QI Initiatives for Psychotropic Use in Foster Youth in Maine

Lindsey Tweed MD MPHOffice of Child & Family Services;

Maine DHHSLindsey.Tweed@Maine.gov

Sixteen State Collaborative Antipsychotic Study

• This study occurred before the more recent focus on all psychotropics in foster youth

• Focus was on all Medicaid beneficiaries; not just foster youth

• Data analysis covered 2004-2007

16 State Antipsychotic Study: Part II

• Rate for of antipsychotic use for all MaineCare members 0-18: 3.1 %

• Rate for MaineCare members 12-18 varied between 5 and 6%

• Maine was above the median• Rate for foster youth: 20%• Nobody knows what the rates should be;

but these seemed high

Rationale for More Intense Focus on Antipsychotics

• Although psychotropics should never be used inappropriately, stimulants and antidepressants are relatively safe

• Medically important side effects are very common with antipsychotics

• Majority of psychotropic side effect burden would seem to be due to antipsychotics

• Other less prevalent meds that commonly have medically important side effects…

Handling Antipsychotic Outliers

• More than one; high dose; very young• Pharmacy benefit manager had

implemented Prior Authorization process; mainly as a cost saving tool

• PA requirement added for two AP’s or for doses over FDA approved

• PA for AP use in children under 5 later added; requires a chart review

Reaction to Initial Prior Authorization Requirements

• PA approved by committee including community psychiatrists

• Still, there was a very strong reaction against the PA

• M.D. at benefit manager: We should have had a conference, other means of input and education, before implementing.

• We may now be in a different era

But Non-Outliers Are Majority of the Problem

• Most AP prescription is to youth 5 and over; one antipsychotic; and at FDA approved doses

• These youth commonly/usually experience medically important side effects

• The majority of foster youth side effect burden would appear to come from non-outlier use of AP’s

Goals and Members of AP Use in Foster Youth Workgroup

• Goal: Ensure that Foster Youth are prescribed antipsychotics only when clinically indicated

• Members: Foster Youth, Foster Parents, Residential Treatment Providers, Child Psychiatrists, DHHS

• We began in September 2009 and met for about one year

Strategies Chosen

• Strengthen teen consent process– Tool developed to empower youth

• Strengthen caseworker consent process; be the best parent you can

• Worksheet for caseworkers

Worksheet for Caseworkers/Supervisors

• Use in psychosis and for Bipolar Disorder• Use for aggression as a target symptom

• In context of Autism Spectrum• In context of Disruptive Behavior Disorders (CD,

ADHD with aggression)• Maximize good casework• Maximize psychosocial interventions

– EBT’s

• Maximize treatment of primary disorders (e.g., ADHD, depression) with safer meds

Worksheet (cont.)

• Monitoring therapeutic effects• Monitoring side effects

– Ask specifically about weight, BMI, BMI percentile, glucose and lipids

• When aggression is target symptom, and when youth has done well for 6 months, expectation is to taper

• All good med decisions are risk vs benefit

Additional Strategies

• Additional Support for Caseworkers– By clinicians who work within OCFS

• Education on Guidelines: Youth, Caseworkers, Prescribers, Foster Parents, Residential Providers

• Monitoring Our Progress– Both via MACWIS and via MaineCare claims– Proportion of youth on each category of med; by

district, supervisor, caseworker– How to measure if process followed?

AP Use Rate 0-18 YearsMinimum one month MaineCare eligibility

AP Use in MaineCare Members Under 19Maine 2004-2011

Other States 2004-2007

0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%

2004 2005 2006 2007 2008 2009 2010 2011

Maine Maximum Median Minimum

Year % of AP

Users2004 3.1%2005 3.1%2006 3.2%2007 3.1%2008 3.1%2009 3.0%2010 2.8%2011 2.6%

Maine

DRAFT 8/8/2012

Foster/Non-Foster AP Use Rate 0-18 Years

One month MaineCare eligibilityvirtually all atypical anti-psychotics

AP Use in Children/ Youth 0-18Maine 2004-2011

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2004 2005 2006 2007 2008 2009 2010 2011

Foster Care Non-Foster Care

AP Use Demographics

Year Foster Care

Non-Foster

2004 10.9% 3.0%2005 9.2% 3.0%2006 8.5% 3.0%2007 9.5% 3.0%2008 17.2% 2.8%2009 16.8% 2.7%2010 16.7% 2.5%2011 14.6% 2.4%

DRAFT 8/8/2012

Recent Initiatives for All MaineCare Members

• Legislator introduced a bill to regulate AP prescription in youth– Compromise was a DHHS report– Similar stakeholder group made similar recs

for all prescribers– Method for monitoring agencies’ QI being

devised• New PA: required monitoring of metabolic

side effects within first 20 weeks of use

Role of Evidence Based Treatments

• Most youth started on AP’s have significant mental health symptoms

• EBT’s have not been widely disseminated• Overuse of AP’s may be a logical

consequence of non-dissemination of EBT’s• Significant prevalence of disruptive

behavior, anxiety, depression, and post-traumatic stress in foster youth