Foster Care: HHS Has Taken Steps to Support States' Oversight of Psychotropic Medications, but Additional Assistance Could Further Collaboration
Published: 2017-01-05T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: GAO previously reported that children in foster care in five selected states were prescribed psychotropic medications at higher rates than other children on Medicaid. GAO also reported that some prescriptions were not supported by research and could pose health risks. GAO was asked to study efforts to oversee psychotropic medications for children in foster care since GAO last reported on the issue in 2014.
GAO examined (1) how child welfare and Medicaid agencies in selected states ensure the appropriate use of psychotropic medications for children in foster care, (2) what is known about the results of their efforts, and (3) the extent to which HHS helps states support appropriate medication use. GAO reviewed relevant federal laws, regulations, and guidance; visited a nongeneralizable group of seven states and five counties in two of those states, selected by foster care population and diversity of location; analyzed selected states' data on medication use in foster care populations; and interviewed officials from federal, state, and county child welfare, Medicaid, and other agencies, as well as officials from nine relevant national organizations selected to represent a variety of views.
section_title: What GAO Found
paragraphs: State child welfare and Medicaid officials in seven selected states reported a variety of practices to support the appropriate use of psychotropic medications, which affect mood, thought, or behavior, for children in foster care. Practices include screening for mental health conditions, developing prescription guidelines, and monitoring a child's health while on medication. Additional state efforts aim to increase mental health knowledge among stakeholders and improve access to mental health services. However, officials in four selected states and from five national mental health organizations said limited access to mental health services was a challenge. Five of the selected states have begun offering remote consultation services that connect patients with mental health specialists. State officials said strong interagency collaboration and outreach to stakeholders helped them implement practices more effectively.
While some selected states have reduced medication use among these children, states focused on other measures to gauge the results of their efforts. Four of the seven selected states reduced medication use from 2011 through 2015, two states had steady rates, and the remaining state did not have data during this time period. These data, however, cannot be compared across states because states use different methodologies to collect data. Officials in three selected states said reducing medication use may not be appropriate for every child, and officials in all seven states said they focus instead on measures such as tracking the use of medications that can have negative side effects and the use of psychosocial services (e.g., therapy) for children in foster care. Officials in most selected states discussed limitations with gathering data needed to oversee medication use, such as disparate data systems, resource constraints, and privacy concerns related to data sharing among state child welfare and Medicaid agencies and with managed care organizations. Officials in some states that shared data said they overcame privacy concerns through written interagency agreements and educating stakeholders.
The Department of Health and Human Services (HHS) has taken steps to help state child welfare and Medicaid agencies support the appropriate use of psychotropic medications and identify mental health needs and treatments for children in foster care. HHS has focused its efforts on practices for prescribing, screening and diagnosis, and access to trauma-related services. HHS is also working with states to implement voluntary measures to track medication use, other mental health treatments, and a child's overall health. In 2012, HHS hosted a meeting for state leaders to help them establish effective medication oversight practices. Despite the positive outcomes resulting from this meeting, and HHS guidance that says an agency goal is to facilitate cross-system collaborations, such as in the oversight of psychotropic medications, it has not convened meetings with all stakeholders together since 2012. Though HHS has conducted webinars, created learning communities, and convened smaller meetings, HHS officials said it has no plans to convene all stakeholders as it did in 2012 due to resource constraints. Officials in three selected states said more federal support to bring together state stakeholders could help address ongoing issues, such as privacy concerns around data sharing.
section_title: What GAO Recommends
paragraphs: GAO recommends that HHS consider cost-effective ways to convene state child welfare, Medicaid, and other stakeholders to promote collaboration and information sharing on psychotropic medication oversight. HHS agreed with GAO's recommendation and provided technical comments.

section_title: Letter
paragraphs: Multiple studies have shown that children in foster care may have more  mental health conditions than those in the general population, and prior  GAO reports have looked at the rate at which these children are  prescribed psychotropic medications, which affect mood, thought, or  behavior. While information on the number of children in foster care on  psychotropic medications nationwide is limited, in our prior work we found  that these children in five selected states were prescribed psychotropic  medications at rates 2.7 to 4.5 times higher than other children on  Medicaid in 2008. As part of that review, we also reported on the  prevalence of certain prescribing patterns not supported by research that  could pose health risks. These patterns included the use of five or more  psychotropic medications at the same time, doses exceeding maximum  levels based on labels approved by the Food and Drug Administration,  and prescriptions made to children under the age of 1.
There are a number of state and federal agencies that play a role in  ensuring that children in foster care receive appropriate treatments for  mental health conditions. At the state level, child welfare and Medicaid  agencies, along with other partners, have various responsibilities that  help ensure appropriate treatments for children in foster care. State child  welfare agencies are primarily involved in determining where and with  whom a child in foster care should live (placement) and for providing or  arranging needed supports, including certain physical and mental health  services. In addition, most children in foster care are eligible for Medicaid,  and state Medicaid agencies may choose from a variety of delivery  systems to provide and pay for their health services. At the federal level,  the Department of Health and Human Services (HHS) monitors state  implementation of relevant federal programs, including those that provide  federal assistance to support state child welfare and foster care  programs, through the Administration for Children and Families (ACF).  HHS also oversees the Medicaid program through the Centers for  Medicare & Medicaid Services (CMS), in accordance with federal laws,  regulations, and guidance. These agencies, along with HHS’s Substance  Abuse and Mental Health Services Administration (SAMHSA)—which  undertakes efforts to improve substance abuse and mental health  treatment, prevention, and related services for individuals—provide  support to states in their efforts to ensure child well-being.
You asked us to study efforts to oversee psychotropic medications for  children in foster care since we last reported on the issue in 2014. This  report examines:  1.  how child welfare and Medicaid agencies in selected states work to  ensure the appropriate use of psychotropic medications for children in  foster care;  2.  what is known in selected states about the results of their efforts to  ensure the appropriate use of psychotropic medications for these  children; and  3.  the extent to which HHS helps states support the appropriate use of  psychotropic medications for children in foster care.
To address all objectives, we conducted in-person and telephone  interviews with officials in seven selected states, including those from  child welfare and Medicaid agencies, and with nine national professional  and research organizations selected to represent a variety of views on  child welfare, Medicaid, and mental health-related policy and research.  The states we selected were Arizona, California, Illinois, Maryland, New  Jersey, Ohio, and Washington. Our selection criteria included (1) a high  percentage of children in foster care in the state when compared  nationwide in fiscal year 2014; (2) variation in Medicaid and child  welfare systems; (3) recommendations from national organizations; and  (4) geographic diversity. In the two selected states with county- administered child welfare systems, California and Ohio, we selected five  counties and conducted interviews with officials from the respective  county-level child welfare and Medicaid agencies, as appropriate. These  counties were selected based on factors similar to those mentioned  above as well as variation in population density (i.e., rural versus urban).  We also conducted a review of selected literature related to the use of  psychotropic medications among children in foster care.
To examine how state child welfare and Medicaid agencies work to  ensure the appropriate use of psychotropic medications, we also  reviewed guidance and other documents identified by officials from  selected states and counties. While we identified selected states’  oversight practices related to psychotropic medications based on  interviews and these document reviews, we did not assess states’  implementation of specific practices. In addition, while we focused our  review on children in foster care, state oversight practices may also  pertain to other children on Medicaid. To examine the results of state  efforts to ensure the appropriate use of psychotropic medications, we  gathered and analyzed available data from selected states on the use of  these medications among children in foster care from 2011 through  2015. We determined these data were sufficiently reliable for the  purposes of describing trends in the percentage of children in foster care  on psychotropic medications for each of the selected states. However,  because these states use different methodologies to collect data, the data  are not comparable among them. In addition, the results of our analyses  are not generalizable nationwide. To examine HHS’s actions to support  state efforts related to psychotropic medications, we interviewed officials  from ACF, CMS, and SAMHSA, and we reviewed relevant documents.  We also examined applicable federal laws, regulations, and guidance. For  additional information on our scope and methodology, see appendix I.
