BILL ANALYSIS Ó
SENATE COMMITTEE ON HUMAN SERVICES
Senator McGuire, Chair
2015 - 2016 Regular
Bill No: SB 1466
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|Author: |Mitchell |
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|Version: |March 28, 2016 |Hearing |April 12, 2016 |
| | |Date: | |
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|Urgency: |No |Fiscal: |Yes |
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|Consultant|Mareva Brown |
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Subject: Early and Periodic Screening, Diagnosis, and Treatment
Program: trauma screening
SUMMARY
This bill requires screening services under the children's
Medi-Cal Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) program to include screening for trauma. It also
establishes that child abuse and neglect or removal of the child
from the parent or legal guardian by a child welfare agency as
prima facie evidence of trauma for purposes of conducting a
screening under the EPSDT Program.
ABSTRACT
Existing law:
1) Under federal statute, vests responsibility for caring
for a child who has been removed from home and placed in
foster care with the state and any public agency which is
administering the foster care plan with the state. (42
U.S.C. 672 (a)(2)(B))
2) Establishes a state and local system of child welfare
services, including foster care, for children who have been
removed from their parents for the protection and safety of
the public or the minor. (WIC 202 et seq.)
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3) Under state statute, places the care of a child who has
been removed from his or her parents or guardian under the
jurisdiction of the juvenile court and defines abuse and
neglect criteria for such removal. (WIC 300 et seq)
4) Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care
services. (WIC 14000, et seq.)
5) Establishes that children in foster care have met
residency requirements needed for eligibility under the
Medi-Cal program. (WIC 14007.4)
6) Establishes a schedule of benefits under the Medi-Cal
program, including EPSDT for any individual less than 21
years of age, consistent with federal Medicaid
requirements. Defines, through regulation, "screening
services" for purposes of EPSDT to mean:
a. An initial, periodic, or additional health
assessment of a Medi-Cal eligible individual under 21
years of age provided in accordance with the
requirements of the Child Health and Disability
Prevention (CHDP) program;
b. A health assessment, examination, or
evaluation of a Medi-Cal eligible individual under 21
years of age by a licensed health care professional
acting within his or her scope of practice, at
intervals other than the CHDP intervals, to determine
the existence of physical or mental illnesses or
conditions; or
c. Any other encounter with a licensed health
care professional that results in the determination of
the existence of a suspected illness or condition or a
change or complication in a condition for a Medi-Cal
eligible person under 21 years of age.
7) Requires mental health plans to provide specialty mental
health services to eligible Medi-Cal beneficiaries.
Includes EPSDT within the scope of specialty mental health
services for eligible Medi-Cal beneficiaries under the age
of 21. (WIC 14684)
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8) Requires DHCS, in collaboration with the California
Health and Human Services Agency, and in consultation with
the Mental Health Services Oversight and Accountability
Commission, to create a plan for a performance outcome
system for EPSDT mental health services. (WIC 14707.5)
This bill:
1) Requires that screening services provided under the
EPSDT Program, as defined, must include screening for
trauma.
2) Establishes that child abuse and neglect or removal of
the child from the parent or legal guardian by a child
welfare agency shall be prima facie evidence of trauma for
purposes of conducting a screening consistent with this
section under the EPSDT Program.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
Purpose of the bill:
According to the author, this bill clarifies that foster
children are eligible for screening services under the federal
Early and Periodic Screening Diagnosis and Treatment (EPSDT)
program, which is a benefit of the Medi-Cal program. "Situations
have arisen where foster children have experienced significant
delays in receiving mental health treatment while the Mental
Health Plan and the Medi-Cal managed care plan decide which
system should be responsible for treatment," the author states.
State law and regulations do not provide a clear definition of
services and therefore, the author states, it is not always
clear which agency needs to provide what mental health services.
This bill adds a required screening for trauma as part of the
health and developmental history portion of the existing EPSDT
screening. The bill additionally establishes that a child who is
in the custody of the child welfare system has experienced
trauma, under the EPSDT screening criteria.
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Child Welfare System
California's county-based child welfare system protects children
at risk of child abuse and neglect or exploitation by providing
intensive services to families to allow children to remain in
their homes safely, or by arranging placement of the child in
the safest and least restrictive environment possible. As of
October 1, 2015, approximately 62,600 children were in the
custody of the child welfare system in California.<1>
Outcomes of Children in Foster Care
Various national studies have documented the poor outcomes of
children and youth who are removed from their homes into the
child welfare system. Children have increased rates of chronic
health problems, developmental delays and disabilities, mental
health needs, and substance abuse problems, according to a 2013
report by the Children's Aid Society and the Community Service
Society.<2> Many youth have experienced traumatic events that
lead to symptoms such as depression, behavior problems,
hypersensitivity, and emotional difficulties. Being removed from
one's home is, in itself, a traumatic event, leading to the loss
of family, friends, and neighbors.
