FRAGMENTED OVERSIGHT AND POOR DATA HAVE HAMPERED STATE AND COUNTY EFFORTS TO ENSURE THE APPROPRIATE PRESCRIBING OF PSYCHOTROPIC MEDICATIONS TO CHILDREN IN FOSTER CARE
As described in the Introduction, California’s current government structure for overseeing psychotropic medications prescribed to children in foster care (foster children) is fragmented, with state and local executive and judicial branch entities performing various functions. Although these entities have made some efforts to collaborate, the State’s approach provides little system‑level oversight to help ensure that the entities’ efforts actually work as intended. Further, the State has not developed a comprehensive oversight plan that identifies each of its various oversight mechanisms and describes how these mechanisms should work together.
The State’s fragmented oversight structure has contributed to the problems we identified in Chapter 1 and has led to other weaknesses in the monitoring of foster children’s psychotropic medications as well. For instance, at the four counties we visited, many foster children’s Health and Education Passports—critical health summary documents that follow foster children should their placement change—contained omissions and errors in their health information. Specifically, the Health and Education Passports for all 80 of the foster children whose case files we reviewed had incorrect start dates for psychotropic medications. Further, many of these Health and Education Passports did not identify all the psychotropic medications that the courts authorized, and none contained complete summaries of the psychosocial services that the foster children had received. When Health and Education Passports contain inaccurate and incomplete health information, health care providers and caregivers may not have critical information that they need to make sound health care decisions for the foster children in their care. Further, inaccurate and incomplete information hampers the State’s and counties’ oversight efforts.
We also found weaknesses in the State’s oversight of the counties, physicians, and pharmacists who are involved with foster children’s mental health care. The California Department of Social Services (Social Services) only recently began examining psychotropic medications prescribed to foster children through its California Child and Family Services Reviews (California reviews) of the counties. Further, the Medical Board of California (Medical Board) does not currently take steps to proactively identify physicians for further investigation who might have inappropriately prescribed psychotropic medications to foster children. Finally, the Department of Health Care Services (Health Care Services) has not programmed its claims system to prompt pharmacists to submit treatment authorization requests for psychotropic medications that are prescribed for off‑label use—a use that has not been approved by the U.S. Food and Drug Administration—to ensure the prescriptions’ medical necessity. Due to its insufficient oversight, the State has reduced assurance that health care providers are reasonably prescribing psychotropic medications to foster children.
The Fragmented Structure of California’s Child Welfare System Has Contributed to Weaknesses in the Oversight of the Prescription of Psychotropic Medications to Foster Children
We believe that the fragmented structure of California’s child welfare system lessens the State’s assurance that psychotropic medications are appropriately prescribed to foster children. As the Introduction explains, oversight of psychotropic medications prescribed to foster children is diffused among multiple government levels and branches. Consequently, executive and judicial branch agencies at the state and local levels share responsibilities for administering and overseeing different aspects of the provision of psychotropic medications to foster children. However, by increasing their current levels of collaboration, the various government agencies involved in child welfare services could improve their oversight and better address many of the problems we discuss later in this chapter and in Chapter 1.
Given the splintered nature of California’s administration of foster care and oversight of psychotropic medications for foster children, we expected to find that the State had a comprehensive oversight plan. Ideally, this plan would describe the State’s various oversight mechanisms, the public entities responsible for employing those mechanisms, and the tools in place to ensure that these entities work individually and collectively to ensure that psychotropic medications are prescribed properly to foster children. However, we found no such plan. Despite some collaborative efforts of the public entities involved, California’s oversight approach to date appears to be piecemeal with little system‑level oversight to help ensure that the collective oversight efforts produce measureable, desirable results.
Social Services created the closest thing to a comprehensive plan that we were able to identify. Specifically, Social Services summarized certain existing efforts to oversee the prescription of psychotropic medications to foster children as part of its 2015–2019 Child and Family Services Plan (state plan) required by the federal government. Within this state plan, Social Services included a section covering the oversight of prescription medicines, including psychotropic medications. Social Services identified four critical components of the State’s oversight of prescription medicines:
- Public health nurses, who are responsible for ensuring that foster children have current records of their prescribed medications and that their medication information is documented in their Health and Education Passports and in Social Services’ Child Welfare Services/Case Management System (Social Services’ data system), as we will discuss later in this chapter.