We conducted this performance audit from September 2015 to January  2017 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Administration of Child Welfare and Medicaid Programs
paragraphs: Children enter foster care when they have been removed from their  parents or guardians for reasons such as abuse or neglect, and placed  under the responsibility of a state child welfare agency. The agency  generally places the child in the home of a relative, with unrelated foster  parents, or in a group home or residential treatment center, depending on  the child’s needs. Child welfare caseworkers at the agency are typically  responsible for coordinating placement and needed support services for  these children, including those for mental health. If a child is determined  to be in need of mental health services, the caseworker is generally  responsible for arranging such services to be provided by primary care  physicians, child psychiatrists, or other mental health providers. State  courts, typically juvenile or family courts, are also frequently involved in  decisions regarding a child’s removal, placement, and services.
Most children in foster care are eligible for Medicaid, and those enrolled  may receive physical and mental health services through a variety of  service delivery and provider payment systems, such as fee-for-service  and managed care. In the traditional fee-for-service delivery system, the  state Medicaid agency manages the program and reimburses physicians  directly and on a retrospective basis for each health service delivered.  Under a managed care model, states contract with one or more managed  care organizations and prospectively pay the organizations a fixed  monthly fee per patient to provide or arrange for defined health services,  which may include mental health services and prescription medications.  These organizations, in turn, pay physicians.
States are primarily responsible for administering their child welfare and  foster care programs, consistent with applicable federal laws and  regulations, which include some requirements that relate to ensuring the  well-being of children served by these programs. For example, title IV-E  of the Social Security Act authorizes federal funding to states to help  cover the costs of operating their foster care and certain other  programs. In addition, title IV-B of the Social Security Act authorizes  federal funds to support state child welfare programs and services. Both  of these programs establish various requirements that participating states  must comply with in order to receive the federal funding. The Fostering  Connections to Success and Increasing Adoptions Act of 2008 amended  title IV-B to add a requirement that states develop a plan for the ongoing  oversight and coordination of health care services for children in foster  care, including mental health and oversight of prescription medications.  The Child and Family Services Improvement and Innovation Act amended  this provision to require that these plans include protocols for the  appropriate use and monitoring of psychotropic medications. HHS’s  ACF is responsible for monitoring state implementation of title IV-E and  IV-B programs. For example, ACF conducts reviews of state child welfare  and foster care programs every 5 years to ensure conformity with  requirements under these federal programs. ACF also monitors state  compliance with title IV-B plan requirements, including the health care  oversight and coordination plan, through its review of states’ five-year  Child and Family Services Plans and Annual Progress and Services  Reports. In addition, ACF’s mission is to promote the economic and  social well-being of families, children, individuals, and communities  through funding, guidance, training, and technical assistance.
Under the Medicaid program, states are required to provide eligible  children under age 21 with coverage for certain health services, which  may include mental health services, through the Early and Periodic  Screening, Diagnostic, and Treatment (EPSDT) benefit. Specifically,  federal law requires coverage of periodic screening services, including a  comprehensive health and developmental history of both physical and  mental health development, a comprehensive physical exam, appropriate  immunizations, laboratory tests, and health education. The EPSDT  benefit also covers treatment services necessary to correct or ameliorate  any identified physical or mental illnesses or conditions. HHS’s CMS  oversees state Medicaid programs and provides federal matching funds  for eligible services. On an annual basis, states are required to report to  CMS information on their Drug Utilization Review programs, including  prescribing patterns, cost savings generated by the programs, an  assessment of the programs’ impact on quality of care, and program  operations, including information on new innovative practices adopted by  states. CMS includes these reports on its website.
In addition, state mental health agencies are generally responsible for  planning and operating state mental health systems, and play an  important role in administering, funding, and providing treatments.  These agencies may manage mental health-related federal grants and  may work with other state agencies—such as state Medicaid agencies— to identify and treat mental health conditions. They may also contract  directly with physicians to deliver treatments or may contract with county  or city governments responsible for the delivery of treatments within their  local areas. HHS’s SAMHSA engages in activities intended to help  improve the behavioral health of children in foster care. Such efforts  include grants that support the development of community-based services  for children with mental health conditions and information sharing on  psychotropic medication practices. Many stakeholders may be involved in  ensuring appropriate mental health treatments for children in foster care  (see fig. 1).
section_title: Psychotropic Medications and Other Mental Health Treatments for Children
paragraphs: Psychotropic medications can have significant benefits for those with  mental health conditions by affecting brain activity associated with mental  processes and behavior. However, they can also have side effects  ranging from mild to serious, depending on the class and type of  medication used. According to the American Academy of Child &  Adolescent Psychiatry (AACAP), medications for attention deficit  hyperactivity disorder (ADHD), such as amphetamines (e.g., Adderall)  and methylphenidate (e.g., Ritalin and Concerta), can reduce symptoms  such as hyperactivity in children as well as improve their attention and  increase their ability to get along with others. These medications have  been widely tested in children and are generally considered safe;  however, ADHD medications have also been associated with side effects  such as sleeplessness, loss of appetite, tics, agitation, hallucinations, liver  problems, and suicidal thoughts. In addition, antidepressants, such as  fluoxetine (e.g., Prozac) and sertraline (e.g., Zoloft) can be used to treat  conditions such as depression and anxiety. However, possible adverse  side effects include agitation, sleeplessness or drowsiness, and suicidal  thoughts. The use of antipsychotics—one class of psychotropic  medication—has been of particular concern. Antipsychotic medications,  such as aripiprazole (e.g., Abilify) and risperidone (e.g., Risperdal), were  developed to treat conditions such as bipolar disorder or schizophrenia.
However, possible adverse side effects can be serious, including  increased levels of cholesterol, rapid weight gain, and the development of  diabetes or irreversible movement disorders. Mental health researchers  and others have stated the need for further research on the safety,  effectiveness, and long-term effects of antipsychotics for children.
Psychosocial services are mental health treatments that generally involve  therapy sessions with a mental health professional that are designed to  reduce patients’ emotional or behavioral symptoms. Such therapies may  be used instead of, or in combination with, psychotropic medications to  treat children with mental health conditions. Several large, federally  funded studies have demonstrated that treatment with a combination of a  psychosocial therapy and a psychotropic medication can be more  effective than either treatment alone for certain conditions. Further,  psychosocial services shown to be effective in treating mental health  conditions may be referred to as evidence-based therapies. While there is  no standard definition of what constitutes “evidence-based,” some federal  agencies and provider organizations, such as SAMHSA and AACAP,  evaluate and compile information on available therapies.
section_title: Guidance on Oversight of Psychotropic Medications
paragraphs: In response to concerns about psychotropic prescribing practices for  children, especially involving those in foster care, AACAP has developed  multiple resources to promote the appropriate and safe use of these  medications. For physicians, AACAP issued best practice guidelines in  2009 that establish key activities before and after prescribing  psychotropic medications to children (see fig. 2).
