BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: SB 319 --------------------------------------------------------------- |AUTHOR: |Beall | |---------------+-----------------------------------------------| |VERSION: |March 26, 2015 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |April 29, 2015 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Reyes Diaz | --------------------------------------------------------------- SUBJECT : Child welfare services: public health nursing SUMMARY : Requires counties to contract with the community child health and disability prevention program established in the county to provide services by a foster care public health nurse (PHN). Requires the foster care PHN to consult and collaborate with a child's social worker, as specified. Expands the duties of a foster care PHN, as specified, related to a foster youth's prescription for psychotropic medications. Existing law: 1.Requires the Department of Social Services (DSS) to establish a program that provides health-related case management services from a foster care PHN to coordinate with child welfare service workers regarding the provision of health care services to children in foster care. 2.Requires foster care PHNs to perform health-related case management duties that include, but are not limited to, documenting that each child receives initial and follow-up screenings, collecting health information and other relevant data, expediting referrals, and facilitating the acquisition of necessary court authorizations for procedures or medications. 3.Limits the scope of services provided by a foster care PHN to services reimbursable under Title XIX of the federal Social Services Act, which provides a 75 percent match for health-related case management but excludes the direct provision of health care services. 4.Requires counties to establish a community child health and disability prevention (CHDP) program for the purpose of SB 319 (Beall) Page 2 of ? providing early and periodic assessments of the health status of children in the county or counties. Requires counties to be reimbursed for the amount required in accordance with the approved community CHDP plan. 5.Requires only a juvenile court judicial officer to 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. This bill: 1.Requires counties to contract with the community CHDP program established in that county to provide services by the foster care PHN. Requires the foster care PHN and the child's social worker to consult and collaborate to ensure that the child's physical, mental, dental, and developmental needs are met. 2.Requires the foster care PHN to liaise with health care professionals and other providers of health-related services. Gives foster care PHNs access to the child's medical, dental, and mental health care information. 3.Expands the duties of foster care PHNs to include: a. Assisting a non-minor dependent in making an informed decision to begin or continue taking psychotropic medications; b. Monitoring and oversight of each foster care child who is administered one or more psychotropic medications, including the review of each request for psychotropic medication filed with a juvenile court judicial officer to ensure lab tests, other screenings, evaluations, and assessments meet reasonable standards of medical practice; c. Ensuring the juvenile court has authorized the psychotropic medication to be administered to the child; d. Ensuring periodic follow-up visits with the prescribing physician, lab work, and other measurements are completed; e. Ensuring the child's health and education passport includes accurate documentation concerning psychotropic medications; SB 319 (Beall) Page 3 of ? f. Ensuring the medication's efficacy in addressing the illness or symptoms for which it was prescribed is documented; and, g. Ensuring any adverse effects of the medication reported by the child's caregiver are promptly addressed, and, if necessary, brought to the attention of the court. FISCAL EFFECT : This bill has not been analyzed by a fiscal committee. COMMENTS : 1.Author's statement. According to the author, nearly one in four children in foster care and 56 percent of children in group homes are receiving psychotropic medications, often without adequate oversight. It is currently unclear if foster youth are being given these potent drugs as part of a therapeutic regimen or whether these medications are being used solely to control their behavior. Without adequate oversight, these powerful drugs can cause irreversible damage, and many youth experience long-term side effects, including diabetes, tics, weight gain, and drowsiness. SB 319 is grounded in the expertise the state has developed working with medical experts in the Quality Improvement Project, the federally mandated process for developing protocols and procedures to govern the use of these medications on foster youth. SB 319 utilizes PHNs, one of the great resources of our child welfare system, to oversee the medical monitoring of psychotropic medications to increase oversight and reduce the number of children prescribed these powerful drugs. 2.National Institute of Mental Health (NIMH) on psychotropics. According to NIMH, psychotropic medications are substances that affect brain chemicals related to mood and behavior. In recent years, research has been conducted to understand the benefits and risks of using psychotropic medications in children. More needs to be learned about the effects of psychotropics, especially in children under six years of age. NIMH states that while researchers are trying to clarify how early treatment affects a growing body, families and doctors should weigh the benefits and risks of medication. Each child has individual needs, and each child needs to be monitored closely while taking medications. Psychiatric medications treat mental disorders. Sometimes called psychotropic or psychotherapeutic medications, they have changed the lives of SB 319 (Beall) Page 4 of ? people with mental disorders for the better, according to NIMH. Many people with mental disorders live fulfilling lives with the help of these medications. Without them, people with mental disorders might suffer serious and disabling symptoms. 