A report released Tuesday from the California State Auditor shows that the state and counties have failed to provide adequate oversight for the prescription of psychotropic medications to children in foster care.

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[State Auditor] – Our audit concerning the oversight of psychotropic medications prescribed to California’s foster children revealed the following:

* Nearly 12 percent of California’s more than 79,000 foster children were prescribed psychotropic medications during fiscal year 2014-15.

* Some foster children were prescribed psychotropic medications in amounts and dosages that exceeded state guidelines, and counties did not follow up with prescribers to ensure the appropriateness of these prescriptions.

* Many foster children did not receive follow-up visits or recommended psychosocial services in conjunction with their prescriptions for psychotropic medications.

* Counties did not always obtain required court or parental approval for psychotropic medications prescribed to foster children as required by law.

* The State’s fragmented oversight structure of its child welfare system has contributed to weaknesses in the monitoring of foster children’s psychotropic medications.

* The California Department of Social Services and the Department of Health Care Services data systems together cannot completely identify which foster children are prescribed psychotropic medications.

* Foster children’s Health and Education Passports—documents summarizing critical health and education information—contained inaccurate and incomplete mental health data.

Results in Brief

Psychotropic medications such as antidepressants, mood stabilizers, and antipsychotics can provide significant benefits in the treatment of psychiatric illnesses, but they can also cause serious adverse side effects. Although the American Psychological Association has mentioned that studies since the 1970s have found that children in foster care (foster children) often have a greater need for mental health treatment, public and private entities have expressed concerns about the higher prescription rates of psychotropic medication among foster children than among nonfoster children. This issue is of particular importance to California, which has the largest population of foster children in the country. In fact, our analysis of the available state data found that nearly 12 percent of California’s more than 79,000 foster children were prescribed psychotropic medications during fiscal year 2014-15, whereas studies suggest that only about 4 to 10 percent of nonfoster children are prescribed these medications.

To examine the oversight of psychotropic medications prescribed to foster children, we reviewed case files for a total of 80 foster children in Los Angeles, Madera, Riverside, and Sonoma counties and analyzed available statewide data. We found that many foster children had been authorized to receive psychotropic medications in amounts and dosages that exceeded the State’s recommended guidelines (state guidelines), circumstances that should have prompted the counties responsible for their care to follow up with the children’s prescribers. For example, 11 of the 80 children whose files we reviewed had been authorized to take multiple psychotropic medications within the same drug class. Further, 18 of the 80 children had been authorized to take psychotropic medications in dosages that exceeded the State’s recommended maximum limits. Medications that exceed the State’s recommended guidelines may be appropriate under some circumstances, and we are not questioning prescribers medical expertise. However, in the instances above, the counties did not contact the prescribers to ensure the safety and necessity of the medications in question, as the state guidelines recommend.

Compounding these concerns is the fact that many of these children do not appear to have received follow-up visits or recommended psychosocial services in conjunction with their prescriptions for psychotropic medications. The American Academy of Child and Adolescent Psychiatry recommends that children should receive follow-up visits with their health care providers ideally within two weeks, but at least within a month, after they start psychotropic medications. Nonetheless, one-third of the 67 foster children who started at least one psychotropic medication during our audit period did not receive follow-up appointments with their prescriber or other health care provider within 30 days after they began taking new psychotropic medications, thus increasing the risk that any harmful side effects would go unaddressed. In addition, our review of the 80 case files indicates that foster children did not always receive corresponding psychosocial services before or while they were taking psychotropic medications, even though such services are critical components of most comprehensive treatment plans.

In response to a recent state law, the Judicial Council of California adopted new and revised forms—which became effective in July 2016—to be used in the court authorization process for foster children’s psychotropic medications. The proper completion of these newly revised forms should provide county staff with additional information necessary to identify instances when foster children are prescribed psychotropic medications in amounts or dosages that exceed the state guidelines. Among other things, these revised forms require prescribers to explain for each foster child why they prescribed more than one psychotropic medication in a class or dosages that are outside the state guidelines. If these forms are not properly completed, county staff will need to follow up with prescribers to obtain information necessary to ensure that the prescriptions beyond the state guidelines are appropriate.

We also found that, in violation of state law, counties did not always obtain required court or parental approval before foster children received prescriptions for psychotropic medications. Specifically, when we reviewed the case files for 67 foster children who should not have received psychotropic medications without authorization from a juvenile court, we found that 23 (34 percent) did not contain evidence of such authorization for at least one psychotropic medication. Similarly, when we reviewed the case files for 13 foster children who should not have received psychotropic medications without the consent of their parents, we found that five (38 percent) did not contain evidence of such consent for at least one psychotropic medication. In effect, these children were prescribed psychotropic medications without proper oversight from the counties responsible for their care.

