BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 484
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|AUTHOR: |Beall |
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|VERSION: |April 22, 2015 |
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|HEARING DATE: |April 29, 2015 | | |
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|CONSULTANT: |Reyes Diaz |
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SUBJECT : Juveniles
SUMMARY : Requires Department of Social Services' (DSS) director to
compile specified information 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.
Existing law:
1.Establishes the Community Care Facilities Act, which provides
for the licensure and regulation of community care facilities,
including group homes, by DSS, and requires that licensed
facilities be subject to unannounced inspections under
specified circumstances.
2.Requires DSS to establish a rate classification level (RCL)
structure for group homes with a corresponding rate structure
according to the level of care and services that will be
provided, as specified.
3.Permits a group home to be classified as an RCL 13 or 14 if
the program only accepts children with special treatment needs
and meets other requirements. Additionally, requires the
Department of Health Care Services (DHCS) to annually certify
group homes seeking classification as RCL 13 or 14, and
permits such facilities to accept minor dependents who are
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seriously or emotionally disturbed if certain conditions are
met.
4.Requires DSS to publish and make available to interested
persons a list or lists covering all licensed community care
facilities, other than foster family homes and certified
family homes, to include specified information regarding group
homes, transitional housing placement providers, community
treatment facilities, or runaway and homeless youth shelters,
including complaints, citations, fines, and the number of law
enforcement contacts made by group homes.
This bill:
1.Requires the director of DSS to compile, at least annually,
the information below concerning group homes to identify those
in which psychotropic medications may be inappropriately
administered to children. Specifically, the information is
required to include the number of children who:
a. were administered psychotropic medications;
b. for ages six to 11, were administered
psychotropic medications;
c. for ages 12 to 17, were administered
psychotropic medications;
d. were preauthorized by the juvenile court to be
administered psychotropic medications;
e. were administered psychotropic medications on
an emergency basis;
f. were administered antipsychotic, mood
stabilizing, or antidepressant medications;
g. received two or more drugs from the same
class, including, but not limited to, antidepressants,
antipsychotics, and antianxiety medications;
h. received two or more psychotropic medications
concurrently, and whether those children received two,
three, four, or more than four psychotropic
medications concurrently;
i. received one or more medications for more than
90 days;
j. received psychosocial services while in a
group home placement while they received a
psychotropic medication;
aa. received a dosage of a psychotropic medication
at a dosage above the maximum dosage approved by the
federal Food and Drug Administration (FDA);
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bb. received metabolic monitoring in accordance
with professional standards of care while they
received a psychotropic medication; and,
cc. prescribed antipsychotic medications for a
use not approved by the FDA.
2.Requires the data required in 1) above concerning psychotropic
medications, mental health services, and placement to be drawn
from existing data systems, including, but not limited to, the
Medicaid Management Information System's medical and pharmacy
claims data and the Child Welfare Services/Case Management
System through the data sharing agreement between DHCS and
DSS.
3.Requires DSS, based on the information required in 1) above,
to consult with the foster care ombudsman and stakeholder
quality improvement groups to establish a methodology to
identify group homes that have disproportionately high levels
of psychotropic medication usage that warrants additional
review of the facility.
4.Requires DHCS to post, at least annually, on its Internet Web
site a summary progress report with data of the information
required in #1 above that excludes personally identifiable
information.
5.Requires DSS to visit facilities with high levels of
psychotropic medication usage at least once a year to review
the facilities' plans of operation, policies, procedures,
practices, child-to-staff ratios, staff qualifications and
training, implementation of children's needs and services
plans, and other factors that DSS determines contributes to
the high utilization of dangerous psychotropic medication
regimens and low utilization of monitoring and psychosocial
services. Requires DSS to seek input for these visits from
stakeholders, including, but not limited to, the foster care
ombudsman and foster care mental health ombudsman, foster
youth and advocates, county welfare departments, and county
mental health departments.
6.Requires DSS to include in each visit confidential discussions
with current and former foster youth placed in a particular
facility and confidential discussions with physicians who
prescribe the medications to those individuals. Requires DHCS
and DSS to use existing data systems that identify
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prescribers' names, addresses, and contact information in
order to facilitate interviews with physicians.
7.Requires a facility identified as having high utilization of
psychotropic medications and inadequate alternative, less
invasive psychosocial, crisis management, and other services
to submit to DSS a plan to address steps that the facility is
required to take to reduce inappropriate prescribing and
treatment regimens within 60 days of DSS's visit to the
facility. Requires the facility's plan to:
a. include an improved crisis management plan,
including de-escalation techniques and procedures in
which facility staff will be trained;
b. include an overall behavioral management plan
that is a trauma-informed plan;
c. identify a quantifiable goal to decrease the
use of antipsychotic medications for behavioral
control, to decrease polypharmacy, and to decrease the
use of pro re nata (or "as needed") medications; and,
d. identify a quantifiable goal of appropriate
metabolic monitoring as set forth in state prescribing
guidelines and psychosocial, physical, mental,
behavioral, and nutritional services for children
previously or currently prescribed psychotropic
medications while placed in that facility.