3.San Jose Mercury News exposé. In a recent series published in the San Jose Mercury News, "Drugging Our Kids," an August 24, 2014, report by Karen de Sa noted that nearly one of every four adolescents in California's foster system is receiving psychotropic medications, which is 3 1/2 times the rate for all adolescents nationwide. Over the last decade, almost 15 percent of the state's foster youth of all ages were receiving the medications. Long-term effects, particularly in children, have received little study, but for some psychotropics, there is evidence of persistent tics, increased risk of suicide, and brain shrinkage. The report stated that over the past decade, nearly 60 percent of foster youth received antipsychotic medications, which is a class of psychotropic medications with the highest risk. The federal Food and Drug Administration (FDA) authorizes antipsychotics for children only with the most severe mental health conditions, but evidence showed that doctors were prescribing them to foster youth with behavioral problems. In 2013, 12.2 percent of foster children who were prescribed these medications were on up to four or more medications at the same time, up from 10.1 percent in 2004, with even more cases of foster youth being on up to eight or nine different psychotropic medications at a time. In another case highlighted, a nine-year-old was on a medication dose ten times higher the amount recommended for a psychotic adult. Hundreds of children aged five and younger have also been prescribed psychotropic medications even though federal health officials warn about the safety for use by children, and some states actively discourage it. According to the report, over the last decade, Medi-Cal spent more than $313 million on the ten most expensive drugs for foster youth, of which 72 percent was for psychotropic medications and 50 percent was for antipsychotics. According to the report, California was not the only state with this problem: in 2009, one study showed that some states, including Texas, Colorado, and Missouri, prescribed antipsychotics at a higher rate than California. 4.Treatment Authorization Request (TAR) policy. Effective October 1, 2014, the Department of Health Care Services (DHCS) implemented a TAR policy for children up to age 17 in order to review the appropriateness and safety of the requested SB 319 (Beall) Page 5 of ? medication for all juvenile beneficiaries. According to DHCS, a TAR for all antipsychotic medications has existed for children from birth through age 5 since 2006 without known reports of detriment to access. Adjudication of TARs is done on a case-by-case basis based on the clinical information included in the TAR and on the compliance with corresponding regulations. Adjudicators review the information to check if the request is for an FDA-approved indication, reflects the age-appropriate dose, avoids duplication of medication in the same therapeutic class and/or adverse interaction with other medications the beneficiary is taking, and falls within reasonable treatment parameters in respect to frequency and duration of therapy. DHCS states that although it does not provide an official manual of adjudication criteria or a compilation of medical literature for the adjudicating staff, in the case of antipsychotic medications, the Clinical Assurance and Administrative Support staff were provided with an in-service training by DHCS's board certified psychiatric pharmacists prior to implementing the new TAR policy. While some advocates and providers have been critical of DHCS's new TAR policy, claiming long wait times (from weeks to up to a month) for beneficiaries to receive needed medications, DHCS states that, when submitted accurately, TAR adjudication typically takes 24 hours. In addition, DHCS states that there are options to ensure that beneficiaries have access to needed psychotropic medications while a TAR is being adjudicated, such as requesting an emergency 72-hour supply, which can be requested twice for up to six days' worth of medications. 5.California guidelines. DHCS and DSS have the shared responsibility for the oversight of mental health services provided to children and youth involved with county child welfare and probation agencies. In early April 2015, the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care were released specific to those children and youth who are: (a) involved with child welfare services and/or probation services, and (b) are placed in foster care. According to DHCS's Web site, the Guidelines are a statement of best practice for the treatment of children and youth in out-of-home care, who may require psychotropic medications. Depending on the nature, severity, and persistence of their symptoms, medication may be indicated as part of an initial treatment plan (as with ADHD, major SB 319 (Beall) Page 6 of ? depression, psychosis and disabling anxiety); may be considered only after appropriate psychosocial interventions are employed (as with moderate anxiety/depression); or may not be indicated at all (as with learned defiance and predatory aggression). When psychotropic medication is indicated, it should be used in conjunction with psychosocial interventions. The exception is when psychosocial interventions have been effective and are therefore terminated, but continued use of medication is necessary to prevent the recurrence of symptoms. DHCS notes that the Guidelines represent the first comprehensive effort at the state level to address the use of psychotropic medication in children and youth in out-of-home care being served by the child welfare and/or probation system. DHCS expects that the Guidelines, which will be reviewed annually, will evolve over time in response to updated research and the evolution of best practices, and in response to feedback from youth, families, prescribers, other providers, and additional community stakeholders. 