consent for psychotropic medication connecticut’s model for children and youth in foster care...
TRANSCRIPT
Consent for Psychotropic Medication
Connecticut’s Model for Children and Youth in Foster
Care
Lesley Siegel, MD Chief of Psychiatry
CT Dept. of Children and Families
CT Department of Children and Families (DCF):
A Multi-Mandate Agency
Abuse/Neglect Mental Health
Juvenile Justice
Foster Care/Adoption
State-Wide Advisory Committee began in 1999O Psychotropic Medication Advisory
Committee (PMAC) meets monthlyO Members include private and public
APRNs, Child Psychiatrists, Pharmacists, Pediatricians, Medicaid Agency Representatives, Parents
O Initially set-up by former DCF Chief of Psychiatry, Dr. Pat Leebens
O Reviews “Best Practice” for evaluation and treatment of foster care children and youth, including all aspects of evidence-informed care
CT adapts Illinois Model
OFormer Chief of Psychiatry, Dr. Pat Leebens, worked with Dr. Mike Naylor (from U of Illinois) on AACAP Practice Standards for Prescribing in Foster Care PopulationOUsed Illinois state/university partnership when proposing CT informed consent model and new legislationOGiven small size of state and multi-mandate child welfare agency, decision made to develop unit within DCF for consultations/consent instead of partnership with a university
Sec. 17a-21a. Guidelines for use and management of psychotropic medications. Database established. The Department of Children and Families shall, within available resources and with the assistance of The University of Connecticut Health Center, (1) establish guidelines for the use and management of psychotropic medications with children and youths in the care of the Department of Children and Families, and (2) establish and maintain a database to track the use of psychotropic medications with children and youths committed to the care of the Department of Children and Families.
(P.A. 04-238, S. 2; P.A. 06-196, S. 112.)
Connecticut Law passed 2004
Centralized Medication Consent Unit (CMCU)
Chief of Psychiatry
Child Psychiatrist(
s)
Advanced Practice Nurse(s)
Support Staff
Youth Worker Foster Family PCP CMCU
Stakeholders in Informed Consent
CT Guidelines for Consent/Assent
Guardian Consent Required under age 18
Patient Assent: Required by age 14; Best practice age 9 and over
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Shared Decision-Making
O Shared decision-making is a description of the process that should be happening regarding psychotropic medication prescribing and has been associated with better outcomes due to increased youth and other stakeholder involvement and compliance.
O Components include agreement with what is being prescribed, knowledge about side effects and necessary monitoring, and alternatives to medication.
O Similar principles to team decision making which child welfare staff in CT and many other states are currently being trained on.
Consent ProcedurePrescriber completes
465 and emails or faxes it to CMCU
CMCU Child Psychiatrist or APRN reviews
information, checks SACWIS (electronic data
base) for past prescribing info
**If after review request is considered
appropriate, consent is given and
emailed/faxed to provider
CMCU enters information in SACWIS and emails worker, regional nurse,
and regional clinical manager of details
Prescription filled
Consent Decisions Based On:
Legal Status Verified
Form relatively complete
Baseline Monitoring
Done
Meds fit Diagnosis
Consent Decisions, cont.
Med on Approved
List
Dosing appropriate
Number of psych meds
overall
Generally only one
antipsychotic
Other factors informing decision:
O Past psychiatric history available in LINK(SACWIS)
O Child’s setting (PRNs and more than one change at once might be approved for hospitals)
O History with prescriberO Other ongoing treatment, especially
trauma-informed modalitiesO Over-arching goal of least number of
meds long-term
2007-2010•More likely to give consent if within core guidelines (approved med at approved dose)
2011/2012• More dialogue
with prescribers• More
discussion of trauma-informed treatment approaches
• Consents “modified” by CMCU increased from 5% to 29%
Consent Process Practice Changes
Quarterly Consent Data
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CMCU WebsiteO Readily available on CT DCF home
page and user-friendly, with frequent updates.
O Link to the website on all CMCU members’ electronic signatures.
O Information about meds, prescribing doses, monitoring protocols, risk in pregnancy, links to NIMH and NYU information on all psychotropic medications, handbook written for families and DCF workers by PMAC, etc.
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Pros and Cons of Centralized Process
O Pros: Standardized system; quick turn-around; providers are happy; Medical team enters note directly in LINK; Medical team aware of need for medical information prior to starting med; doses; monitoring. Centralized unit can review past psychotropic med history easily as available in LINK notes since CMCU began in 2007.
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Pros and Cons, cont.O Cons: Area office CPS staff feel
disconnected from process; may have information from the foster family or the child/adolescent that is different from what the prescriber is told; may feel they don’t have the authority or access to question the APRN/Physician. Also, area office staff may feel they can’t alter or undo the official CMCU consent.
O Children/Youth may feel they don’t have a voice in the process, may feel they have no choice about taking prescribed medication.
“Crisis of Credibility”O Training developed to address “crisis of
credibility” between CPS workers and prescribers; includes Diane Sawyer’s 20/20 segment with foster children describing their experiences on psychotropic medication.
O Purpose is to increase collaboration so that CPS workers don’t feel prescribers just “over-medicate” foster kids and prescribers don’t feel that child welfare is “black hole” of information (i.e. multiple requirements to produce documents with no information given out).
Next Steps
Complete psychotropic med training for all case
workers
Train Foster Families Develop
training in Spanish
Link trauma treatment data with medication
dataAnalyze data by race/ethnicity
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Consent data 2011
Examples:
Consent Process
•15 year old adolescent girl newly admitted to a psych hospital•8 year old boy in a foster home•17 ½ year old boy in a residential treatment setting
Questions?
Lesley Siegel, MDDCF Chief of Psychiatry, State of
860-560-5020 (w); 203-530-0351(c)www.ct.gov/dcf/