- Juvenile courts, which are responsible for authorizing prescriptions for psychotropic medications for foster children.
- The Quality Improvement Project, which began in 2012 and whose goals include reducing the inappropriate prescribing of multiple psychotropic medications to foster children and supporting the use of psychosocial services in lieu of medications.
- Outcome Measure 5F, which uses information recorded in Social Services’ data system to track the proportion of foster children for whom the courts have authorized psychotropic medications.
Although these components may play a role in the oversight of the prescription of psychotropic medications to foster children, they do not as a whole represent the sort of comprehensive, systemwide effort that could best ensure that children do not receive these medications unnecessarily.
Other states have taken more streamlined approaches to their oversight of psychotropic medications prescribed to foster children. According to its 2015–2019 Child and Family Services Plan, Texas has dedicated specialized staff within its Department of Family and Protective Services to coordinate and oversee health care services for foster children, including a medical director who is a child and adolescent psychiatrist and who coordinates with Texas’ health care plan to ensure the appropriate prescribing of psychotropic medications. In contrast to California, which provides psychosocial services through multiple Medi‑Cal mental health plans, various Medi‑Cal managed care plans, and fee‑for‑service providers, its Child and Family Services Plan states that Texas contracts with a single health plan in which all Texas foster children are enrolled. Further, Texas requires the health plan to oversee the administration of psychotropic medications to foster children to ensure compliance with that state’s requirements. These requirements identify utilization parameters, maximum dosage amounts, warnings about side effects, and nine criteria that trigger further review of children’s clinical status and care. Further, Texas’ health plan also includes a psychotropic medications utilization review process that allows it to identify and investigate physicians who consistently prescribe outside the state’s utilization parameters.
Another state with a single public entity responsible for oversight is Illinois. By law, the Illinois Department of Children and Family Services (department) is responsible for consenting to the medical, surgical, and psychiatric care for children and adolescents in its custody. To meet these responsibilities related to the prescription of psychotropic medications, the department established a medication consent program. To support the consent process, the department contracted with a university to independently review all consent requests from clinicians to prescribe psychotropic medications to children in their care. Furthermore, Illinois includes in its Administrative Code—the equivalent of the California Code of Regulations—guidelines regarding the use of psychotropic medications for children in foster care. The Illinois guidelines contain similar clinical parameters to those in the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care (state guidelines). However, while Illinois’ guidelines are an appendix in its state regulations that specifically direct Illinois’ child welfare department to oversee administration of psychotropic medications, California simply makes its guidelines available to counties for their use.
Foster Children’s Health and Education Passports Contained Incomplete and Inaccurate Mental Health Data
Health and Education Passports are critical documents that summarize health and education information for foster children. Nonetheless, our review of 80 case files at the four counties we visited—Los Angeles, Madera, Riverside, and Sonoma—found that many children’s Health and Education Passports were incomplete and inaccurate. For example, many of these Health and Education Passports did not include foster children’s psychosocial services or authorized psychotropic medications. As a result, individuals and agencies involved with the foster children may be unaware of important components of their mental health histories. Absent such information, caregivers, health care providers, judicial officers, or county staff could make inappropriate or harmful health care decisions, such as prescribing new psychotropic medications that could interact harmfully with those a child is already receiving. Furthermore, inaccurate and incomplete data hamper the State’s ability to ensure that foster children only receive medications that are safe and medically necessary.
Counties Often Did Not Adequately or Accurately Record Information About Foster Children’s Psychotropic Medications in Social Services’ Data System
Health and Education Passport Information
State law specifies the contents of a Health and Education Passport or summary required for each foster child. The relevant health information includes the following:
- Names and addresses for the child’s health care providers, including mental health care providers.
- Immunizations and allergies.
- Known medical problems.
- Current medications.