Building on these guidelines for physicians, AACAP developed best  practice guidelines for states in 2012 and 2015, with support and partial  funding from SAMHSA, that establish practices for overseeing the use of  psychotropic medications for children in foster care as well as other  children in state custody. An overarching principle outlined in AACAP  guidelines is that the use of psychotropic medications for these children  should be part of a holistic and collaborative mental health treatment  approach that recognizes (1) the biological, psychological, and social  factors that may impact a child; (2) trauma-informed care principles that  acknowledge the prevalence and impact of trauma, and a commitment to  minimize its effects and avoid additional traumatization; and (3) child- serving agencies as part of a system of care for the child, and services  that should be youth-guided, home and community-based, integrated  across systems, data-driven, and outcome-oriented, among other things.
HHS issued an Information Memorandum to states in April 2012 to  provide guidance to states on complying with the statutory requirement to  develop protocols for the appropriate use and monitoring of psychotropic  medications. The memorandum cited our previous work that raised  concerns about states’ efforts to oversee the use of psychotropic  medications among children in foster care. This memorandum identified  policy statements and guidelines from AACAP, the American Academy of  Pediatrics, and the state of Texas, among others, and discussed  consistent elements among these sets of guidelines. These elements,  summarized below, include the need for state policies to contain  provisions for:  screening, assessment, and treatment planning mechanisms to  identify children’s mental health and trauma-treatment needs;  informed and shared decision-making and methods for ongoing  communication among the physician, child, family, and other key  stakeholders; effective medication monitoring; availability of mental health expertise and consultation; and mechanisms for sharing up-to-date information and educational  materials related to mental health and trauma-related interventions,  including psychotropic medications.
In addition to issuing this memorandum to states, we reported in April  2014 that ACF had worked collaboratively with CMS and SAMHSA to  provide technical assistance; facilitate information sharing; and  emphasize the need for collaboration among state child welfare,  Medicaid, and mental health officials in overseeing psychotropic  medications from January 2012 through July 2013. Notably, these  agencies cohosted a conference entitled “Because Minds Matter” in  August 2012 that focused on collaborative medication monitoring as well  as creating data systems to facilitate collaboration, among other things.  According to ACF, CMS, and SAMHSA officials, the conference was an  opportunity for states to talk and share practices, and representatives  from 49 states attended.
section_title: Selected States Have Practices to Support the Prescribing Process and Educate Stakeholders on the Appropriate Use of Psychotropic Medications
subsections: section_title: Selected States Have Practices to Support Appropriate Treatment Decisions and Monitor the Child
paragraphs: Officials we spoke with in the seven selected states told us they  developed a variety of practices to better support appropriate mental  health diagnoses and treatments for children in foster care in their  states. These range from requiring initial mental health screenings to  monitoring children after they are prescribed psychotropic medications.
subsections: section_title: Screenings
paragraphs: State officials in all seven of the selected states told us they require  mental health screenings of children entering foster care, which is  consistent with the guidelines on screenings identified in HHS guidance  (see fig. 3).
For example, Washington officials told us that staff in their child welfare  screening program are expected to screen children entering foster care  within thirty days using validated tools, such as a trauma-related screen  for anxiety and post-traumatic stress disorder, which have been tested  and found to draw consistent results for the same child across multiple  screeners. In addition, the screeners ask children whether they are taking  psychotropic medications or receiving health services, and how their  symptoms are progressing. Screeners then provide a report to  caseworkers, who can follow up to ensure the child receives the  appropriate referrals and services. Washington child welfare officials said  they also use screening data to analyze how many children with mental  health needs are receiving services. Arizona requires that children  entering foster care receive a mental health screening within 72 hours to  identify and provide services for any immediate mental health needs and  reduce the child’s stress and anxiety. Screenings are also to include  provision of mental health services to each child’s new caregiver. These  services include guidance on how to respond to the child’s immediate  needs as the child transitions to foster care, information on mental health  symptoms to watch for and report, assistance in responding to such  symptoms, and provision of a contact in the mental health system. The  child’s caseworker is to be provided with findings and recommendations  for needed mental health services. Illinois officials said their child welfare  agency requires all children in foster care to receive a comprehensive  health assessment from a licensed social worker and the child’s  caseworker within 55 days of entering the foster care system. According  to these officials, this assessment should include a discussion of mental  health issues and can prompt a referral for a psychiatric evaluation for the  child.
section_title: Guidelines and Restrictions for Prescribing
paragraphs: State officials in the seven selected states said they have a variety of  guidelines and restrictions to support appropriate mental health  treatments for children in foster care (see fig. 4).
State and county officials from some of the selected states described  physicians’ lack of knowledge of child and adolescent mental health  issues as a challenge, and officials in all seven states said they  developed practices to promote effective treatment decisions. For  example, all seven of the selected states developed guidance on the use  of psychotropic medications, such as dosage limits for children of different  ages and weights, or medication lists that identify medications considered  psychotropic. All seven states also require or recommend restricting  who can prescribe psychotropic medications, or require or recommend  the physician consult a specialist in some cases. For example, in New  Jersey, only a psychiatrist, pediatric neurologist, neurodevelopmental  pediatrician, or an advanced practice nurse certified in psychiatry or  mental health and collaborating with one of these specialists may  prescribe psychotropic medications, except in cases of ADHD. In  Maryland, if the prescribing physician is not a child psychiatrist, he or she  must consult with or refer the child to a specialist before prescribing a  psychotropic medication and within 60 to 90 days after making the initial  prescription. In addition, Maryland officials said the state’s Medicaid  agency contracts with mental health specialists at the University of  Maryland to review all antipsychotic medication prescriptions for children  in Medicaid.
section_title: Agreement on Prescriptions
paragraphs: State officials in all seven of the selected states said they require or  recommend that physicians obtain agreement—sometimes in writing— from an adult who has responsibility for the child in foster care (informed  consent) and from the child (assent) on prescriptions for psychotropic  medications (see fig. 5). These practices are among the consistent  elements across guidelines identified by HHS on informed and shared  decision-making.
In Washington, the child welfare agency requires agreement from the  parent if the child is under age 13, or from the child if he or she is age 13  or older. If the parent of a young child is unavailable, unable, or unwilling  to consent, the child’s caseworker must obtain a court order approving  the use of psychotropic medication. In Maryland, caseworkers must  collect a consent form signed by the parent or legal guardian as well as  the child (if age 16 or older), when able. Similar to Washington, if the  parent or guardian is unavailable or unwilling to provide consent, child  welfare officials may obtain a court order in cases of medical necessity.
section_title: Ongoing Monitoring of the Child
paragraphs: State officials in all seven of the selected states said they have practices  related to monitoring children: They track or recommend tracking of high- risk prescriptions, such as those involving antipsychotic medications or  multiple medications taken at the same time, or they require or  recommend periodic follow-up visits or reauthorization of certain  prescriptions (see fig. 6). Monitoring medication use for each child in  foster care is one of the consistent elements across guidelines identified  in HHS guidance.
In Illinois, child welfare officials said their agency conducts ongoing  oversight of prescriptions by examining a list of children taking  antipsychotics and children under age 6 referred for uncommon  conditions, such as aggression or bipolar disorder; consulting with mental  health specialists; and referring cases for intensive case management, as  needed. California officials said county courts review psychotropic  medications every 6 months, while in Maryland, officials said that, for  children taking antipsychotic medications, they require physicians to  monitor the child’s height, weight, tremors, liver functioning, and blood  sugar and lipid levels to identify side effects. They must then submit  results to mental health specialists for review. In addition, Maryland  caseworkers are required to review positive and negative effects of  medications at their monthly home visits.
section_title: Selected States Have Taken Steps to Increase Stakeholders’ Mental Health Knowledge and Access to Related Services, but Concerns about Limited Access to These Services Remain
paragraphs: State officials in all seven of the selected states said they work to educate  relevant stakeholders on mental health conditions and treatments.  Practices to educate stakeholders are among the consistent elements  across guidelines identified by HHS on sharing information on mental  health and trauma-related interventions with clinicians, child welfare staff,  and consumers. In addition, officials in most of the selected states said  their state works to increase access to mental health services for children  in foster care (see fig. 7).
