Selected States Have Practices to Support the Prescribing Process and Educate Stakeholders on the Appropriate Use of Psychotropic Medications

		Selected States Have Practices to Support Appropriate Treatment Decisions and Monitor the Child

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. They must then submit  results to mental health specialists for review. 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

State officials in all seven of the selected states said they work to educate  relevant stakeholders on mental health conditions and treatments. 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. While Some Selected States Reduced the Use of Psychotropic Medications, They All Focused on Other Measures to Gauge the Results of Their Efforts

		Some Selected States Reduced Psychotropic Medication Use, though Mental Health and Foster Care Stakeholders Said Reducing Medications May Not Be Appropriate for Every Child

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. 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. 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. 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. 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. HHS Has Supported Some State Collaboration on Medication Oversight, and Selected States Said More Federal Assistance Would Help

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. Officials we spoke with said it helped them develop prescribing guidelines  and expand reporting on psychotropic medications. 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. Recommendation for Executive Action

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. Finally, HHS provided technical comments, which we  incorporated as appropriate. Appendix I: Objectives, Scope, and Methodology

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. Foster Children: HHS Guidance Could Help States Improve Oversight of  Psychotropic Prescriptions.
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

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.