentially dangerous side eff ects. A Signifi cant Number of the Foster Children We Reviewed Who Were Prescribed New Psychotropic Medications Did Not Receive Timely Follow-Up Visits With Prescribers or Other Health Care Providers Our review of the 80 case fi les found that one-third of the foster children who were prescribed new psychotropic medications did not receive follow-up care with prescribers or other health care providers in a timely manner. Specifi cally, the academy guidelines state that providers should follow up with patients ideally within Follow-up visits with prescribers or two weeks, but at least within a month, after they start psychotropic other health care providers within medications. Follow-up visits within 30 days are critical because 30 days are critical because adverse adverse side eff ects from these medications are most common side eff ects from psychotropic during the initial trial period. We excluded 13 cases from our medications are most common analysis of follow-up visits because the foster children had been during the initial trial period. authorized to start all of their psychotropic medications before California State Auditor Report 2015-131 35 August 2016 the start of our audit period. However, as Table 9 shows, we found no evidence in the county case fi les or the state data that one-third of the remaining 67 children had follow-up visits with their prescribers or other health care providers within 30 days of fi lling their prescriptions for psychotropic medication or receiving authorization to do so.9 Table 9 Cases in Which Counties Did Not Follow the American Academy of Child and Adolescent Psychiatry’s Guidelines Regarding Follow-Up Appointments With Providers NO EVIDENCE THAT PROVIDERS FOLLOWED UP WITHIN 30 DAYS COUNTY AFTER A FOSTER CHILD STARTED A PSYCHOTROPIC MEDICATION Los Angeles 2/16 cases Madera 8/20 Riverside 7/19 Sonoma 6/12 Total 23/67 cases 34% Sources: California State Auditor’s analysis of county records at welfare services and behavioral health departments, as well as data obtained from the Department of Health Care Services’ Paid Claims and Encounters System. Note: We excluded 13 cases from our analysis of follow-up visits because, in those cases, the foster children were authorized to start all of their psychotropic medications before our audit period. As a result, the foster children may have received follow-up appointments before the audit period. One case in which a foster child did, in fact, have a follow-up meeting with a psychiatrist within 30 days of starting a higher dose of a psychotropic medication illustrates the importance of timely follow-up visits. About three weeks after starting the higher dose of the medication, the child complained of shaking hands and chest pain; on the advice of another doctor, the child stopped taking the medication. When the psychiatrist who had increased the medication dosage met with the foster child within 30 days as the academy guidelines recommend, the psychiatrist determined that the child’s symptoms had greatly worsened since the child stopped taking the medication. In response, the psychiatrist restarted the child’s medication but at a lower dosage. If this follow-up visit had not occurred or had been delayed, this child might have experienced worsening symptoms as a result of discontinuing the medication. 9 Rather than using the ideal two-week time frame, we tested whether the foster children had a follow-up visit with their prescriber or other health care provider within 30 days because we lacked information about the exact dates that the children began taking the medications. Instead, we used the dates the prescriptions were fi lled or—if we did not have that information—we used the dates on which courts or parents authorized the medications. The 30-day time frame allows a two-week buff er in case children did not begin taking the medication immediately after the prescriptions were fi lled or authorized. 36 California State Auditor Report 2015-131 August 2016 Th ree of the four counties we visited off ered similar explanations for the fact that so many foster children did not receive timely follow-up care. For example, a division chief in Los Angeles County’s Department of Children and Family Services indicated that the department supports follow-up appointments with providers within 30 days (or sooner, if indicated) for all foster children on psychotropic medications. However, she also noted that the limited number of child psychiatrists who accept Medi-Cal-insured clients may explain why some foster children did not receive a follow-up visit with their prescriber within 30 days of starting their medication. Similarly, a division manager within Madera County Behavioral Health Services noted that the limited number of child and adolescent psychiatrists make it diffi cult for small counties to schedule follow-up visits with these prescribers. Th e Sonoma County Behavioral Health Division’s medical director also agreed that it is reasonable for psychiatrists to arrange follow-up visits within 30 days of foster children's starting psychotropic medications and stated that the county is in the process of revising its policies to adhere to the academy guidelines as closely as possible. On the other hand, Riverside County Behavioral Health’s medical director stated that child and adolescent psychiatrists are trained extensively in their fi eld and that the county defers to the individual prescriber’s discretion regarding any follow-up on a foster child’s We believe that counties that medications. However, we believe that counties that defer to defer to an individual prescriber’s individual providers are missing an opportunity to better protect discretion regarding any follow-up the foster children under their care. Unless counties ensure that on a foster child’s medications are all foster children who start new psychotropic medications receive missing an opportunity to better follow-up visits with their prescribers within 30 days, they cannot protect the foster children under be certain that the prescribers will monitor the children for their care. potential adverse side eff ects. Th e state data show that the lack of appropriate follow-up care appears to be a statewide problem. As Table 10 illustrates, 1,881 (29 percent) of the 6,471 foster children statewide had fi lled prescriptions for a new psychotropic medication in fi scal year 2013–14 without a corresponding Medi-Cal claim for a follow-up service within 30 days after the prescription was fi lled. We acknowledge that in some of these cases, the foster child may not have shown up for a scheduled follow-up appointment. Th e state data show that Los Angeles County had follow-up appointment rates that were better than the statewide statistics by 14 percentage points. Th ey also indicate that 41 and 51 percent of the foster children in Riverside and Sonoma counties who had a fi lled prescription for a new psychotropic medication did not have a corresponding Medi-Cal claim for a follow-up service within 30 days after the prescription was fi lled. Further, although the state data show that the rate of foster children who had a California State Auditor Report 2015-131 37 August 2016 fi lled prescription for a new psychotropic medication without a corresponding follow-up medication service within 30 days after the prescription was fi lled is 29 percent throughout the state, 15 of the counties referred to in Table A-8 beginning on page 90 in the Appendix had rates that exceeded 50 percent. However, the state data only cover services provided through Medi-Cal, and some of the children may have received follow-up services outside of Medi-Cal. We discuss this issue further in Chapter 2. As discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications for foster children. Th ese forms now require county staff to list the dates of all medication management appointments since the last court hearing. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications. Table 10 Number and Proportion of Children in Foster Care With New Psychotropic Medication Prescriptions Filled in Fiscal Year 2013–14 Without a Corresponding Medi-Cal Claim for a Follow-Up Medication Service Within 30 Days, Statewide and for Four Counties NUMBER OF FOSTER CHILDREN WITH AT LEAST ONE FILLED PRESCRIPTION FOR A NEW PSYCHOTROPIC MEDICATION WITHOUT A CORRESPONDING MEDICAL CLAIM FOR NUMBER OF FOSTER CHILDREN FOLLOWUP MEDICATION SERVICES WITH NEW PSYCHOTROPIC MEDICATION PRESCRIPTIONS* NUMBER PERCENT Statewide 6,471 1,881 29.1% Counties We Visited Los Angeles 2,252 334 14.8% Madera 17 † † Riverside 406 167 41.1 Sonoma 90 46 51.1 Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Note: The term foster children refers to children aged zero to 17 in the foster care system. * We defi ned a new prescription as any prescription for a psychotropic medication that the child had not been prescribed in the prior 120 days and, as discussed in the Scope and Methodology section on page 17, we applied the National Committee for Quality Assurance's methodology for follow-up care. † To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. 38 California State Auditor Report 2015-131 August 2016 Many of the State’s Foster Children Who Were Prescribed Psychotropic Medications May Not Have Received Corresponding Psychosocial Services Both the academy and state guidelines emphasize the importance of providing foster children with alternative treatments in addition to psychotropic medications. Specifi cally, the academy guidelines point out that, while many youth benefi t from psychotropic medications used as part of a comprehensive treatment plan, this plan should include nonmedication interventions as well, if appropriate. In fact, the academy guidelines caution that medication may be overprescribed when insuffi cient attention is paid to other supports and services, such as psychosocial treatments.10 Th e academy guidelines also state that actively pursuing alternative interventions is especially important when the medications can have serious side eff ects and are prescribed over an extended period of time. Similarly, the state guidelines indicate that psychotropic medications should be used in conjunction with psychosocial services. According to the state guidelines, the only exception is when a health care provider terminates a child’s psychosocial services because they have been eff ective but the provider determines that the continued use of medication is necessary to prevent the recurrence of symptoms. Traditionally, psychosocial services are recommended before pharmacological treatment. However, the academy guidelines acknowledge that pharmacological treatments can be initiated before, concurrent with, or after psychosocial services, depending on the available research evidence and needs of the patient. For example, randomized controlled trials suggest that medication management for attention-defi cit/hyperactivity disorder should be the fi rst-line treatment, while medication combined with behavioral treatment may be necessary for optimal outcomes for a child with more complex problems. Conversely, for obsessive-compulsive disorder, the best fi rst option is either cognitive-behavioral therapy, especially if delivered by an expert psychotherapist, or combined treatment (i.e., therapy and medication). However, the academy guidelines also note that although empirically supported psychosocial treatments may be the optimal fi rst step for many disorders, many communities lack skilled providers of such treatments. In these communities, starting treatment with medication may be the best intervention available. We found that many foster children Despite the importance of psychosocial services to children’s may not have received psychosocial overall treatment plans, we found that many foster children services before and after starting may not have received such services before and after starting psychotropic medications. psychotropic medications. We reviewed the case fi les of 67 foster 10 Psychosocial treatments can include behavioral health counseling and therapy, therapeutic behavioral services, crisis intervention, and services provided in a psychiatric health facility. California State Auditor Report 2015-131 39 August 2016 children at the four counties we visited to determine whether they received psychosocial services before and after starting new psychotropic medications. Because the foster children may have received psychosocial services that the counties did not adequately document in their case fi les, we also analyzed the State’s Medi-Cal data for these children to determine whether the Medi-Cal program paid for their psychosocial services. As Table 11 illustrates, our analysis found that between 9 and 15 percent of the 67 foster children did not receive psychosocial services six months before starting psychotropic medications. Furthermore, this evidence also indicates that between 4 and 7 percent of the 67 foster children did not receive psychosocial services within six months after starting medications. Table 11 Cases in Which Children in Foster Care Prescribed Psychotropic Medications Did Not Receive Corresponding Psychosocial Services OF THOSE CASES THAT RECEIVED PSYCHOSOCIAL SERVICES WITHIN 6 MONTHS... NO PSYCHOSOCIAL SERVICES WITHIN 6 MONTHS... ...BEFORE, THE NUMBER THAT ...AFTER, THE NUMBER THAT DID NOT RECEIVE THOSE SERVICES DID NOT RECEIVE THOSE SERVICES ...BEFORE STARTING AT LEAST ...AFTER STARTING AT LEAST WITHIN 30 DAYS BEFORE STARTING WITHIN 30 DAYS AFTER STARTING ONE PSYCHOTROPIC MEDICATION, ONE PSYCHOTROPIC MEDICATION, AT LEAST ONE MEDICATION, AT LEAST ONE MEDICATION, BASED ON COUNTY RECORDS AND BASED ON COUNTY RECORDS AND BASED ON COUNTY RECORDS AND BASED ON COUNTY RECORDS AND COUNTY STATE DATA STATE DATA STATE DATA STATE DATA Los Angeles 1/16–2/16 cases 0/16–1/16 cases 0/15–1/14 cases 0/16–0/15 cases Madera 3/20–4/20 0/20 4/17–5/16 7/20–8/20 Riverside 1/19–2/19 1/19–2/19 3/18–4/17 3/18–4/17 Sonoma 1/12–2/12 2/12 4/11–3/10 4/10 Totals 6/67–10/67 cases* 3/67–5/67 cases* 11/61–13/57 cases† 14/64–16/62 cases‡ 9–15 percent 4–7 percent 18–23 percent 22–26 percent Sources: California State Auditor’s analysis of county records at welfare services and behavioral health departments, as well as data obtained from the Department of Health Care Services’ Paid Claims and Encounters System. Note: As described on page 41, we report a range in the number of foster children who did not receive timely psychosocial services because of diff erences in the procedure codes used by the National Committee for Quality Assurance and the Department of Health Care Services to identify psychosocial services. * We excluded 13 cases from these analyses because, in those cases, the foster children were authorized to start all of their psychotropic medications before our audit period. Therefore, the services may have occurred outside the audit period and we did not review the documentation. † We excluded a number of cases from this analysis because the foster children were either authorized to start all of their psychotropic medications before our audit period or because the foster children did not have psychosocial services within six months before starting at least one of their psychotropic medications. ‡ We excluded a number of cases from this analysis because the foster children were either authorized to start all of their psychotropic medications before our audit period or because the foster children did not have psychosocial services within six months after starting at least one of their psychotropic medications. In addition, counties may not be ensuring that foster children receive the optimal care if those children do not promptly receive the necessary psychosocial services. We evaluated whether the foster children whose fi les we reviewed received services within 30 days of starting psychotropic medications. As Table 11 shows, of the foster children who had received psychosocial services within 40 California State Auditor Report 2015-131 August 2016 the six months before starting psychotropic medications and who started at least one psychotropic medication within our audit period, we found that between 18 and 23 percent did not receive these psychosocial services within 30 days before starting their medications. Of the foster children who received psychosocial services within six months after starting medications and who started at least one psychotropic medication within our audit period, the evidence suggests that between 22 and 26 percent did not receive those services within the fi rst 30 days of starting the medications. When we reviewed the state data to determine the extent to which foster children statewide who had a fi lled prescription for psychotropic medications also received supporting psychosocial services, we found that between 3,965 and 7,489 (41 to 77 percent) of the 9,707 foster children with paid prescriptions for psychotropic medications in fi scal year 2013–14 did not receive corresponding psychosocial services through Medi-Cal both 30 days before and 30 days after receiving psychotropic medications, as shown in Table 12.11 Table 12 Number of Children in Foster Care With Filled Prescriptions for Psychotropic Medications Without a Corresponding Medi-Cal Claim for Psychosocial Services, Statewide and for Four Counties, Fiscal Year 2013–14 NUMBER OF FOSTER CHILDREN FOSTER CHILDREN WITH WITH AT LEAST ONE INSTANCE OF NO SERVICE WITHIN... FILLED PRESCRIPTIONS FOR PSYCHOTROPIC ...30 DAYS BEFORE OR AFTER, ...180 DAYS BEFORE OR AFTER, MEDICATIONS FILLING A PRESCRIPTION FILLING A PRESCRIPTION Statewide 9,707 3,965–7,489 1,564–4,512 Counties We Visited Los Angeles 3,267 742–2,185 204–994 Madera 23 * * Riverside 600 385–556 146–363 Sonoma 142 98–* 56–98 Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Note: The term foster children refers to children aged zero to 17 in the foster care system. In addition, as described on page 41, we report a range in the number of foster children who did not receive timely psychosocial services because of diff erences in the procedure codes used by the National Committee for Quality Assurance and the Department of Health Care Services to identify psychosocial services. * To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. 11 To determine an approximate start date for the psychotropic medications, we used the date the medication was fi lled at the pharmacy. California State Auditor Report 2015-131 41 August 2016 We report a range in the number of foster children who did not receive psychosocial services because of diff erences in the way psychosocial services are identifi ed in the state data. We based the high estimate in our range on the defi nition of psychosocial services contained in the Healthcare Eff ectiveness Data and Information Set (HEDIS), a set of health care performance measures developed by the National Committee for Quality Assurance and used by more than 90 percent of the health care plans in the United States. However, Health Care Services uses an expanded version of the HEDIS defi nition of psychosocial services—which includes services provided by certain mental health professionals and billed as comprehensive community support services or provided at federally qualifi ed health centers or rural health clinics—which is refl ected in the low estimate in our range. Th e chief medical information offi cer of Health Care Services noted that the HEDIS defi nition does not count community support services as psychosocial services. However, she stated that mental health professionals such as psychiatrists and licensed clinical social workers provide most of the community support services in California and should therefore be counted as a psychosocial service. Further, the services provided at federally qualifi ed health centers or rural health clinics that Health Care Services includes in its defi nition are provided by this same group of mental health professionals. Consequently, our analysis estimates the likely range in which foster children who took psychotropic medications also received psychosocial services through the Medi-Cal program based on both the HEDIS and Health Care Services' defi nition of psychosocial services. In addition, the state data used in our analysis only include those services for which Medi-Cal paid and does not include services paid for outside of Medi-Cal. Further, although children may enter and exit the foster care system on multiple occasions over time, we did not adjust our calculations to account for this. Information from the California Child Welfare Indicators Project for 2013 indicated that 75 percent of foster children had lengths of stay in their last foster care placement of 7.7 months or longer.12 Finally, as discussed earlier, the Judicial Council adopted new The Judicial Council of California and revised forms to request court authorization of psychotropic (Judicial Council) adopted new medications for foster children. Th ese forms place an increased and revised forms—which became emphasis on the provision of psychosocial services to these children. eff ective in July 2016—that For example, the forms now require prescribing physicians to providers must use to request court provide more detailed information about the psychosocial services authorization of psychotropic foster children previously received. In addition, the forms now medications for foster children. require social workers and probation offi cers to identify the specifi c 12 The California Child Welfare Indicators Project is a collaborative venture between the University of California, Berkeley School of Social Work and Social Services that makes available child welfare administrative data to policymakers, child welfare workers, and the public on a website. 