Stephen Crystal Director, Center for Education and Research

1. Understanding and Improvingthe Quality of Psychotropic Management and Mental Health Services for Foster Youth:Metric-Driven State QI Strategies Stephen Crystal Director, Center for Education and Research On Mental Health Therapeutics/PI, MEDNET and Mental Health CERTs Rutgers U. scrystal@rci.rutgers.edu Presented at ACYF Summit Conference Because Minds Matter: Collaborating to Strengthen Management of Psychotropic Medications for Children and Youth in Foster Care August 27-28, 2012 – Washington, D.C.

2. Data Driven State QI Strategies:Development and Use of Metrics at Multiple Levels • Use of Metrics at State Level • Decision support for data-informed policymaking/planning. • Assessing treatment rates, patterns, trends, guideline consistency, comparison to cross-state and other benchmarks, variation across geographic areas and provider type. • Support communication/collaboration with state stakeholders on identification of needs and improvement strategies. • Turning data into information: maps, graphics, trend analysis to support CQI and a “learning care system” for children. • What outcomes are we achieving? Toward integration of treatment and outcome data as framework for tracking progress.

3. Use of Metrics at Provider Level • Identifying outlier providers and prioritizing provider-level interventions. • Feedback to clinical providers on treatment patterns; comparison of patterns to treatment recommendations, benchmarking vs. other providers, etc. • Elements of effective provider messaging: well organized messaging formats; persistence and followup (preferably with peer clinicians); communication to address pushback. Change often not immediate, but feedback can have significant impact over time. Missouri is an example of well-developed provider messaging procedures. • Some states have used incentives for prescribers with best practices—e.g., TN Best Practice Provider (BPN) network. Referrals, exemption from PA requirements, CME access, etc. can serve as incentives.

4. Use of Metrics at Patient Level • “Review flags” for second opinions and other interventions. (Washington State is significant example of well-developed, mature second opinion programs, as will be discussed in Dr. Hilt’s presentation). • Prior authorizations. • Identifying nonadherence. • Supporting communication among participants in decisionmaking and care for child, including multiple prescribers and other clinicians; casework and agency staff; judges; foster care providers; parents.

5. Data Sources for Metrics • Medicaid pharmacy claims: starting point, but medication use alone is not an island; use best understood in context of other clinical and service information. • Medicaid data on mental health services, diagnoses, co-occurring conditions, monitoring. Challenge: Comparability/integration of FFS, MC. • Data on carved-out or non-Medicaid-funded services. Important to consider limitations on Medicaid data (generated for billing purposes) including potential bias in diagnosis data; best complemented with other sources of patient data. • Integration with CWIS has great potential for improving care mgt and outcomes assessment.

6. Collaboration Between and Within States: Key Tool for Effective QI • MMDLN/CERTs Antipsychotics in Children Project. • Collaborative development of guidelines • Texas’ development of foster care parameters. • T-MAY. • CERTs toolkit for management of aggression. • CHCS collaboration. • MEDNET multistate collaboration. • State Quality Collaboratives.

7. Measuring and Acting on Dimensions of Quality • Antipsychotic use rates. • Too Young: Retrospective and prospective reviews for antipsychotic treatment of very young children. Trend to PAs for youngest children: What age to draw the line? • Too Many • Antipsychotic Polypharmacy • Cross-Class Polypharmacy. • Importance of Concurrent Use Measures (Texas an early exemplar). • Too Much—Dosage Parameters and Reviews. • Managing Metabolic Risk • Monitoring metabolic parameters, prior to and during treatment. • Appropriate use of agents with lower metabolic burden. • Mental health evaluation; psychosocial treatment prior to/concurrent with pharmacological treatment.

8. Measuring and Acting on Dimensions of Quality • Adherence • MPR • Gaps • Diagnosis Consistent with Treatment. • Widespread Use of APs in Children Diagnosed with ADHD, Without More Severe Diagnoses. • Bipolar Diagnosing: Challenges of Consistency and Appropriateness. • Mental Health Services Consistent with Treatment. • Appropriate Evaluation. • Psychosocial Interventions Prior to/Concurrent with Pharmacological Treatment. • Measuring Use of Evidence-Based Interventions: Data and Coding Challenges.

9. Monitoring of Mental Health Evaluation,Psychosocial Treatment, and Followup • Need for monitoring includes multiple aspects of treatment, including access/use of comprehensive psychiatric evaluation and psychosocial treatment, including supply of and access to evidence-based psychosocial interventions. • Particularly for antipsychotic-treated youth, elements of appropriate management of concern may include: • Adequate initial psychiatric evaluation; • Utilization of appropriate psychosocial services prior to or concurrent with pharmacological treatment; • Appropriate followup contacts for treatment management and monitoring, and management of metabolic risks. • MEDNET mental health services metric in development.

10. Collaborative Development of Monitoring and QI Plans • Collaborative planning, engaging multiple state agencies as well as other key stakeholders, can be an effective tool in achieving buy-in, engagement, and coordination across systems. A state QI collaborative can serve as a vehicle both for planning and for implementation of the state plan. • Baseline data on current utilization patterns/quality metrics (optimally utilizing graphic presentations, mapping, etc.) can be a constructive means of engaging stakeholders in planning. • IM-12-03 provides links to numerous resource materials. • For appropriate psychotropic use in management of aggression, the CERTs T-MAY (Treatment of Maladaptive Aggression in Youth) guidelines provide an additional resource (currently incorporated in T-MAY clinician toolkit and in in-press papers in Pediatrics). • Development and refinement of consensus guidelines for foster youth; Texas parameters and beyond.

11. ACP Report/Resource Guide and other materials at: http://chsr.rutgers.edu/MMDLNAPKIDS.html (or google Rutgers MMDLN Resource Guide) Clinician’s Toolkit for Management of Atypical Aggression in Youth http://www.chainonline.org/content.cfm?menu_id=232 Email: scrystal@rci.rutgers.edu

12. “Ask your doctor if taking a pill to solve all your problems is right for you.”