8. Requires DSS to monitor a facility's implementation of the
plan to determine whether:
a. the facility has reduced the rate at which
residents are administered pro re nata, multiple, and
off-label psychotropic medications, and, if so, the
percentage decrease in the administration of those
medications;
b. alternative, less invasive treatments are
being provided, and to what extent, to residents, and,
if so, the percentage increase in the provision of
those services; and,
c. appropriate metabolic monitoring is being
conducted, and to what extent, and, if so, the
percentage increase in the provision of appropriate
monitoring.
9.Requires DSS's Community Care Licensing Division, following
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DSS's inspection of a facility, to provide a report to DSS's
Children and Family Services Division and to any other public
agency that has certified the facility's program or any
component of the facility's program, including, but not
limited to, DHCS.
10.Provides DSS the authority to implement the provisions in
this bill through all-county letters or similar instructions
from the department's director until emergency regulations are
adopted. Requires DSS to adopt final regulations on or before
January 1, 2018.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1.Author's statement. According to the author, more than half
of the children in our state's group homes for foster children
are medicated with powerful psychotropic medications. Refusal
to take the drugs can be, and is, punished by expulsion from
the facility. The most problematic of the drugs are
antipsychotic medications designed to suppress the most
uncontrollable behavior of schizophrenics. As a witness at
last year's Congressional hearing said, "These drugs are too
often misused as 'chemical straitjackets.' This is a haphazard
attempt to simply control and suppress undesirable behavior,
rather than treat, nurture, and develop these treasured young
people."
The more-than-1,000 group homes throughout California vary
widely in size, staffing, and quality of care. Some are
accredited, but many are not. In 2011, the state's foster care
ombudsman rated more than a third of the group homes
unsatisfactory. Causes of overmedication include: poorly
trained staff, sedated children allow for reduced staffing
ratios, lack of therapeutic intervention alternatives,
energetic promotion by drug manufacturers, and lack of state
oversight.
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, but more needs to be learned about the effects of
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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
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. A 2014 series published in the
San Jose Mercury News, entitled "Drugging Our Kids," reported
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
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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.DHCS Treatment Authorization Request (TAR) policy for Medi-Cal
beneficiaries. Effective October 1, 2014, the Department of
Health Care Services (DHCS) extended its TAR policy for
children ages six to 17 in order to review the appropriateness
and safety of the requested medication for all juvenile
beneficiaries. TARs are required for certain medications and
must be submitted by prescribing health care professionals to
DHCS for approval before a medication can be dispensed to a
beneficiary. A TAR requirement for all antipsychotic
medications has existed for children from birth through age
five 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.
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
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are a statement of best practice for the treatment of children
and youth in out-of-home care, who may require psychotropic
medications, which 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 out with a
vote of 5-0.
7.Related legislation. SB 319 (Beall), 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. SB 319 is scheduled
for hearing in the Senate Health Committee on April 29, 2015.
SB 238 (Mitchell), 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. 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
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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), requires 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, which include consumer
advocates and legal aid organizations, argue that it addresses
a longstanding crisis in many of the group homes in which
California's foster youth are living: the medicating of
children and youth, with powerful antipsychotic medications,
to sedate and control behaviors that are natural responses to
grief, suffering, and trauma. Supporters state that, on
average, 56 percent of the children in group homes are given
one or more psychotropic medication, often in lieu of
counseling and appropriate care. They further state that, in
contrast, approximately five percent of children placed with
relatives and 12 percent of children in foster family homes
are administered psychotropic medications. Supporters note
that such medications can cause crippling sedation, morbid
obesity, memory loss, diabetes, heart disease, irreversible
tremors, and other long-term disabilities, and, in extreme
cases, death.
9.Support if Amended. The Children's Law Center of California,
which supports this bill if amended, writes that some group
homes specifically serve youth with the highest level of
mental health needs where medications may indeed be an
important part of a comprehensive treatment plan. They would
like to see an amendment to take into consideration group
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homes that treat this population so that such facilities are
not unnecessarily subjected to corrective action plans.
SUPPORT AND OPPOSITION :
Support: National Center for Youth Law (sponsor)
Advokids
Alameda County Foster Youth Alliance
California Chapter of the National Association of
Social Workers
California CASA Association
California Youth Connection
Children Now
Children's Advocacy Institute
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
Legal Services for Prisoners with Children
Peers Envisioning and Engaging in Recovery Services
Public Counsel's Children's Rights Project
The Youth Law Center
Five individuals
Oppose: None received.
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