BILL ANALYSIS Ó SENATE COMMITTEE ON HUMAN SERVICES Senator McGuire, Chair 2015 - 2016 Regular Bill No: SB 1466 ----------------------------------------------------------------- |Author: |Mitchell | ----------------------------------------------------------------- |----------+-----------------------+-----------+-----------------| |Version: |March 28, 2016 |Hearing |April 12, 2016 | | | |Date: | | |----------+-----------------------+-----------+-----------------| |Urgency: |No |Fiscal: |Yes | ---------------------------------------------------------------- ----------------------------------------------------------------- |Consultant|Mareva Brown | |: | | ----------------------------------------------------------------- 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.) SB 1466 (Mitchell) PageB of? 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) SB 1466 (Mitchell) PageC of? 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. SB 1466 (Mitchell) PageD of? 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 --------------------------- <1>http://cssr.berkeley.edu/ucb_childwelfare <2> http://www.childrensaidsociety.org/files/upload-docs/report_final _April_2.pdf SB 1466 (Mitchell) PageE of? 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 --------------------------- <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 SB 1466 (Mitchell) PageF of? 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 SB 1466 (Mitchell) PageG of? 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 SB 1466 (Mitchell) PageH of? 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 SB 1466 (Mitchell) PageI of? 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, screeningScreeningservices provided under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)Programbenefit 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. SB 1466 (Mitchell) PageJ of? (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. -- END --