BILL ANALYSIS Ó
SENATE COMMITTEE ON HUMAN SERVICES
Senator McGuire, Chair
2015 - 2016 Regular
Bill No: SB 319
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|Author: |Beall |
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|Version: |March 26, 2015 |Hearing |April 21, 2015 |
| | |Date: | |
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|Urgency: |No |Fiscal: |Yes |
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|Consultant|Sara Rogers |
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Subject: Child welfare services: public health nursing
SUMMARY
This bill expands the duties of the foster care public health
nurse to include monitoring and oversight of the administration
of psychotropic medication to foster children, as specified.
This bill also requires counties to provide child welfare public
health nursing services by contracting with the community child
health and disability prevention program established by the
county.
ABSTRACT
Existing law:
1) Establishes a program of public health nursing in the
child welfare services program that provides health-related
case management services from a foster care public health
nurse to coordinate with child welfare service workers
regarding the provision of health care services to children
in foster care. (WIC 16501.3)
2) Specifies, but does not limit, the health related case
management duties of the foster care public health nurse to
include documenting that each child receives initial and
follow-up screenings, collecting health information and
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other relevant data, expediting referrals, facilitating the
acquisition of necessary court authorizations for
procedures or medications, and others. (WIC 16501.3)
3) Limits the scope of services provided by the foster care
public health nurse to services reimbursable under Title
XIX of the federal Social Services Act, which provides a
75% match for health-related case management, but which
excludes the direct provision of health care services. (WIC
16501.3 and 42 USC Sec. 1396)
4) Requires counties to establish a community child health
and disability prevention program for the purpose of
providing early and periodic assessments of the health
status of children in the county or counties and provides
that counties shall be reimbursed for the amount required
in accordance with the approved community child health and
disability prevention plan. (HSC 124040 and 124065)
5) Provides that only a juvenile court judicial officer
shall have authority to make orders regarding the
administration of psychotropic medications for a minor who
has been adjudged a dependent of the court and removed from
the physical custody of his or her parent. (WIC 395.5)
This bill:
1) Requires counties to provide child welfare public health
nursing services by contracting with the community child
health and disability prevention program established by the
county.
2) Recasts the requirement for collaboration between the
foster care public health nurse and the child's social
worker, requiring both to consult and collaborate to ensure
that the child's physical, mental, dental and developmental
needs are met and to and share information in a timely
manner
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3) Provides that the foster care public health nurse shall
have access to the child's medical, dental and mental
health care information.
4) Assigns the following additional duties to the foster
care public health nurse:
Monitoring and oversight of each child in
foster care who is administered one or more
psychotropic medications, including the review of each
court request pursuant to WIC 395.5, to ensure that
lab tests, and other specified assessments required to
meet reasonable standards of medical practice have
been completed.
Ensuring the juvenile court has authorized the
psychotropic medication to be administered to the
child.
Ensuring periodic followup visits with the
prescribing physician, lab work, and other measurments
are completed.
Ensuring the child's health and education
passport includes accurate documentation concerning
authorized psychotopic medication.
Assessing, monitoring, and documenting the
response of the child to the administration of
psychotropic medication through review and
interpretation of the laboratory tests, reports by the
child and caregiver, and other screenings.
Ensuring that any adverse effects of the
medication reported by the child or child's caregiver
are promptly addressed, and, if necessary, brought to
the attention of the court, the child's social worker,
or both.
1) Authorizes a provider of health care to disclose medical
information to the foster care public health nurse acting
pursuant to scope of the public health nursing program
established in statute.
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2) Authorizes the disclosure of information and records
obtained in the course of providing services under
specified divisions of the Welfare and Institutions Code
pertaining to specified state and county mental health
services and services related to developmental disabilities
to the foster care public health nurse.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
Purpose of the bill:
The author states that nearly one in four foster children and 56
percent of children in group homes are receiving psychotropic
drugs, often without adequate oversight. The author further
states that without adequate oversight, these medications can
cause irreversible damage, and many youth experience long-term
side effects, including diabetes, heart disease, irreversible
tremors, tics, weight gain and drowsiness. According to the
author, this bill utilizes public health nurses to oversee the
medical monitoring of psychotropic drugs to increase oversight
and reduce the number of children prescribed these drugs.