- Past health problems and hospitalizations.
- Relevant mental health history.
- Known mental health conditions and medications.
- Any other relevant mental health information concerning the child determined to be appropriate by the director of the California Department of Social Services.
Source: California Welfare and Institution Code, Section 16010(a).
State law requires that every foster child’s case plan include a summary of his or her health and education information, as shown in the text box. According to state law, county staff must provide the summary to the foster child’s caregivers within 30 days of placement and update the summary before each court date or within 48 hours of a change in placement. Although state law allows counties to maintain the summary in the form of a Health and Education Passport, it does not require it; however, the four counties we visited all use Health and Education Passports. According to Social Services, it designed the Health and Education Passport to meet the State’s requirements. Social Services also stated that information in the Health and Education Passports is for use by caregivers, social workers, probation officers, the courts, medical professionals, and foster children.
Social Services issued an information notice to all county welfare directors and chief probation officers in March 2008 that included specific requirements and instructions for properly entering the necessary information into its data system, which then populates the Health and Education Passports. Social Services also established a process for updating the Health and Education Passports, as Figure 4 shows. Specifically, each printed Health and Education Passport instructs a caregiver to bring it to all the foster child’s health visits and to remind health care providers to add or correct information on it. It also instructs the caregiver to give the updated or corrected Health and Education Passport to the foster child’s social worker or probation officer during his or her next visit. The social worker or probation officer should then forward the updated or corrected information to a public health nurse and then work with the public health nurse to enter the information into Social Services’ data system.
Flow of Information to Update the California Department of Social Services’ Child Welfare Services/Case Management System and to Populate Health and Education Passports for Children in Foster Care
Sources: California State Auditor’s review of the California Department of Social Services’ Child Welfare Services/Case Management System training instructions, the Department of Health Care Services’ Plan and Fiscal Guidelines for the Health Care Program for Children in Foster Care, and Health and Education Passports.
Note: The documents we examined do not specifically identify the persons who provide the Health and Education Passports to the caregivers.
Nonetheless, our review of the Health and Education Passports for 80 foster children at the four counties we visited found that the mental health information they contained—including psychotropic medications and psychosocial services—was frequently incomplete and inaccurate. Table 15 summarizes the nature and extent of the concerns we identified. It shows that all 80 Health and Education Passports we reviewed were missing information about the corresponding psychosocial services the children should have received for at least one psychotropic medication, as we describe in Chapter 1. Table 15 also shows that the Health and Education Passports for 13 (16 percent) of these foster children were missing at least one prescribed psychotropic medication that the courts or parents had authorized. Ten of these 13 Health and Education Passports were for foster children from two counties—Los Angeles and Sonoma. In fact, the Health and Education Passport for one of these foster children was missing three authorized psychotropic medications.
In addition, 12 of the 80 Health and Education Passports were missing at least one prescription for a psychotropic medication that had been filled for the child but did not appear to have been authorized by the courts or parents. In these instances, the caregivers were apparently in possession of the prescribed psychotropic medications, but the counties never obtained court authorizations or parental consents. In fact, we identified one instance in which a court denied a request to prescribe an antidepressant to a foster child, but the pharmacist filled the prescription for that medication shortly thereafter.
|COUNTY||FOSTER CHILDREN’S HEALTH AND EDUCATION PASSPORTS…|
|…WERE MISSING…||…CONTAINED INACCURACIES SUCH AS…|
|…CORRESPONDING PSYCHOSOCIAL SERVICES FOR AT LEAST ONE PSYCHOTROPIC MEDICATION||…AT LEAST ONE AUTHORIZED PRESCRIBED PSYCHOTROPIC MEDICATION||…AT LEAST ONE FILLED PRESCRIPTION FOR PSYCHOTROPIC MEDICATIONS THAT WERE NOT AUTHORIZED||…INCORRECT START DATES FOR AT LEAST ONE PSYCHOTROPIC MEDICATION||…INCORRECT COURT AUTHORIZATION DATES FOR AT LEAST ONE PSYCHOTROPIC MEDICATION*||…LESS RECENT INFORMATION THAN CONTAINED IN THE CHILD WELFARE SERVICES/CASE MANAGEMENT SYSTEM|
Sources: California State Auditor’s analysis of selected foster care case files at each of the counties’ welfare services departments and data obtained from the Department of Health Care Services’ Paid Claims and Encounters System, the California Department of Social Services’ Child Welfare Services/Case Management System, and matched Medi-Cal pharmacy data.
