A new report by the HHS Inspector General (IG), released last week, Treatment Planning and Medication Monitoring Were Lacking for Children in Foster Care Receiving Psychotropic Medication was critical of health care services and treatment of children in foster care as it relates to the use of psychotropic medication. The report by the in-house investigator IG seemed to focus much of its attention on what ACF can do to better assist states. The report examined a sample from five states that the report said were the states with the highest percentage of children in foster care taking psychotropic drugs. Of the five states the IG report indicated that 34 percent of children being prescribed psychotropic medication did not receive either health treatment planning/screening or medication monitoring. Eight percent (of the 34 percent) received neither. As stated in the report:

“…in the five States we reviewed, did not receive either treatment planning or medication monitoring. Eight percent of these children received neither treatment planning nor medication monitoring. Treatment planning and effective medication monitoring are imperative because of the risks of inappropriate treatment and inappropriate prescribing practices (e.g., too many medications, incorrect dosage, incorrect duration, incorrect indications for use).”

The five states selected were: Iowa, Maine, New Hampshire, North Dakota and Virginia. The review asked for samplings of 125 children from each state based on any children in foster care between a six month period of October 1, 2014 through March 31, 2015. According to the sampling the percentage of children in foster care being treated at least in part with the use of psychotropic medication was 35 percent Iowa, 32 percent Maine, 36 percent New Hampshire, 37 percent North Dakota, and 37 percent Virginia.

The IG report also noted that, “Up to 80 percent of children enter foster care with significant mental health needs. For children with mental health needs, psychotropic medications (i.e., medication used to treat clinical psychiatric symptoms or mental disorders such as depression, bipolar disorder, and schizophrenia) may be effective treatments. However, these medications can have serious side effects and, as ACF suggests and the five States in our sample require, should be used in conjunction with treatment planning mechanisms and effective medication monitoring.”

Under the recommendations there were four more specific suggestions for ACF:

• providing enhanced training and technical assistance, through collaboration with professional provider organizations, for States related to implementing treatment-planning mechanisms and effective medication monitoring (e.g., continued education for caseworkers and supervisors).

• strengthen its annual review of States’ protocols to confirm that State requirements incorporate professional practice guidelines related to treatment planning and medication monitoring,

• publish an Information Memorandum regarding specific mechanisms for child-level treatment planning and methods to achieve effective medication monitoring, and

• provide enhanced training and technical assistance for States related to incorporating professional practice guidelines in State protocols through collaboration with professional provider organizations.
In an official response to the recommendations by Administration for Children and Families (ACF), the IG report states,

“…ACF stated that it is amenable to assessing what additional technical assistance and best practice guidance to provide to States regarding the monitoring of psychotropic medication. ACF described the mechanisms through which it makes technical assistance available to States and noted that, to date, no States have reached out around this area of need. ACF also stated that the Child Welfare Information Gateway will include a new article on improving the use of psychotropic medication for children in foster care…”

The targeting of the states to review was based on Medicaid data. The report indicates that the data is based on the population of children in foster care in each state which represent the total unique children that were eligible for Medicaid because of their foster care status at any point during FY 2013 (Massachusetts was not included). The data however indicates that there were over a million children in foster care in 2013 although AFCARS data would tell you that there were less than 700,000 children that spent any time in care in that year. Based on that chart which was the basis for selecting the five states, New Jersey—which has nurse oversight of each child in foster care—has the lowest percentage of children on psychotropic medication at 13 percent followed by Nevada (15 percent) and New York (16 percent).