6.Double referral. This bill was heard in the Senate Human Services Committee on April 21, 2015, and passed with a vote of 5-0. 7.Related legislation. SB 484 (Beall), would require DSS's director to compile specified information, at least annually, using specified data systems, to identify group homes that inappropriately administer psychotropic medications to children. Requires DSS to consult with specified entities to establish a methodology to identify group homes that have disproportionately high levels of psychotropic medication usage. Requires DSS to perform inspections on identified facilities and to require a plan from those facilities to reduce inappropriate prescribing and treatment regimens, as specified. Requires DSS to monitor the implementation plans of identified facilities and to submit reports to specified entities. SB 484 is scheduled for hearing in the Senate Health Committee on April 29, 2015. SB 238 (Mitchell), would require 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 SB 319 (Beall) Page 7 of ? specified, for children receiving child welfare services. SB 238 requires the Judicial Council to update court forms pertaining to the authorization of psychotropic medication and requires DSS 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 238 is scheduled for hearing in the Senate Judiciary Committee on April 28, 2015. SB 253 (Monning), would require an order of the juvenile court authorizing psychotropic medication to require clear and convincing evidence of specified conditions. SB 253 also prohibits the authorization of psychotropic medications without a second independent medical opinion under specified circumstances; prohibits the authorization of psychotropic medications unless the court is provided documentation that appropriate lab screenings, measurements, or tests have been completed, as specified; and requires the court, no later than 45 days following an authorization for psychotropic medication, to conduct a review to determine specified information regarding the efficacy of the child's treatment plan. SB 253 is scheduled for hearing in the Senate Judiciary Committee on April 28, 2015. 8.Support. Supporters of this bill argue that it strengthens California's Health Care Program for Children in Foster Care by explicitly giving PHNs access to information and the authority needed to monitor and oversee thousands of foster youth who are prescribed psychotropic medications. They also cite that this bill gives non-minor foster youth access to PHNs to help them make informed decisions about beginning or continuing the use of such medications. Supporters state that psychotropic medications have debilitating effects on children and cite that of all foster youth administered the medications 52 percent are given one or more antipsychotics-a class of drugs with few FDA-approved indications for children and adolescents. Supporters further argue that the benefits and risks of such medications must be periodically reevaluated, including follow-up labs and other measures, which this bill provides. 9.Support if Amended. The Youth Law Center, which supports this bill if amended, writes that they have concerns because the bill does not provide the necessary structure and supports to SB 319 (Beall) Page 8 of ? ensure that PHNs are able to carry out the services required in this bill. They would like to see the bill clarify, among other things, how PHNs will receive necessary ongoing training on psychotropic medication issues to competently serve foster youth; how assistance in health care decision making will be provided to transition-age foster youth; what documentation will be reviewed in conducting assessments; and ensuring that PHNs have access to information about the youth's health and general well-being. SEIU California also supports this bill if it is amended to better align with the administrative role of the foster care PHNs and to include additional training needed to further the policy goals of this bill. Specifically, SEIU California would like to see the word "ensure" throughout the bill amended to say "confirm," which they believe will make the distinction about direct services versus administrative roles clearer and will better adhere to the foster care PHN's scope of practice. Additionally, SEIU California would like to see the bill include training for foster care PHNs specific to psychotropic medications. SUPPORT AND OPPOSITION : Support: National Center for Youth Law (sponsor) Advokids Alameda County Foster Youth Alliance All Saints Foster Care Project California Alliance of Child and Family Services California Court Appointed Special Advocates Association California Nurses Association California Youth Connection Children Now Children's Advocacy Institute Children's Law Center of California County Welfare Directors Association of California Dependency Legal Group of San Diego First Focus Campaign for Children Humboldt County Transition Age Youth Collaboration John Burton Foundation Legal Advocates for Children and Youth Peers Envisioning and Engaging in Recovery Services Public Counsel's Children's Rights Project Eight individuals SB 319 (Beall) Page 9 of ? Oppose: None received. -- END --