42 California State Auditor Report 2015-131 August 2016 psychosocial services that foster children received in the past six months, as well as to indicate the types of therapeutic services the children are enrolled in or are recommended to participate in during the next six months. Although the Judicial Council’s changes to the court authorization forms place increased emphasis on the psychosocial services provided to foster children, we believe additional steps are necessary. Specifi cally, counties must develop and implement stronger procedures to ensure that foster children who are prescribed psychotropic medications consistently receive corresponding psychosocial services. In addition, the counties must adequately document these services so that caregivers can better monitor the children, as we will discuss in further detail in Chapter 2. In Violation of State Law, More Than a Third of the Foster Children We Reviewed Received At Least One Prescription for Psychotropic Medications Without Required Court Approval or Parental Consent Counties do not always obtain required court or parental approval before foster children Information Required With Applications receive psychotropic medications. As previously for Court Authorization to Administer discussed, state law requires that juvenile courts Psychotropic Medications either authorize the administration of psychotropic • A description of the child’s psychiatric diagnosis to medications for foster children or delegate that be treated with the medication. authority to the children’s parents upon fi ndings on the record that the parents pose no danger to • The proposed medication to be administered along the children and have the capacity to authorize with a maximum daily dosage and length of time for the course of treatment. psychotropic medications. Although California rules of court allow for the administration of • The anticipated benefi ts and possible side eff ects psychotropic medications without prior court associated with using the medication. authorization in emergency situations, even • A list of any other drugs that the child is currently in emergency situations physicians must seek taking and a description of any eff ect these authorization no more than two "court days" after drugs may produce in combination with the administering the medications. psychotropic medication. • A description of any other therapeutic services A physician seeking court authorization to prescribe related to the child’s mental health status. a psychotropic medication to a foster child must submit the application forms developed by the • A statement that the child has been informed in Judicial Council for that purpose. As shown in the an age-appropriate manner of the recommended course of treatment, the basis for it, and its text box, the application must include a number of possible results, along with the child’s response to items to help the court decide how to adjudicate the the information. request. A parent or guardian, or others as allowed by the court’s rules, may fi le an opposition to the Source: California Rules of Court, Rule 5.640, in eff ect before July 2016 for the period covered by our testing. request with the court. Based on the information in the application and any opposition to the request, the court may grant authorization without a hearing. Alternatively, it can schedule a hearing, at which it California State Auditor Report 2015-131 43 August 2016 may grant, deny, or modify the application. At that time, it may also set a date for review of the child’s progress and condition. A court order to authorize a psychotropic medication is eff ective for 180 days unless the court terminates or modifi es it sooner. However, when we reviewed the 80 case fi les we selected, we found that more than a third of the foster children had at least one prescription for psychotropic medications without court authorization or parental consent. Specifi cally, 23 (34 percent) of the case fi les of the 67 foster children who should not have received psychotropic medications without court approval lacked evidence of such approval for at least one of the psychotropic medications that the child was prescribed, as shown by Table 13. For example, we identifi ed one foster child who was prescribed both an antipsychotic medication and an antidepressant medication without receiving prior court approval. Further, fi ve (38 percent) of the case fi les for 13 foster children who should have received parental consent before taking psychotropic medications lacked evidence of consent for at least one of the psychotropic medications prescribed for the child. In fact, one of these case fi les did not contain evidence of parental consent for six of the child’s psychotropic medications. Table 13 Counties Did Not Always Have Approvals for Psychotropic Medications Prescribed to Children in Foster Care NO DOCUMENTATION OF NO DOCUMENTATION OF COURT AUTHORIZATION FOR PARENTAL CONSENTS FOR LATE COURT AUTHORIZATION FOR PRESCRIPTION FOR AT LEAST ONE PSYCHOTROPIC AT LEAST ONE PSYCHOTROPIC AT LEAST ONE PSYCHOTROPIC PSYCHOTROPIC MEDICATION COUNTY MEDICATION PRESCRIPTION MEDICATION PRESCRIPTION MEDICATION PRESCRIPTION* FILLED PRIOR TO AUTHORIZATION Los Angeles 8/18 cases 2/2 cases 4/18 cases 2/20 cases Madera 6/20 0/0 6/20 3/20 Riverside 6/20 0/0 7/20 3/20 Sonoma 3/9 3/11 3/9 4/20 Totals 23/67 cases 5/13 cases 20/67 cases 12/80 cases 34% 38% 30% 15% Sources: California State Auditor’s analysis of county records at welfare services and behavioral health departments, as well as data obtained from the Department of Health Care Services’ Paid Claims and Encounters System. * We defi ned late court authorizations as either counties not obtaining a renewed court authorization within 180 days for continuing psychotropic medications, or not seeking a court authorization within two court days of the emergency administration of psychotropic medications to a foster child. Further, we attempted to compile statewide data, however Social Services' data is not formatted in a way that allows us to defi nitively identify if court authorizations or parental consents are associated with a specifi c psychotropic medication. As a result, we analyzed the statewide data to identify the frequency with which court authorizations or parental consents existed for any medication and if that consent was either 180 days before or 30 days after 44 California State Auditor Report 2015-131 August 2016 the psychotropic medication prescription was fi lled. As Table 14 illustrates, more than 65 percent of the 9,317 foster children that the state data show as having had paid prescriptions for psychotropic medications in fi scal year 2014–15 were prescribed at least one psychotropic medication for which Social Services’ data system lacks any record of court or parental approval. In fact, more than 3,400 (37 percent) of these children had no court authorization or parental consent recorded in Social Services’ data system for any of their psychotropic medications. Th ese outcomes were even more pronounced at the four counties we reviewed— more than 20 percent to nearly 78 percent of the prescriptions at these counties lacked records of consent. We acknowledge that both the counties’ case fi les and the state data related to court authorizations and parental consents may be incomplete; in fact, we discuss the defi ciencies in the state data in Chapter 2. Nonetheless, our analyses strongly suggest that a sizeable number of foster children were prescribed psychotropic medications without prior court authorization or parental consent. Table 14 Number and Proportion of Children in Foster Care With Filled Prescriptions for Psychotropic Medication by Type of Approval Recorded in Social Services’ Data, Statewide and for Four Counties, Fiscal Year 2014–15 TYPES OF CONSENT NO COURT AUTHORIZATION COURT AUTHORIZATION OR NO COURT AUTHORIZATION OR OR PARENTAL CONSENT TOTAL NUMBER OF PARENTAL CONSENT FOR ALL PARENTAL CONSENT FOR ANY FOR ONE OR MORE FOSTER CHILDREN WITH PSYCHOTROPIC MEDICATIONS PSYCHOTROPIC MEDICATIONS PSYCHOTROPIC MEDICATIONS FILLED PRESCRIPTIONS FOR PSYCHOTROPIC MEDICATIONS NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT Statewide 9,317 3,232 34.7% 3,448 37.0% 6,085 65.3% Counties We Visited Los Angeles 3,194 920 28.8% 1,475 46.2% 2,274 71.2% Madera 21 * * * * * * Riverside 595 300 50.4 121 20.3 295 49.6 Sonoma 140 31 22.1 65 46.4 109 77.9 Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. Notes: The term foster children refers to children aged zero to 17 in the foster care system. * To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. We also found that the counties we visited did not always obtain court authorizations for psychotropic medications in a timely manner. As previously mentioned, court authorizations for psychotropic medications are only eff ective for up to 180 days. For a foster child to continue to receive a psychotropic medication after six months, the county must seek to renew the court’s authorization. Furthermore, a foster child in an emergency situation may take psychotropic medications without an authorization; California State Auditor Report 2015-131 45 August 2016 however, the court must receive a request for authorization within two days after the child starts the medication. If counties do not seek court authorization within two days, the foster child is taking psychotropic medications without proper approval. However, our review of the case fi les for the 67 children who required court authorization for their psychotropic medications found that 20 (30 percent) contained court authorizations that counties had obtained from 12 days to more than seven months late. In fact, in one case, Madera County renewed the court’s authorization for three of a child’s medications seven months late. In this instance, staff stated that the county opposed one of the proposed medications, and because of delays in the process, the county never followed up to ensure the other requested medications were approved. When counties do not seek to obtain court approvals in a timely manner, they deprive courts of the opportunity to assess whether ongoing psychotropic medications are necessary and safe for foster children to receive. Moreover, weaknesses in the court and parental authorization processes could lead to foster children receiving psychotropic medications before the prescriptions are approved. For example, as Figure 3 on the following page shows, the processes used at the four counties we visited allow providers to write prescriptions for psychotropic medications at the same time they request authorization from the courts or parents. Th e caregivers of the foster children could then take the prescriptions to pharmacies to be fi lled. In fact, 12 (15 percent) of 80 case fi les we reviewed contained instances in which foster children’s caregivers fi lled their prescriptions before they were authorized. When we asked what mechanisms prevent children from taking their medications without the necessary authorizations, staff at three of the counties asserted that their caregivers are responsible for ensuring that they administer the psychotropic medications only after the prescriptions are authorized. Alternatively, Madera County Social Services’ deputy director stated that he believes social workers are ultimately responsible for ensuring that foster children do not take psychotropic medications that are not yet approved. Given the results of our case fi le review, we believe that better Better safeguards are necessary safeguards are necessary to prevent children from taking to prevent children from taking psychotropic medications without the legally required approvals. psychotropic medications without For example, counties could create a process in which the caregiver the legally required approvals. notifi es a foster child’s social worker or public health nurse when the child is ready to start a psychotropic medication. Th e social worker or public health nurse could then determine whether court or parental authorizations exist for the medication, and inform the caregiver about whether the foster child can start the psychotropic medication. Th is process would also allow counties to obtain more accurate medication start dates, an issue that we discuss in 46 California State Auditor Report 2015-131 August 2016 Chapter 2. By ensuring that caregivers know when to properly administer psychotropic medications to their foster children, counties can gain better assurance that foster children do not take psychotropic medications before those prescriptions are approved. Figure 3 Psychotropic Medication Oversight of Children in Foster Care Child Court Authorization Request Process* Request to administer psychotropic medication Child Welfare Services Worker / Public County Approval Health Nurse Caregiver Physician Coordinators† Courts Treatment Authorization Request Process Request treatment authorization (if applicable) Approval Department of Pharmacist Health Care Services sretsinimdA noitacidem Coordinate health care sesnepsiD noitacidem C o or dinate health care M edical a p p o in tm e n t Paper prescription Court authorization n o pti escri pr nic Electro Sources: California State Auditor’s analysis of state laws and regulations, county policies and procedures, and interviews with county offi cials at Los Angeles, Madera, Riverside, and Sonoma counties. Note: We use the term foster children to refer to children aged zero to 17 in the foster care system. * The court may delegate its authority to administer psychotropic medications to a foster child’s parents, which removes the court authorization process. † County coordinators include social workers, probation offi cers, public health nurses, and other county staff who coordinate gathering the court authorization request documents to provide to the courts. Because most counties we visited identifi ed the caregiver as the point of control in the administration of psychotropic medications to foster children, the entity that oversees the caregivers should logically be responsible for providing instructions related to those medications’ authorization. Social Services’ Community Care Licensing Division—specifi cally, its Children’s Residential Licensing California State Auditor Report 2015-131 47 August 2016 Program (Licensing Program)—issues licenses to homes and facilities that house foster children and performs inspections of those homes to ensure they provide a safe and healthy environment. Th e Licensing Program created a medications guide specifi c to group homes that includes detailed information concerning psychotropic medication use and explains the court authorization process. According to a program manager, the Licensing Program posted this medication guide on its website on December 31, 2015. She indicated that the Licensing Program is currently creating a similar guide for foster family agencies and homes. By issuing clear, detailed instructions to caregivers in all types of facilities, the State can better ensure that foster children do not receive psychotropic medications without or before approval. Two of the counties we reviewed also recently implemented processes that may help mitigate the issues we found related to missing or late court authorizations. Specifi cally, in July 2015, Riverside County hired a public health nurse whose primary responsibility is to monitor and ensure compliance with the court authorization process at both a case level and a systemic level. Th e public health nurse produces a monthly report for Riverside County’s Department of Social Services summarizing the number of court authorizations that have lapsed without renewals. Similarly, in November 2015 Sonoma County started to track expiring court authorizations and parental consents to help ensure foster children have current approvals for psychotropic medications. A program development manager from Sonoma County Family, Youth and Children Division creates monthly summary reports of foster children prescribed psychotropic medications from Social Services’ Child Welfare Service Case Management System and provides the reports to social worker supervisors and their managers for follow up. Despite Sonoma County’s recent positive steps, we remain concerned about its problematic practices for obtaining parental consent for psychotropic medications. As mentioned earlier, Sonoma County used parental consent far more frequently than most other counties in fi scal year 2014–15. Sonoma County told us that its use of parental consent is in line with its local legal culture to keep parents involved in their children’s lives. Consequently, its social workers generally advocate to the court to delegate authorization of psychotropic medications to the parents. As a Most counties recorded parental result, Social Services’ data show that most counties recorded consent for 1 percent or less of their parental consent for 1 percent or less of their foster children, foster children, whereas Sonoma whereas Sonoma County recorded parental consent for more than County recorded parental consent 20 percent. for more than 20 percent. 48 California State Auditor Report 2015-131 August 2016 According to a deputy director at Social Services, a county may have valid reasons for having parents consent for a foster child’s psychotropic medications. However, Sonoma County currently does not follow its policy related to obtaining parental consent for psychotropic medications. Specifi cally, the Sonoma County Family, Youth and Children Division purportedly operates under a 16-year-old policy related to parental consent, fi rst adopted in response to the statutes that established the requirement. Among other things, the policy states that social workers will mail parents copies of physician recommendations for medications along with consent forms—a process that would clearly document the request for medications and the parents’ consent. However, according to a Sonoma County division director, the county does not follow this policy. Instead, prescribing physicians must work with the parents directly to obtain their informed consent. Th is process seems problematic, since it is unclear how physicians would know whom to contact if caregivers bring the children to appointments. Contrary to what the department director indicated, a program manager stated the county’s practice is that social workers obtain parental consent, verbal or otherwise, and then record the consent into Social Services’ data system every six months. Recommendations Counties To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should take the following actions: • Implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specifi c age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children’s case fi les. In instances in which counties do not believe that prescribers have adequate justifi cation for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents. • Ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication. California State Auditor Report 2015-131 49 August 2016 • Implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications. • Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. Th e process should also ensure that the counties better document the court authorizations and parental consents in the foster children’s case fi les. • Develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. Th is process should also ensure that the counties obtain accurate medication start dates from caregivers. Riverside County To improve its oversight of foster children who are prescribed psychotropic medications, Riverside County should take the following actions: • Immediately adopt the state guidelines for its physicians’ use when prescribing psychotropic medications and for the county's use when reviewing court authorization requests. • Continue to use its new tracking process to better ensure that court authorizations are renewed within 180 days. Sonoma County To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should take the following actions: • Immediately adopt the state guidelines for its physicians’ use when prescribing psychotropic medications and the county’s use when reviewing court authorization requests. • Within six months, implement a process to review psychotropic medications that receive parental consent rather than court authorization. • Update its policies to describe methods for obtaining and documenting in the foster children's case fi les parental consents for psychotropic medications. 50 California State Auditor Report 2015-131 August 2016 California Department of Social Services To better ensure that counties only use parental consent in place of court authorization when it is appropriate, Social Services should assess Sonoma County’s practice of advocating to the juvenile court that it delegate to parents the authority to administer psychotropic medications to foster children. To better ensure that all caregivers are informed and educated regarding the use of psychotropic medications and the court authorization process, Social Services should develop instructions regarding these topics and provide them to caregivers, such as foster family agencies, that do not operate group homes. California State Auditor Report 2015-131 51 August 2016 Chapter 2 FRAGMENTED OVERSIGHT AND POOR DATA HAVE HAMPERED STATE AND COUNTY EFFORTS TO ENSURE THE APPROPRIATE PRESCRIBING OF PSYCHOTROPIC MEDICATIONS TO CHILDREN IN FOSTER CARE Chapter Summary As described in the Introduction, California’s current government structure for overseeing psychotropic medications prescribed to children in foster care (foster children) is fragmented, with state and local executive and judicial branch entities performing various functions. Although these entities have made some eff orts to collaborate, the State’s approach provides little system-level oversight to help ensure that the entities’ eff orts actually work as intended. Further, the State has not developed a comprehensive oversight plan that identifi es each of its various oversight mechanisms and describes how these mechanisms should work together. Th e State’s fragmented oversight structure has contributed to the problems we identifi ed in Chapter 1 and has led to other weaknesses in the monitoring of foster children’s psychotropic medications as well. For instance, at the four counties we visited, many foster children’s Health and Education Passports—critical health summary documents that follow foster children should their placement change—contained omissions and errors in their health information. Specifi cally, the Health and Education Passports for all 80 of the foster children whose case fi les we reviewed had incorrect start dates for psychotropic medications. Further, many of these Health and Education Passports did not identify all the psychotropic medications that the courts authorized, and none contained complete summaries of the psychosocial services that the foster children had received. When Health and Education Passports contain inaccurate and incomplete health information, health care providers and caregivers may not have critical information that they need to make sound health care decisions for the foster children in their care. Further, inaccurate and incomplete information hampers the State’s and counties’ oversight eff orts. We also found weaknesses in the State’s oversight of the counties, physicians, and pharmacists who are involved with foster children’s mental health care. Th e California Department of Social Services (Social Services) only recently began examining psychotropic medications prescribed to foster children through its California Child and Family Services Reviews (California reviews) of the counties. Further, the Medical Board of California (Medical Board) does not currently take steps to proactively identify 52 California State Auditor Report 2015-131 August 2016 physicians for further investigation who might have inappropriately prescribed psychotropic medications to foster