The Health Care Program for Children in Foster Care (HCPCFC)
HCPCFC implements California statute establishing a program of
public health nursing within the child welfare services system.
According to the Department of Health Care Services, the program
provides public health nurse expertise to meet the medical,
dental, mental and developmental needs of children and youth in
foster care. Currently, administrative responsibilities for the
program are managed by the local Child Health and Disability
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Prevention (CHDP) program. Under the program, public health
nurses provide the following services in consultation and
collaboration with social workers and probation officers.
" Medical and health care case planning
" Assistance foster caregivers in obtaining
timely health assessments and dental examinations for
children
" Expediting referrals for medical, dental,
mental health and developmental services
" Coordinating health services for children in
out-of-county and out-of-state placements;
" Providing medical education through the
interpretation of medical reports and training
" Participating in the creation and updating
of the Health and Education Passport
Child Health and Disability Prevention Program (CHDP)
According to the Department of Health Care Services which
oversees CHDP, this preventive program delivers "periodic health
assessments and services to low income children and youth in
California including care coordination to assist families with
medical appointment scheduling, transportation, and access to
diagnostic and treatment services. Health assessments are
provided by enrolled private physicians, local health
departments, community clinics, managed care plans, and some
local school districts. The CHDP program provides complete
health assessments for the early detection and prevention of
disease and disabilities for low-income children and youth. A
health assessment consists of a health history, physical
examination, developmental assessment, nutritional assessment,
dental assessment, vision and hearing tests, a tuberculin test,
laboratory tests, immunizations, health education/anticipatory
guidance, and referral for any needed diagnosis and
treatment."<1>
Psychotropic Medication Use in Children
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<1> http://www.dhcs.ca.gov/services/chdp/Pages/default.aspx
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Concern over the use of psychotropic medications among children
has been well-documented in research journals and the mainstream
media for more than a decade. The category of psychotropic
medication is fairly broad, intending to treat symptoms of
conditions ranging from ADHD to childhood schizophrenia. Some of
the drugs used to treat these conditions are FDA-approved,
including stimulants like Ritalin for ADHD, however only about
31 percent of psychotropic medications have been approved by the
U.S. Food and Drug Administration (FDA) for use in children or
adolescents. It is estimated that more than 75 percent of the
prescriptions written for psychiatric illness in this population
are "off label" in usage, meaning they have not been approved by
the FDA for the prescribed use, though the practice is legal and
common across all manner of pharmaceuticals.<2>
Anti-psychotic medications, used to treat more severe mental
health conditions, include powerful brand-name drugs such as
Haldol, Risperdal, Abilify, Seroquel and Zyprexa. They have very
limited approval by the FDA for pediatric use beyond rare and
severe conduct problems that are resistant to other forms of
treatment, such as Tourette's syndrome, behavioral symptoms
associated with autistic disorder, childhood schizophrenia, and
bipolar disorder.<3> However, the off-label use of these
anti-psychotics among children is high, particularly among
foster children. According to a study published in 2011,
children who took antipsychotic medications were likely to
suffer ill health effects including "cardio metabolic and
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<2>https://www.magellanprovider.com/mhs/mgl/providing_care/clinic
al_guidelines/clin_monographs/psychotropicdrugsinkids.pdf
<3> Harrison, et al, "Antipsychotic Medication Prescribing
Trends in Children and Adolescents," Journal of Pediatric Health
care, March 2012.
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endocrine side-effects" as well as significant weight gain.<4>
The authors recommended that collaboration between child and
adolescent psychiatrists, general practitioners and
pediatricians is essential to "reduce the likelihood of
premature cardiovascular morbidity and mortality."