* Unless noted otherwise in the Table, we reviewed the case files for 20 foster children at each of the four counties, for a total of 80 foster children. For two counties, we reviewed fewer than 20 case files because the courts had delegated authority to administer psychotropic medications to some foster children’s parents, and therefore, this column is not applicable for these children.
Besides missing certain information, all 80 Health and Education Passports we reviewed included inaccurate dates showing when the foster children started taking psychotropic medications, as shown in Table 15. In its 2008 information notice, Social Services instructed counties to enter into its data system the actual date that a foster child started taking a psychotropic medication. However, instead of entering this date, the four counties we visited entered the dates that prescribers saw children, the dates that court authorizations were filed, or the dates on which courts authorized prescriptions. Moreover, the Health and Education Passports for 19 (28 percent) of the 67 foster children for whom the court authorized psychotropic medications had inaccurate court authorization dates.
Table 15 also shows that seven foster children’s Health and Education Passports were missing authorized psychotropic medications even though Social Services’ data system included this information. Six of these seven children were from Sonoma County. For example, Social Services’ data system showed that one foster child had two authorized psychotropic medications, both of which were antipsychotics; however, the child’s Health and Education Passport did not reflect this information. We determined that although Sonoma County staff had entered information about the six foster children’s psychotropic medications into Social Services’ data system, they did not follow Social Services’ instructions to have the data system update the children’s Health and Education Passports. In fact, in the above example, Sonoma County had not updated the foster child’s Health and Education Passport in more than 10 years. In contrast, Riverside County, which had no such errors, provides written instructions to its staff on how to properly update Health and Education Passports after entering new medical information into Social Services’ data system.
Finally, Social Services’ data system includes a field for county staff to log the date when they provide the Health and Education Passports to caregivers. This field was blank in the records for 49 (61 percent) of the 80 foster children we examined. It is therefore unclear whether county staff actually provided the Health and Education Passports to these caregivers. We noted that Los Angeles and Riverside counties were responsible for 37 of the 49 case files with blank fields. Without these completed fields in Social Services’ data system, the State lacks information to ensure that counties provided caregivers with critical information about foster children’s health.
Two General Factors Appear to Have Consistently Contributed to Foster Children’s Incomplete Health and Education Passports
Selected Responsibilities of
Foster Care Public Health Nurses
Foster Care Public Health Nurses
- Work with child welfare case workers to coordinate health care services, including psychosocial services.
- Serve as a liaison with health care professionals.
- Document that each child receives initial and follow‑up health screenings that meet reasonable standards of medical practice.
- Collect health information and other relevant data on each foster child as available, including mental health services.
- Participate in medical care planning and coordinating for each foster child, which may include facilitating the acquisition of any necessary court authorizations for procedures or medications, as well as monitoring and providing oversight of psychotropic medications.
- Provide follow‑up contact to assess each foster child’s progress in meeting treatment goals.
- Assist nonminor dependents in making informed decisions about their health care, specifically helping them assume responsibility for their ongoing health care management while transitioning out of foster care.
Source: Welfare and Institutions Code, Section 16501.3.
We determined that two general factors may have contributed to foster children’s incomplete Health and Education Passports: the counties’ insufficient number of public health nurses and a lack of information sharing among county departments. As described earlier, public health nurses work with social workers and probation officers to enter and update foster children’s health and medical information in Social Services’ data system. The public health nurses are part of the Health Care Program for Children in Foster Care (Health Program), a public health nursing program that is located in county child welfare services agencies and county probation departments. The Health Program provides public health nursing expertise in meeting the medical, dental, behavioral, and developmental health needs of children in out‑of‑home placements or foster care. State law identifies the public health nurses’ responsibilities, as shown in the text box.