children. Finally, the Department of Health Care Services (Health Care Services) has not programmed its claims system to prompt pharmacists to submit treatment authorization requests for psychotropic medications that are prescribed for off -label use—a use that has not been approved by the U.S. Food and Drug Administration—to ensure the prescriptions’ medical necessity. Due to its insuffi cient oversight, the State has reduced assurance that health care providers are reasonably prescribing psychotropic medications to foster children. The Fragmented Structure of California’s Child Welfare System Has Contributed to Weaknesses in the Oversight of the Prescription of Psychotropic Medications to Foster Children We believe that the fragmented structure of California’s child welfare system lessens the State’s assurance that psychotropic medications are appropriately prescribed to foster children. As the Introduction explains, oversight of psychotropic medications prescribed to foster children is diff used among multiple government levels and branches. Consequently, executive and judicial branch agencies at the state and local levels share responsibilities for administering and overseeing diff erent aspects of the provision of psychotropic medications to foster children. However, by increasing their current levels of collaboration, the various government agencies involved in child welfare services could improve their oversight and better address many of the problems we discuss later in this chapter and in Chapter 1. Given the splintered nature of California’s administration of foster care and oversight of psychotropic medications for foster children, we expected to fi nd that the State had a comprehensive oversight plan. Ideally, this plan would describe the State’s various oversight mechanisms, the public entities responsible for California’s oversight approach for employing those mechanisms, and the tools in place to ensure its administration of foster care that these entities work individually and collectively to ensure that and monitoring of psychotropic psychotropic medications are prescribed properly to foster children. medications appears to be However, we found no such plan. Despite some collaborative eff orts piecemeal with little system-level of the public entities involved, California’s oversight approach to oversight to help ensure that the date appears to be piecemeal with little system-level oversight collective oversight eff orts produce to help ensure that the collective oversight eff orts produce measureable, desirable results. measureable, desirable results. Social Services created the closest thing to a comprehensive plan that we were able to identify. Specifi cally, Social Services summarized certain existing eff orts to oversee the prescription of psychotropic medications to foster children as part of its 2015–2019 Child and Family Services Plan (state plan) required California State Auditor Report 2015-131 53 August 2016 by the federal government. Within this state plan, Social Services included a section covering the oversight of prescription medicines, including psychotropic medications. Social Services identifi ed four critical components of the State’s oversight of prescription medicines: • Public health nurses, who are responsible for ensuring that foster children have current records of their prescribed medications and that their medication information is documented in their Health and Education Passports and in Social Services’ Child Welfare Services/Case Management System (Social Services’ data system), as we will discuss later in this chapter. • Juvenile courts, which are responsible for authorizing prescriptions for psychotropic medications for foster children. • Th e Quality Improvement Project, which began in 2012 and whose goals include reducing the inappropriate prescribing of multiple psychotropic medications to foster children and supporting the use of psychosocial services in lieu of medications. • Outcome Measure 5F, which uses information recorded in Social Services’ data system to track the proportion of foster children for whom the courts have authorized psychotropic medications. Although these components may play a role in the oversight of the prescription of psychotropic medications to foster children, they do not as a whole represent the sort of comprehensive, systemwide eff ort that could best ensure that children do not receive these medications unnecessarily. Other states have taken more streamlined approaches to their oversight of psychotropic medications prescribed to foster children. According to its 2015–2019 Child and Family Services Plan, Texas has dedicated specialized staff within its Department of Family and Protective Services to coordinate and oversee health care services for foster children, including a medical director who is a child and adolescent psychiatrist and who coordinates with Texas’ health care plan to ensure the appropriate prescribing of psychotropic medications. In contrast to California, which provides In contrast to California, which psychosocial services through multiple Medi-Cal mental health provides psychosocial services plans, various Medi-Cal managed care plans, and fee-for-service through multiple Medi-Cal mental providers, its Child and Family Services Plan states that Texas health plans, managed care plans, contracts with a single health plan in which all Texas foster and fee-for-service providers, Texas children are enrolled. Further, Texas requires the health plan to contracts with a single health plan oversee the administration of psychotropic medications to foster for all foster children. children to ensure compliance with that state’s requirements. Th ese requirements identify utilization parameters, maximum dosage amounts, warnings about side eff ects, and nine criteria that trigger 54 California State Auditor Report 2015-131 August 2016 further review of children’s clinical status and care. Further, Texas’ health plan also includes a psychotropic medications utilization review process that allows it to identify and investigate physicians who consistently prescribe outside the state’s utilization parameters. Another state with a single public entity responsible for oversight is Illinois. By law, the Illinois Department of Children and Family Services (department) is responsible for consenting to the medical, surgical, and psychiatric care for children and adolescents in its custody. To meet these responsibilities related to the prescription of psychotropic medications, the department established a medication consent program. To support the consent process, the department contracted with a university to independently review all consent requests from clinicians to prescribe psychotropic medications to children in their care. Furthermore, Illinois includes in its Administrative Code—the equivalent of the California Code of Regulations—guidelines regarding the use of psychotropic medications for children in foster care. Th e Illinois guidelines contain similar clinical parameters to those in the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care (state guidelines). However, while Illinois’ guidelines are an appendix in its state regulations that specifi cally direct Illinois’ child welfare department to oversee administration of psychotropic medications, California simply makes its guidelines available to counties for their use. Foster Children’s Health and Education Passports Contained Incomplete and Inaccurate Mental Health Data Health and Education Passports are critical documents that summarize health and education information for foster children. Nonetheless, our review of 80 case fi les at the four counties we visited—Los Angeles, Madera, Riverside, and Sonoma—found that many children’s Health and Education Passports were incomplete We found that many Health and inaccurate. For example, many of these Health and Education and Education Passports did Passports did not include foster children’s psychosocial services not include foster children's or authorized psychotropic medications. As a result, individuals psychosocial services or authorized and agencies involved with the foster children may be unaware of psychotropic medications. important components of their mental health histories. Absent such information, caregivers, health care providers, judicial offi cers, or county staff could make inappropriate or harmful health care decisions, such as prescribing new psychotropic medications that could interact harmfully with those a child is already receiving. Furthermore, inaccurate and incomplete data hamper the State’s ability to ensure that foster children only receive medications that are safe and medically necessary. California State Auditor Report 2015-131 55 August 2016 Counties Often Did Not Adequately or Accurately Record Information About Foster Children’s Psychotropic Medications in Social Services’ Data System State law requires that every foster child’s case plan include a summary of his or her health and Health and Education Passport Information education information, as shown in the text box. State law specifi es the contents of a Health and Education According to state law, county staff must provide the Passport or summary required for each foster child. The summary to the foster child’s caregivers within relevant health information includes the following: 30 days of placement and update the summary before each court date or within 48 hours of a change • Names and addresses for the child’s health care in placement. Although state law allows counties to providers, including mental health care providers. maintain the summary in the form of a Health and • Immunizations and allergies. Education Passport, it does not require it; however, • Known medical problems. the four counties we visited all use Health and Education Passports. According to Social Services, it • Current medications. designed the Health and Education Passport to meet • Past health problems and hospitalizations. the State’s requirements. Social Services also stated • Relevant mental health history. that information in the Health and Education Passports is for use by caregivers, social workers, • Known mental health conditions and medications. probation offi cers, the courts, medical professionals, • Any other relevant mental health information and foster children. concerning the child determined to be appropriate by the director of the California Department of Social Services issued an information notice to Social Services. all county welfare directors and chief probation Source: California Welfare and Institution Code, Section 16010(a). offi cers in March 2008 that included specifi c requirements and instructions for properly entering the necessary information into its data system, which then populates the Health and Education Passports. Social Services also established a process for updating the Health and Education Passports, as Figure 4 on the following page shows. Specifi cally, each printed Health and Education Passport instructs a caregiver to bring it to all the foster child’s health visits and to remind health care providers to add or correct information on it. It also instructs the caregiver to give the updated or corrected Health and Education Passport to the foster child’s social worker or probation offi cer during his or her next visit. Th e social worker or probation offi cer should then forward the updated or corrected information to a public health nurse and then work with the public health nurse to enter the information into Social Services’ data system. Nonetheless, our review of the Health and Education Passports for 80 foster children at the four counties we visited found that the mental health information they contained—including psychotropic medications and psychosocial services—was frequently incomplete and inaccurate. Table 15 on page 57 summarizes the nature and extent of the concerns we identifi ed. It shows that all 80 Health and Education Passports we reviewed were missing information about the corresponding psychosocial services the children should have received for at least one psychotropic medication, as we 56 California State Auditor Report 2015-131 August 2016 describe in Chapter 1. Table 15 also shows that the Health and Education Passports for 13 (16 percent) of these foster children were missing at least one prescribed psychotropic medication that the courts or parents had authorized. Ten of these 13 Health and Education Passports were for foster children from two counties— Los Angeles and Sonoma. In fact, the Health and Education Passport for one of these foster children was missing three authorized psychotropic medications. Figure 4 Flow of Information to Update the California Department of Social Services’ Child Welfare Services/Case Management System and to Populate Health and Education Passports for Children in Foster Care Sources: California State Auditor’s review of the California Department of Social Services’ Child Welfare Services/Case Management System training instructions, the Department of Health Care Services’ Plan and Fiscal Guidelines for the Health Care Program for Children in Foster Care, and Health and Education Passports. Note: The documents we examined do not specifi cally identify the persons who provide the Health and Education Passports to the caregivers. In addition, 12 of the 80 Health and Education Passports were missing at least one prescription for a psychotropic medication that had been fi lled for the child but did not appear to have been authorized by the courts or parents. In these instances, the caregivers were apparently in possession of the prescribed psychotropic medications, but the counties never obtained court authorizations or parental consents. In fact, we identifi ed California State Auditor Report 2015-131 57 August 2016 one instance in which a court denied a request to prescribe an antidepressant to a foster child, but the pharmacist fi lled the prescription for that medication shortly thereafter. Table 15 Errors and Omissions in the Health and Education Passports for Children in Foster Care FOSTER CHILDREN’S HEALTH AND EDUCATION PASSPORTS… …WERE MISSING… …CONTAINED INACCURACIES SUCH AS… …CORRESPONDING …AT LEAST ONE …AT LEAST ONE …INCORRECT COURT …LESS RECENT PSYCHOSOCIAL AUTHORIZED FILLED PRESCRIPTION …INCORRECT START AUTHORIZATION INFORMATION THAN SERVICES FOR AT LEAST PRESCRIBED FOR PSYCHOTROPIC DATES FOR AT LEAST DATES FOR AT LEAST CONTAINED IN THE CHILD ONE PSYCHOTROPIC PSYCHOTROPIC MEDICATIONS THAT WERE ONE PSYCHOTROPIC ONE PSYCHOTROPIC WELFARE SERVICES/CASE COUNTY MEDICATION MEDICATION NOT AUTHORIZED MEDICATION MEDICATION* MANAGEMENT SYSTEM Los Angeles 20/20 6/20 3/20 20/20 6/18 1/20 Madera 20/20 0/20 2/20 20/20 4/20 0/20 Riverside 20/20 3/20 3/20 20/20 2/20 0/20 Sonoma 20/20 4/20 4/20 20/20 7/9 6/20 Totals 80/80 13/80 12/80 80/80 19/67 7/80 100% 16% 15% 100% 28% 9% Sources: California State Auditor’s analysis of selected foster care case fi les at each of the counties’ welfare services departments and data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, the California Department of Social Services’ Child Welfare Services/ Case Management System, and matched Medi-Cal pharmacy data. * Unless noted otherwise in the Table, we reviewed the case fi les for 20 foster children at each of the four counties, for a total of 80 foster children. For two counties, we reviewed fewer than 20 case fi les because the courts had delegated authority to administer psychotropic medications to some foster children’s parents, and therefore, this column is not applicable for these children. Besides missing certain information, all 80 Health and Education Passports we reviewed included inaccurate dates showing when the foster children started taking psychotropic medications, as shown in Table 15. In its 2008 information notice, Social Services instructed counties to enter into its data system the actual date that a foster child started taking a psychotropic medication. However, instead of entering this date, the four counties we visited entered the dates that prescribers saw children, the dates that court authorizations were fi led, or the dates on which courts authorized prescriptions. Moreover, the Health and Education Passports for 19 (28 percent) of the 67 foster children for whom the court authorized psychotropic medications had inaccurate court authorization dates. Table 15 also shows that seven foster children’s Health and Education Passports were missing authorized psychotropic medications even though Social Services’ data system included this information. Six of these seven children were from Sonoma County. For example, Social Services’ data system showed that one foster child had two authorized psychotropic medications, both of which were antipsychotics; however, the child’s Health and Education Passport did not refl ect this information. We determined that although Sonoma County staff had entered information about the 58 California State Auditor Report 2015-131 August 2016 six foster children’s psychotropic medications into Social Services’ data system, they did not follow Social Services’ instructions to have the data system update the children’s Health and Education Passports. In fact, in the above example, Sonoma County had not updated the foster child’s Health and Education Passport in more than 10 years. In contrast, Riverside County, which had no such errors, provides written instructions to its staff on how to properly update Health and Education Passports after entering new medical information into Social Services’ data system. Finally, Social Services’ data system includes a fi eld for county staff to log the date when they provide the Health and Education Passports to caregivers. Th is fi eld was blank in the records for 49 (61 percent) of the 80 foster children we examined. It is therefore unclear whether county staff actually provided the Health and Education Passports to these caregivers. We noted that Los Angeles and Riverside counties were responsible for 37 of the 49 case fi les with blank fi elds. Without these completed fi elds in Social Services’ data system, the State lacks information to ensure that counties provided caregivers with critical information about foster children’s health. Selected Responsibilities of Two General Factors Appear to Have Consistently Foster Care Public Health Nurses Contributed to Foster Children’s Incomplete Health and Education Passports • Work with child welfare case workers to coordinate health care services, including psychosocial services. We determined that two general factors may • Serve as a liaison with health care professionals. have contributed to foster children’s incomplete Health and Education Passports: the counties’ • Document that each child receives initial and follow-up health screenings that meet reasonable standards of insuffi cient number of public health nurses and medical practice. a lack of information sharing among county departments. As described earlier, public health • Collect health information and other relevant data on each nurses work with social workers and probation foster child as available, including mental health services. offi cers to enter and update foster children’s • Participate in medical care planning and coordinating health and medical information in Social Services’ for each foster child, which may include facilitating the data system. Th e public health nurses are part acquisition of any necessary court authorizations for of the Health Care Program for Children in procedures or medications, as well as monitoring and Foster Care (Health Program), a public health providing oversight of psychotropic medications. nursing program that is located in county child • Provide follow-up contact to assess each foster child’s welfare services agencies and county probation progress in meeting treatment goals. departments. Th e Health Program provides • Assist nonminor dependents in making informed decisions public health nursing expertise in meeting the about their health care, specifi cally helping them assume medical, dental, behavioral, and developmental responsibility for their ongoing health care management health needs of children in out-of-home while transitioning out of foster care. placements or foster care. State law identifi es the public health nurses’ responsibilities, as shown in Source: Welfare and Institutions Code, Section 16501.3. the text box. California State Auditor Report 2015-131 59 August 2016 Social Services’ inclusion of public health nurses and the Health Program in its state plan for 2015–2019 demonstrates the signifi cance the State places on their role in overseeing psychotropic medications prescribed to foster children. In this federally required plan—which we describe in the Introduction— Social Services stated that public health nurses, in consultation and collaboration with others, are responsible for ensuring that every foster child has a current record of prescribed medications and for documenting medication information in the Health and Education Passports. Social Services also stated that the Health Program provides assurance that counties continue to identify and address foster children’s physical and mental health needs. However, the public health nurses at the four counties we visited Limited staff resources and the need indicated that limited staff resources and the need to address to address foster children’s serious foster children’s serious medical conditions constrain their ability medical conditions are asserted to maintain accurate and complete data in Social Services’ data to be two reasons that constrain system, which is then refl ected in inaccurate and incomplete Health public health nurses' ability to and Education Passports. For example, one public health nurse maintain accurate and complete explained that she spent an estimated eight hours just to arrange an data in Social Services’ data system. emergency root canal surgery for one foster child. She stated that foster children with threatening or serious medical conditions take precedence over basic medical data entries to update the Health and Education Passports. Th e statements from the public health nurses are consistent with the ratio of public health nurses to foster children within each county. Documents issued by both Social Services and Health Care Services from around the time of the Health Program’s original implementation in 2000 indicate that it intended to maintain an ideal ratio of one public health nurse per 200 foster children. However, Health Care Services’ information from February 2016 showed that only 13 of California’s 58 counties had public health nurse-to-foster-children ratios at or below 1-to-200. Further, the ratios for the four counties we visited ranged from 1-to-252 to 1-to-413. Counties could improve these caseload ratios by funding additional public health nurses. Federal