State officials from five of the seven selected states said they provide  relevant stakeholders with access to informational materials. For  example, California maintains an online information bank of evidence- based treatments, and Ohio officials developed guides to help children  and their families communicate with physicians and participate more  actively in treatment decisions. States may offer other types of  informational resources as well. For example, Washington child welfare  officials said they staff mental health specialists to a telephone hotline to  provide physicians who call with consultations on mental health  diagnoses and treatments as well as information about local service  providers. In addition, officials said the state’s child welfare agency and  managed care provider offer in-person and online trainings on children’s  mental health, psychotropic medications and other mental health  treatments, and the child welfare system.
State and county officials in four of the seven selected states and five of  nine national organizations identified limited access to mental health  services as a challenge. These officials described a variety of factors  limiting access, including insufficient numbers of professionals  specializing in related fields, low Medicaid reimbursement rates,  underserved rural areas, and physicians’ limited knowledge of services  available in their area. As officials from one state explained, patients  need access to a wider variety of evidence-based treatments. Other  officials noted there are particular shortages among some specialties,  such as child psychiatrists, or needed training in areas such as trauma- informed care. To increase children’s access to mental health services,  state and county officials in five of the selected states said they provide  remote consultation services. In addition, Ohio state officials said the  state offers fellowships for medical students in needed mental health  specialties as well as training curricula for students to provide mental  health services as part of primary care.
section_title: State Officials Said Collaboration, Outreach, and Gradual Rollout of New Practices Were Key to Effective Implementation
paragraphs: Officials in the seven selected states identified factors that helped them  implement oversight practices for psychotropic medications, such as  collaborating with other agencies, conducting outreach with relevant  stakeholders, and gradually implementing new oversight practices. State  officials in all seven of the selected states said strong collaboration  among child welfare, Medicaid, or other partnering agencies was key to  implementing these practices. Specifically, Washington officials said  supporting children in foster care requires coordinated solutions across  the agencies serving this population. In Ohio, officials said the directors of  their child welfare, Medicaid, and mental health agencies have worked in  the other agencies and as a result share resources and talent more easily  and encourage open communication. In Washington, officials said strong  collaboration allows their agencies to complement each other’s roles,  develop more holistic practices, and implement oversight programs more  effectively. Officials in Ohio and Washington attributed successful  collaboration within their state to executive leadership support, the  commitment and longevity of state agency leaders, and leaders’ and  managers’ breadth of experience in multiple agencies and front-line roles.  Washington officials emphasized the importance of developing integrated  programs in order to institutionalize collaboration.
State and county officials in three of the seven selected states said  conducting outreach helped them educate stakeholders on relevant  issues and requirements and gain stakeholders’ buy-in. For example,  Maryland officials said conducting extensive outreach to physicians on  how to best implement new requirements for medication approval and  monitoring helped ensure stakeholder adoption of the program and was  essential to its success. These officials said they shared information with  physicians about antipsychotic medications, monitoring side effects, and  available psychosocial services. In response to physicians’ feedback,  Maryland officials said they adapted the program to allow physicians to  call in required information over the phone to avoid having to complete  forms.
Officials in two of the selected states said the gradual rollout of new  practices enabled mid-course corrections or supported higher rates of  adoption or compliance with the practice. For example, Ohio officials said  they developed their medications oversight program in several stages.  One step entailed a pilot program that flagged potentially inappropriate  prescriptions and required physicians to consult with mental health  specialists. Through this program, officials said they identified a lack of  mental health knowledge and access to mental health specialists as two  causes of inappropriate prescriptions. They said they redesigned their  oversight practices to address these causes, tested the new practices,  and are now implementing them statewide.
section_title: While Some Selected States Reduced the Use of Psychotropic Medications, They All Focused on Other Measures to Gauge the Results of Their Efforts
subsections: section_title: Some Selected States Reduced Psychotropic Medication Use, though Mental Health and Foster Care Stakeholders Said Reducing Medications May Not Be Appropriate for Every Child
paragraphs: Our analysis of available data from the seven selected states show that  four of these states—California, Illinois, New Jersey, and Washington— reduced the percentage of children in foster care on psychotropic  medications from 2011 through 2015. Two other selected states— Arizona and Maryland—had steady rates of medication use. Ohio did  not have data for this time period. Because states use different  methodologies to collect data, these data cannot be compared across  states.
While identifying all the factors that contribute to reduced medication use  can be difficult, Washington child welfare and Medicaid officials said  their second opinion program, which requires physicians to consult a child  psychiatrist when prescribing certain medications, has likely prevented  inappropriate prescribing. A 2009 study on this program also found that it  helped reduce ADHD medications that were provided in high doses, in  combinations, and for children under 6.
Child welfare and Medicaid officials in some selected states and officials  from most national professional and research organizations we  interviewed said reducing medications may not be appropriate for every  child. For example, child welfare and Medicaid officials in one selected  state explained that without medication, a child in foster care may not be  able to sit through a therapy session or perform in school. In addition,  officials in all seven states said a child’s mental health can be affected by  many factors, including psychotropic medications, psychosocial services,  and other situational and environmental factors. Rather than focusing on  reducing medications overall, officials in these states said their goal is to  ensure the child receives appropriate treatment, which may involve efforts  related to all of the factors mentioned above.
section_title: States Use Information on Physician Prescribing Patterns and State Oversight Practices to Gauge Results, though Data Sharing Can Be a Challenge
paragraphs: Child welfare and Medicaid officials in all seven of the selected states told  us they use a variety of measures to gauge the results of their efforts  related to psychotropic medication use among children in foster care.  These measures generally examine physician prescribing patterns, state  oversight practices, and child placement, health, education, and juvenile  justice outcomes. For additional information on measures collected by  each selected state, see appendix II.
Physician prescribing patterns. All seven selected states examine  data to better understand certain prescribing patterns, such as the use  of antipsychotics, the use of multiple psychotropic medications at the  same time, and dosage levels for the medications prescribed. Child  welfare and Medicaid officials in all of these states said they have  particularly focused on antipsychotic medications, in part due to  concerns about inappropriate use of these medications and their  potential negative side effects for children. Officials in five states told  us their state has experienced reductions in antipsychotic use among  children in foster care in recent years. Researchers have also noted  that concerns about the use of antipsychotic medications spurred  state efforts to oversee and improve prescription behavior, and a June  2016 study examining Medicaid data in 20 states from 2005 through  2010 found that trends in the use of these medications are no longer  increasing. However, the study noted that current prescribing  patterns for antipsychotics at the “new normal” rates of use remain of  great concern to many stakeholders.
Child welfare and Medicaid officials in one state also underscored the  significance of examining prescribing patterns after they observed  spikes in the use of certain medications. These officials said that after  their state started requiring second opinions for ADHD prescriptions,  they saw increases in prescriptions of antipsychotics, and after  requiring second opinions on antipsychotics, they saw increases in  prescriptions for the use of multiple psychotropic medications at the  same time. Officials interpreted these patterns as showing that some  physicians choose to prescribe certain medications partly to avoid  their state’s oversight practices. These officials expressed concern  that new requirements may cause increased medication use in other  areas, which would need to be monitored.
