DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
Center for Medicaid and CHIP Services 
CMCS Informational Bulletin  
 
DATE:           August 24, 2012 
 
FROM:   Cindy Mann, Director 
Center for Medicaid and CHIP Services (CMCS) 
 
SUBJECT: Collaborative Efforts and Technical Assistance Resources to Strengthen the 
Management of Psychotropic Medications for Vulnerable Populations  
 
The Center for Medicaid and CHIP Services (CMCS) is issuing this Informational Bulletin to inform 
states about additional opportunities and resources to address the use of psychotropic drugs in 
vulnerable populations. The collaborative efforts and technical assistance resources highlighted in 
this bulletin provide states with additional tools and mechanisms to promote the appropriate use, and 
enhance oversight of, psychotropic medications for children in foster care and individuals living in 
nursing facilities.  
 
Background 
The Centers for Medicare and Medicaid Services (CMS), the Administration for Children and 
Families (ACF) and the Substance Abuse and Mental Health Services Administration (SAMHSA) 
have been working collaboratively to expand opportunities for states, territories and Tribes to 
strengthen their systems of prescribing and monitoring use of psychotropic medication among 
children in foster care. The November 23, 2011 State Director letter, jointly signed by leadership at 
CMS, ACF and SAMHSA, described this cross-agency collaboration and the commitments that each 
agency would undertake in the months after publication to address this important issue. The letter can 
be viewed at:  
http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-11-23-11.pdf 
 
This Informational Bulletin continues this tri-agency coordinated effort to explore, identify, and 
support effective strategies for states in overseeing and monitoring the use of psychotropic 
medications with youth in the foster care system.   
 
Because Minds Matter: Collaborating to Strengthen Management of Psychotropic Medications 
for Children and Youth in Foster Care 
Children in foster care often have significant emotional and behavioral challenges as a result of 
maltreatment and trauma, and a high proportion receive psychotropic medications to manage their 
symptoms. The use of these medications with this vulnerable population must be managed with care. 
Provisions in the Child and Family Services Improvement and Innovation Act of 2011 (P.L. 112-34) 
require State IV-B agencies, as part of their Health Care Coordination and Oversight Plan, to describe 
protocols planned or in place for the appropriate use and oversight of prescription medications, 
including psychotropic medications.  States were required to submit these plans by June 30, 2012 as 
part of the Annual Progress and Services Report.  
  CMCS Informational Bulletin, Page 2 
 
Creating and implementing integrated oversight and monitoring protocols that ensure the appropriate 
use of psychotropic medications for children in foster care require thoughtful collaboration across 
complex systems. To fulfill the commitment made in the November 2011 letter, ACF, in 
collaboration with SAMHSA and CMS, is convening a two-day working meeting, Because Minds 
Matter: Collaborating to Strengthen Management of Psychotropic Medications for Children and 
Youth in Foster Care, August 27 and 28, 2012, to bring together representatives from state child 
welfare, Medicaid, and mental health systems from all fifty States, the District of Columbia, and 
Puerto Rico to work together to strengthen oversight and monitoring of psychotropic medications for 
children in foster care.  
 
The purpose of this meeting is to:  
  Provide an opportunity for state leaders to enhance existing cross-system efforts to ensure 
appropriate use of psychotropic medications;  
  Showcase collaborative projects and initiatives at state and local levels;  
  Offer state-of-the art information on cross-system approaches to improving mental health and 
well being for children and their families;  
  Encourage participants to think in a deep and nuanced way about strategies for addressing the 
mental health and trauma related needs of children in foster care with evidence-based and 
evidence informed interventions; and  
  Facilitate each states development of action steps to improve upon and implement their 
existing oversight plans.  
 
Additional information: 
HHS is focused on advancing the work of child welfare in America to promote the well-being of the 
youth and families it serves. Supporting the appropriate use of psychotropic medications to treat 
mental, emotional, and behavioral disorders is one piece of this work. HHS has used its grant-making 
and regulatory authority, available technical assistance, and cross-agency collaborations to bring 
focus and expertise to the topic. A wealth of information, research, and resources, including specific 
information about the summit and recordings of technical assistance webinars held in the past few 
months, is available at: 
http://www.childwelfare.gov/systemwide/mentalhealth/effectiveness/psychotropic.cfm. 
 