law states that the federal government will cover 75 percent of the costs for skilled professional medical personnel, such as public health nurses, as well as 75 percent of the cost for the medical personnel’s necessary support staff . Th ese support staff could enter information into the Health and Education Passports, freeing the public health nurses to oversee the support staff ’s work and to perform their other, more pressing responsibilities. However, counties may not be obligated to implement Social Services’ directives to address inaccurate and incomplete mental health information in Social Services’ data system by taking actions such as hiring additional Health Program staff . As discussed in the 60 California State Auditor Report 2015-131 August 2016 Introduction, realignment laws enacted in 2011 and 2012 moved program and fi scal responsibility for foster care to the counties, leaving Social Services with the role of providing oversight, training, and technical assistance to the counties. Around the same time, California voters enacted Proposition 30, which states that the counties are not obligated to implement new state laws, regulations, or administrative directives that increase local costs to administer child welfare services that were transferred to them as a result of the realignment laws, unless the State provides additional annual funding to pay for the increased costs. As a result, Social Services cannot simply issue directions and expect the counties to take steps to correct the data in its data system; instead, Social Services and the counties must reach agreement on a plan to improve the health information in Social Services’ data system and on acceptable funding sources—likely from both the counties and the State—if that plan results in additional costs for the counties. Another reason for incomplete Health and Education Passports is a lack of information sharing among the diff erent county departments involved with foster children who receive psychosocial Although the counties appear services, including psychotropic medications. Although the to maintain records pertaining counties appear to maintain records pertaining to foster children’s to foster children’s psychosocial psychosocial services, that information is split among separate services, that information is county departments, which do not always share information split among separate county with each other. For instance, staff at two of the four counties we departments, which do not always visited cited concerns over health information privacy laws as an share information with each other. impediment to the sharing of information about foster children’s psychosocial services by county departments of mental health with county child welfare departments. In fact, according to the medical director of Sonoma County’s Division of Behavioral Health, clearer guidance from the State as to what psychosocial services information can or cannot be shared is necessary; he stated that federal and state laws governing such information sharing are subject to interpretation and the California courts take very seriously the right to confi dentiality and privacy of psychosocial services information. However, according to a deputy director at Social Services and the chief medical information offi cer at Health Care Services, the federal Health Insurance Portability and Accountability Act (HIPAA), California’s Confi dentiality of Medical Information Act, and other state medical privacy laws do not prevent entities from sharing certain summary level information about foster children’s psychosocial services for purposes of care coordination. Both the chief medical information offi cer at Health Care Services and the deputy director at Social Services stated that they would be amenable to issuing guidance to counties regarding the sharing of information to help ensure more complete Health and Education Passports. California State Auditor Report 2015-131 61 August 2016 As we mentioned in Chapter 1, the Judicial Council of California (Judicial Council) adopted new and revised forms—which became eff ective in July 2016—to be used in the court authorization process for foster children’s psychotropic medications. Th e Judicial Council also revised its court rules to allow counties to develop their own processes to share information from the new forms with public health nurses. As a result, the use of the new forms may help the public health nurses obtain information on foster children’s psychosocial services, which they or support staff can then include in Social Services’ data system and in foster children’s Health and Education Passports. Such changes could mitigate some of the problems that the lack of information sharing has likely caused in the past. The State’s and Counties’ Lack of Reliable Data Has Impeded Their Oversight of Psychotropic Medications for Foster Children As discussed previously, Social Services’ data system contains Social Services’ data system does incomplete and inaccurate mental health information related not accurately record whether to foster children. It does not accurately record whether foster foster children have been prescribed children have been prescribed psychotropic medications, how psychotropic medications, how many psychotropic medications they were prescribed, or whether many medications were prescribed, maximum daily dosages were within acceptable limits. Further, or whether maximum daily dosages using the data system, we were unable to determine whether foster were within acceptable limits. children had follow-up visits with their prescribers or other health care providers within 30 days after starting new psychotropic medications and whether they received psychosocial services before or concurrent with their psychotropic medications. Finally, the data system does not accurately and consistently record whether counties obtained court or parental authorizations before foster children received psychotropic medications. Th ese incomplete and inaccurate data can hinder county and state oversight of psychotropic medications prescribed to foster children. Social workers, probation offi cers, caregivers, public health nurses, health care providers, and others at the county level use the health information in Social Services’ data system and in the foster children’s Health and Education Passports to assist in the provision of appropriate mental health care to foster children. If this health information is inaccurate or incomplete, these individuals could make decisions that are less than optimal or that could even result in harm to these children. In addition to potentially hampering county-level coordination and oversight of foster children’s mental health care, inaccurate and incomplete information in Social Services’ data system may also impede the State’s ability to oversee psychotropic medications prescribed to foster children. Social Services uses information from its data system for several purposes. For instance, it provides 62 California State Auditor Report 2015-131 August 2016 data from its system to the California Child Welfare Indicators Project to allow policymakers, child welfare workers, researchers, and the public access to information on California’s child welfare system.13 However, users could draw inaccurate conclusions if they relied only on this information. For example, Measure 5F—which captures the number of foster children authorized for psychotropic medications recorded in Social Services’ data system—does not accurately refl ect the number of foster children with prescriptions for psychotropic medications because county staff have not entered all court or parental authorization information into the data system. Th e State’s ability to identify foster children who receive psychotropic medication prescriptions has improved since various state agencies and other government entities—including some counties—entered a data-sharing agreement in April 2015. Among other things, this data-sharing agreement between Health Care Services, Social Services, and other government entities allows them to share confi dential data about foster children’s psychosocial services and prescriptions. For example, Health Care Services used this agreement to share Medi-Cal pharmacy data about psychotropic medications with Social Services so Social Services could identify which foster children have prescriptions for psychotropic medications. Because this data-sharing agreement is still relatively new, Social Services and Health Care Services are still working to improve the links between their diff erent data systems. However, even with these improvements, county and state stakeholders are likely to continue to lack the accurate, complete information they need to make decisions or to analyze whether improvements occur over time. As discussed, Social Services’ data are Health Care Services’ data do not inaccurate and incomplete. However, Health Care Services’ data also refl ect psychosocial services or cannot paint a complete picture of foster children’s psychosocial psychotropic medications for foster services and medications because, as shown in Figure 5, the data do children for which Medi-Cal did not refl ect those psychosocial services or psychotropic medications not pay. for which Medi-Cal did not pay and, as mentioned in Chapter 1, Health Care Services' procedure codes do not capture precisely the extent to which psychosocial services are provided to foster children. For example, a program manager at Sonoma County’s Family, Youth and Children Division stated that the county paid for therapy services for three of the 20 foster children whose case fi les we reviewed; thus, Health Care Services’ data did not refl ect these services. Because neither Social Services nor Health Care Services has complete information on foster children’s psychosocial services and psychotropic medications, combining their data will likely continue to result in an inaccurate summary. Consequently, state and county oversight of psychotropic medications administered to foster children 13 The California Child Welfare Indicators Project is a collaborative venture between the University of California, Berkeley School of Social Work and Social Services that makes available child welfare administrative data to policymakers, child welfare workers, and the public on a website. California State Auditor Report 2015-131 63 August 2016 is likely to continue to be limited by weaknesses in the available data until Social Services successfully works with the counties to improve its data system. Figure 5 Gaps in the State’s Data Related to the Prescription of Psychotropic Medications to Children in Foster Care State Data for Foster Care Medications and Services Other Health Care Providers California Department of Department of Social Services’ Health Care Services’ Non-Medi-Cal-Reimbursed (Social Services) (Health Care Services) Services Source Child Welfare Services / Medi-Cal Data Systems Case Management System • Psychotropic medication • Psychotropic medication prescriptions • Court authorization or prescriptions parental consent for the use • Psychosocial services • Psychosocial services of psychotropic medications • Medication management Information • Psychiatric diagnoses • Medication management services services FOSTER CHILDREN’S HEALTH CARE INFORMATION Incomplete Other psychosocial services, psychotropic medications, information on and medication foster children management services Result Sources: California State Auditor’s analysis of the Social Services’ Child Welfare Services/Case Management System, Health Care Services’ Medi-Cal data, and interviews with county offi cials. Until Recently, the State’s County-Level Reviews Included Only Minimal Examination of Psychotropic Medications Prescribed to Foster Children As discussed in the Introduction, Social Services and Health Care Services took steps starting in 2012 to address the issue of psychotropic medications prescribed to foster children. However, the eff ectiveness of the practices that the two departments developed are largely dependent upon the counties’ willingness to implement those practices—which many counties have not yet done. Further, neither Social Services nor Health Care Services included examinations of the prescription of psychotropic medications to foster children as part of their periodic reviews at the county level until recently. Consequently, the State has lacked assurance that the counties’ monitoring of this issue adequately protects the best interests of foster children. 64 California State Auditor Report 2015-131 August 2016 In response to heightened national awareness regarding psychotropic medications prescribed to Quality Improvement Project foster children, Social Services and Health Care Educational and Informational Materials Services established the Quality Improvement California Guidelines for the Use of Psychotropic Project in 2012. Although it does not have offi cial Medication with Children and Youth in Foster Care: monitoring duties, the Quality Improvement Released jointly by the California Department of Social Project has since produced educational and Services and the Department of Health Care Services, informational materials—as shown in the text the document describes best practices for the treatment box—to help assure the safe and appropriate of children in out-of-home care who may require prescribing and monitoring of psychotropic psychotropic medications. medications prescribed to foster children. Questions to Ask About Medications: A document to help foster children, parents, and caregivers to improve their skills Additionally, the Quality Improvement Project and knowledge about side eff ects and adverse symptoms devised ways in which the two departments and related to medications. counties, under their data-sharing agreement, Foster Youth Mental Health Bill of Rights: A document could use data results to aid in the oversight to educate foster children, parents, and caregivers of psychotropic medications prescribed to about the rights of foster children as they pertain to foster children. For instance, since May 2015, psychotropic medications. Social Services has distributed to counties quarterly reconciliation reports that included case Sources: California Department of Social Services’ All County Information Notice I-36-15—issued May 2015—and website. numbers of foster children who had paid Medi-Cal claims for psychotropic medications but no prior or concurrent authorizations recorded in Social Service’s data system. Our review of these reports for the four counties we visited indicated that the counties used them to resolve possible discrepancies. For example, Los Angeles County’s fi rst reconciliation report identifi ed 558 possible discrepancies. Its reconciliation report two quarters later listed only 240, a reduction of 318. Also, Social Services will provide more detailed case information, including foster children’s names, identifi cation numbers, medication names and dates, and placement types to those counties that sign on to the data-sharing agreement. Although these and other practices we examined can help counties to ensure that providers properly prescribe psychotropic medications to foster children, the counties do not universally use them. For example, we found that counties did not always use the educational and informational materials the Quality Improvement Project produced. Furthermore, Social Services told us in May 2016 that only 19 of California’s 58 counties—including Madera and Sonoma—had signed on to the data-sharing agreement. Consequently, the Quality Improvement Project’s eff orts to date have not resulted in widespread assurance that the State’s and counties’ collective oversight and monitoring mechanisms actually produce measureable, desirable results. Until recently, the State’s actual monitoring mechanisms for overseeing child welfare systems and the provision of health care services at the county level included only minimal examinations of psychotropic California State Auditor Report 2015-131 65 August 2016 medications prescribed to foster children. Social Services and Health Care Services conduct at least three diff erent types of periodic reviews at the county level to examine diff erent aspects of each county’s child welfare system or health care and mental health service operations. We summarize these reviews in Table 16. Because the two departments have not included substantive examinations of the provision of psychotropic medications to foster children as part of these periodic reviews in the past, they missed opportunities to obtain critical information from more in-depth, county-by-county reviews of this issue. However, as of March 2016, Social Services and Health Care Services began collecting from the counties certain information about the provision of these medications. Table 16 Types of County Reviews PSYCHOTROPIC CASE FILE MEDICATIONS AND ENTITIES PERFORMING ENTITIES PURPOSE FREQUENCY REVIEW FOSTER CARE INCLUDED REVIEW TYPE THE REVIEW REVIEWED OF REVIEW OF REVIEW INCLUDED AS PART OF REVIEW RESULTS OF REVIEW California Child Collaboration County child To strengthen the Ongoing. Yes, Yes, starting County and Family between the welfare accountability However, counties starting in 2008 and self-assessments, Services Review California departments system used are to prepare in 2015. expanded in 2014. system improvement Department of and probation in the State to and submit plans, and annual Social Services placement monitor and assess self-assessments progress reports (Social Services) agencies. the quality of and system linked on Social and county services provided improvement Services’ website. child welfare on behalf of plans every departments maltreated children. fi ve years and and probation progress reports placement annually. agencies. Program Department County Medi-Cal Verify that county Triennial. Yes. Yes, starting in County Medi-Cal Oversight and of Health Care mental health Medi-Cal mental fi scal year 2015–16. mental health plans’ Compliance Services (Health plans. health plans submissions to Review Care Services). provided medically Health Care Services necessary services of plans of correction in compliance with for any items out of state regulations complance. and the contract between Health Care Services and the plan. External Quality Health Care County Medi-Cal To evaluate the Annual. No. Not substantively. Annual reports Reviews Services, via managed care quality, access, linked on Health Care contracts with plans and county and timeliness of Services’ website. private vendors. Medi-Cal mental health care services health plans. off ered to Medi-Cal benefi ciaries through Medi-Cal plans. Sources: Federal and state laws and regulations, documents obtained from Social Services and Health Care Services, and interviews with staff of Social Services. 66 California State Auditor Report 2015-131 August 2016 One of the State’s oversight mechanisms is Social Services’ California Child and Family Services Review (California review). Social Services implemented the California review in 2004 in response to a state law requiring it to monitor county child welfare systems’ performance, including foster care. According to Social Services, this review is an enhanced version of the federal Child and Family Services Review, through which the U.S. Department of Health and Human Services reviews each state’s child welfare system to ensure that it provides quality services to children and families. Th e California review contains more measures than the federal review and has a primary focus on measuring each county child welfare system’s performance in the areas of safety, permanence, and family well-being. Th e State’s goal for the California review is to strengthen the accountability system it uses to monitor and assess the quality of services provided to maltreated children. According to Social Services, the review establishes core outcomes that are central to maintaining an eff ective system of child welfare services. Th e California review is an ongoing, cyclical process that requires counties every fi ve years to submit self-assessments in which they review their child welfare and probation offi ce placement programs to determine the eff ectiveness of their current practices, programs, and resources. Th ey must also submit system improvement plans every fi ve years, which are operational agreements between the counties and Social Services that outline how counties plan to improve their system of care for children and families and address priority needs within the child welfare services system. Finally, the counties must prepare and submit annual progress reports to Social Services that provide a written analysis assessing whether their system improvement plans are achieving the desired results. As part of the California review, the California Child Welfare Indicators Project publishes on its website data on all 58 counties’ child welfare systems’ performance related to specifi ed outcome measures. Social Services also makes the data available on its website. With these measures, counties can identify areas in which they could improve performance. Currently, only one measure— Measure 5F—addresses the number of foster children authorized to receive psychotropic medications. As previously discussed, we found a number of weaknesses in the information this measure provides. As of January 2014, Social Services expanded the county Further, until 2014, the county self-assessment component of self-assessment reporting Social Services’ California reviews did not specifi cally address requirements to include a psychotropic medications prescribed to foster children other than description and analysis of how the what was required for Measure 5F. As of January 2014, Social Services counties monitor the administration expanded the self-assessment reporting requirements to include a of prescription drugs, including description and analysis of how the counties monitor the appropriate psychotropic medications. administration of prescription medications, including psychotropic California State Auditor Report 2015-131 67 August 2016 medications for foster children. Th e most recent self-assessment reports for the four counties we visited are all dated before 2014, before implementation of the new requirement. Although the four counties have yet to fulfi ll this specifi c requirement, all have written procedures associated with the court’s consideration of requests to authorize prescriptions of psychotropic medications to foster children. In addition, Sonoma County was the only county of the four to address Sonoma County was the only psychotropic medications as an area of needed improvement in its county of the four to address most recent system improvement plan for 2014 to 2019. In the plan, psychotropic medications as an Sonoma noted