Further, the fragmented structure of the State’s child welfare system contributed both to the specific problems we identified in our review of the 80 case files and to larger oversight deficiencies that we noted statewide. Specifically, oversight of the administration of psychotropic medications to foster children is spread among different levels and branches of government, leaving us unable to identify a comprehensive plan that coordinates the various mechanisms currently in place to ensure that the foster children’s health care providers prescribe these medications appropriately. Although the different public entities involved have made efforts to collaborate, the State’s overall approach has exerted little system-level oversight to help ensure that these entities collective efforts actually work as intended and produce desirable results.

The State’s fragmented oversight structure has also contributed to its failure to ensure it has the data necessary to monitor the prescription of psychotropic medications to foster children. The two state entities most directly involved in overseeing foster children’s mental health care are the California Department of Social Services (Social Services) and the Department of Health Care Services (Health Care Services). Even when combined, results from data systems these two departments operate still contain inaccurate and incomplete data related to foster children who are prescribed psychotropic medications. Consequently, neither agency can completely identify which foster children statewide are prescribed psychotropic medications or which medications those children are prescribed.

Further, the inaccurate and incomplete information in Social Services data system is used to produce Health and Education Passports, which are critical documents that are meant to follow foster children should their placement change. We found that all 80 of the Health and Education Passports we reviewed contained instances of incorrect start dates for psychotropic medications. Moreover, 13 of these 80 Health and Education Passports did not identify all the psychotropic medications that the courts authorized, and all 80 were missing information about the corresponding psychosocial services the foster children should have received for at least one psychotropic medication. These errors and omissions appear to have been caused in large part by a lack of county staff to enter foster children’s health information into Social Services data system and an unwillingness of some county departments to share foster children’s information with each other. However, caretakers, health care providers, social workers, and others rely on the Health and Education Passports to make decisions about foster children’s care; without accurate information, they may inadvertently make decisions that do not reflect the children’s best interests.

Also, the State has missed opportunities to ensure that the counties have reasonable processes for overseeing the prescription of psychotropic medications to foster children. For example, Social Services California Child and Family Services Reviews of the counties only recently began examining in more depth psychotropic medications prescribed to foster children. Because Social Services and Health Care Services have not historically examined the prescription of psychotropic medications to foster children in their periodic reviews, they have missed opportunities for in-depth, county-by-county reviews of this issue. However, as of March 2016, both departments had begun collecting from the counties certain information about these medications.

Finally, rather than publishing this audit report in June 2016 as originally intended, we had to delay publication by two months to allow us time to obtain and analyze additional data from Health Care Services and to revise the report’s text and graphics accordingly. In November 2015, our office began analyzing data originally provided by Health Care Services in response to our request for all Medi-Cal data related to the provision of psychotropic medications and related psychosocial services to foster children. These data provided the basis for the audit report we intended to publish in June 2016. However, about one week before we were to originally publish our audit report, Health Care Services confirmed that it had not provided all the medical services data that we originally requested. Although it had provided us data for medications, treatment authorizations, and services provided by specialty mental health plans, it had not given us services data for managed care plans or fee-for-service providers.1 Our review showed that the additional June 22, 2016, data consisted of approximately 617 million medical service records. The related text and graphics in our audit report reflect a consolidation of the original more than 46 million medical service records provided by Health Care Services in November 2015 and the additional 617 million medical service records it subsequently provided on June 22, 2016, for a total of more than 663 million claims for medical services. Because the results from the consolidated data did not substantively affect the conclusions we reached originally or the recommendations we made, we did not ask the auditees to resubmit their written responses to our June 2016 draft report.

Recommendations

Legislature

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 insufficiencies in oversight and monitoring of psychotropic medications prescribed to foster children highlighted in this report.

California Department of Social Services

To improve the oversight of psychotropic medications prescribed to foster children, Social Services should collaborate with counties and other relevant stakeholders to develop and implement a reasonable oversight structure that addresses, at a minimum, the monitoring and oversight weaknesses highlighted in this report and that ensures the accuracy and completeness of Social Services data system and the resulting Health and Education Passports.

Counties

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should take the following actions:

* Implement procedures to more closely monitor requests for authorizations for psychotropic medications for foster children that exceed the state guidelines for multiple prescriptions or excessive dosages. 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 the prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up 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, counties should relay their concerns and related recommendations to the courts or the children’s parents.

* Ensure that all foster children are scheduled to receive a follow-up appointment within 30 days of starting a new psychotropic medication.

* Implement a process to ensure that foster children receive any needed mental health, psychosocial, behavioral health, or substance abuse services before and concurrently with receiving psychotropic medications.

* Implement a systemic process for ensuring that court authorizations or parental consents are obtained and documented before foster children receive psychotropic medications.

Agency Comments

The state entities and the counties agreed with our recommendations.

Further, Madera County told us that because it agreed with our report’s recommendations, it did not intend to submit a written response. We look forward to assessing Madera County’s implementation of our recommendations when it provides updates to us at 60 days, 6 months, and one year following the issuance of our report.