State oversight practices. While selected states may have similar  reported practices for overseeing the use of psychotropic medications,  they vary in whether they examine data to determine if their practices  are followed. For example, while child welfare and Medicaid officials in  all seven states told us their state requires some form of agreement or  informed consent for a child’s treatment plan, officials in three of these  states told us they review reports on whether such an agreement was  obtained. In addition, while officials in six states said their state  requires or recommends a caseworker or physician conduct follow-up  visits with a child on psychotropic medications, officials in one of these  states told us they examine data on the required follow-up, specifically  for ADHD medications. Officials in three of these states told us they  do examine data on whether a physician monitors the child’s  metabolic health, including height, weight, and lipid panels. These  measures can be used to monitor whether a child is experiencing any  adverse effects as a result of taking medications. Child welfare and  Medicaid officials in most selected states said they have particularly  focused on ensuring children in foster care receive psychosocial  services to help address experiences with trauma. Officials in all  seven states said their state has guidelines that require or  recommend the use of psychosocial services prior to or concurrently  with a psychotropic medication, and officials in all of these states told  us they examine data on the number of children in foster care who  received such services. Officials in four of these states told us their  state has increased the use of psychosocial services. For example, a  2013 study on physicians’ use of Washington’s telephone line for  mental health consultations between 2008 and 2011 found a 132  percent increase in outpatient mental health visits for children  currently or previously in foster care after a consultation. However,  as mentioned earlier, child welfare and Medicaid officials in most of  the selected states—as well as multiple studies—have noted  continuing challenges with access to psychosocial services.
While we did not assess states’ implementation of specific practices to  oversee the use of psychotropic medications, findings from a 2016  California State Auditor report highlight the importance of having  measures in place to ensure that state practices are followed.  Specifically, the report found multiple cases where children in foster  care received prescriptions for psychotropic medications without court  authorization or parental consent, which, according to the report, is a  violation of state law.
Child placement, health, education, and juvenile justice  outcomes. Most of the seven selected states collect data to monitor  outcomes for children on psychotropic medications. For example,  child welfare and Medicaid officials in four selected states told us they  monitor information on whether a child in foster care on psychotropic  medications experiences a placement disruption (the child is moved  from one placement to another). Multiple studies have shown that  placement disruptions are associated with increased mental health  needs and poor social-emotional outcomes, and that problem  behavior can be an indicator of risk for future placement disruptions.  Since children may be prescribed psychotropic medications to help  treat problem behaviors, examining data on disruptions can help  states better understand whether children with problem behaviors on  medications are improving or are still having serious behavioral  problems. Some states also examine health, education, and juvenile  justice outcome measures for children in foster care on psychotropic  medications. Child welfare and Medicaid officials in a few states said  such measures can help them determine whether the care and  services provided to children in foster care are helping these children  lead healthy and productive lives. For example, Illinois child welfare  officials told us they examine whether a child under the age of 6 on a  psychotropic medication has symptoms of self-harm or is hospitalized.  In addition, Maryland child welfare officials told us they examine data  on school enrollment and academic performance for children in foster  care on psychotropic medications, whereas Washington officials told  us they examine data on whether children in foster care with mental  health needs, including those on psychotropic medications, have any  involvement in the juvenile justice system.
Child welfare and Medicaid officials in most of the seven selected states  discussed common challenges in their efforts to collect data needed to  oversee the use of medications by children in foster care and to monitor  outcomes for these children. In five of the seven states, officials  discussed technical issues with obtaining reliable data. They said data on  psychotropic medications and other mental health services for children in  foster care can involve data systems from state child welfare, Medicaid, and mental health agencies. In addition, they said data needed to gauge  whether a child’s life improves with treatment—such as the child’s living  situation and their health, education, and juvenile justice outcomes—can  involve many other data systems, including those from state education  and juvenile justice agencies. Because some of these agencies may not  collect information specifically on the foster care population, officials said  gathering these data may require data matching across these systems. In  some selected states, officials said this information may also involve  county-level agencies that can vary in the types of data they collect as  well as one or more third-party managed care organizations that report to  state Medicaid agencies. These officials said matching such data can be  difficult and time-consuming, and state child welfare and Medicaid  officials in three selected states discussed limitations with data gathering  due to resource and time constraints, given other competing priorities.
State child welfare and Medicaid officials in five selected states also  discussed privacy concerns related to data sharing. For example, officials  in two of these states said state agencies are reluctant to share sensitive  data on individuals due to their concerns about privacy protections under  the Health Insurance Portability and Accountability Act of 1996 for health  information and the Family Educational Rights and Privacy Act for  education information. Similarly, officials in two other states expressed  uncertainty over the types of data they were able to share under state and  federal laws. Child welfare and Medicaid officials in three of the five  counties where we conducted interviews discussed similar privacy  concerns with data sharing among county-level agencies. Child welfare  and Medicaid officials in two of the five states that expressed privacy  concerns also discussed concerns about sharing data with managed care  organizations. They said they were in the process of determining how to  share information specifically on the foster care population with these  organizations as well as what data to collect from them.
State child welfare and Medicaid officials in some selected states that  were able to share data said they overcame privacy concerns through  negotiating written agreements and educating stakeholders about sharing  data consistent with state and federal privacy requirements. For example,  Maryland child welfare and Medicaid officials said their agencies each  formed an agreement to share data with the same contractor, who  matched data on children in foster care with Medicaid data on claims for  psychotropic medications and mental health services, and reported the information to state agencies without providing personal data. In addition,  Maryland child welfare officials said their agency entered into an  agreement with their state education agency to share education  information for children in foster care. This agreement granted certain  officials access to personal information, and these officials assigned  anonymous identifiers to each child to protect their privacy while  facilitating data sharing. California child welfare officials told us they  recently worked with their state education and juvenile justice agencies to  issue a letter that summarizes existing state and federal laws that pertain  to the sharing of information and records between local education  agencies, county child welfare agencies, and caregivers for children in  foster care. In addition, Washington child welfare officials discussed data  sharing agreements among multiple state agencies that allowed the state  to match and share client-level information across more than 30 state  data systems. These officials attributed the success of their agreements  to strong state leadership and the development of trust and buy-in among  the stakeholders involved.
section_title: HHS Assists States in Addressing Medication Use and the Mental Health Needs of Children, Though More Could Be Done to Support Collaboration across State Agencies
subsections: section_title: HHS Supports States in Overseeing Medication Use and Determining Children’s Mental Health Needs and Treatment Options
paragraphs: Since our 2014 review of psychotropic medications for children in foster  care, ACF, CMS, and SAMHSA have continued to provide support to  states—generally in the form of funding and technical assistance—to  assist with oversight of these medications. Specifically, these efforts aim  to support states’ practices for prescribing medications, for diagnosis and  treatment options, and for implementing measures to assess the quality  of health care delivery to children in foster care.
subsections: section_title: States’ Practices to Oversee Medication Use
paragraphs: Through funding and information sharing, SAMHSA, CMS, and ACF help  state agencies with practices related to prescribing medication and their  oversight efforts. For example, SAMHSA partly funded AACAP’s  development of voluntary recommendations for states on the use of  psychotropic medications for children and adolescents. As discussed  earlier, these recommendations emphasize that holistic mental health  treatment can include medication, but that medication should be only one  part of the overall plan. State officials in most of our selected states said  they reviewed AACAP recommendations when developing their own  guidelines and oversight practices for children in foster care. For  example, child welfare officials in Illinois said they worked with a  representative of their state AACAP branch, among others, to develop  guidelines on prescribing medications, which, according to these officials,  were included in their state law. In addition, Ohio’s medication  management and oversight program included clinical resources and  prescribing guidelines for physicians based on AACAP’s  recommendations.