that, with the exception of two counties with very small area of needed improvement in its populations of foster children, it had the highest rate of foster children most recent system improvement authorized for psychotropic medications: more than 24 percent in the plan for 2014 to 2019. fourth quarter of 2012, or nearly double the statewide rate at that time. Consequently, the plan stated that Sonoma’s child welfare department would identify the causes of the high rate and develop monitoring processes to reduce by 5 percent the number of youth authorized for psychotropic medications. Although a subsequent annual progress report did not identify the causes for its high rate, it mentioned that Sonoma was implementing a number of steps to reduce the number of foster children prescribed psychotropic medications. Th ese steps included engaging county partners in conversation about the problem, implementing an internal review process for court authorization requests for psychotropic prescriptions, and providing training on the issue for all its social workers. Th e State also monitors county mental health care plans (Medi-Cal mental health plans) through triennial program oversight and compliance reviews. Health Care Services conducts these triennial reviews, which verify that the Medi-Cal mental health plans provide medically necessary services to benefi ciaries in compliance both with the terms of their contracts with Health Care Services and with state and federal laws and regulations. However, the review protocol for fi scal year 2014–15—which was essentially a checklist more than 90 pages long containing questions for which Health Care Services seeks answers—did not include any questions regarding psychotropic medications for foster children. Health Care Services recently took a step toward ensuring that its triennial reviews better address this issue in the future. Specifi cally, its review protocol for fi scal year 2015–16 includes three questions on the prescription of psychotropic medications to foster children. A third state mechanism for monitoring counties’ provision of health care is Health Care Services’ annual external quality review (external review) of local Medi-Cal health plans. In accordance with federal law and regulations, Health Care Services must contract with third-party vendors to conduct external reviews that examine Medi-Cal benefi ciaries’ access to timely health care 68 California State Auditor Report 2015-131 August 2016 services as well as the quality of their outcomes under county mental health care plans and county Medi-Cal managed care plans (Medi-Cal managed care plans). Health Care Services contracts with two organizations to conduct these external reviews and includes links to the organizations’ reports on its website. However, the reports for the most recent annual external reviews for the Medi-Cal mental health plans and Medi-Cal managed care plans for the four counties we visited did not include substantive information regarding psychotropic medications prescribed to foster children. Although external reviews annually examine the counties’ Medi-Cal mental health plans and Medi-Cal managed care plans, the assistant chief of the Medical Review Branch within Health Care Services’ Audits and Investigations Division indicated that the State has no similar oversight mechanism in place for health professionals who provide psychosocial services and then bill Medi-Cal via the fee-for-service approach. While more Medi-Cal benefi ciaries are enrolling in managed care plans, foster children have the option to receive health care services from fee-for-service providers instead. Health Care Services is responsible for signing up and screening these providers. However, according to the assistant chief of the Medical Review Branch, the only oversight Health Care Services performs related to this type of provider involves identifying appropriate billing based on medical necessity criteria and federal and state reimbursement guidelines. The three types of county-level Th e three types of county-level reviews that Social Services and reviews that Social Services and Health Care Services perform present an opportunity for the Health Care Services perform departments to gather fi rst-hand information regarding the counties’ present an opportunity to gather administration of psychotropic medications to foster children. Th ese fi rst-hand information regarding reviews could allow Social Services and Health Care Services to the counties’ administration identify relevant defi ciencies in this area and work with counties of psychotropic medications to to resolve those defi ciencies. Further, using the relevant results of foster children. these reviews in conjunction with complete and accurate state data, Social Services, Health Care Services, and their county partners could consider whether to modify their oversight structures to better ensure that providers only prescribe psychotropic medications to foster children when reasonably necessary. The State Has Not Proactively Overseen Physicians Who Prescribe Psychotropic Medications for Foster Children Although the State has mechanisms in place for reacting to complaints about physicians who may have inappropriately prescribed psychotropic medications to foster children, it does not currently take routine proactive steps to identify and correct inappropriate prescribing practices. Th e State oversees physicians through the Medical Board, which is responsible for issuing California State Auditor Report 2015-131 69 August 2016 physicians’ licenses, investigating complaints, and imposing discipline. Its disciplinary actions may include administrative citations, fi nes, or license revocation. However, as of February 2016, its executive director stated that the Medical Board had not received any complaints against physicians for inappropriately prescribing psychotropic medications to foster children. Given the nature and extent of the issues we identifi ed in Chapter 1 related to psychotropic medications, we believe that the lack of complaints to the Medical Board may suggest that this reactive approach alone is not suffi cient to help ensure that physicians properly prescribe psychotropic medications to foster children. Although the State also has other reactive methods through which it can monitor physicians who prescribe psychotropic medications to foster children, it is unclear whether these methods provide adequate oversight. For instance, state law requires Social Services to establish a foster care ombudsman’s offi ce to disseminate information on the rights of foster children and to investigate and attempt to resolve complaints made by or on behalf of foster children related to their care, placement, or services. Nonetheless, according to a consultant in the foster care ombudsman’s offi ce, a review of a sample of child welfare complaints over a four-year period showed that the offi ce had not received complaints regarding children being overprescribed psychotropic medications. Similarly, state regulations allow Health Care Services to designate a Medi-Cal managed care ombudsman to investigate and resolve complaints between Medi-Cal benefi ciaries and their managed care health plans. However, the chief of Health Care Services’ Managed Care Operations Division told us that the managed care ombudsman’s offi ce does not investigate complaints regarding inappropriate prescribing of psychotropic medications to foster children and would refer any such complainants to another appropriate program. Consequently, we believe that the State’s reactive approach for We believe the State’s reactive overseeing physicians should be supplemented by more proactive approach for overseeing physicians steps to better ensure that physicians who prescribe psychotropic should be supplemented by more medications to foster children adhere to applicable guidelines. proactive steps to better ensure Although the Medical Board is trying to take proactive steps, its that physicians who prescribe progress has been slow. Specifi cally, in April 2015 the Medical psychotropic medications Board entered into an agreement with Health Care Services to foster children adhere to and Social Services to obtain pharmacy claims data for all foster applicable guidelines. children who were or had been on three or more psychotropic medications for 90 days or longer. Th e Medical Board’s executive director stated that her staff had planned to analyze these data and investigate those physicians who exhibited inappropriate patterns of prescribing psychotropic medications to foster children. However, even though the Medical Board received these data in May 2015, 70 California State Auditor Report 2015-131 August 2016 the executive director explained in February 2016 that the board had not yet been able to use it to identify physicians with potentially inappropriate prescribing habits. Th e executive director attributed the delay to a number of causes. Specifi cally, she stated that the Medical Board was unable to contract with a consultant to analyze the data until November 2015 because it took longer than expected to identify an appropriate, available expert in the Sacramento area. She further stated that in late January 2016, the consultant reported to the Medical Board that the data were inadequate to perform the desired assessment. Th e consultant presented a list of additional information necessary to perform the desired analysis, such as each child’s targeted diagnosis and weight, and each medication’s dosage and frequency. In February 2016, the Medical Board met with Health Care Services and Social Services to request the additional information. Health Care Services responded in March 2016, stating that its claims system does not capture data for the targeted diagnoses, dosages, or frequency of the medications but that it could provide other data fi elds as substitutes. Health Care Services also said that Social Services could provide each child’s weight to the extent its data system captured that information. Th e Medical Board requested these substitute data fi elds but, according to the executive director, was still waiting as of April 2016 to hear from the two departments. Off -label Use of Because the Medical Board has not yet received Prescription Medications by Children the necessary information from Health Care According to studies and other documents that we Services and Social Services, it does not know examined, physicians may prescribe medications for when it will be able to complete this project. off -label uses, which are any uses that are not indicated on However, its executive director asserted that if this the medications’ approved drug labels. Federal regulations project is successful in identifying physicians who state that any prescription medication approved by the may have inappropriately prescribed psychotropic U.S. Food and Drug Administration (FDA) must contain medications to foster children, the Medical Board a drug label that identifi es its approved uses, including will continue working with Health Care Services the target population, diagnosis, dosages, and method and Social Services to review their data on a of administration. According to the FDA, most medicines regular basis. prescribed for children have not been tested in children and, by necessity, doctors have routinely prescribed medications for off -label use in children. However, the safety and Health Care Services Does Not Ensure That eff ectiveness of a medication may or may not extend to all Pharmacists Obtain Its Approval Before They age groups or diagnoses that were not tested, which could pose additional risks to a patient prescribed a medication for Dispense Psychotropic Medications to Foster off -label purposes. Nevertheless, according to the American Children for Off -Label Uses Academy of Child and Adolescent Psychiatry, it is ethical, appropriate, and consistent with general medical practice to Health Care Services has not consistently ensured prescribe medication off -label when clinically indicated. that pharmacists obtain its approval before they dispense psychotropic medications to foster Sources: California State Auditor’s review of the FDA’s regulations and website and of studies and other documents related to children for purposes other than those indicated off -label use of medications. on the medications’ product labels. As the text box describes, such uses of prescription medications California State Auditor Report 2015-131 71 August 2016 are considered off -label because they do not have the approval of the U.S. Food and Drug Administration (FDA). State regulations require pharmacists to obtain approved treatment authorization requests (TARs) before dispensing any medication, including psychotropic medications, to be used for off -label purposes, except in cases of emergency. According to an American Bar Association 2011 Practice and Policy Brief, more than 75 percent of psychotropic medication use by children and adolescents is likely prescribed for off -label purposes. However, our review found that few pharmacists had obtained TARs when dispensing these medications to foster children. Health Care Services’ staff pharmacists review and adjudicate TARs, either approving the requests, denying them, or deferring them in order to gather more information from the health care providers— including the prescribing physicians—before making decisions. According to the chief of its Clinical Assurance and Administrative Support Division, Health Care Services’ staff pharmacists look at the type of medication and the child’s diagnosis, and then evaluate the following questions as part of each TAR review: • Whether the intended use is FDA-approved. • Whether the usage is age-appropriate. • Whether the regular and daily dosage amounts are appropriate for a child’s age and size. • Whether the medication is medically necessary. • Whether the medication is in the same pharmaceutical class as any other medications the child is receiving. • In the case of antipsychotic medications, whether the child is receiving metabolic monitoring as part of monitoring side eff ects. State regulations allow Health Care Services to authorize the State regulations allow Health Care off -label use of medications when that use represents reasonable Services to authorize the off -label and current prescribing practice. For example, our review of the use of medications when that use case fi les for 80 foster children at the four counties we visited represents a reasonable and current showed that a number of physicians prescribed trazodone—an prescribing practice. antidepressant—to treat insomnia. Although this usage is not indicated on the medication’s FDA-approved label, a 2010 survey of the members of the American Academy of Child and Adolescent Psychiatry found that trazodone was the most commonly prescribed insomnia medication for children with anxiety disorders.14 Th e results of this survey suggest that prescribing trazodone for insomnia is a reasonable off -label use. 14 The FDA-approved label for trazodone lists somnolence, or sleepiness, as an adverse reaction. 72 California State Auditor Report 2015-131 August 2016 Although the TARs review process provides an opportunity for the State to ensure that foster children only receive psychotropic medications for appropriate off -label purposes, our review found that pharmacists rarely obtained approved TARs before dispensing these medications. Specifi cally, when we reviewed the case fi les for the 80 foster children, we identifi ed 45 children to whom physicians prescribed at least one psychotropic medication for an off -label use. However, when we asked Health Care Services to provide approved TARs for the medications prescribed for these 45 foster children, it Pharmacists failed to submit TARs, could not do so for 44 of them—even though some of the children as state regulations require, in were receiving multiple psychotropic medications for off -label nearly all instances of off -label use purposes. In other words, pharmacists failed to submit TARs, as we reviewed. state regulations require, in nearly all instances of off -label use. When it does not receive, review, and approve TARs for psychotropic medications prescribed for off -label use by foster children, Health Care Services has less assurance that physicians have properly prescribed these medications. For example, in April 2014 a physician prescribed Seroquel—an antipsychotic medication that the FDA approved to treat symptoms of bipolar disorder in patients 10 and older or schizophrenia in patients 13 and older—to a 15-year-old foster child. However, the physician prescribed Seroquel to treat “mood dysregulation” with symptoms of moodiness, irritability, anger problems, and arguing. Although we concluded that this was an off -label use because the documents did not mention bipolar disorder or schizophrenia, Health Care Services could not provide an approved TAR. Pharmacists rarely submitted TARs for off -label prescriptions in part because Health Care Services has not programmed its claims system to identify medications prescribed for off -label use in order to prompt pharmacists to submit TARs. According to a section chief in its Clinical Assurance and Administrative Services Division (section chief), Health Care Services relies on pharmacists to voluntarily identify when medications are prescribed for off -label uses. However, the section chief acknowledged that few dispensing pharmacists devote the time or have the information necessary to determine whether psychotropic medications are prescribed for off -label purposes. Th e chief of Health Care Services’ Pharmacy Benefi ts Division (chief of pharmacy benefi ts) indicated that Health Care Services has not programmed its claims system to identify off -label prescriptions of psychotropic medications using children’s diagnoses because prescriptions do not always include reliable diagnoses that indicate the purposes of the medications. Without a diagnosis, the system cannot determine whether a medication is being prescribed for an off -label purpose. Th e chief of pharmacy benefi ts also stated that for Health Care Services to use diagnoses to enforce the TAR requirement for off -label purposes through its claims system, California State Auditor Report 2015-131 73 August 2016 it would need to require TARs for all psychotropic medication prescriptions, which would result in the submission of unnecessary TARs and impede foster children’s access to medications they need. However, even if Health Care Services cannot reasonably program Health Care Services' claims its claims system to detect prescriptions for off -label uses based on system could better oversee the diagnoses, the claims system could still trigger a TAR requirement for appropriateness of off -label use for off -label use for psychotropic medications based on children’s ages, psychotropic medications by creating just as it currently does for antipsychotic medications. Specifi cally, for a TAR process based on children’s ages. service dates on or after October 1, 2014, Health Care Services began requiring TARs for antipsychotic medications prescribed to Medi-Cal benefi ciaries under age 18, including foster children. According to the chief of pharmacy benefi ts, Health Care Services enacted this TAR requirement to ensure the safe and appropriate use of these medications by children given their severe and potentially irreversible side eff ects. Health Care Services enforces this TAR requirement by having its claims system automatically prompt pharmacists to submit TARs whenever they submit claims for antipsychotic medications prescribed to Medi-Cal benefi ciaries under 18 years old. Health Care Services appears to properly enforce this TAR requirement; it provided approved TARs for the 27 foster children we reviewed who had prescriptions for antipsychotic medications fi lled after October 1, 2014. Th e section chief noted that since implementing the TAR requirement in October 2014, Health Care Services has denied some TARs for antipsychotics that it deemed were medically inappropriate for various reasons, including for too-high dosages, concurrent use of multiple psychotropic medications, and off -label uses that were not medically justifi ed. In fact, in April 2015 Health Care Services denied a TAR for the foster child we mentioned previously who had been prescribed Seroquel—an antipsychotic medication—for an off -label use. According to the section chief, the claims system required the TAR because of the patient’s age, which allowed Health Care Services to request additional information—including the child’s specifi c diagnosis, the clinical justifi cation for the medication, and evidence of metabolic monitoring—to assess the medication’s appropriateness. According to the section chief, the pharmacist did not provide the requested information within 30 business days, so Health Care Services automatically denied the TAR. Although Health Care Services may not be able to ensure that it reviews all off -label uses of psychotropic medications by foster children, we believe it can better oversee the appropriateness of some of these medications by creating a TAR process similar to the one it uses to for antipsychotic medications but focused specifi cally on children’s ages. Of the 45 psychotropic medications we identifi ed from the case fi les we reviewed, 19—or 42 percent—were not FDA-approved for any use by patients under age 18 as of March 2016. 74 California State Auditor Report 2015-131 August 2016 Th e chief of pharmacy benefi ts agreed that Health Care Services should consider programming its claims system to trigger TAR requirements for these psychotropic medications based on the patients’ ages. He also stated that Health Care Services should evaluate alternative tools and procedures to identify off -label use of medications and better enforce compliance with TAR requirements. For example, he stated Health Care Services could consider developing a process through which its Audits and Investigations Division could include off -label TARs in its retail pharmacy audits. Finally, as discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications prescribed to foster children. Th ese forms now require physicians to describe why they prescribed psychotropic medications not approved for a child this age. