Michael W. Naylor, M.D. University of Illinois at Chicago

1. Psychiatric Consultation in a Psychotropic Medication Oversight Program for Foster Children: The Illinois Model Michael W. Naylor, M.D. University of Illinois at Chicago Director, Clinical Services in Psychopharmacology

3. Background • Historical context • DCFS challenged by federal courts, DOJ and ACLU • inadequate casework • chaotic and dangerous placements • substandard care • Illinois violating constitutional rights of children

4. Background • Historical context • ChicagoTribune 1995 editorial series: • DCFS called “the worst child welfare system in America…” and “a cruel, indifferent bureaucracy that harms kids.” • “system of shame”

5. Background • Historical context • Federal court-approved consent decree (B.H. v Suter, 1991) • DCFS and ACLU agree to collaborate on system reform plan

6. State Context • Psychotropic medication consent • DCFS Rule 325 • Clinicians wishing to start a foster child on a psychotropic medication must obtain consent from the DCFS Guardian

7. State Context • DCFS Psychotropic Medication Consent Program • Two components: • Centralized Psychotropic Medication Consent Line • Office of the DCFS Guardian • Clinical Services in Psychopharmacology • University of Illinois at Chicago

8. State Context • Centralized Psychotropic Medication Consent Line • Office of the DCFS Guardian • legal guardian for children committed to the Department • responsible for providing consent for medical, surgical, and psychiatric treatment

9. State Context • Clinical Services in Psychopharmacology • provide independent review for all psychotropic medication requests • monitor utilization of psychotropic medications • provide consultation on particularly complicated cases

10. State Context • Clinical Services in Psychopharmacology • notify the Guardian where provider patterns warrant review • conduct training for DCFS, foster parents and childcare providers on psychotropic medications • disseminate information regarding new pharmaceutical developments and alerts

11. Consent Process

12. Psychotropic MedicationRequest Form • Demographic information • name • DCFS ID Number • date of birth • sex • race • weight and height • placement • physician’s name and specialty

13. Psychotropic MedicationRequest Form • Clinical information • diagnosis • current medications and dosage • symptoms/rationale • requested medication • dosage and frequency

15. Consultation • Three main providers of consultation for clinicians treating foster children: • Clinical Services in Psychopharmacology • DocAssist • Consult for Kids

17. Clinical Services in Psychopharmacology • Consultation • consent process • independent review of the appropriateness of the psychotropic medication consent request • recommend action to DCFS • approve • deny • modify

18. Clinical Services in Psychopharmacology • Consultation • oversight • formal • high risk prescribers • emergency medication utilization • informal • feedback from Administrative Case Reviews • concerns expressed by caseworkers, regional nurses, guardian ad litem, Court Appointed Special Advocates, judges, Office of the DCFS Guardian

19. Clinical Services in Psychopharmacology • Consultation • clinical • clinical concerns that arise in the course of the independent medication review • MD:MD • review of consent history • chart review • face-to-face

20. Clinical Services in Psychopharmacology • Consultation • prior authorization • provided consultation to HFS vis-à-vis prior authorization for antipsychotic medications and stimulants for children • DCFS consent for a medication serves as prior authorization for foster children

21. Clinical Services in Psychopharmacology • Consultation • systemic • consult on development of policies, best practice guidelines re: mental health care for foster children • co-write legislation

22. Clinical Services in Psychopharmacology • Consultation • monitoring/QI • medication utilization patterns • rate of copharmacy with two or more antipsychotics • rate of polypharmacy by age group • timeliness of consent process • compliance with Rule 325

23. Impact of Consultation

24. Consultation • Illinois DocAssist • established through the joint efforts of the Department of Healthcare and Family Services, the Department of Human Services – Mental Health, and the University of Illinois at Chicago • funding support by the Illinois Children’s Mental Health Partnership

25. Consultation • Illinois DocAssist • clinical • quality of treatment for Medicaid funded children with mental illness in the primary care setting • client – Medicaid funded providers with a focus on primary care • purpose – improve the identification, diagnosis and treatment of children and youth with mental health issues through consultation, education and referral services

26. Consultation • Consult for Kids Program • established by DCFS to provide primary care clinicians participating in HealthWorks with resources to evaluate foster children in their care for mental health and behavioral concerns

27. Consultation • Consult for Kids Program • clinical • address questions and concerns about a foster child’s emotional, interpersonal, behavioral or cognitive problems • client – primary care providers • purpose – help primary care providers navigate a challenging child through the child welfare system

28. Consultation • Challenges to effective consultation • “silo-ization” • duplication of services • lack of coordination • informing stakeholders of the services • meeting demand for services

29. Consultation “The Curse of Unwelcome Oversight and Unrequested Consultation.”