SAMHSA also supports child welfare agency staff and mental health  stakeholders seeking to ensure the appropriate use of psychotropic  medications for children in foster care through a contract with the  Technical Assistance Network at the University of Maryland’s School of  Social Work. SAMHSA funds a medical director position at the network,  and that director works with 55 child and adolescent psychiatrists in state  and county governments to address issues regarding psychotropic  medication, including strategies to help ensure children receive  appropriate treatment. Specifically, the director created a community  listserv of child and adolescent psychiatrists to disseminate best practices  and developed webinars on medication oversight. According to SAMHSA  officials, the medical director, with input from the listserv community, is  developing guidance on how to take youth off medication, an issue that  child welfare officials in one selected state said can be a challenge. As  these officials explained, psychiatrists generally are reimbursed more for  medication management than psychotherapy, which can create a  disincentive for keeping children off medication. Through the network’s  Clinical Distance Learning Series, SAMHSA also developed webinars and  issue briefs on the oversight of psychotropic medications for children on  Medicaid, including one on developing performance measures. According  to SAMHSA officials, the technical assistance network has also begun  planning for a multi-year collaborative for residential treatment centers  that have an interest in addressing the use of antipsychotic medications  among the youth they serve. As they explained, the goal of this group is  to increase best practices related to the use of antipsychotic medications  for youth in residential care and reduce outlier practices, such as  prescribing children too many medications or at dosages exceeding  maximum levels based on labels approved by the Food and Drug  Administration. Through funding, SAMHSA has continued to support a  multi-year virtual learning community in which community participants  receive technical assistance, including monthly e-newsletters, webinar  invitations, and access tools and resources. SAMHSA-funded webinars have included issues such as cross-system data sharing, education and  engagement of key stakeholders, phone psychiatric consultation models,  and red flag and response systems for medication oversight.
CMS, in its 2015 Quality Conference, hosted a Medicaid Track that  included a session for Medicaid and health care professionals on  physician prescribing patterns considered high risk because of the  adverse side effects, including the use of antipsychotic medications. The  National Committee for Quality Assurance, a nationally recognized quality  improvement entity, presented the results of its efforts to develop  measures to oversee medication use at the conference. According to  CMS officials, this session prompted formation of a group for interested  state Medicaid agencies and their partners on the use of antipsychotic  medications for children. Eights states are participating in the group as of  October 2016. These states are working on various projects to improve  appropriate medication use and monitoring for possible side effects. In  addition, in February 2016, CMS collaborated with the National  Association of Medicaid Directors and the American Drug Utilization  Review Society to host a national call for 12 Medicaid drug utilization  review program directors to share their strategic efforts on their child  antipsychotic monitoring programs with all other states and the District of  Columbia.
ACF developed two guides related to psychotropic medication use for  children in foster care. The first guide provides tools to help children ask  questions about medications as they meet with physicians. The second  publication is a companion guide for child welfare staff and foster parents  on mental health issues, the impact of trauma, and psychotropic  medications. According to ACF officials, both guides have been  distributed nationally and are posted on ACF’s Child Welfare Information  Gateway website.
section_title: Diagnosis and Treatment Options
paragraphs: HHS also helps states address mental health screenings for children— which affects their diagnosis and treatment options—and increase  awareness of and access to trauma-informed care services among the  child welfare workforce.
Misdiagnosis and inappropriate medication use: ACF and the Centers  for Disease Control and Prevention partnered to study the relationship  between misdiagnosis and inappropriate medication use. Their study was  spurred by prior research that examined a large sample of children in a  child welfare population who underwent a comprehensive diagnostic  evaluation. The prior study found that over 85 percent of children  diagnosed with fetal alcohol spectrum disorder had never been previously  diagnosed or had been misdiagnosed. For these children, the most  common mental health diagnosis prior to the comprehensive evaluation  was ADHD—a diagnosis that often leads to psychotropic medication  prescriptions. ACF and the Centers for Disease Control and Prevention  are currently completing a pilot study at a local child welfare agency to  understand why a diagnosis of fetal alcohol spectrum disorder might be  missed and what information agencies and families need in order to  maximize outcomes for children and families. According to ACF officials,  they also plan to gather information from other sites to understand this  issue at a national level, and to develop training materials for  caseworkers and caregivers on a child’s likely prenatal exposure to  alcohol as well as the types of information that caseworkers and  caregivers need to help these children.
Trauma-informed care and evidence-based practices: ACF provides a  variety of trauma-related grants, including grants focused on screening,  assessment, treatment, and bridging the gaps between child welfare and  mental health. Through support of another ACF grant, the National  Center for Evidence Based Practice in Child Welfare provides training  and capacity building for child welfare and mental health staff on trauma- focused therapy and on improving access to mental health services. In  Washington, the state used ACF’s informational briefs on trauma for its  own training and ACF grant funds to develop a handbook on trauma for  foster care families.
SAMHSA also provided competitive grants to a cohort of states to help  increase quality of care and access to trauma-related services. In 2014,  SAMHSA initiated an online and television campaign to inform the public  about efforts to treat child trauma and resources available through the  National Child Traumatic Stress Initiative. SAMHSA has also formed a  relatively new partnership with the National Center for Trauma-informed  Care to develop coordinated networks focused on treatments shown to be  effective in treating mental health conditions. In addition, SAMHSA has  provided funding for webinars and a national technical assistance  program that supports research and training centers focused on trauma.
section_title: Health Care Quality Reporting Measures
paragraphs: CMS added a measure on the use of multiple antipsychotic medications  to the 2016 Core Set of Children’s Health Care Quality Measures for  Medicaid and the State Children’s Health Insurance Program. The core  set is a voluntary set of measures that states may use to monitor and  improve the quality of health care delivery to children covered under  Medicaid, including those in foster care. In addition to the measure added  by CMS, other measures related to children’s use of antipsychotic  medications include behavioral or mental health counseling services and  metabolic monitoring. Through its group on antipsychotic medication  use in children, CMS facilitates information sharing and provides technical  assistance to help eight state Medicaid agencies improve their  evaluations of state programs through the voluntary use of these  measures. This will be the first year that states may voluntarily report on  the measure for the use of multiple antipsychotic medications at the same  time among children and adolescents. According to CMS officials, they  provided a technical assistance webinar in August 2016 to help states  determine how to measure this information. CMS officials said that a key  CMS goal is to encourage and support national reporting by state Medicaid agencies on a uniform set of measures to facilitate assessment  of quality of care.