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications. Recommendations Legislature To improve the State’s and counties’ oversight of psychotropic medications prescribed to foster children, the Legislature should require Social Services to collaborate with its county partners and other relevant stakeholders to develop and implement a reasonable oversight structure that addresses, at a minimum, the concerns identifi ed in this audit report. To improve the State’s oversight of physicians who prescribe psychotropic medications to foster children, the Legislature should require the Medical Board to analyze Health Care Services’ and Social Services data in order to identify physicians who may have inappropriately prescribed psychotropic medications to foster children. If this initial analysis successfully identifi es such physicians, the Legislature should require the Medical Board to periodically perform the same or similar analyses in the future. Further, the Legislature should require Health Care Services and Social Services to provide periodically to the Medical Board the data necessary to perform these analyses. California Department of Social Services To improve the oversight of psychotropic medications prescribed to foster children, Social Services should collaborate with the counties and other relevant stakeholders—including Health Care Services, as California State Auditor Report 2015-131 75 August 2016 necessary—to develop and implement a reasonable oversight structure that ensures the coordination of the State’s and counties’ various oversight mechanisms as well as the accuracy and completeness of the information in Social Services’ data system. Th is structure should include at least the following items: • Identifi cation of the specifi c oversight responsibilities to be performed by the various state and local government agencies. • An agreement on how county staff such as social workers, probation offi cers, and public health nurses will use printed Health and Education Passports to obtain foster children’s necessary mental health information—including psychotropic medications and psychosocial services—for inclusion in Social Services’ data system. • A plan to ensure that counties have suffi cient staff available to enter foster children’s mental health information into Social Services’ data system and the resources to pay for those staff . • An agreement on the specifi c information related to psychotropic medication—including but not limited to the medication name, maximum daily dosage, and court authorization date—and psychosocial services and medication follow-up appointment information that county staff must enter into Social Services’ data system for inclusion in foster children’s Health and Education Passports. • Specifi c directions from Social Services regarding the correct medication start dates and court authorization dates counties should include in its data system and foster children’s Health and Education Passports. • An agreement on the training or guidance Social Services should provide to county staff members working with Social Services’ data system to ensure that they know how to completely and accurately update foster children’s Health and Education Passports. • An agreement on how the counties will use information on the new authorization forms that the Judicial Council approved to better oversee the prescription of psychotropic medications to foster children. • An agreement regarding how counties will implement, use, or disseminate the educational and informational materials the Quality Improvement Project has produced, including the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care, Questions to Ask About Medications, and the Foster Youth Mental Health Bill of Rights. 76 California State Auditor Report 2015-131 August 2016 • An agreement on the specifi c measures and the best available sources of data the State and counties will use to oversee foster children prescribed psychotropic medications, including psychosocial services and medication follow-up appointments. • An agreement on how the State and counties will oversee psychotropic medications prescribed to foster children by fee-for-service providers who are not affi liated with county Medi-Cal mental health plans. • An agreement on the extent of information related to psychotropic medications prescribed to foster children that counties will include in the self-assessments, system improvement plans, and annual progress reports they develop as part of Social Services’ California Child and Family Services Reviews. • An agreement on the extent of the information related to psychotropic medications prescribed to foster children that counties will include in their responses to Health Care Services’ reviews, including its county Medi-Cal mental health plan compliance reviews and external quality reviews. California Department of Social Services and the Department of Health Care Services To ensure that the Medical Board can promptly complete its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, Social Services and Health Care Services should continue to work with the Medical Board and its consultant to meet their data needs. If the Medical Board’s analysis is able to identify these physicians, Social Services and Health Care Services should enter into an agreement with the Medical Board to provide the information the Medical Board needs to perform similar analyses in the future. Department of Health Care Services To increase the State’s assurance that foster children do not receive medically inappropriate or unnecessary psychotropic medications, Health Care Services should devise and implement within six months methods to better enforce its prior authorization requirement for the off -label use of psychotropic medications. For example, Health Care Services should revise its claims system to automatically prompt pharmacists to submit treatment authorization requests when fi lling prescriptions for Medi-Cal benefi ciaries under age 18 when the prescribed psychotropic medications have no FDA-approved pediatric uses. Furthermore, California State Auditor Report 2015-131 77 August 2016 as part of its collaboration with Social Services and the counties to develop and implement a reasonable oversight structure, Health Care Services should determine whether information from the Judicial Council’s revised court authorization forms would help it better enforce its prior authorization requirements. Medical Board of California To ensure that physicians do not inappropriately prescribe psychotropic medications to foster children, the Medical Board should take the following steps: • Within 60 days, obtain and analyze the data from Health Care Services and Social Services to identify physicians who may have inappropriately prescribed psychotropic medications for foster children. • Following the completion of this analysis, take the appropriate follow-up actions that it deems necessary, including the investigation of physicians identifi ed in its analysis. • To the extent that its analysis is able to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, the Medical Board should enter into an agreement with Health Care Services and Social Services within six months of completing its initial review to periodically obtain the data necessary to perform the same or similar analyses. 78 California State Auditor Report 2015-131 August 2016 We conducted this audit under the authority vested in the California State Auditor by Section 8543 et seq. of the California Government Code and according to generally accepted government auditing standards. Th ose standards require that we plan and perform the audit to obtain suffi cient, appropriate evidence to provide a reasonable basis for our fi ndings and conclusions based on our audit objectives specifi ed in the Scope and Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for our fi ndings and conclusions based on our audit objectives. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor Date: August 23, 2016 Staff : Mike Tilden, CPA, Audit Principal Dale A. Carlson, MPA, CGFM Michelle J. Sanders Oswin Chan, MPP, CIA Nisha Chandra Molly Hogan, MPP Hunter Wang IT Audits: Michelle J. Baur, CISA, Audit Principal Lindsay M. Harris, MBA, CISA Richard W. Fry, MPA, ACDA Legal Counsel: J. Christopher Dawson, Sr. Staff Counsel For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Aff airs, at 916.445.0255. California State Auditor Report 2015-131 79 August 2016 Appendix SUMMARY TABLES SHOWING STATEWIDE AND COUNTY DATA REGARDING PSYCHOTROPIC MEDICATIONS PRESCRIBED TO FOSTER CHILDREN As part of our review of psychotropic medications prescribed to children in foster care (foster children), we analyzed data obtained from the California Department of Social Services’ (Social Services) Child Welfare Services/Case Management System and Medi-Cal pharmacy data from the Department of Health Care Services (Health Care Services). We present the results of our analysis that pertain to the four counties we visited in Chapter 1 and Chapter 2. Th e following tables summarize the results of our analysis for the State as a whole and for each of California’s 58 counties. To protect individual privacy, we omitted results of 10 foster children or fewer. Table A-1, beginning on the following page, shows the number of foster children in California and the number and proportion of those foster children with fi lled prescriptions for psychotropic medications for three fi scal years. As this Table shows, the number of foster children in California increased from fi scal year 2012–13 through 2014–15, while the number of foster children with fi lled prescriptions for psychotropic medications decreased over the same time period. Data for the counties included in the Table showed varying trends. August 2016 80 California State Auditor Report 2015-131 Table A-1 Number and Proportion of Children in Foster Care With Filled Psychotropic Medication Prescriptions During Fiscal Years 2012–13 Through 2014–15, Statewide and by County FOSTER CHILDREN FOSTER CHILDREN WITH FILLED PRESCRIPTIONS FOR PSYCHOTROPIC MEDICATIONS FISCAL YEAR 201213 FISCAL YEAR 201314 FISCAL YEAR 201415 FISCAL YEAR 201213 FISCAL YEAR 201314 FISCAL YEAR 201415 PERCENT OF PERCENT OF PERCENT OF PERCENT OF PERCENT OF PERCENT OF FOSTER CHILDREN FOSTER CHILDREN FOSTER CHILDREN FOSTER CHILDREN IN FOSTER CHILDREN IN FOSTER CHILDREN IN NUMBER STATEWIDE NUMBER STATEWIDE NUMBER STATEWIDE NUMBER THE STATE/COUNTY NUMBER THE STATE/COUNTY NUMBER THE STATE/COUNTY Statewide 77,043 100.0% 78,859 100.0% 79,166 100.0% 10,048 13.0% 9,707 12.3% 9,317 11.8% Counties Alameda 2,048 2.7% 2,001 2.5% 1,939 2.4% 384 18.8% 323 16.1% 298 15.4% Amador 64 0.1 75 0.1 90 0.1 12 18.8 12 16.0 17 18.9 Butte 647 0.8 610 0.8 643 0.8 111 17.2 85 13.9 76 11.8 Calaveras 140 0.2 205 0.3 190 0.2 * * 22 10.7 26 13.7 Contra Costa 1,435 1.9 1,450 1.8 1,454 1.8 236 16.4 221 15.2 215 14.8 Del Norte 136 0.2 144 0.2 137 0.2 18 13.2 16 11.1 14 10.2 El Dorado 428 0.6 418 0.5 398 0.5 59 13.8 64 15.3 69 17.3 Fresno 2,258 2.9 2,408 3.1 2,534 3.2 225 10.0 234 9.7 246 9.7 Glenn 88 0.1 119 0.2 95 0.1 11 12.5 17 14.3 12 12.6 Humboldt 330 0.4 366 0.5 444 0.6 43 13.0 38 10.4 43 9.7 Imperial 403 0.5 452 0.6 517 0.7 50 12.4 68 15.0 75 14.5 Kern 2,185 2.8 2,105 2.7 2,190 2.8 251 11.5 253 12.0 249 11.4 Kings 582 0.8 611 0.8 761 1.0 51 8.8 46 7.5 51 6.7 Lake 165 0.2 164 0.2 186 0.2 32 19.4 34 20.7 33 17.7 Lassen 111 0.1 129 0.2 113 0.1 * * 18 14.0 17 15.0 Los Angeles 27,100 35.2 27,577 35.0 27,466 34.7 3,487 12.9 3,267 11.8 3,194 11.6 Madera 393 0.5 443 0.6 427 0.5 24 6.1 23 5.2 21 4.9 Marin 150 0.2 137 0.2 142 0.2 18 12.0 14 10.2 20 14.1 Mariposa 43 0.1 33 0.0 14 0.0 11 25.6 * * * * Mendocino 327 0.4 354 0.4 343 0.4 52 15.9 55 15.5 48 14.0 Merced 845 1.1 883 1.1 788 1.0 90 10.7 85 9.6 81 10.3 Monterey 495 0.6 520 0.7 573 0.7 107 21.6 116 22.3 94 16.4 Napa 181 0.2 196 0.2 208 0.3 34 18.8 36 18.4 30 14.4 Nevada 145 0.2 129 0.2 118 0.1 30 20.7 16 12.4 18 15.3 continued on next page . . . August 2016 California State Auditor Report 2015-131 81 FOSTER CHILDREN FOSTER CHILDREN WITH FILLED PRESCRIPTIONS FOR PSYCHOTROPIC MEDICATIONS FISCAL YEAR 201213 FISCAL YEAR 201314 FISCAL YEAR 201415 FISCAL YEAR 201213 FISCAL YEAR 201314 FISCAL YEAR 201415 PERCENT OF PERCENT OF PERCENT OF PERCENT OF PERCENT OF PERCENT OF FOSTER CHILDREN FOSTER CHILDREN FOSTER CHILDREN FOSTER CHILDREN IN FOSTER CHILDREN IN FOSTER CHILDREN IN NUMBER STATEWIDE NUMBER STATEWIDE NUMBER STATEWIDE NUMBER THE STATE/COUNTY NUMBER THE STATE/COUNTY NUMBER THE STATE/COUNTY Orange 3,126 4.1% 3,024 3.8% 2,923 3.7% 322 10.3% 301 10.0% 257 8.8% Placer 406 0.5 445 0.6 424 0.5 51 12.6 57 12.8 56 13.2 Plumas 91 0.1 71 0.1 79 0.1 * * * * 12 15.2 Riverside 5,673 7.4 6,093 7.7 6,191 7.8 558 9.8 600 9.8 595 9.6 Sacramento 3,062 4.0 3,394 4.3 3,436 4.3 442 14.4 456 13.4 424 12.3 San Bernardino 5,457 7.1 5,789 7.3 6,378 8.1 695 12.7 680 11.7 660 10.3 San Diego 4,662 6.1 4,412 5.6 4,239 5.4 590 12.7 548 12.4 475 11.2 San Francisco 1,256 1.6 1,180 1.5 1,088 1.4 203 16.2 183 15.5 150 13.8 San Joaquin 1,641 2.1 1,834 2.3 1,820 2.3 253 15.4 269 14.7 248 13.6 San Luis Obispo 549 0.7 492 0.6 460 0.6 92 16.8 86 17.5 79 17.2 San Mateo 437 0.6 387 0.5 386 0.5 66 15.1 66 17.1 69 17.9 Santa Barbara 776 1.0 749 0.9 672 0.8 111 14.3 102 13.6 103 15.3 Santa Clara 1,628 2.1 1,685 2.1 1,689 2.1 205 12.6 205 12.2 213 12.6 Santa Cruz 419 0.5 407 0.5 377 0.5 47 11.2 56 13.8 43 11.4 Shasta 765 1.0 769 1.0 708 0.9 100 13.1 113 14.7 96 13.6 Siskiyou 175 0.2 173 0.2 157 0.2 32 18.3 27 15.6 20 12.7 Solano 516 0.7 515 0.7 564 0.7 84 16.3 86 16.7 85 15.1 Sonoma 733 1.0 680 0.9 616 0.8 173 23.6 142 20.9 140 22.7 Stanislaus 919 1.2 958 1.2 875 1.1 120 13.1 116 12.1 117 13.4 Sutter 188 0.2 172 0.2 182 0.2 35 18.6 40 23.3 36 19.8 Tehama 259 0.3 280 0.4 311 0.4 37 14.3 41 14.6 33 10.6 Tulare 1,221 1.6 1,363 1.7 1,435 1.8 169 13.8 166 12.2 165 11.5 Tuolumne 145 0.2 157 0.2 170 0.2 16 11.0 * * 16 9.4 Ventura 1,198 1.6 1,243 1.6 1,213 1.5 185 15.4 167 13.4 153 12.6 Yolo 334 0.4 372 0.5 377 0.5 45 13.5 41 11.0 43 11.4 Yuba 196 0.3 224 0.3 275 0.3 27 13.8 36 16.1 40 14.5 Other counties* 512 0.7 462 0.6 351 0.4 29 5.7 30 6.5 * * Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. Note: The term foster children refers to children aged zero to 17 in the foster care system. * To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. 82 California State Auditor Report 2015-131 August 2016 Table A-2 lists the number and proportion of fi lled psychotropic medication prescriptions for foster children for three fi scal years. Th is Table shows that the number of psychotropic medication prescriptions statewide dropped from more than 110,000 in fi scal year 2012–13 to about 95,750 in fi scal year 2014–15, a decrease of 13 percent. Similarly, all but 12 counties had a decrease in their number of psychotropic medication prescriptions from fi scal year 2012–13 through 2014–15. Table A-2 Number and Proportion of Filled Psychotropic Medication Prescriptions for Children in Foster Care, Statewide and by County FISCAL YEAR 201213 FISCAL YEAR 201314 FISCAL YEAR 201415 NUMBER PERCENT OF PRESCRIPTIONS NUMBER PERCENT OF PRESCRIPTIONS NUMBER PERCENT OF PRESCRIPTIONS Statewide 110,014 100.0% 106,510 100.0% 95,748 100.0% Counties Alameda 3,751 3.4% 3,469 3.3% 3,097 3.2% Alpine 0 NA 0 NA 0 NA Amador 211 0.2 226 0.2 214 0.2 Butte 1,244 1.1 1,058 1.0 1,139 1.2 Calaveras 79 0.1 226 0.2 358 0.4 Colusa 55 0.0 50 0.0 68 0.1 Contra Costa 3,091 2.8 2,918 2.7 2,585 2.7 Del Norte 236 0.2 184 0.2 217 0.2 El Dorado 771 0.7 853 0.8 702 0.7 Fresno 2,443 2.2 2,566 2.4 2,582 2.7 Glenn 136 0.1 162 0.2 84 0.1 Humboldt 465 0.4 512 0.5 414 0.4 Imperial 362 0.3 488 0.5 576 0.6 Inyo 61 0.1 11 0.0 0 NA Kern 3,373 3.1 3,105 2.9 2,804 2.9 Kings 552 0.5 533 0.5 606 0.6 Lake 462 0.4 464 0.4 424 0.4 Lassen 117 0.1 185 0.2 212 0.2 Los Angeles 33,825 30.7 31,208 29.3 29,894 31.2 Madera 231 0.2 275 0.3 158 0.2 Marin 189 0.2 150 0.1 146 0.2 Mariposa 108 0.1 60 0.1 34 0.0 Mendocino 724 0.7 690 0.6 426 0.4 Merced 1,336 1.2 1,220 1.1 850 0.9 Modoc 17 0.0 44 0.0 53 0.1 Mono 30 0.0 21 0.0 * * Monterey 1,156 1.1 1,286 1.2 1,067 1.1 Napa 451 0.4 415 0.4 265 0.3 Nevada 365 0.3 181 0.2 212 0.2 California State Auditor Report 2015-131 83 August 2016 FISCAL YEAR 201213 FISCAL YEAR 201314 FISCAL YEAR 201415 NUMBER PERCENT OF PRESCRIPTIONS NUMBER PERCENT OF PRESCRIPTIONS NUMBER PERCENT OF PRESCRIPTIONS Orange 3,576 3.3% 3,368 3.2% 2,795 2.9% Placer 454 0.4 585 0.5 603 0.6 Plumas 67 0.1 79 0.1 95 0.1 Riverside 6,214 5.6 6,753 6.3 6,024 6.3 Sacramento 4,804 4.4 5,241 4.9 4,391 4.6 San Benito 37 0.0 69 0.1 105 0.1 San Bernardino 8,291 7.5 7,979 7.5 7,192 7.5 San Diego 7,122 6.5 6,718 6.3 4,898 5.1 San Francisco 2,071 1.9 2,076 1.9 1,749 1.8 San Joaquin 3,115 2.8 3,183 3.0 2,919 3.0 San Luis Obispo 1,098 1.0 966 0.9 977 1.0 San Mateo 759 0.7 746 0.7 607 0.6 Santa Barbara 1,424 1.3 1,248 1.2 1,185 1.2 Santa Clara 2,608 2.4 2,410 2.3 2,165 2.3 Santa Cruz 490 0.4 428 0.4 354 0.4 Shasta 1,183 1.1 1,187 1.1 760 0.8 Sierra 11 0.0 0 NA * * Siskiyou 380 0.3 365 0.3 303 0.3 Solano 837 0.8 905 0.8 792 0.8 Sonoma 2,126 1.9 1,809 1.7 1,479 1.5 Stanislaus 1,215 1.1 1,072 1.0 1,138 1.2 Sutter 556 0.5 643 0.6 508 0.5 Tehama 306 0.3 432 0.4 266 0.3 Trinity 79 0.1 25 0.0 72 0.1 Tulare 2,109 1.9 2,212 2.1 1,913 2.0 Tuolumne 189 0.2 119 0.1 164 0.2 Ventura 2,133 1.9 2,298 2.2 2,057 2.1 Yolo 486 0.4 455 0.4 422 0.4 Yuba 432 0.4 579 0.5 613 0.6 Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. Notes: The term foster children refers to children aged zero to 17 in the foster care system. The average number of fi lled prescriptions per foster child may refl ect that some foster children received more than one type of psychotropic medication. Alternatively, it may indicate that some foster children had paid prescriptions of a single medication fi lled a number of times during the year (perhaps on a monthly or bimonthly basis). NA = Not applicable. * To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. For Table A-3 beginning on the following page, we separated the number and proportion of prescriptions for psychotropic medications into fi ve diff erent categories for fi scal year 2014–15. Th is Table shows that antidepressants and antipsychotics each made up 35 percent or more of all psychotropic medication prescriptions, and stimulants made up 26 percent. Th e last two classifi cations—antianxiety medications and mood stabilizers— were a very small proportion of the total psychotropic medication prescriptions, with each representing 2 percent or less. In many instances, county-level data mirrored the State’s results. August 2016 84 California State Auditor Report 2015-131 Table A-3 Number and Proportion of Filled Prescriptions for Psychotropic Medications for Children in Foster Care in Fiscal Year 2014–15 by Classifi cation, Statewide and by County TOTAL NUMBER OF ANTIANXIETY MEDICATIONS ANTIDEPRESSANTS ANTIPSYCHOTICS MOOD STABILIZERS STIMULANTS FILLED PRESCRIPTIONS FOR PSYCHOTROPIC PERCENT OF PERCENT OF PERCENT OF PERCENT OF PERCENT OF MEDICATIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS Statewide 95,748 852 0.9% 34,586 36.1% 33,303 34.8% 1,898 2.0% 25,109 26.2% Counties Alameda 3,097 22 0.7% 1,229 39.7% 1,154 37.3% 81 2.6% 611 19.7% Alpine 0 0 NA 0 NA 0 NA 0 NA 0 NA Amador 214 0 NA 64 29.9 51 23.8 4 1.9 95 44.4 Butte 1,139 5 0.4 273 24.0 464 40.7 26 2.3 371 32.6 Calaveras 358 1 0.3 98 27.4 123 34.4 13 3.6 123 34.4 Colusa 68 0 NA 36 52.9 10 14.7 0 NA 22 32.4 Contra Costa 2,585 29 1.1 972 37.6 953 36.9 43 1.7 588 22.7 Del Norte 217 1 0.5 26 12.0 22 10.1 15 6.9 153 70.5 El Dorado 702 3 0.4 294 41.9 231 32.9 20 2.8 154 21.9 Fresno 2,582 31 1.2 472 18.3 1,025 39.7 27 1.0 1,027 39.8 Glenn 84 2 2.4 20 23.8 11 13.1 12 14.3 39 46.4 Humboldt 414 4 1.0 124 30.0 159 38.4 16 3.9 111 26.8 Imperial 576 1 0.2 167 29.0 151 26.2 17 3.0 240 41.7 Inyo 0 0 NA 0 NA 0 NA 0 NA 0 NA Kern 2,804 18 0.6 1,234 44.0 908 32.4 35 1.2 609 21.7 Kings 606 5 0.8 109 18.0 190 31.4 0 NA 302 49.8 Lake 424 15 3.5 128 30.2 165 38.9 13 3.1 103 24.3 Lassen 212 0 NA 96 45.3 86 40.6 0 NA 30 14.2 Los Angeles 29,894 301 1.0 12,217 40.9 9,791 32.8 477 1.6 7,108 23.8 Madera 158 1 0.6 72 45.6 64 40.5 0 NA 21 13.3 Marin 146 6 4.1 53 36.3 44 30.1 0 NA 43 29.5 Mariposa 34 0 NA 12 35.3 9 26.5 5 14.7 8 23.5 Mendocino 426 10 2.3 117 27.5 143 33.6 36 8.5 120 28.2 Merced 850 1 0.1 289 34.0 299 35.2 12 1.4 249 29.3 Modoc 53 0 NA 33 62.3 20 37.7 0 NA 0 NA Mono * * * * * * * * * * * Monterey 1,067 8 0.7 504 47.2 270 25.3 0 NA 285 26.7 Napa 265 0 NA 85 32.1 92 34.7 0 NA 88 33.2 continued on next page . . . August 2016 California State Auditor Report 2015-131 85 TOTAL NUMBER OF ANTIANXIETY MEDICATIONS ANTIDEPRESSANTS ANTIPSYCHOTICS MOOD STABILIZERS STIMULANTS FILLED PRESCRIPTIONS FOR PSYCHOTROPIC PERCENT OF PERCENT OF PERCENT OF PERCENT OF PERCENT OF MEDICATIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS NUMBER PRESCRIPTIONS Nevada 212 1 0.5% 88 41.5% 32 15.1% 15 7.1% 76 35.8% Orange 2,795 30 1.1 821 29.4 1,087 38.9 81 2.9 776 27.8 Placer 603 3 0.5 221 36.7 240 39.8 27 4.5 112 18.6 Plumas 95 0 NA 35 36.8 23 24.2 0 NA 37 38.9 Riverside 6,024 47 0.8 2,117 35.1 2,499 41.5 178 3.0 1,183 19.6 Sacramento 4,391 17 0.4 1,392 31.7 1,718 39.1 109 2.5 1,155 26.3 San Benito 105 0 NA 30 28.6 41 39.0 0 NA 34 32.4 San Bernardino 7,192 42 0.6 2,597 36.1 2,657 36.9 83 1.2 1,813 25.2 San Diego 4,898 70 1.4 1,736 35.4 1,487 30.4 87 1.8 1,518 31.0 San Francisco 1,749 11 0.6 672 38.4 525 30.0 70 4.0 471 26.9 San Joaquin 2,919 20 0.7 839 28.7 1,005 34.4 75 2.6 980 33.6 San Luis Obispo 977 17 1.7 256 26.2 371 38.0 47 4.8 286 29.3 San Mateo 607 7 1.2 291 47.9 206 33.9 8 1.3 95 15.7 Santa Barbara 1,185 4 0.3 351 29.6 433 36.5 5 0.4 392 33.1 Santa Clara 2,165 25 1.2 771 35.6 859 39.7 18 0.8 492 22.7 Santa Cruz 354 2 0.6 182 51.4 90 25.4 0 NA 80 22.6 Shasta 760 7 0.9 206 27.1 220 28.9 18 2.4 309 40.7 Sierra * * * * * * * * * * * Siskiyou 303 7 2.3 73 24.1 139 45.9 24 7.9 60 19.8 Solano 792 5 0.6 257 32.4 315 39.8 4 0.5 211 26.6 Sonoma 1,479 25 1.7 622 42.1 559 37.8 45 3.0 228 15.4 Stanislaus 1,138 7 0.6 448 39.4 392 34.4 11 1.0 280 24.6 Sutter 508 1 0.2 107 21.1 239 47.0 3 0.6 158 31.1 Tehama 266 0 NA 78 29.3 76 28.6 0 NA 112 42.1 Trinity 72 0 NA 19 26.4 32 44.4 0 NA 21 29.2 Tulare 1,913 27 1.4 476 24.9 607 31.7 60 3.1 743 38.8 Tuolumne 164 0 NA 51 31.1 71 43.3 10 6.1 32 19.5 Ventura 2,057 1 0.0 788 38.3 515 25.0 28 1.4 725 35.2 Yolo 422 12 2.8 174 41.2 106 25.1 19 4.5 111 26.3 Yuba 613 0 NA 164 26.8 321 52.4 21 3.4 107 17.5 Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. NA = Not applicable. * To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. 