In addition, ACF has published two Information Memoranda (IM) detailing research, legislation, 
programs and practices in support of an expectation that child welfare systems will support and 
enhance the social and emotional well-being of the children and youth served.  The first IM, 
Promoting the Safe, Appropriate, and Effective Use of Psychotropic Medication for Children in Foster 
Care, can be found 
here:http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1203.pdf.   
 
The second IM, Promoting Social and Emotional Well-Being for Children and Youth Receiving Child 
Welfare Services, can be found here: 
http://www.acf.hhs.gov/programs/cb/laws_policies/policy/im/2012/im1204.pdf 
 
Drug Utilization Review Programs 
As part of the collaboration with ACF and SAMHSA, CMS is encouraging states to utilize the 
framework provided by their Drug Utilization Review (DUR) programs. CMS requires all States to 
have DUR programs in place that oversee the prescribing of drugs for Medicaid beneficiaries.  States  CMCS Informational Bulletin, Page 3 
 
report annually to CMS (as required) on their pharmacy program operations and the monitoring of 
prescribing of drugs by screening for appropriate dose, duration, duplicate therapy, drug-drug 
interactions and other criteria to determine if filling the prescription or requiring further intervention 
with the prescriber is appropriate.  These criteria may vary from drug to drug as well as from state to 
state.  It is the responsibility of each states DUR Board to meet regularly to determine the specific 
criteria to apply to each drug.   
 
States have become acutely aware of the concerns regarding the use of psychotropic medications in 
children, particularly among children in foster care.  Accordingly, the states have employed various 
techniques to provide a range of oversight for this population. Nearly all states, unless prohibited by 
their state law, have opted to program their systems with edits to screen for predetermined criteria 
based on accepted medical practices; however, the override capabilities that allow the prescriptions to 
be filled differs depending on the states DUR Board.  
 
Many state programs organize their program of edits around commonly accepted practices of 
concern (high dose, young age, polypharmacy).  For example, a number of states have implemented 
requirements that psychotropic medications for children under the age of 5, 6, or 7 require a prior 
authorization. In this example, the prescriber may have to complete a form providing information 
regarding prescriber credentials, patient diagnosis, target symptoms being treated, other drugs 
prescribed, laboratory tests, whether mental health resources are available/ being utilized and if the 
child is in foster care. Other states require that each case be reviewed by a panel of experts in the field 
of psychiatry.   
 
Some states have opted for a different approach and developed a comprehensive program composed 
of a multi-disciplinary team that works in partnership with other state agencies and/or works in 
concert with academia (school of pharmacy, school of medicine and/or psychiatry) to review cases 
and ensure that the patient is getting the appropriate combination of psychosocial and medical care.  
 
The treatment of children in state custody who present with potential behavioral health problems 
presents a number of unique problems that require a collaborative team effort.  Psychotropic 
medications may be one component of a comprehensive biopsychosocial treatment plan. Bio 
refers to the physical and genetic factors, psycho refers to psychological factors contributing to the 
emotional and behavioral functioning and social refers to the environmental factors influencing 
functioning. Robust screening and assessment practices that are attentive to trauma and 
social/emotional functioning, careful and coordinated treatment planning, and the judicious and 
thoughtful use of all treatment options available to the youth, especially those with a strong evidence 
base, are practice parameters most likely to support health and well-being. CMS encourages states to 
explore how their DUR programs can partner with prescribers to implement a plan for screening this 
population of children for trauma, as this is often missed and requires careful treatment planning.   
 
CMS recognizes the many challenges in providing optimal care to children with mental health and/or 
behavioral health issues, such as wide variations in services availability within the same state.  To 
provide additional information to states, CMS has posted on Medicaid.gov a few examples of states 
that have created programs that address this issue in the context of their DUR programs.   
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Prescription-
Drugs/Drug-Utilization-Review.html 
   CMCS Informational Bulletin, Page 4 
 
Additional information: 
CMS recognizes that there may be a variety of actions that states may take to improve oversight of 
this vulnerable population. Therefore, we are providing the link below to the basic principles set forth 
by the American Academy of Child & Adolescent Psychiatry (AACAP) as a resource for states to 
review as they consider how to strengthen medication use oversight for this population.    
http://www.aacap.org/galleries/PracticeInformation/FosterCare_BestPrinciples_FINAL.pdf. 
 