Officials from most of the seven selected states we reviewed said they  use or plan to use some or all of these measures. For example, in  February 2017 California’s Medicaid agency will report to CMS measures  on ADHD medication use and the use of multiple antipsychotic  medications at the same time, among other things. The measures will  include data on all children covered under their fee-for-service, managed  care, and specialty mental health programs. In Ohio, state officials said  they will build into managed care contracts two Healthcare Effectiveness  Data and Information Set (HEDIS) measures as an oversight mechanism:  the use of multiple antipsychotics at the same time in children and the first  line psychosocial care for children and adolescents on antipsychotics.
section_title: HHS Has Supported Some State Collaboration on Medication Oversight, and Selected States Said More Federal Assistance Would Help
paragraphs: Although HHS has a variety of efforts to assist states in overseeing  psychotropic medication use among children, since 2014 the agency has  not convened meetings with all the relevant stakeholder groups needed to  share information and work together on these issues. Under title IV-B of  the Social Security Act, states are required to develop their plans for  oversight and coordination of health care services for children in foster  care in collaboration with the state Medicaid agency, and in consultation  with pediatricians, experts in health care, and experts in and recipients of  child welfare services. HHS’s guidance on implementing this provision  and overseeing psychotropic medication use notes that state oversight  should include coordination among and mechanisms to actively engage  with child welfare, Medicaid, and mental health stakeholders to improve  outcomes for this population. This guidance also discussed HHS’s goal  of facilitating cross-system collaborations for the purposes of promoting  improved behavioral health diagnosis, treatment, service delivery, and  service tracking for children in foster care, which includes actions to  increase oversight and monitoring of psychotropic medications. However,  HHS’s assistance to states around collaboration has generally focused on  a limited number of states or certain stakeholder groups. For example,  SAMHSA hosted a day-long technical assistance meeting in 2015 for  states with the capacity and commitment to implement improved cross- agency oversight of medication use, however, the meeting was limited to  five states. In addition, at its August 2016 National Conference on Child  Abuse and Neglect, HHS held a breakout session which focused on a  range of issues, including evaluation and oversight of medication, and  how effective psychotropic medication oversight systems work in concert  with efforts to ensure access to effective psychosocial services. While  the conference included this session, ACF officials said it was limited in  scope compared to previous events it hosted on this issue.
ACF also finalized regulations in June 2016 that established requirements  for a new, optional comprehensive child welfare information system that  states can use to maintain their child welfare data. If a state chooses to  develop one, the new information system is required to support data  exchanges with specified other systems, including Medicaid, court, and  education systems, among other requirements. In the final rule, ACF  stated that the new information system will provide child welfare agencies  with the tools and flexibility to rapidly share data among multiple  programs, including Medicaid and mental health. As discussed earlier,  officials from child welfare and Medicaid agencies in most of the selected  states spoke of challenges related to concerns about state and federal  laws protecting individuals’ privacy. In 2013, we reported that state and  local human services agencies, among others surveyed, identified  challenges related to the interpretation of federal privacy requirements as  they balance the need to protect clients’ personal information while  increasing the use of data sharing. These challenges included confusion  or misperceptions about what agencies are allowed to share as well as a  tendency to be risk averse and overly cautious in their interpretation of  federal privacy requirements. ACF officials told us some states interpret  federal laws on protecting confidentiality to have barriers when there often  are not barriers at the federal level. They added that they have used their  confidentiality toolkit to debunk myths and concerns with data sharing,  though child welfare officials we interviewed in a few of the selected  states said they were not aware of a federal toolkit on data sharing.
State officials in all seven selected states spoke of the importance of  collaboration, and some said successful cross-agency collaboration has  helped them oversee the use of psychotropic medications more  effectively. Further, officials in most of these states said they benefitted  from HHS’s national convening in August 2012 of state directors of child  welfare, Medicaid, and mental health agencies to address the use of  psychotropic medications for children in foster care and their mental  health needs. The meeting (“Because Minds Matter”), hosted by ACF,  CMS, and SAMHSA, provided an opportunity for state leaders to enhance  their collaboration on the appropriate use of psychotropic medications.  Officials we spoke with said it helped them develop prescribing guidelines  and expand reporting on psychotropic medications. According to officials  in one selected state, their child welfare agency worked with its mental  health agency partner at the HHS meeting to develop its informed  consent process. Likewise, the meeting was the impetus for another  selected state’s child welfare and Medicaid agency partnership and its  quality improvement project, according to state officials. This project  involved engaging with multiple stakeholders throughout the state,  forming work groups to study psychotropic medication use, and  developing training materials and guidance on the proper use of these  medications. In a third selected state, three lead agency directors and  medical directors formed a team to provide clinical oversight of their foster  care population. In addition, officials in one selected state said their  participation in the meeting, and in other collaborative efforts, helped  them learn about the work of other states in effective monitoring of mental  health care for children in foster care, including an improved ability to  monitor medication use.
State officials in three of the seven selected states said more federal  government leadership could help them work through ongoing  challenges, including (1) obtaining best practices in medication use  concurrent with other treatments; (2) overcoming siloes across child  welfare, Medicaid, and mental health systems serving the foster care  population; and (3) enhancing access to child and adolescent psychiatric  resources. In addition, officials in selected states transitioning their foster  care populations into managed care expressed concern about the  transition, and the need to manage the transition to ensure optimal care  coordination. Some of the concerns identified include (1) ensuring state  agencies share data with the managed care providers to facilitate  continuity of care, (2) bringing all the necessary stakeholders onboard  during the transition to ensure a common understanding of concepts and  roles, and (3) ensuring managed care plans have the needed tools to  accommodate non-traditionally served populations that have high medical  needs.
State child welfare, Medicaid, and mental health officials in three selected  states said having other events similar to the one hosted by HHS in 2012  could provide further support in addressing these challenges. While ACF,  CMS, and SAMHSA have held various events with limited numbers of  states or certain stakeholder groups, as mentioned above, they have not  convened a 50-state meeting that includes child welfare, Medicaid, and  mental health stakeholders since 2012 to continue discussions about how  best to oversee psychotropic medications. ACF officials said they have no  plans to hold a national convening of state agency stakeholders. They  explained that, in response to recent mandates on efficient government,  they have moved toward hosting more virtual meetings. While virtual  meetings can be a useful and cost-effective tool in facilitating  collaboration and information sharing, none of HHS’s virtual meetings on  psychotropic medications have included most states and stakeholders  across multiple services. HHS noted in its 2012 guidance to states on  oversight of psychotropic medications that children in foster care are  typically involved in multiple service delivery systems, and a coordinated,  multi-system approach is necessary to meaningfully improve outcomes  for this population. Additional efforts from HHS to include relevant  stakeholders in collaborations to address continuing challenges can  better position states in their work to improve practices to oversee  medication use and effectively ensure appropriate treatments for the  foster care population.
section_title: Conclusions
paragraphs: Though the benefits of using psychotropic medications have been  documented, the health risks or side effects associated with certain  prescribing patterns—such as the use of multiple psychotropic  medications at the same time and the use of antipsychotics—make it  important to ensure that a given treatment is appropriate for addressing a  child’s condition. State agencies in our seven selected states have taken  steps to curb inappropriate prescriptions of psychotropic medications  among children in foster care, often by collaborating with each other and  with other stakeholders involved in the child’s care. Officials in these  states credited HHS with helping them jumpstart or further their efforts by  fostering collaboration and providing forums to share information at  HHS’s 2012 conference.
While the states included in our review have made efforts to improve  medication oversight, selected state officials and their partners discussed  a need for continued collaboration and information sharing to help  effectively implement oversight practices, improve access to mental  health services, share data, and monitor outcomes. Information on  oversight practices can be especially important for states that may not be  as far along in their efforts to oversee medication use as those selected  for this review, or for those experiencing a period of change as they  transition their foster care populations into managed care. While HHS has  made efforts to help support states in their oversight activities, additional  support from HHS to convene state child welfare and Medicaid agencies  and other stakeholders could create opportunities for state agencies to  learn from one another’s experience, collaboratively develop solutions to  mitigate common challenges, strengthen oversight practices for  psychotropic medications, and more effectively ensure appropriate  treatments for children in foster care.
section_title: Recommendation for Executive Action
paragraphs: To help states effectively address ongoing challenges related to ensuring  the appropriate use of psychotropic medications for children in foster  care, the Secretary of HHS should consider cost-effective ways to  convene state child welfare, Medicaid, and other stakeholders to promote  collaboration and information sharing within and across states on  psychotropic medication oversight.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Secretary of HHS for review and  comment. HHS agreed with our recommendation and provided some  examples of a virtual convening of select groups of professionals and  agencies it employed to facilitate information sharing and collaboration  around different issues. We believe that convening child welfare,  Medicaid, and mental health stakeholders across all 50 states, in virtual  or other settings, is an important step towards helping these stakeholders  ensure the appropriate use of psychotropic medications for children in  foster care. HHS also provided additional information on their efforts to  date to help states address medical and mental health care for children in  foster care. Finally, HHS provided technical comments, which we  incorporated as appropriate. A letter conveying HHS’s formal comments  is reproduced in appendix III.