86 California State Auditor Report 2015-131 August 2016 Table A-4 shows the number and proportion of foster children within certain age ranges who had psychotropic medication prescriptions fi lled during fi scal year 2014–15. As indicated in the Table, almost three-quarters of foster children with fi lled prescriptions for psychotropic medications were aged 12 to 17. County-level data mirrored the state results: most psychotropic medications in each county were also prescribed to foster children aged 12 to 17. California State Auditor Report 2015-131 87 August 2016 Table A-4 Number and Proportion of Children in Foster Care With Prescriptions for Psychotropic Medications That Were Filled in Fiscal Year 2014–15 by Age Range AGE RANGE FISCAL YEAR 201415 TOTAL 01* 25* 611 1217 NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT Statewide 9,317 100.0% 17 0.2% 217 2.3% 2,604 27.9% 6,895 74.0% Counties Alameda 298 3.2% 44 14.8% 254 85.2% Butte 76 0.8 31 40.8 50 65.8 Calaveras 26 0.3 11 42.3 17 65.4 Contra Costa 215 2.3 45 20.9 175 81.4 El Dorado 69 0.7 16 23.2 54 78.3 Fresno 246 2.6 84 34.1 168 68.3 Humboldt 43 0.5 12 27.9 31 72.1 Imperial 75 0.8 30 40.0 43 57.3 Kern 249 2.7 61 24.5 193 77.5 Kings 51 0.5 22 43.1 31 60.8 Los Angeles 3,194 34.3 924 28.9 2,336 73.1 Merced 81 0.9 18 22.2 62 76.5 Monterey 94 1.0 19 20.2 72 76.6 Orange 257 2.8 66 25.7 201 78.2 Placer 56 0.6 16 28.6 41 73.2 Riverside 595 6.4 165 27.7 440 73.9 Sacramento 424 4.6 100 23.6 335 79.0 San Bernardino 660 7.1 213 32.3 460 69.7 San Diego 475 5.1 130 27.4 348 73.3 San Francisco 150 1.6 46 30.7 115 76.7 San Joaquin 248 2.7 88 35.5 168 67.7 San Luis Obispo 79 0.8 20 25.3 58 73.4 San Mateo 69 0.7 13 18.8 58 84.1 Santa Barbara 103 1.1 36 35.0 71 68.9 Santa Clara 213 2.3 40 18.8 178 83.6 Shasta 96 1.0 42 43.8 59 61.5 Solano 85 0.9 20 23.5 70 82.4 Sonoma 140 1.5 21 15.0 121 86.4 Stanislaus 117 1.3 27 23.1 90 76.9 Sutter 36 0.4 13 36.1 25 69.4 Tehama 33 0.4 11 33.3 22 66.7 Tulare 165 1.8 64 38.8 97 58.8 Ventura 153 1.6 38 24.8 120 78.4 Yuba 40 0.4 16 40.0 28 70.0 Other counties 406 4.4 102 25.1 304 74.9 Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. Notes: Totals may not add up to 100 percent because some children aged into a new age range during fi scal year 2014–15. The term foster children refers to children aged zero to 17 in the foster care system. * The 0–1 year and 2–5 years age ranges for each county contained 10 or fewer foster children in at least one of the two age ranges. To protect individual privacy, we omitted all county data for these two columns. 88 California State Auditor Report 2015-131 August 2016 Table A-5 shows the number of foster children in each age range who had fi lled antipsychotic medication prescriptions in fi scal year 2014–15. Similar to Table A-4, the majority of foster children with fi lled prescriptions for antipsychotic medications were aged 12 to 17. Again, county-level data mirrored the state results. Table A-5 Number and Proportion of Children in Foster Care With Prescriptions for Antipsychotic Psychotropic Medications That Were Filled in Fiscal Year 2014–15 by Age Range FOSTER CHILDREN WITH AGE RANGE FILLED PRESCRIPTIONS FOR NUMBER OF FOSTER CHILDREN ANTIPSYCHOTICS 01* 25* 611 1217 WITH FILLED PRESCRIPTIONS FOR PSYCHOTROPIC MEDICATIONS NUMBER PERCENT NUMBER NUMBER NUMBER NUMBER Statewide 9,317 4,339 46.6% 1,069 3,380 Counties Alameda 298 147 49.3% 20 127 Butte 76 44 57.9 18 30 Contra Costa 215 108 50.2 17 95 Fresno 246 108 43.9 25 84 Kern 249 122 49.0 26 98 Los Angeles 3,194 1,409 44.1 389 1,051 Orange 257 127 49.4 33 98 Riverside 595 342 57.5 82 271 Sacramento 424 214 50.5 39 178 San Bernardino 660 359 54.4 87 279 San Diego 475 190 40.0 34 160 San Francisco 150 56 37.3 21 40 San Joaquin 248 111 44.8 37 82 San Luis Obispo 79 47 59.5 13 34 Santa Barbara 103 49 47.6 17 35 Santa Clara 213 108 50.7 19 91 Shasta 96 32 33.3 12 21 Tulare 165 71 43.0 23 51 Yuba 40 29 72.5 13 20 Other counties 1,534 666 43.4 144 535 Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. Notes: Total percentages may not add up to 100 percent because some children aged into a new age range during fi scal year 2014–15. The term foster children refers to children aged zero to 17 in the foster care system. * The 0-to-1 year and 2-to-5 years age ranges for each county and the State contained fewer than 10 foster children in at least one of the two age ranges. To protect individual privacy, we omitted all data for these two columns. California State Auditor Report 2015-131 89 August 2016 Table A-6 shows the number and proportion of foster children in fi scal year 2014–15 who had fi lled prescriptions for more than one psychotropic medication in the same class for antidepressants, antipsychotics, and stimulants, the three most widely prescribed classifi cations from Table A-3. Th e data refl ect that it is more common for foster children to be on multiple antidepressants than on multiple antipsychotics or multiple stimulants. Th e county-level data show the same trend as the statewide data. Table A-6 Number and Proportion of Children in Foster Care With Multiple Filled Psychotropic Medication Prescriptions From the Same Class, Statewide and by County, Fiscal Year 2014–15 FOSTER CHILDREN WITH FILLED FOSTER CHILDREN WITH FILLED FOSTER CHILDREN WITH FILLED TOTAL NUMBER OF PRESCRIPTIONS FOR MORE THAN PRESCRIPTIONS FOR MORE THAN PRESCRIPTIONS FOR MORE THAN FOSTER CHILDREN WITH ONE ANTIDEPRESSANT* ONE ANTIPSYCHOTIC* ONE STIMULANT* FILLED PSYCHOTROPIC MEDICATION PRESCRIPTIONS NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT Statewide 9,317 851 9.1% 330 3.5% 193 2.1% Counties Alameda 298 36 12.1% 13 4.4% † † Contra Costa 215 21 9.8 † † † † Fresno 246 † † 21 8.5 † † Kern 249 63 25.3 14 5.6 † † Los Angeles 3,194 267 8.4 69 2.2 42 1.3% Monterey 94 14 14.9 † † † † Orange 257 12 4.7 18 7.0 † † Riverside 595 71 11.9 26 4.4 † † Sacramento 424 25 5.9 21 5.0 † † San Bernardino 660 86 13.0 13 2.0 † † San Diego 475 37 7.8 19 4.0 13 2.7 San Joaquin 248 17 6.9 11 4.4 † † Santa Clara 213 19 8.9 † † † † Sonoma 140 25 17.9 † † † † Tulare 165 † † † † 11 6.7 Ventura 153 22 14.4 † † 18 11.8 Other counties 1,691 116 6.9 72 4.3 45 2.7 Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ California Medicaid Management Information System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Note: The term foster children refers to children aged zero to 17 in the foster care system. * For our analysis, we only considered foster children to be on more than one psychotropic medication if they received more than one psychotropic medication within the same medication classifi cation for more than 30 days. † To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. 90 California State Auditor Report 2015-131 August 2016 Table A-7 shows the number of foster children by age range in fi scal year 2014–15 whose number of fi lled prescriptions for psychotropic medications exceeded Social Services and Health Care Services’ guidelines for the safe administration of psychotropic medications to foster children. Table A-7 Number of Children in Foster Care With Filled Prescriptions for Psychotropic Medications That Exceeded the State's Recommended Guidelines for Age Groups, Statewide and by County, Fiscal Year 2014–15 TOTAL NUMBER OF FOSTER CHILDREN AGE 05 FOSTER CHILDREN AGE 611 FOSTER CHILDREN AGE 1217 FOSTER CHILDREN PRESCRIBED PRESCRIBED MORE THAN ONE PRESCRIBED MORE THAN TWO PRESCRIBED MORE THAN THREE PSYCHOTROPIC MEDICATIONS PSYCHOTROPIC MEDICATION* PSYCHOTROPIC MEDICATIONS* PSYCHOTROPIC MEDICATIONS* Statewide 9,317 29 159 90 Counties Kern 249 † 12 † Los Angeles 3,194 † 34 14 Riverside 595 † † 11 San Bernardino 660 † 17 † Other Counties 4,619 17 † 55 Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ California Medicaid Management Information System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Notes: State guidelines recommend that children aged zero to 5 take no more than one psychotropic medication, children aged 6 to 11 take no more than two psychotropic medications, and children aged 12 to 17 take no more than three psychotropic medications. The term foster children refers to children aged zero to 17 in the foster care system. * For our analysis, we considered foster children to be on multiple psychotropic medications when their prescriptions overlapped for more than 30 consecutive days. † To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. Table A-8 shows the number of foster children in fi scal year 2013–14 who did not have follow-up medical appointments within 30 days after starting at least one new psychotropic medication. As the Table indicates, more than 29 percent of foster children who started new psychotropic medications did not have a corresponding Medi-Cal claim for a follow-up medication service visit. Table A-8 Number and Proportion of Children in Foster Care With New Psychotropic Medication Prescriptions Filled in Fiscal Year 2013–14 Without a Corresponding Medi-Cal Claim for a Follow-Up Medication Service Within 30 Days, Statewide and by County NUMBER OF FOSTER CHILDREN WITH AT LEAST ONE FILLED PRESCRIPTION FOR A NEW PSYCHOTROPIC MEDICATION WITHOUT A NUMBER OF FOSTER CHILDREN CORRESPONDING MEDICAL CLAIM FOR A WITH NEW PSYCHOTROPIC FOLLOWUP MEDICATION SERVICE MEDICATION PRESCRIPTIONS* NUMBER PERCENT Statewide 6,471 1,881 29.1% Counties Alameda 220 73 33.2% Butte 54 20 37.0 Calaveras 17 † † Contra Costa 136 37 27.2% California State Auditor Report 2015-131 91 August 2016 NUMBER OF FOSTER CHILDREN WITH AT LEAST ONE FILLED PRESCRIPTION FOR A NEW PSYCHOTROPIC MEDICATION WITHOUT A NUMBER OF FOSTER CHILDREN CORRESPONDING MEDICAL CLAIM FOR A WITH NEW PSYCHOTROPIC FOLLOWUP MEDICATION SERVICE MEDICATION PRESCRIPTIONS* NUMBER PERCENT Del Norte 12 † † El Dorado 43 17 39.5 Fresno 156 63 40.4 Glenn 13 † † Humboldt 28 † † Imperial 60 39 65.0 Kern 158 58 36.7 Kings 31 17 54.8 Lake 20 † † Lassen 16 † † Los Angeles 2,252 334 14.8 Madera 17 † † Mendocino 32 15 46.9 Merced 50 27 54.0 Monterey 62 23 37.1 Napa 26 15 57.7 Orange 186 45 24.2 Placer 39 13 33.3 Riverside 406 167 41.1 Sacramento 283 83 29.3 San Bernardino 454 228 50.2 San Diego 372 86 23.1 San Francisco 116 28 24.1 San Joaquin 160 60 37.5 San Luis Obispo 58 21 36.2 San Mateo 45 22 48.9 Santa Barbara 63 25 39.7 Santa Clara 125 27 21.6 Santa Cruz 42 13 31.0 Shasta 75 20 26.7 Siskiyou 20 † † Solano 60 26 43.3 Sonoma 90 46 51.1 Stanislaus 80 39 48.8 Sutter 25 † † Tehama 35 13 37.1 Tulare 101 30 29.7 Ventura 114 19 16.7 Yolo 25 12 48.0 Yuba 24 † † Other counties 70 36 51.4 Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Notes: The term foster children refers to children aged zero to 17 in the foster care system. * We defi ned a new prescription as any prescription for a psychotropic medication that the child had not been prescribed in the prior 120 days and, as discussed in the Scope and Methodology section on page 17, we applied the National Committee for Quality Assurance's methodology for follow-up care. † To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. 92 California State Auditor Report 2015-131 August 2016 Table A-9 shows the number of foster children in fi scal year 2013–14 who had at least one instance in which they did not receive psychosocial services within 30 days, either before or after receiving a prescription for psychotropic medications. In addition, Table A-9 shows the number of foster children in the same fi scal year who had at least one instance in which they did not receive psychosocial services within 180 days, either before or after beginning a new prescription. As shown in the Table, between 3,965 and 7,489 (41 and 77 percent) of foster children statewide had at least one instance in which they did not receive corresponding psychosocial services within 30 days of receiving a prescription. We report a range in the number of foster children who did not receive psychosocial services to accommodate for diff erences in the way the Department of Health Care Services and the National Committee for Quality Assurance use procedure codes to defi ne psychosocial services. Further, when compiling statewide data, we found that Social Services' data is not formatted in a way that allows us to defi nitively identify if court authorizations or parental consents are associated with a specifi c psychotropic medication. As a result, we analyzed the statewide data to identify the frequency with which court authorizations or parental consents existed for any medication and if that approval was either 180 days before or 30 days after the date the psychotropic medication prescription was fi lled. Table A-10 on page 94 shows the number and proportion of foster children in fi scal year 2014–15 who had prescriptions fi lled for psychotropic medications and the type of authorization they received. As the data show, only 35 percent of the foster children statewide had court authorizations or parental consents for all their psychotropic medications. Th e other 65 percent were missing authorizations or consents for at least one psychotropic medication. Further, only 11 of the 35 counties shown had court authorizations or parental consents rates of 50 percent or more for all psychotropic medications prescribed for foster children. Table A-9 Number of Children in Foster Care With Filled Prescriptions for Psychotropic Medications Without a Corresponding Medi-Cal Claim for Psychosocial Services, Statewide and by County, Fiscal Year 2013–14 NUMBER OF FOSTER CHILDREN FOSTER CHILDREN WITH WITH AT LEAST ONE INSTANCE OF NO SERVICE WITHIN... FILLED PRESCRIPTIONS ...30 DAYS BEFORE ...180 DAYS BEFORE FOR PSYCHOTROPIC OR AFTER FILLING OR AFTER FILLING MEDICATIONS A PRESCRIPTION A PRESCRIPTION Statewide 9,707 3,965–7,489 1,564–4,512 Counties Alameda 323 134–242 44–131 California State Auditor Report 2015-131 93 August 2016 NUMBER OF FOSTER CHILDREN FOSTER CHILDREN WITH WITH AT LEAST ONE INSTANCE OF NO SERVICE WITHIN... FILLED PRESCRIPTIONS ...30 DAYS BEFORE ...180 DAYS BEFORE FOR PSYCHOTROPIC OR AFTER FILLING OR AFTER FILLING MEDICATIONS A PRESCRIPTION A PRESCRIPTION Butte 85 44–* 14–65 Contra Costa 221 88–165 32–118 El Dorado 64 37–* 23–* Fresno 234 118–193 59–118 Humboldt 38 17–* *–14 Imperial 68 47–* 21–56 Kern 253 124–210 48–134 Kings 46 33–* 15–33 Lake 34 *–* *–15 Los Angeles 3,267 742–2,185 204–994 Mendocino 55 25–* 14–43 Merced 85 53–73 24–50 Monterey 116 51–82 *–36 Napa 36 22–* 13–* Orange 301 107–275 46–210 Placer 57 32–45 16–30 Riverside 600 385–556 146–363 Sacramento 456 196–367 80–225 San Bernardino 680 442–545 196–343 San Diego 548 206–349 92–224 San Francisco 183 59–103 26–42 San Joaquin 269 116–252 65–184 San Luis Obispo 86 37–63 18–31 San Mateo 66 31–* *–32 Santa Barbara 102 59–83 35–61 Santa Clara 205 73–180 27–118 Santa Cruz 56 16–43 *–23 Shasta 113 57–* 12–91 Siskiyou 27 *–* 12–* Solano 86 40–* *–53 Sonoma 142 98–* 56–98 Stanislaus 116 60–103 29–76 Sutter 40 16–* *–20 Tehama 41 21–* *–* Tulare 166 72–142 34–80 Ventura 167 44–124 16–74 Yolo 41 *–* 21–* Yuba 36 20–* *–19 Other counties 198 131–175 61–137 Sources: California State Auditor’s analysis of data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data. Note: The term foster children refers to children aged zero to 17 in the foster care system. * To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. 94 California State Auditor Report 2015-131 August 2016 Table A-10 Number and Proportion of Children in Foster Care With Filled Prescriptions for Psychotropic Medications by Type of Consent Recorded in Social Services’ Data, Statewide and by County, Fiscal Year 2014–15 TYPES OF CONSENT TOTAL NUMBER OF FOSTER CHILDREN WITH NO COURT AUTHORIZATION FILLED PRESCRIPTIONS FOR COURT AUTHORIZATION OR NO COURT AUTHORIZATION OR OR PARENTAL CONSENT PSYCHOTROPIC MEDICATIONS PARENTAL CONSENT FOR ALL PARENTAL CONSENT FOR ANY FOR ONE OR MORE IN FISCAL YEAR 201415 PSYCHOTROPIC MEDICATIONS PSYCHOTROPIC MEDICATIONS PSYCHOTROPIC MEDICATIONS NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT NUMBER PERCENT Statewide 9,317 100.0% 3,232 34.7% 3,448 37.0% 6,085 65.3% Counties Alameda 298 3.2% 39 13.1% 174 58.4% 259 86.9% Butte 76 0.8 21 27.6 12 15.8 55 72.4 Fresno 246 2.6 141 57.3 58 23.6 105 42.7 Humboldt 43 0.5 28 65.1 13 30.2 15 34.9 Imperial 75 0.8 14 18.7 29 38.7 61 81.3 Kern 249 2.7 143 57.4 54 21.7 106 42.6 Kings 51 0.5 17 33.3 18 35.3 34 66.7 Lake 33 0.4 13 39.4 11 33.3 20 60.6 Los Angeles 3,194 34.3 920 28.8 1,475 46.2 2,274 71.2 Mendocino 48 0.5 25 52.1 * * 23 47.9 Merced 81 0.9 31 38.3 28 34.6 50 61.7 Monterey 94 1.0 57 60.6 * * 37 39.4 Napa 30 0.3 13 43.3 * * 17 56.7 Orange 257 2.8 106 41.2 51 19.8 151 58.8 Placer 56 0.6 16 28.6 24 42.9 40 71.4 Riverside 595 6.4 300 50.4 121 20.3 295 49.6 Sacramento 424 4.6 176 41.5 135 31.8 248 58.5 San Bernardino 660 7.1 227 34.4 201 30.5 433 65.6 San Diego 475 5.1 227 47.8 133 28.0 248 52.2 San Francisco 150 1.6 76 50.7 34 22.7 74 49.3 San Joaquin 248 2.7 108 43.5 54 21.8 140 56.5 San Luis Obispo 79 0.8 15 19.0 21 26.6 64 81.0 San Mateo 69 0.7 29 42.0 12 17.4 40 58.0 Santa Barbara 103 1.1 56 54.4 23 22.3 47 45.6 Santa Clara 213 2.3 50 23.5 69 32.4 163 76.5 Santa Cruz 43 0.5 18 41.9 15 34.9 25 58.1 Shasta 96 1.0 76 79.2 * * 20 20.8 Solano 85 0.9 29 34.1 33 38.8 56 65.9 Sonoma 140 1.5 31 22.1 65 46.4 109 77.9 Stanislaus 117 1.3 12 10.3 65 55.6 105 89.7 Sutter 36 0.4 21 58.3 * * 15 41.7 Tehama 33 0.4 13 39.4 * * 20 60.6 Tulare 165 1.8 17 10.3 73 44.2 148 89.7 Ventura 153 1.6 65 42.5 25 16.3 88 57.5 Yuba 40 0.4 23 57.5 * * 17 42.5 Other counties 562 6.0 79 14.1 369 65.7 483 85.9 Sources: California State Auditor’s analysis of data obtained from the California Department of Social Services’ Child Welfare Services/Case Management System and matched Medi-Cal pharmacy data. Note: The term foster children refers to children aged zero to 17 in the foster care system. * To protect individual privacy, we omitted this number because it would identify 10 or fewer foster children. Such omission is in accordance with aggregate data reporting guidelines issued by the Department of Health Care Services. California State Auditor Report 2015-131 95 August 2016 * * California State Auditor’s comment appears on page 103. 96 California State Auditor Report 2015-131 August 2016 California State Auditor Report 2015-131 97 August 2016 98 California State Auditor Report 2015-131 August 2016 California State Auditor Report 2015-131 99 August 2016 100 California State Auditor Report 2015-131 August 2016 1 California State Auditor Report 2015-131 101 August 2016 102 California State Auditor Report 2015-131 August 2016 Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 103 August 2016 Comment CALIFORNIA STATE AUDITOR’S COMMENT ON THE RESPONSE FROM THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES To provide clarity and perspective, we are commenting on the response from the California Department of Social Services (Social Services) to the audit. Th e number below corresponds to the number we have placed in the margin of its response. Our audit report did not “fail to acknowledge” measures 5a.1 (use 1 of psychotropic medications by foster children) and 5a.2 (use of antipsychotic medications by foster children) as Social Services asserts; we intentionally omitted them. On page 66 of our report, we indicate that only one measure—5F—published on the website for the California Child Welfare Indicators Project addresses the number of foster children authorized to receive psychotropic medications. Despite Social Services' statement that measures 5a.1 and 5a.2 have been published since October 2015, Social Services waited until April 2016 to inform counties of their availability through an all-county letter. In an all-county letter to county child welfare directors and other county offi cials dated April 28, 2016, Social Services mentioned that county child welfare and probation agencies could view the results of these two measures at the California Child Welfare Indicators Project website. Because the contents of the all-county letter had no direct bearing on our report’s fi ndings, conclusions, or recommendations, we opted to not mention the two new measures. 104 California State Auditor Report 2015-131 August 2016 Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 105 August 2016 106 California State Auditor Report 2015-131 August 2016 California State Auditor Report 2015-131 107 August 2016 108 California State Auditor Report 2015-131 August 2016 California State Auditor Report 2015-131 109 August 2016 110 California State Auditor Report 2015-131 August 2016 California State Auditor Report 2015-131 111 August 2016 * * California State Auditor’s comments begin on page 115. 112 California State Auditor Report 2015-131 August 2016 1 2 3 California State Auditor Report 2015-131 113 August 2016 4 5 6 114 California State Auditor Report 2015-131 August 2016 Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 115 August 2016 Comments CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM LOS ANGELES COUNTY To provide clarity and perspective, we are commenting on Los Angeles County’s response to the audit. Th e numbers below correspond to the numbers we have placed in the margin of its response. Although we appreciate Los Angeles County’s suggested wording 1 change, we believe that it does not diff er substantially from the current wording of our recommendation. Th e page numbers on Los Angeles County’s redacted draft copy of 2 the audit report do not correspond to the page numbers of the fi nal audit report. Th e content Los Angeles County refers to appears on page 38 of our fi nal report. Los Angeles County appears to restate one of the key points from 3 Chapter 2 of our report; namely, certain psychosocial services provided to foster children are not included in the State’s information, including the Health and Education Passports. As we mention on page 55 of our report, all 80 of the Health and Education Passports we reviewed were missing information about the corresponding psychosocial services foster children should have received for at least one psychotropic medication. Furthermore, Figure 4 on page 56 summarizes the process for providing updated information, including psychosocial services, for the Child Welfare Services/ Case Management System operated by the California Department of Social Services (Social Services) and the resulting Health and Education Passports. A key source of that updated information is the health care provider, regardless of where that provider works. In fact, state law states that caregivers are responsible for obtaining and maintaining accurate and thorough information from physicians to be included as part of Health and Education Passports. Th erefore, Los Angeles County’s statement underscores the need for counties to ensure that caregivers and county staff are properly updating Health and Education Passports with mental health information to give counties a more accurate and up-to-date picture of foster children’s mental health treatments. We appreciate Los Angeles County’s acknowledgement of the 4 concern regarding unauthorized psychotropic medications for foster children and its idea for a longer-term solution, a concern that can be included as part of the discussions during the collaboration between Social Services and the counties as we recommend in Chapter 2. However, because it is not yet clear whether or when such a solution may be implemented, counties 116 California State Auditor Report 2015-131 August 2016 need to take steps in the near term to better ensure that foster children receive appropriate court authorizations or parental consents for their psychotropic medications, as we recommend on page 49. 