Children's Voice November/
December 2008


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Tennessee Begins Tracking Medications for Children in State Custody


Dr. Deborah Gatlin, standing, chief medical officer, and Lynn Pollard, a nurse consultant, of the Tennessee Department of Children's Services.
                    Photo courtesy Lynn Pollard

Tennessee Department of Children's Services (DCS), a CWLA member agency, is a step closer to having a one-stop information shop to help them serve the children in their care: their TNKIDS database now has an area for health records. The development comes after nearly a decade of work to improve accountability after a 2001 settlement agreement in a civil rights lawsuit filed by Children's Rights the year before.

Parts of the lawsuit focused specifically on concerns about the use of psychotropic medications, and accordingly, so does the addition to the TNKIDS database. "As part of the settlement agreement, we track the medications that our children are on," explained Tricia Lea, who from April 2002 until earlier this year was the director of medical and behavioral services for the DCS, a job created in the settlement. Lea knew that getting a health component into TNKIDS--Lea calls it "the end-all, be-all database for our department"--was the overarching goal, but that it couldn't happen overnight. In fact, DCS had a few incarnations of the medications database before its final move to TNKIDS about a year ago.

The first step to take was to, under the settlement terms, review DCS policies and procedures for the use of psychotropic medications. Lea, a psychologist, worked with Deborah Gatlin, chief medical officer for DCS, and CWLA consultant psychiatrist Christopher Bellonci. Gatlin's Pharmacy and Therapeutics committee tweaked standards used in Texas and created guidelines for the use and dosage of psychotropic medications for children in Tennessee custody. "They were fairly minor changes that we made from the Texas parameters," Gatlin says. Based on the Tennessee guidelines, any prescription falling outside the norm acts as a "trigger" for review by Gatlin and the committee.

Rather than being dependent on a person's careful observation, these triggers are set off through the system itself. As information about children's prescriptions are added into the database, any of several criteria can figuratively throw a red flag (literally, send an e-mail alert to Gatlin): prescribing more than one psychotropic medication from the same class; prescribing more than three psychotropic medications in general; using any of 30 "concerning" medications; giving a dosage above the recommended maximum; or prescribing to a child under the recommended minimum age.

In investigating the alerts, she's found that most of the prescriptions that set off triggers actually fall within the bounds of reasonable care. She gave an example of two similar medications overlapping for a short period of time, as a doctor transitioned a child from one to the other. The critical thing, Gatlin says, is having an explanatory note in the database. "What I want to see in that electronic record is something regarding the doctor's thought process."

Lynn Pollard is a nurse consultant with DCS. She explained that there are 14 nurses working in Tennessee's 13 regions who add information to the health section of TNKIDS. "We're fortunate here in Tennessee that we have a lot of clinical people on staff," she says. "Each region has one or two nurses depending on the number of children in custody." While many statewide programs would have more people involved, the small group made education and training easier, Pollard adds. "We had a small, focused audience who would be putting [data] in, who would be monitoring it. Our case management staff can view the information--can pull or print it--but our nurses are really the ones who are getting it in," she says. The notes that nurses input are paid claims data from TennCare Select, the managed care company that covers children in custody, and pharmacy data from Blue Cross and Blue Shield.

Reports from TNKIDS are not technically a medical record, but there's a feature that compiles a customizable health summary. "If you just wanted immunization, you can print out immunizations; if you just wanted psychotropic medications, you can print that out," Pollard explains. "You can pick and choose and customize and create whatever health summary you want." The summaries, similar to the health passport model from Texas, are helpful materials for care meetings, health appointments, and even court hearings. "It's not going to replace the child's medical records, but it's a nice little concise summary," Pollard says.

Gatlin encourages those with questions about the database who might be interested in starting a similar project in their states to contact her at 615/741-9723 or deborah.gatlin@state.tn.us.

Alaska

In June, the search for a missing 12-year-old girl led Vermont to issue its first AMBER Alert, the public announcement of a child's abduction. Alaska is now the only state that has not used the emergency response system, which was started in Texas in 1997 and supported with federal money in 2002. Alaska's program started in 2003 and state troopers almost proceeded with an alert in June when an 8-year-old boy was abducted, but he was quickly recovered. Nationwide, AMBER Alerts are declining. For more on the AMBER Alert system, see the Stateline.org article.

Iowa

A Polk County woman lost custody of her 12-year-old son in August after a judge decided that sharing his home with foster children caused Chandler Bosch too much stress, the Des Moines Register reported. The boy now lives with his father and stepmother. District Judge Richard Blane II, in an order to modify a divorce custody decision, noted that over three years, Desiree Bosch has hosted a series of foster children, many of whom had psychological problems, and their actions could cause Chandler undue anxiety. "Although altruistic and admirable on one hand, this is not in the best interest of Chandler," the judge wrote. Read the story.

Ohio

Ten Ohio counties are participating in an alternative response pilot program. Alternative response gives caseworkers flexibility in their approach to families with suspected abuse and neglect. Variation in the reports is mirrored by a variation in the response to them: traditional investigation or a family assessment, which discovers the needs of the child without requiring a disposition of abuse or neglect. Families should also be linked to community services sooner in this system. The pilot project was approved last year by the Ohio General Assembly and is a joint effort by the Supreme Court and the Department of Job and Family Services. View more information.


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