Social Services’ inclusion of public health nurses and the Health Program in its state plan for 2015–2019 demonstrates the significance the State places on their role in overseeing psychotropic medications prescribed to foster children. In this federally required plan—which we describe in the Introduction—Social Services stated that public health nurses, in consultation and collaboration with others, are responsible for ensuring that every foster child has a current record of prescribed medications and for documenting medication information in the Health and Education Passports. Social Services also stated that the Health Program provides assurance that counties continue to identify and address foster children’s physical and mental health needs.
However, the public health nurses at the four counties we visited indicated that limited staff resources and the need to address foster children’s serious medical conditions constrain their ability to maintain accurate and complete data in Social Services’ data system, which is then reflected in inaccurate and incomplete Health and Education Passports. For example, one public health nurse explained that she spent an estimated eight hours just to arrange an emergency root canal surgery for one foster child. She stated that foster children with threatening or serious medical conditions take precedence over basic medical data entries to update the Health and Education Passports.
The statements from the public health nurses are consistent with the ratio of public health nurses to foster children within each county. Documents issued by both Social Services and Health Care Services from around the time of the Health Program’s original implementation in 2000 indicate that it intended to maintain an ideal ratio of one public health nurse per 200 foster children. However, Health Care Services’ information from February 2016 showed that only 13 of California’s 58 counties had public health nurse‑to‑foster‑children ratios at or below 1‑to‑200. Further, the ratios for the four counties we visited ranged from 1‑to‑252 to 1‑to‑413.
Counties could improve these caseload ratios by funding additional public health nurses. Federal law states that the federal government will cover 75 percent of the costs for skilled professional medical personnel, such as public health nurses, as well as 75 percent of the cost for the medical personnel’s necessary support staff. These support staff could enter information into the Health and Education Passports, freeing the public health nurses to oversee the support staff’s work and to perform their other, more pressing responsibilities.
However, counties may not be obligated to implement Social Services’ directives to address inaccurate and incomplete mental health information in Social Services’ data system by taking actions such as hiring additional Health Program staff. As discussed in the Introduction, realignment laws enacted in 2011 and 2012 moved program and fiscal responsibility for foster care to the counties, leaving Social Services with the role of providing oversight, training, and technical assistance to the counties. Around the same time, California voters enacted Proposition 30, which states that the counties are not obligated to implement new state laws, regulations, or administrative directives that increase local costs to administer child welfare services that were transferred to them as a result of the realignment laws, unless the State provides additional annual funding to pay for the increased costs. As a result, Social Services cannot simply issue directions and expect the counties to take steps to correct the data in its data system; instead, Social Services and the counties must reach agreement on a plan to improve the health information in Social Services’ data system and on acceptable funding sources—likely from both the counties and the State—if that plan results in additional costs for the counties.
Another reason for incomplete Health and Education Passports is a lack of information sharing among the different county departments involved with foster children who receive psychosocial services, including psychotropic medications. Although the counties appear to maintain records pertaining to foster children’s psychosocial services, that information is split among separate county departments, which do not always share information with each other. For instance, staff at two of the four counties we visited cited concerns over health information privacy laws as an impediment to the sharing of information about foster children’s psychosocial services by county departments of mental health with county child welfare departments. In fact, according to the medical director of Sonoma County’s Division of Behavioral Health, clearer guidance from the State as to what psychosocial services information can or cannot be shared is necessary; he stated that federal and state laws governing such information sharing are subject to interpretation and the California courts take very seriously the right to confidentiality and privacy of psychosocial services information.
However, according to a deputy director at Social Services and the chief medical information officer at Health Care Services, the federal Health Insurance Portability and Accountability Act (HIPAA), California’s Confidentiality of Medical Information Act, and other state medical privacy laws do not prevent entities from sharing certain summary level information about foster children’s psychosocial services for purposes of care coordination. Both the chief medical information officer at Health Care Services and the deputy director at Social Services stated that they would be amenable to issuing guidance to counties regarding the sharing of information to help ensure more complete Health and Education Passports.