Twenty-five percent of youth who age-out of care experience
Post-Traumatic Stress Disorder - double the rate of U.S. war
veterans, according to the report. Nationally, the birth rate
for teen girls in foster care is more than double that for those
outside the foster care system. Additionally, the education of
youth in foster care is more likely to be disrupted because they
frequently move from school to school. Former foster youth are
less likely to graduate high school, attend a community or
four-year college, or to receive a postsecondary degree. In
addition, they are less likely to obtain a GED than their peers
who dropped out of high school and more likely to experience
suspension or expulsion, the report said.
Mental health treatment
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<1>http://cssr.berkeley.edu/ucb_childwelfare
<2>
http://www.childrensaidsociety.org/files/upload-docs/report_final
_April_2.pdf
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California's county-operated mental health system provides a
range of "specialty" mental health services and supports to
Medi-Cal beneficiaries and other vulnerable individuals whose
mental health needs are serious, including foster youth. Youth
with mild to moderate mental health needs, which are not covered
by the county mental health plans, are intended to be treated by
Medi-Cal managed care plans. Foster children and other children
enrolled in Medi-Cal are eligible for EPSDT, which provides for
periodic screenings and, if health conditions are identified,
treatment.
Under EPSDT, screening services must at a minimum include a
comprehensive health and developmental history, including mental
health development, a comprehensive unclothed physical exam,
appropriate immunizations, laboratory tests and health
education. EPSDT's continuum of mental health services include
assessment, crisis intervention, day treatment, intensive care
coordination, medication management, targeted case management
and therapeutic behavioral services. Treatment must be medically
necessary to correct or ameliorate any identified conditions. To
satisfy the "periodic" requirement of EPSDT, states have adopted
guidelines for screening frequency based on the child's age and
nature of the screening.<3>
Trauma
A 2013 letter from the US Department of Health and Human
Services encouraged state social services and Medicaid directors
to use trauma-focused screening, assessments and evidence-based
practices. "Complex trauma is a common yet serious concern for
children, especially those referred to child welfare services.
Rates of trauma exposure are approximately 90 percent among
children in foster care," said the letter, which was signed by
the directors of three key federal agencies.<4> The letter drew
a link between high rates of untreated, complex trauma and high
prescribing rates of psychotropic medications for foster youth.
"These high rates of trauma have far-reaching consequences. The
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<3>
http://files.medi-cal.ca.gov/pubsdoco/publications/Masters-Other/
CHDP/forms/periodhealth_c01.pdf
<4>
https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13
-07-11.pdf
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term "complex trauma" describes children's exposure to multiple
or prolonged traumatic events, which are often invasive and
interpersonal in nature. Complex trauma exposure involves the
simultaneous or sequential occurrence of child maltreatment,
including psychological maltreatment, neglect, exposure to
violence and physical and sexual abuse.
California class action cases for foster youth
Settlements in two lawsuits involving the mental health care of
foster children have drawn additional attention and resources to
the issue. In 1998, Emily Q. v Bonta, filed on behalf of seven
children, alleged the state denied Medicaid eligible children
with the full scope of mental health services to which they were
entitled. The lawsuit identified the lack of Therapeutic
Behavioral Services, which involves having a trained,
experienced staff person available on a one-on-one basis to work
with a troubled child in his or her home and community. Emily Q.
had been in institutional placements since she entered foster
care at age 6, was never placed in a home-like setting, and at
the time of the lawsuit was age 18 and living in a state mental
hospital. A settlement order required the state to provide
Therapeutic Behavioral Services as a short-term service intended
to prevent a young person from having to go into a more
restrictive placement, or to support the transition of a young
person from an institutional placement back to home or
community.
In 2002, plaintiffs filed a class action lawsuit, Katie A. vs
Bonta, alleging violations of federal Medicaid laws, and the
American with Disabilities Act. The suit sought to improve the
provision of mental health and supportive services for children
and youth in, or at imminent risk of placement in, foster care
in California. Katie A. entered foster care at age 4, received a
mental health assessment at age 5, and, by age 14, had been
assigned 37 foster care placements, 19 psychiatric institution
placements and 7 stays in children's shelters.
The Katie A. lawsuit alleged a failure to properly assess her
mental health needs, a failure to provide adequate mental health
treatment and an overuse of congregate and shelter care. A
subsequent settlement requires children in foster care who are
being considered for high-level group care, inpatient
psychiatric care or other intensive treatments, as specified, to
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be eligible for EPSDT services. The state subsequently developed
a series of intensive mental health services for such children,
a manual for care coordination between state and local mental
health and child welfare providers, and a program of therapeutic
foster care.
Psychotropic medications and foster youth
Psychotropic medications include drugs prescribed to manage
psychiatric and mental health disorders such as bipolar
disorder, schizophrenia, depression, obsessive-compulsive
disorder, attention deficit hyperactivity disorder (ADHD) and
others. These medications include antipsychotics such as
Seroquel, antidepressants like Prozac, mood stabilizers
including Lithium, and stimulants like Ritalin. Researchers and
administrators at the federal Health and Human Services Agency
have expressed significant concern over the use of psychotropic
medications for children, because effects can include aggressive
behavior, hostility, seizures, significant weight gain, and
because the long-term effects for children using these drugs are
largely unknown. One class of psychotropic medications,
antipsychotics, raises particular concern: These are potent
drugs with a high potential for side-effects, and there is
little known about their impact on children's neurological
systems.
