BILL ANALYSIS                                                                                                                                                                                                    



          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:      |                 |
          |----------+-----------------------+-----------+-----------------|
          |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

          ---------------------------
          <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  
          ---------------------------
          <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.
                                      -- END --