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If you or your staffs have any questions about this report, please contact  me at (202) 512-7215 or Brownke@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: This appendix discusses in detail our methodology for addressing three  research questions: (1) how child welfare and Medicaid agencies in  selected states work to ensure the appropriate use of psychotropic  medications for children in foster care; (2) what is known about the results  of their efforts, and (3) the extent to which the Department of Health and  Human Services (HHS) helps states support the appropriate use of  psychotropic medications for children in foster care. To address these  questions, we reviewed relevant federal laws, regulations, and guidance.  We interviewed HHS officials, and state officials in seven selected states  and county officials in two of those states as well as officials in nine  national professional and research organizations. We reviewed national,  state, and county guidance and other documents identified by our  interview subjects, and analyzed available data from selected states on  medication use in foster care over a 5-year period.
To address all objectives, we conducted in-person and telephone  interviews with officials in seven selected states, including officials from  child welfare and Medicaid agencies and other partners, and with nine  national child welfare, Medicaid, and mental health professional and  research organizations. The states we selected were Arizona, California,  Illinois, Maryland, New Jersey, Ohio, and Washington. Our selection  criteria included: (1) a high percentage of children in foster care and  congregate care in the state when compared nationwide in fiscal year  2014; (2) variation in the type of Medicaid delivery system covering  psychotropic medications and other mental health services for children in  foster care (i.e., fee-for-service versus single or multiple managed care  organizations) and in the type of child welfare system (i.e., state- versus  county-administered); (3) recommendations from national organizations  we interviewed for states that have or are in the process of implementing  practices to oversee and monitor psychotropic medications; and (4)  diversity in geographic location. In two states with county-administered  child welfare systems, California and Ohio, we selected five counties and  conducted interviews with officials from the respective county-level child  welfare and Medicaid agencies, as appropriate. These counties were  selected based on factors similar to those mentioned above as well as  variation in population density (i.e., rural versus urban). Our findings  cannot be generalized to states or counties outside our selection sample.
In the report we use qualifiers, such as “a few,” “some,” and “most” to  quantify responses from officials across our interviews with state and  county child welfare and Medicaid agencies and their partners, such as  universities and state or county mental health agencies. We reported the  total number of the seven selected states in which at least one official or  partner gave the reported response. These qualifiers are defined as  follows:  “All” states represents seven  “Most” states represents five to six  “Some” states represents three to four  “A few” states represents two  We interviewed representatives from nine national professional and  research organizations selected to represent a variety of views on child  welfare, Medicaid, and mental health-related policy and research. These  organizations were: American Academy of Child & Adolescent Psychiatry,  American Academy of Pediatrics, Center for Health Care Strategies, Child  Welfare League of America, Medicaid and CHIP Payment and Access  Commission, National Association of Medicaid Directors, National  Association of Public Child Welfare Administrators, National Association  of State Mental Health Program Directors, and National Alliance on  Mental Illness.
For all our interviews, we used a semi-structured interview protocol that  included open-ended questions about state child welfare and Medicaid  delivery systems; state and county oversight practices, including related  challenges and measurement of outcomes; and federal efforts to assist  states. Information was volunteered by officials in each interview in  response to these open-ended questions. Thus, the counts of  organizations citing such responses vary. We reviewed relevant  documents to corroborate information obtained in our interviews, when  possible.
To examine how state child welfare and Medicaid agencies work to  ensure the appropriate use of psychotropic medications, we also  reviewed guidance and other documents identified by officials from  selected states and counties. While we identified selected states’  oversight and monitoring practices related to psychotropic medications  based on interviews and these document reviews, we did not assess the  effectiveness of states’ implementation of these practices, nor did we  evaluate their compliance with state or federal requirements or whether  there are controls in place to help ensure that required practices are  followed. In addition, while we focused our review on children in foster  care, state oversight practices may also pertain to other children on  Medicaid. We also reviewed guidance on oversight and monitoring of  psychotropic medications for children issued by national health care  professional organizations. In addition, we reached out to selected  states’ audit agencies and HHS’s Office of Inspector General to identify  past, ongoing, or planned work in this area. We also conducted a review  of selected literature, including reports from academic, professional, and  governmental organizations, related to the use of psychotropic  medications and published since GAO’s report in April 2014.
To examine the results of state efforts to ensure the appropriate use of  psychotropic medications, we gathered and analyzed available data from  selected states on the use of these medications among children in foster  care from 2011 through 2015. We selected this range in order to gather  data on 5-year trends that included the most recent data available. To  examine the reliability of these data, we interviewed and sent a  questionnaire to relevant state child welfare and Medicaid officials and  examined the data received to identify any obvious outliers. We  determined that these data were sufficiently reliable for the purposes of  describing trends in the percentage of children in foster care on  psychotropic medications for each of the selected states. However,  because these states use different methodologies to collect data (e.g.,  states collected data for different time periods and ages of children in  foster care), the data are not comparable among them. In addition, the  results of our analyses are not generalizable nationwide. Information  collected from selected states, such as on their oversight practices and  measures collected to examine the results of their efforts, was provided to  officials in each selected state for their review and verification.
To examine HHS’s actions to support state efforts related to psychotropic  medications, we interviewed officials from the Administration for Children  and Families, Centers for Medicare & Medicaid Services, and Substance  Abuse and Mental Health Services Administration, and reviewed relevant  documents. In addition, we reviewed guidance on oversight and  monitoring of psychotropic medications for children issued by HHS and  used it as criteria for our recommendation.
section_title: Appendix II: Selected State Information
section_title: Appendix III: Agency Comments from the Department of Health and Human Services
section_title: Appendix IV: Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Elizabeth Morrison (Assistant  Director), Claudine Pauselli (Analyst-in-Charge), Linda Collins, and Nhi  Nguyen made key contributions to this report. Also contributing to this  report were Seto Bagdoyan, James Bennett, David Chrisinger, Sarah  Cornetto, Celina Davidson, Sara Edmondson, Sandra George, Katherine  Iritani, Angie Jacobs, Kirsten Lauber, Hannah Locke, Sheila McCoy,  Jonathan McMurray, and Jennifer Whitworth.
section_title: Related GAO Products
paragraphs: Foster Children: HHS Could Provide Additional Guidance to States  Regarding Psychotropic Medications. GAO-14-651T. Washington, D.C.:  May 29, 2014.
Foster Children: Additional Federal Guidance Could Help States Better  Plan for Oversight of Psychotropic Medications Administered by  Managed-Care Organizations. GAO-14-362. Washington, D.C.: April 28,  2014.
Children’s Mental Health: Concerns Remain about Appropriate Services  for Children in Medicaid and Foster Care. GAO-13-15. Washington, D.C.:  December 10, 2012.
Foster Children: HHS Guidance Could Help States Improve Oversight of  Psychotropic Prescriptions. GAO-12-201. Washington, D.C.: December  14, 2011.
Foster Children: HHS Guidance Could Help States Improve Oversight of  Psychotropic Prescriptions. GAO-12-270T. Washington, D.C.: December  1, 2011.