As we mentioned in Chapter 1, the Judicial Council of California (Judicial Council) adopted new and revised forms—which became effective in July 2016—to be used in the court authorization process for foster children’s psychotropic medications. The Judicial Council also revised its court rules to allow counties to develop their own processes to share information from the new forms with public health nurses. As a result, the use of the new forms may help the public health nurses obtain information on foster children’s psychosocial services, which they or support staff can then include in Social Services’ data system and in foster children’s Health and Education Passports. Such changes could mitigate some of the problems that the lack of information sharing has likely caused in the past.
The State’s and Counties’ Lack of Reliable Data Has Impeded Their Oversight of Psychotropic Medications for Foster Children
As discussed previously, Social Services’ data system contains incomplete and inaccurate mental health information related to foster children. It does not accurately record whether foster children have been prescribed psychotropic medications, how many psychotropic medications they were prescribed, or whether maximum daily dosages were within acceptable limits. Further, using the data system, we were unable to determine whether foster children had follow‑up visits with their prescribers or other health care providers within 30 days after starting new psychotropic medications and whether they received psychosocial services before or concurrent with their psychotropic medications. Finally, the data system does not accurately and consistently record whether counties obtained court or parental authorizations before foster children received psychotropic medications.
These incomplete and inaccurate data can hinder county and state oversight of psychotropic medications prescribed to foster children. Social workers, probation officers, caregivers, public health nurses, health care providers, and others at the county level use the health information in Social Services’ data system and in the foster children’s Health and Education Passports to assist in the provision of appropriate mental health care to foster children. If this health information is inaccurate or incomplete, these individuals could make decisions that are less than optimal or that could even result in harm to these children.
In addition to potentially hampering county‑level coordination and oversight of foster children’s mental health care, inaccurate and incomplete information in Social Services’ data system may also impede the State’s ability to oversee psychotropic medications prescribed to foster children. Social Services uses information from its data system for several purposes. For instance, it provides data from its system to the California Child Welfare Indicators Project to allow policymakers, child welfare workers, researchers, and the public access to information on California’s child welfare system.13 However, users could draw inaccurate conclusions if they relied only on this information. For example, Measure 5F—which captures the number of foster children authorized for psychotropic medications recorded in Social Services’ data system—does not accurately reflect the number of foster children with prescriptions for psychotropic medications because county staff have not entered all court or parental authorization information into the data system.
The State’s ability to identify foster children who receive psychotropic medication prescriptions has improved since various state agencies and other government entities—including some counties—entered a data‑ssharing agreement in April 2015. Among other things, this data‑ssharing agreement between Health Care Services, Social Services, and other government entities allows them to share confidential data about foster children’s psychosocial services and prescriptions. For example, Health Care Services used this agreement to share Medi‑sCal pharmacy data about psychotropic medications with Social Services so Social Services could identify which foster children have prescriptions for psychotropic medications. Because this data‑ssharing agreement is still relatively new, Social Services and Health Care Services are still working to improve the links between their different data systems.
However, even with these improvements, county and state stakeholders are likely to continue to lack the accurate, complete information they need to make decisions or to analyze whether improvements occur over time. As discussed, Social Services’ data are inaccurate and incomplete. However, Health Care Services’ data also cannot paint a complete picture of foster children’s psychosocial services and medications because, as shown in Figure 5, the data do not reflect those psychosocial services or psychotropic medications for which Medi‑Cal did not pay and, as mentioned in Chapter 1, Health Care Services' procedure codes do not capture precisely the extent to which psychosocial services are provided to foster children. For example, a program manager at Sonoma County’s Family, Youth and Children Division stated that the county paid for therapy services for three of the 20 foster children whose case files we reviewed; thus, Health Care Services’ data did not reflect these services. Because neither Social Services nor Health Care Services has complete information on foster children’s psychosocial services and psychotropic medications, combining their data will likely continue to result in an inaccurate summary. Consequently, state and county oversight of psychotropic medications administered to foster children is likely to continue to be limited by weaknesses in the available data until Social Services successfully works with the counties to improve its data system.