The use of psychotropic medication among children in foster care
is of particular concern. Research has repeatedly indicated that
these children face heightened levels of medication use, and
that those foster youth placed in group home settings are
particularly vulnerable to over-prescription and misuse of
psychotropic medications. Data provided by DHCS indicates that,
in fiscal year 2013-14, almost 15 percent of all foster youth in
California aged 0 to 20 were prescribed at least one
psychotropic medication. Nearly one in four foster youth between
age 12 and 20 was prescribed at least one psychotropic
medication and, among youth in group homes, the rate rose to
half of all youth.
In late 2011, the U.S. Department of Health and Human Services
issued a letter to states encouraging them to appropriately
prescribe and monitor psychotropic medication among children
placed in out-of-home care. As a result, DHCS and DSS developed
the Quality Improvement Project to strengthen the state's
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Medicaid and child welfare services system by, among other
things, improving safe and appropriate prescribing and
monitoring of psychotropic drugs. In 2015, DHCS and CDSS
released state guidelines for the use of psychotropic medication
with children and youth in foster care.
In two 2015 hearings, the Senate Human Services and Health
committees heard testimony that breakdowns in the provision of
effective trauma-informed psychosocial services has led to
system-wide failures in treating children. In many of these
cases, psychotropic medication is seen as the only available
treatment option. Widespread reports from foster youth,
caregivers, children's attorney's and others report a lack of or
delayed delivery of mental health services that leaves many
children without adequate treatment and at risk of failing
placements.
Related legislation:
SB 1291 (Beall, 2016) requires each county to develop a foster
care mental health plan and define its scope of services for
annual submission to DHCS. It additionally requires an External
Quality Review Organization (EQRO) to review each county's plan
and report to the state.
SB 1220 (McGuire, 2016) requires a case plan for a child being
assessed as needing behavioral health services to include a
treatment plan, as defined.
SB 238 (Mitchell, Chapter 534, Statutes of 2015) required
additional training on psychotropic medications for foster care
providers, and required the California Department of Social
Services (CDSS) to provide a monthly report to each county
placing agency with information about each child for whom one or
more psychotropic medications have been paid for under Medi-Cal.
SB 1009 (Committee on Budget and Fiscal Review, Chapter 34,
Statutes of 2012), required DHCS, in collaboration with the
California Health and Human Services Agency, and in consultation
with the Mental Health Services Oversight and Accountability
Commission and a stakeholder advisory committee to develop a
plan for a performance outcomes system for EPSDT specialty
mental health services provided to eligible Medi-Cal
beneficiaries under the age of 21. The purpose of the system is
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to improve beneficiary outcomes and inform decisions regarding
the purchase of services.
COMMENTS
The 2015 Senate oversight hearings and media coverage on
psychotropic medication overuse among foster youth prompted a
series of bills last year. This bill and several others
introduced this year continue to address issues that were
brought to light. While this bill would clarify that foster
youth are entitled to trauma screenings under EPSDT, it may not
resolve the issue of responsibility for treatment when a county
mental health plan identifies a child's needs as being less
acute and therefore in the scope of the primary care system, and
the primary care system identifies the same child's needs as
serious enough to warrant care in the county's speciality mental
health system. The amendments that were proposed in Health
committee attempt to resolve that issue.
Due to the short time line between committee hearings, the
author has agreed to take amendments proposed by Health
Committee in this hearing. They include:
14132.19.(a) (1) Consistent with federal law, screening Screening
services provided under the Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT) Program benefit pursuant to
subdivision (v) of Section 14132 shall include screening for
trauma at all screenings .
(2) A child found to have experienced trauma through the
screening process shall be referred to the county mental health
plan for an assessment for specialty mental health services.
(b) Child abuse and neglect or removal of the child from the
parent or legal guardian by a child welfare agency shall be
prima facie evidence of trauma for purposes of conducting a
screening consistent with this section under the EPSDT Program.
Any child that is abused, neglected or removed from the custody
or care of his or her parent or legal guardian pursuant to
Welfare and Institutions Code Section 300 et seq or Welfare and
Institutions Section 727 shall be assessed by the county mental
health plan for specialty mental health services.
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(c) Any child found to have experienced trauma during a
screening made pursuant to this section shall be assessed by the
county mental health plan for specialty mental health services.
Any child determined to not be eligible for specialty mental
health services after an assessment by a specialty mental health
plan provider shall be referred for other necessary health care,
diagnostic services, treatment and other measures described in
42 USC 1396d to correct or ameliorate any trauma-related defects
and physical and mental illnesses and conditions.
(d) "Trauma," as used in this section, is defined as any
physiological response to an event, series of events, or set of
circumstances that is experienced by an individual as physically
or emotionally harmful or life threatening and that has lasting
adverse effects on the individual's functional and mental,
physical, social, emotional, or spiritual well-being.
POSITIONS
Support:
Californians for Safety and Justice (Sponsor)
Children Now
County Welfare Directors Association of California
Fight Crime: Invest in Kids California
San Luis Obispo County Department of Social Services
Oppose:
None received.
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