Report 2015-131 Recommendations

To ensure that the Medical Board can promptly complete its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, Social Services and Health Care Services should continue to work with the Medical Board and its consultant to meet their data needs. If the Medical Board's analysis is able to identify these physicians, Social Services and Health Care Services should enter into an agreement with the Medical Board to provide the information the Medical Board needs to perform similar analyses in the future.

To increase the State's assurance that foster children do not receive medically inappropriate or unnecessary psychotropic medications, Health Care Services should devise and implement within six months methods to better enforce its prior authorization requirement for the off-label use of psychotropic medications. For example, Health Care Services should revise its claims system to automatically prompt pharmacists to submit treatment authorization requests when filling prescriptions for Medi-Cal beneficiaries under age 18 when the prescribed psychotropic medications have no FDA-approved pediatric uses. Furthermore, as part of its collaboration with Social Services and the counties to develop and implement a reasonable oversight structure, Health Care Services should determine whether information from the Judicial Council's revised court authorization forms would help it better enforce its prior authorization requirements.

To improve the State's and counties' oversight of psychotropic medications prescribed to foster children, the Legislature should require Social Services to collaborate with its county partners and other relevant stakeholders to develop and implement a reasonable oversight structure that addresses, at a minimum, the concerns identified in this audit report.

To improve the State's oversight of physicians who prescribe psychotropic medications to foster children, the Legislature should require the Medical Board to analyze Health Care Services' and Social Services' data in order to identify physicians who may have inappropriately prescribed psychotropic medications to foster children. If this initial analysis successfully identifies such physicians, the Legislature should require the Medical Board to periodically perform the same or similar analyses in the future. Further, the Legislature should require Health Care Services and Social Services to provide periodically to the Medical Board the data necessary to perform these analyses.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

To ensure that physicians do not inappropriately prescribe psychotropic medications to foster children, the Medical Board within 60 days should obtain and analyze the data from Health Care Services and Social Services to identify physicians who may have inappropriately prescribed psychotropic medications for foster children.

Following the completion of the analysis (described in Recommendation 34), the Medical Board should take the appropriate follow-up actions that it deems necessary, including the investigation of physicians identified in its analysis.

To the extent that its analysis (described in Recommendation 34) is able to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, the Medical Board should enter into an agreement with Health Care Services and Social Services within six months of completing its initial review to periodically obtain the data necessary to perform the same or similar analyses.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

To improve its oversight of foster children who are prescribed psychotropic medications, Riverside County should immediately adopt the state guidelines for its physicians' use when prescribing psychotropic medications and for the county's use when reviewing court authorization requests.

To improve its oversight of foster children who are prescribed psychotropic medications, Riverside County should continue to use its new tracking process to better ensure that court authorizations are renewed within 180 days.

To better ensure that counties only use parental consent in place of court authorization when it is appropriate, Social Services should assess Sonoma County's practice of advocating to the juvenile court that it delegate to parents the authority to administer psychotropic medications to foster children.

To better ensure that all caregivers are informed and educated regarding the use of psychotropic medications and the court authorization process, Social Services should develop instructions regarding these topics and provide them to caregivers, such as foster family agencies, that do not operate group homes.

To improve the oversight of psychotropic medications prescribed to foster children, Social Services should collaborate with the counties and other relevant stakeholders—including Health Care Services, as necessary—to develop and implement a reasonable oversight structure that ensures the coordination of the State's and counties' various oversight mechanisms as well as the accuracy and completeness of the information in Social Services' data system. This structure should include at least the following items:
- Identification of the specific oversight responsibilities to be performed by the various state and local government agencies.
- An agreement on how county staff such as social workers, probation officers, and public health nurses will use printed Health and Education Passports to obtain foster children's necessary mental health information—including psychotropic medications and psychosocial services—for inclusion in Social Services' data system.
- A plan to ensure that counties have sufficient staff available to enter foster children's mental health information into Social Services' data system and the resources to pay for those staff.
- An agreement on the specific information related to psychotropic medication—including but not limited to the medication name, maximum daily dosage, and court authorization date—and psychosocial services and medication follow-up appointment information that county staff must enter into Social Services' data system for inclusion in foster children's Health and Education Passports.
- Specific directions from Social Services regarding the correct medication start dates and court authorization dates counties should include in its data system and foster children's Health and Education Passports.
- An agreement on the training or guidance Social Services should provide to county staff members working with Social Services' data system to ensure that they know how to completely and accurately update foster children's Health and Education Passports.
- An agreement on how the counties will use information on the new authorization forms that the Judicial Council approved to better oversee the prescription of psychotropic medications to foster children.
- An agreement regarding how counties will implement, use, or disseminate the educational and informational materials the Quality Improvement Project has produced, including the "California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care", "Questions to Ask About Medications", and the "Foster Youth Mental Health Bill of Rights".
- An agreement on the specific measures and the best available sources of data the State and counties will use to oversee foster children prescribed psychotropic medications, including psychosocial services and medication follow-up appointments.
- An agreement on how the State and counties will oversee psychotropic medications prescribed to foster children by fee-for-service providers who are not affiliated with county Medi-Cal mental health plans.
- An agreement on the extent of information related to psychotropic medications prescribed to foster children that counties will include in the self-assessments, system improvement plans, and annual progress reports they develop as part of Social Services' California Child and Family Services Reviews.
- An agreement on the extent of the information related to psychotropic medications prescribed to foster children that counties will include in their responses to Health Care Services' reviews, including its county Medi-Cal mental health plan compliance reviews and external quality reviews.

To ensure that the Medical Board can promptly complete its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, Social Services and Health Care Services should continue to work with the Medical Board and its consultant to meet their data needs. If the Medical Board's analysis is able to identify these physicians, Social Services and Health Care Services should enter into an agreement with the Medical Board to provide the information the Medical Board needs to perform similar analyses in the future.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. When prescribers request authorizations for prescriptions that exceed the state guidelines, counties should ensure the new court authorization forms contain all required information and, when necessary, follow up with prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring in the foster children's case files. In instances in which counties do not believe that prescribers have adequate justification for exceeding the state guidelines, the counties should relay their concerns and related recommendations to the courts or parents.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement processes to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications and that court authorizations for psychotropic medications are renewed within 180 days as state law requires. The process should also ensure that the counties better document the court authorizations and parental consents in the foster children's case files.

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should develop and implement a process for county staff and caregivers to work together to ensure the psychotropic medications are authorized before being provided to foster children. This process should also ensure that the counties obtain accurate medication start dates from caregivers.

To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should immediately adopt the state guidelines for its physicians' use when prescribing psychotropic medications and the county's use when reviewing court authorization requests.

To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should within six months, implement a process to review psychotropic medications that receive parental consent rather than court authorization.

To improve its oversight of foster children prescribed psychotropic medications, Sonoma County should update its policies to describe methods for obtaining and documenting in the foster children's case files parental consents for psychotropic medications.