BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 319
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|AUTHOR: |Beall |
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|VERSION: |March 26, 2015 |
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|HEARING DATE: |April 29, 2015 | | |
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|CONSULTANT: |Reyes Diaz |
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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
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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;
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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
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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
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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
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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
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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
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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
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Oppose: None received.
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