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.
          
                                      -- END --