5 We appreciate Los Angeles County’s acknowledgement of the concern regarding weaknesses in Social Services’ data system and its idea for a longer-term solution. We anticipate that Los Angeles County can include this longer-term solution as part of the discussions during the collaboration between Social Services and the counties as we recommend in Chapter 2. 6 Los Angeles County appears to not fully understand our point regarding public health nurses. We agree fully that public health nurses should focus their unique skills on more pressing duties and not on entering data into Social Services’ data system. Th at is why we point out on page 59 of our report that the federal government will cover 75 percent of the costs for necessary support staff for skilled professional medical personnel like public health nurses. Th ese support staff could enter information into the Health and Education Passports, freeing public health nurses to oversee the support staff ’s work and to perform other, more pressing responsibilities. California State Auditor Report 2015-131 117 August 2016 * * California State Auditor’s comments begin on page 121. 118 California State Auditor Report 2015-131 August 2016 1 2 California State Auditor Report 2015-131 119 August 2016 3 120 California State Auditor Report 2015-131 August 2016 Blank page inserted for reproduction purposes only. California State Auditor Report 2015-131 121 August 2016 Comments CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM RIVERSIDE COUNTY To provide clarity and perspective, we are commenting on Riverside County’s response to the audit. The numbers below correspond to the numbers we have placed in the margin of its response. Riverside County recommends in its response that we include 1 rehabilitation and case management services as services that also meet our recommendation regarding the provision of psychosocial services before or concurrent with foster children receiving psychotropic medications. We, in fact, included psychosocial rehabilitation in our analysis. As we mention on page 41 of our report, we based this analysis on the defi nition of psychosocial services contained in the Healthcare Eff ectiveness Data and Information Set (HEDIS), a set of health care performance measures used by more than 90 percent of the health care plans in the United States. Although the HEDIS defi nition includes psychosocial rehabilitation, it does not include case management. We therefore stand by our methodology and the results we present in our report. Riverside County appears to restate one of the key points 2 from Chapter 2 of our report; namely, some quantities of psychosocial services provided to foster children are invisible to the county and the State. As we mention on page 55 of our report, all 80 Health and Education Passports we reviewed were missing information about the corresponding psychosocial services foster children should have received for at least one psychotropic medication. Furthermore, Figure 4 on page 56 summarizes the process for providing updated information, including psychosocial services, for the Child Welfare Services/Case Management System operated by the California Department of Social Services and the resulting Health and Education Passports. A key source of that updated information is the health care provider, regardless of where that provider works. In fact, state law states that caregivers are responsible for obtaining and maintaining accurate and thorough information from physicians to be included as part of Health and Education Passports. Th erefore, Riverside County’s statement underscores the need for counties to ensure that caregivers and county staff are properly updating Health and Education Passports with mental health information to give counties a more accurate and up-to-date picture of foster children’s mental health treatments. 122 California State Auditor Report 2015-131 August 2016 Riverside County states that certain types of services fell outside 3 our defi nition of psychosocial services. As we mentioned earlier under Comment 1, we analyzed those types of psychosocial services included within the HEDIS defi nition. We included within our analysis any HEDIS psychosocial service regardless of the source—whether provided by group homes, foster family agencies, or other provider types—when we saw evidence of those services in the county’s or the State’s records. Furthermore, we did not include services such as intensive care coordination and assessments within our analysis because they are not mentioned in the HEDIS defi nition of psychosocial services. We therefore stand by our methodology and the results we present in the report. California State Auditor Report 2015-131 123 August 2016 * * California State Auditor’s comments begin on page 129. 124 California State Auditor Report 2015-131 August 2016 The County of Sonoma’s Response to the California State Auditor Report on California’s Foster Care System * The County of Sonoma appreciates the opportunity to respond to the draft of the State Auditor report on California’s Foster Care System received on May 31, 2016. The County was asked to respond to both the report’s statewide recommendations as well as those specific to Sonoma County. These responses can be found in the pages that follow this introduction. INTRODUCTION Sonoma County is dedicated to protecting and promoting the safety, health and well-being of children and teens in foster care. The County continues to develop and implement high-quality, responsive programs that support foster youth. This vulnerable population can enter the foster care system for many reasons, including physical or sexual abuse in the home, neglect, abandonment, or mental health needs that are beyond the ability of caregivers to properly manage. Youth in the Juvenile Probation system may also be placed in out-of-home care. Due to their experiences and the subsequent trauma those experiences generate, these youth often need significant mental health support and treatment. Providing effective services to these youth is a primary concern in Sonoma County and statewide. In 2013, two years prior to the Auditors’ visit, Sonoma County identified that data showed higher numbers of local foster children authorized to take psychotropic medications than the statewide average. Addressing that issue became a high priority, as reflected the County’s 2014-19 System Improvement Plan (SIP). Since then, the County has made system-wide changes to ensure that foster youth receive clinically appropriate psychotropic medication. Among these changes, in July 2015, the Sonoma County Human Services Department used prioritized funding to contract with an independent psychiatrist who reviews the recommendations of the treating psychiatrist prior to the social worker seeking court authorization for administration of psychotropic medication. It has been the County’s intent to add this review to cases in which the court has delegated the authority to consent to psychotropic medication to the child’s parent. As another example, ongoing training for social work staff regarding best practices for psychotropic medications, side effects and options treatment continues. Two areas of focus also include how to clearly and effectively communicate with prescribing physicians and with foster youth regarding their experience with those medications and their use and monitoring for potential side effects. Sonoma County is proud of the services it provides to foster youth, including necessary mental health treatment. Nonetheless, it welcomes outside reviews and input on ways to improve. The County intends to implement all the recommendations of the State Auditor, as discussed more fully below. At the same time, the County takes issue with some of the narrative in the audit report, and would like to address those before turning to the recommendations. Page 1 of 5 * California State Auditor’s comments begin on page 129. California State Auditor Report 2015-131 125 August 2016 The audit report has underscored the need for a high-level of detail in documentation. Systematic and consistent documentation is important to monitor and evaluate data, as noted in the audit report, and Sonoma County has focused on improving this since 2014. Sonoma County acknowledges the deficiencies in documentation described in the audit report and is working to improve its documentation. However, as the audit report notes, missing information does not mean that, in fact, foster children were taking psychotropic medications in excessive doses or multiple medications in the same category. Mental health treatment information is maintained by the treatment provider, and in order to 1 understand the treatment received by an individual foster youth, one must review the actual mental health treatment record. We are concerned that many of the cases referred to in the report did not 2 reference the actual treatment decisions of the providers and the data for the audit was based less on chart review and more on claims data. In addition, these medications can only be prescribed to foster youth by medical professionals who have standards to which they must adhere. Furthermore, the judicial system provides oversight, including providing these foster youth with legal counsel, who meet frequently with the youth and advocate on behalf of their client’s best interests. We are confident that if the auditors had an opportunity to look deeper into each child’s records, they 1 would have found that Sonoma County foster youth receive clinically appropriate amounts and types of 2 psychotropic medication. The audit report also gives the incorrect impression that Sonoma County foster youth are not provided 1 non-pharmacological interventions. This is untrue. Foster youth are provided mental health, substance and other alternative services to pharmacological interventions before and/or concurrent with the prescription of psychotropic medication as clinically indicated. This information is often documented in contract, authorization and payments systems of the Human Services Department. The audit report findings do not take these documentation realities into account. Information is also required to be kept 1 by licensed residential treatment providers and individual private practice psychiatrists. An audit of 2 these records would have supplemented the audit report with additional specific information. In addition, the audit report gives the false impression that Sonoma County does not follow generally 3 accepted professional standards when prescribing psychoactive medication to foster care youth. In fact Sonoma County prescribers (who treat serious and severe mental illnesses through the County Mental Health Plan to youth in and outside the foster care system), are bound by and adhere to the prescribing 4 standards established by federal and state law governing county mental health plans. As the audit report points out, Sonoma County’s policies were in need of updating, and the County has made those 5 updates. County policies now incorporate the most current version of the Los Angeles Department of Mental Health, Parameters 3.8, for Use of Psychotropic Medication in Children and Adolescents and the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care (including appendices A-D). If the recommended prescribing guidelines are not met, or if medications Page 2 of 5 126 California State Auditor Report 2015-131 August 2016 are prescribed outside the recommended parameters, the prescribers will be urged to seek peer consultation and/or clinical review with the Sonoma County Behavioral Health Medical Director. Finally, the County has some questions and suggestions about the methodology of the report. First, it 6 would have been helpful to have a clear breakdown between the departments involved with foster youth: Family, Youth and Children’s Services Division and Probation. Children in each of these areas have differing needs for mental health interventions and care. A further description of the methodology in general and case review selection process would help the County understand how these cases relate to the child welfare population taking psychotropic medications, as well as the general child welfare population as a whole. In addition, the data reporting would be enhanced by hypothesis and proportions testing. We note also that some statewide and Sonoma County recommendations, such as those calling for better documentation, are similar, which reinforces our belief that many issues highlighted in the report 7 affect counties across the state. We hope that the State will offer additional guidance and resources to all counties to enhance consistency and clarity of implementation of these recommendations. Therefore, with some caveats, Sonoma County finds the audit report recommendations for 1) all counties statewide and 2) Sonoma County are reasonable and constructive measures that will advance our mission of promoting the well-being of foster children in our care. RESPONSE TO THE STATEWIDE RECOMMENDATIONS: Recommendation 1. Implement procedures to more closely monitor requests for authorizations for psychotropic medications for foster children that exceed the state guidelines for multiple prescriptions or excessive dosages. When request for authorizations exceed the state guidelines, counties should follow-up with providers about the medical necessity of the prescriptions and should document their follow-up in the foster children’s case files. In instances in which counties do not believe that a provider has adequate justification for exceeding the state guidelines, counties should relay their concerns and related recommendations to the court or parent. RESPONSE: Sonoma County supports this recommendation. Recommendation 2. Ensure that prescribing physicians follow up within 30 days with all foster children to whom they prescribed new psychotropic medications. RESPONSE: Sonoma County supports this recommendation. Page 3 of 5 California State Auditor Report 2015-131 127 August 2016 Recommendation 3. Implement a process to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications. RESPONSE: Sonoma County already ensures that foster children receive these services 8 before or concurrently with medication, but will work on putting systems in place that better track and document these services, and therefore Sonoma County supports the recommendation. Recommendation 4. Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as required. The process should also ensure that the counties better document these authorizations in the foster children’s case files. RESPONSE: Sonoma County supports the recommendation. Recommendation 5. Develop and implement a process for county staff and caregivers to work together to ensure that psychotropic medications are approved before administering medications. This process should also ensure that the counties obtain accurate medication start dates from caregivers. RESPONSE: Sonoma County supports the recommendation. RESPONSE TO THE SONOMA COUNTY RECOMMENDATIONS Recommendation I. Immediately adopt the state guidelines for its physicians’ use when prescribing psychotropic medications and the county’s review of court authorization requests. RESPONSE: Sonoma County supports this recommendation. The County was aware of a need to update policies around psychotropic medication before the auditors began their review and have been working on those updates. We have already 5 completed the policy revision necessary to adopt the current state guidelines Page 4 of 5 128 California State Auditor Report 2015-131 August 2016 for physicians’ use when prescribing psychotropic medications and for review of court authorization requests. Recommendation 2. Within six months, implement a process to review psychotropic medications that parents, rather than courts, are able to approve for children. RESPONSE: Sonoma County supports the recommendation. Recommendation 3. Update its policies to describe an acceptable method for obtaining and documenting parental consent for psychotropic medications. RESPONSE: Sonoma County supports the recommendation. Page 5 of 5 California State Auditor Report 2015-131 129 August 2016 Comments CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM SONOMA COUNTY To provide clarity and perspective, we are commenting on Sonoma County’s response to the audit. Th e numbers below correspond to the numbers we have placed in the margin of its response. Sonoma County apparently misunderstands the scope of our audit. 1 Namely, we were directed to examine state and county oversight of psychotropic medications prescribed to foster children, as we state on page 15 of our report. As such and contrary to its statement, we did not need to review provider health records or charts for each foster child to understand the treatment received by individual foster children nor to determine whether each foster child received clinically appropriate amounts and types of psychotropic medication. Rather, to review Sonoma County’s oversight we examined its records, and when necessary, records maintained by relevant state oversight agencies. We did this to understand, analyze, and assess the processes Sonoma County used to oversee such prescriptions, including whether and how Sonoma County ensured that foster children under its charge received psychosocial services in advance of or concurrent with their prescribed psychotropic medications as recommended by relevant guidelines. We stand by the methodology and the results we present in our report. As we stated in the previous comment, we stand by the methodology 2 we used and the results attained by our implementation of that methodology. To identify information relevant to the audit, we examined available records at Sonoma County, such as documents from foster children’s welfare case fi les and behavioral health fi les. We also examined records within certain of the State’s data systems, including the Paid Claims and Encounters System operated by the Department of Health Care Services (Health Care Services) for each foster child. Contrary to Sonoma County’s assertion, reviewing provider records or charts for each foster child was not only unnecessary, it was not within the scope of our audit. Furthermore, we provided Sonoma County opportunities during our audit to provide additional records for every potential Sonoma County exception we identifi ed. Finally, as we indicate on page 21 of our report, we understand that medically appropriate reasons may exist to explain why a provider requests psychotropic medications for foster children in amounts and dosages that exceed the state guidelines. However, if counties do not follow up with providers to obtain assurance that such instances are medically appropriate, counties miss opportunities to better protect their foster children from inappropriate psychotropic medication prescriptions. 130 California State Auditor Report 2015-131 August 2016 3 Sonoma County is incorrect; we do not state, nor do we imply, that it does not follow generally accepted professional standards when prescribing psychoactive medication to foster children. Th e methodology we followed enabled us to examine Sonoma County’s oversight to determine whether it was ensuring whether provider’s prescribed psychotropic medications were within academy and state guidelines and whether it reasonably questioned those prescribers when they prescribed psychotropic medications outside these guidelines. As we mention on pages 14 and 15 of our report, the California Department of Social Services (Social Services) and Health Care Services stated that the prescribing standards within the state guidelines are current best practices, and that they serve as a foundation for review to ensure that children receive the appropriate amounts and dosages of psychotropic medications. Th e academy and state guidelines are appropriate yardsticks to use for our analysis of the counties, and we stand by our conclusion that we often found little indication that counties followed up with providers to ensure the appropriateness of psychotropic medications prescribed in excess of the state guidelines. 4 Sonoma County’s statement that its providers “are bound by and adhere to the prescribing standards established by federal and state law governing mental health plans” is irrelevant to this audit; we did not assess such compliance. As stated in earlier comments, the scope of our audit was to examine the State and county oversight of psychotropic medications prescribed to foster children. Furthermore, as we mention on pages 14 and 15, Social Services and Health Care Services stated that their prescribing standards are current best practices, and that they serve as a foundation for review to ensure that children receive the appropriate amounts and dosages of psychotropic medications. Th e academy and state guidelines are appropriate yardsticks to use for our analysis of the counties, and we stand by our conclusion that we often found little indication that counties followed up with providers to ensure the appropriateness of psychotropic medications prescribed in excess of the state guidelines. 5 Sonoma County only recently adopted the state guidelines. Sonoma County informed us on June 3, 2016, that it had adopted the state guidelines the previous day. 6 We acknowledge Sonoma County’s statement that children entering foster care through the child welfare system may have diff erent mental health needs than children entering through the probation system. However, this point is not relevant for purposes of our audit. Th e methodology we used to assess Sonoma County’s oversight of psychotropic medications prescribed to foster children and its adherence to relevant academy and state guidelines is applicable to children entering foster care through either system. California State Auditor Report 2015-131 131 August 2016 Implementation of the recommendations we make to 7 Social Services beginning on page 74 of our report should address Sonoma County’s comment regarding additional guidance and resources from the State. We recommended that Social Services collaborate with counties and other relevant stakeholders to develop and implement a reasonable oversight structure. Despite its assertion that Sonoma County already ensures that 8 foster children receive psychosocial services before or concurrently with psychotropic medications, our audit demonstrates that Sonoma County’s records cannot provide such assurance. As we show in Table 11 on page 39 of our report, Sonoma County was unable to provide evidence showing that some of the foster children whose case fi les we reviewed had received corresponding psychosocial services in the six months before starting at least one psychotropic medication. We look forward to reviewing Sonoma County’s future updates on the implementation of our recommendation and its eff orts to put systems in place to better track and document these services.