Compounding the potential for unintended side effects is the use
of combinations of psychotropic medications, which foster youth
are particularly likely to be prescribed, despite limited
evidence of clinical efficacy.<5> Protecting the health and
well-being of children who are taking one or more psychotropic
medication requires extensive and ongoing health and metabolic
screenings to identify potential adverse effects quickly,
however in practice many children many fail to receive ongoing
screenings and adverse effects may go undetected causing
permanent injury or death.
Drugging our Children Media Series
A recent series of stories published in the San Jose Mercury
News<6> and most recently in the Los Angeles Times, highlighted
growing concerns that psychotropic medications have been relied
on by California's child welfare and children's mental health
systems as a means of controlling, instead of treating, youth
who suffer from trauma-related behavioral health challenges. The
series detailed significant challenges in accessing pharmacy
benefits claims data held by the California Department of Health
Care Services (DHCS), eventually overcome through a Public
Records Act request and lengthy negotiations, and demonstrated
that prescribing rates were far higher than had been anticipated
by child welfare system experts.
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<4> DeHert, Dobbelaere, Sheridan, et al "Metabolic and endocrine
adverse effects of second-generation antipsychotics in children
and adolescents: A systematic review of randomized, placebo
controlled trials and guidelines for clinical practice,"
European Psychiatry, April 2011, pgs 144-58.
<5> http://www.ncbi.nlm.nih.gov/pubmed/25022817
<6> Drugging our Kids. Karen De Sa. San Jose Mercury News.
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Court oversight mechanisms
SB 543 (Bowen, Chapter 552, Statutes of 1999) mandated that once
a child has been adjudged a dependent of the state, only the
court may authorize psychotropic medications for the child,
based on a request from a physician that includes the
following:<7>
The reasons for the request;
A description of the child's diagnosis and behavior;
The expected results of the medication;
A description of any side effects of the medication.
Related legislation:
SB 238 (Mitchell, 2015) requires specified certification and
training programs for group home administrators, foster parents,
child welfare social workers, dependency court judges and court
appointed council to include training on psychotropic
medication, trauma, and behavioral health, as specified, for
children receiving child welfare services. This bill requires
the Judicial Council to update court forms pertaining to the
authorization of psychotropic medication, and requires CDSS to
develop an individualized monthly report, a form to share
information and an alert system, used by county child welfare
agencies, regarding the administration of psychotropic
medication for a foster youth.
SB 253 (Monning, 2015) provides that an order of the juvenile
court authorizing psychotropic medication shall require clear
and convincing evidence of specified conditions. This bill also
prohibits the authorization of psychotropic medications without
a second independent medical opinion under specified
circumstances. Furthermore, this bill prohibits the
authorization of psychotropic medications unless the court is
provided documentation that appropriate lab screenings,
measurements, or tests have been completed, as specified. This
bill also requires the court, no later than 45 days following an
authorization for psychotropic medication, to conduct a review
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<7> WIC 369.5
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to determine specified information regarding the efficacy of the
child's treatment plan.
SB 484 (Beall, 2015) requires the CDSS to publish and make
available to interested persons specified information regarding
the administration of psychotropic medication in residential
facilities serving dependent children. Additionally, this bill
requires CDSS to inspect facilities at least once per year, as
specified, if the facility is determined to have a higher than
average rate of psychotropic medication authorization rate for
children residing in the facility and to monitor corrective
action plans, as specified.
POSITIONS
Support:
National Center for Youth Law (Sponsor)
Advokids
Alameda County Board of Supervisors
Alameda County Foster Youth Alliance
California Alliance
California Court Appointed Special Advocates (CASA)
California Nurses Association
California Youth Connection
Children's Advocacy Institute
Children Now
Children's Partnership
County Welfare Directors Association of California
Dependency Legal Group of San Diego
First Focus Campaign for Children
Humboldt County Transition Age You Collaboration
John Burton Foundation for Children Without Homes
Legal Advocates for Children and Youth
LIUNA Locals 777 & 792
Peers Envisioning and Engaging in Recovery Services
Public Counsel's Children's Rights Project
Youth Law Center
9 individuals
Oppose:
None.
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