Additionally, AACAPs most recently issued: Guide for Community Child Serving Agencies on 
Psychotropic Medications for Children and Adolescents can be found at: 
http://www.aacap.org/galleries/default-
file/guide_for_community_child_serving_agencies_on_psychotropic_medications_for_children_and
_adolescents_2012.pdf 
 
There is a meaningful body of literature on this topic exploring policy and practice issues.   
The most recent information about the 16-state study CMS encouraged states to explore in the 
November 2011 SMD (Antipsychotic Medication Use in Medicaid Children and Adolescents: Report 
and Resource Guide From a 16-State Study) can be found here: http://rci.rutgers.edu/~cseap/ 
 
Helpful practice information is available here: 
http://www.ahrq.gov/about/annualconf11/crystal_tyutyulkova_yager/crystal.htm 
 
PolicyLab at the Childrens Hospital of Philadelphia recently released a study of state-level trends in 
psychotropic medication use among children in foster care.  They made this article accessible at 
http://dx.doi.org/10.1016/j.childyouth.2012.04.006 . They have used Medicaid data to develop 
interactive maps showing State trends for antipsychotic use and polypharmacy.  These are available 
at: http://policylab.us/index.php/publications/featured/279-data-maps-psychotropic-medication-use-
among-children-in-foster-care.html 
 
We also wanted to make states aware of another important initiative underway at CMS in the Center 
for Clinical Standards and Quality to address unnecessary antipsychotic drug use among individuals 
with dementia.  
 
Partnership to Improve Dementia Care in Nursing Homes 
Unnecessary antipsychotic drug use has been identified as a significant challenge in ensuring 
appropriate dementia care.  A 2011 report by the Health and Human Services Office of Inspector 
General found that 22 percent of the atypical antipsychotic drugs were not administrated in 
compliance with CMS standards, and a CMS study found that over 17 percent of nursing home 
patients had daily doses exceeding recommended levels. 
 
Dementia can significantly impair a nursing home resident's ability to effectively communicate his or 
her needs and concerns. Communication attempts can appear as behaviors that may be perceived as 
disruptive or distressing.  Therefore, caregivers must gain an understanding of what is driving these 
behaviors prior to initiating an intervention or treatment. Sometimes these behaviors may result from 
an undiagnosed medical condition, an adverse reaction to medication, unmet physical need, or mental 
illness. 
  CMCS Informational Bulletin, Page 5 
 
In March 2012, CMS launched the Partnership to Improve Dementia Care in Nursing Homes:  
Rethink, Reconnect, Restore.  This initiative is aimed at improving behavioral health among nursing 
home residents and protecting them from unnecessary drug use.  In collaboration with federal and 
state partners, nursing homes and other providers, advocacy groups, caregivers, and residents, CMS 
is working to reduce the national prevalence rate in long-stay residents of antipsychotic drug use in 
nursing home residents by 15 percent by the end of 2012. Approaches involve research, public 
reporting of nursing home antipsychotic use; training for providers, clinicians, and surveyors.  
Surveyor guidance is being updated, and new surveyor training programs will be available in the fall.  
CMS is emphasizing person-centered, individualized approaches to dementia care such as consistent 
staff assignments, increased exercise or time outdoors, monitoring and managing acute and chronic 
pain, and planning activities consistent with the individuals preferences and choices.  
 
The Partnership promotes the opportunity for the nation to rethink dementia care, reconnect with 
residents via person-centered care practices, and to restore good health and quality of resident life.   
 
Currently, CMS is conducting state implementation calls to disseminate the National Partnership 
resources and promote the Partnership goals on a state and regional level.  Through these calls, CMS 
is assisting in the process of building and empowering every State Coalition to develop or strengthen 
outreach efforts to each states nursing homes.  State Medicaid Medical Directors are encouraged to 
participate on these calls.   
 
Additional Information 
If a State Medicaid Medical Director is interested in participating on these state calls, has any 
questions or comments related to the National Partnership, or would like further information, then 
please contact the CMS Division of Nursing Homes at Dnh_behavioralhealth@cms.hhs.gov. 
 
Additional information about the Partnership itself can be found on the Advancing Excellence 
website at http://www.nhqualitycampaign.org/.