Report 2015-131 Recommendation 18 Responses

Report 2015-131: California's Foster Care System: The State and Counties Have Failed to Adequately Oversee the Prescription of Psychotropic Medications to Children in Foster Care (Release Date: August 2016)

Recommendation #18 To: Sonoma County

To better ensure that foster children only receive psychotropic medications that are appropriate and medically necessary, counties should implement procedures to more closely monitor requests for authorizations for foster children's psychotropic medications that exceed the state guidelines for multiple prescriptions, specific age groups, or dosage amounts. 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 prescribers about the medical necessity of the prescriptions. Counties should also document their follow-up monitoring 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, the counties should relay their concerns and related recommendations to the courts or parents.

1-Year Agency Response

Sonoma County Department of Health Services, Behavioral Health Division: Mental Health Services (DHS MH) uses the Department of Social Services Foster Care Improvement Project, Guidelines for Use of Psychotropic Medication with Children and Youth in Foster Care. In Spring of 2017, Sonoma County's Family, Youth and Children's (FY&C) Division instituted a secondary review process of all psychotropic medications prescribed to foster children by a reviewing psychiatrist. When prescribed medications, client ages, or dosage amounts exceed guidelines, the reviewing psychiatrist consults with the prescribing physician and documents their rationale for exceeding the guidelines. If the psychiatrist does not consider the prescribing physician's rationale for exceeding the guidelines to be adequate or justified, she will document that opinion for Human Services Department (HSD) and the information is passed on to the court or parent.

FY&C developed policies and procedures to ensure that the reviewing psychiatrists' concerns are documented. In the early summer of 2017, 2 Public Health Nurses filled vacancies in HCPCFC program and working directly with the reviewing psychiatrist to monitor clients taking psychotropic medications. The nurses and psychiatrist have begun a monitoring committee that oversees and reviews all foster children taking psychotropic medications. The Psychotropic Medication Oversight Committee (PMOC) meets regularly and reviews cases—the first goal is to address and monitor complex cases and follow up with prescribing physicians, social workers, and caregivers as needed. As a note, FY&C's percentage of foster youth prescribed psychotropic medications, according to Medi-Cal claims data for the 4th Quarter of 2016, was 9.65%.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

6-Month Agency Response

County of Sonoma Department of Health Services, Behavioral Health Division: Mental Health Services (DHS MH) is using the Department of Social Services Foster Care Improvement Project, California Guidelines for Use of Psychotropic Medication with Children and Youth in Foster Care. When numbers of prescribed medications, specific age groups, or dosage amounts exceed the guidelines, the reviewing psychiatrist consults with the prescribing physician and documents the physician's rationale for exceeding the guidelines. If the reviewing psychiatrist does not consider the prescribing physician's rationale for exceeding the guidelines to be adequate or justified, she will document that opinion for the Human Services Department and the information will be passed on to the court or parent.

County of Sonoma Human Services Department, Family, Youth & Children's (FY&C) Division is in the process of developing policies and procedures to ensure that the reviewing psychiatrist's concerns and opinions are documented in each youth's case file. In addition, FY&C has recently received approval from the Board of Supervisors to add 2 Public Health Nurses and a psychiatric nurse effective in first quarter 2017. It is expected, at this time, that these nurses will likely be hired in Summer 2017. We anticipate that psychiatric nurse will be assigned the task of monitoring psychotropic medication prescriptions including, but not limited to, follow-up with physicians to monitor prescriptions including those that exceed the state guidelines and to ensure 30-day follow-up with prescribing physicians when new medications are being taken by a foster youth. As a note, Sonoma County's percentage of foster youth prescribed psychotropic medications, for the 3rd Quarter of 2016, was 12.4%, a one year decrease of 18.9% and a five year decrease of 48.6%.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

County of Sonoma Department of Health Services, Behavioral Health Division: Mental Health Services (DHS MH) is using the Department of Social Services Foster Care Improvement Project, California Guidelines for Use of Psychotropic Medication with Children and Youth in Foster Care. When numbers of prescribed medications, specific age groups, or dosage amounts exceed the guidelines, the reviewing psychiatrist consults with the prescribing physician and documents the physician's rationale for exceeding the guidelines. If the reviewing psychiatrist does not consider the prescribing physician's rationale for exceeding the guidelines to be adequate or justified, she will document that opinion for the Human Services Department and the information will be passed on to the court or parent.

County of Sonoma Human Services Department, Family, Youth & Children's (FY&C) Division is in the process of developing policies and procedures to ensure that the reviewing psychiatrist's concerns and opinions are documented in each youth's case file. In addition, FY&C has recently received approval from the Board of Supervisors to add 3 Public Health Nurses and a psychiatric nurse effective in first quarter 2017. We anticipate that psychiatric nurse will be assigned the task of monitoring psychotropic medication prescriptions including, but not limited to, follow-up with physicians to monitor prescriptions including those that exceed the state guidelines and to ensure 30-day follow-up with prescribing physicians when new medications are being taken by a foster youth.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2015-131

Agency responses received are posted verbatim.