Gaps in the State’s Data Related to the Prescription of Psychotropic Medications to Children in Foster Care
Sources: California State Auditor’s analysis of the Social Services’ Child Welfare Services/Case Management System, Health Care Services’ Medi‑Cal data, and interviews with county officials.
Until Recently, the State’s County‑Level Reviews Included Only Minimal Examination of Psychotropic Medications Prescribed to Foster Children
As discussed in the Introduction, Social Services and Health Care Services took steps starting in 2012 to address the issue of psychotropic medications prescribed to foster children. However, the effectiveness of the practices that the two departments developed are largely dependent upon the counties’ willingness to implement those practices—which many counties have not yet done. Further, neither Social Services nor Health Care Services included examinations of the prescription of psychotropic medications to foster children as part of their periodic reviews at the county level until recently. Consequently, the State has lacked assurance that the counties’ monitoring of this issue adequately protects the best interests of foster children.
Quality Improvement Project
Educational and Informational Materials
Educational and Informational Materials
California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care: Released jointly by the California Department of Social Services and the Department of Health Care Services, the document describes best practices for the treatment of children in out‑of‑home care who may require psychotropic medications.
Questions to Ask About Medications: A document to help foster children, parents, and caregivers to improve their skills and knowledge about side effects and adverse symptoms related to medications.
Foster Youth Mental Health Bill of Rights: A document to educate foster children, parents, and caregivers about the rights of foster children as they pertain to psychotropic medications.
Sources: California Department of Social Services’ All County Information Notice I‑36‑15—issued May 2015—and website.
In response to heightened national awareness regarding psychotropic medications prescribed to foster children, Social Services and Health Care Services established the Quality Improvement Project in 2012. Although it does not have official monitoring duties, the Quality Improvement Project has since produced educational and informational materials—as shown in the text box—to help assure the safe and appropriate prescribing and monitoring of psychotropic medications prescribed to foster children.
Additionally, the Quality Improvement Project devised ways in which the two departments and counties, under their data‑sharing agreement, could use data results to aid in the oversight of psychotropic medications prescribed to foster children. For instance, since May 2015, Social Services has distributed to counties quarterly reconciliation reports that included case numbers of foster children who had paid Medi‑Cal claims for psychotropic medications but no prior or concurrent authorizations recorded in Social Service’s data system. Our review of these reports for the four counties we visited indicated that the counties used them to resolve possible discrepancies. For example, Los Angeles County’s first reconciliation report identified 558 possible discrepancies. Its reconciliation report two quarters later listed only 240, a reduction of 318. Also, Social Services will provide more detailed case information, including foster children’s names, identification numbers, medication names and dates, and placement types to those counties that sign on to the data‑sharing agreement.
Although these and other practices we examined can help counties to ensure that providers properly prescribe psychotropic medications to foster children, the counties do not universally use them. For example, we found that counties did not always use the educational and informational materials the Quality Improvement Project produced. Furthermore, Social Services told us in May 2016 that only 19 of California’s 58 counties—including Madera and Sonoma—had signed on to the data‑sharing agreement. Consequently, the Quality Improvement Project’s efforts to date have not resulted in widespread assurance that the State’s and counties’ collective oversight and monitoring mechanisms actually produce measureable, desirable results.
Until recently, the State’s actual monitoring mechanisms for overseeing child welfare systems and the provision of health care services at the county level included only minimal examinations of psychotropic medications prescribed to foster children. Social Services and Health Care Services conduct at least three different types of periodic reviews at the county level to examine different aspects of each county’s child welfare system or health care and mental health service operations. We summarize these reviews in Table 16. Because the two departments have not included substantive examinations of the provision of psychotropic medications to foster children as part of these periodic reviews in the past, they missed opportunities to obtain critical information from more in‑depth, county‑by‑county reviews of this issue. However, as of March 2016, Social Services and Health Care Services began collecting from the counties certain information about the provision of these medications.
|REVIEW TYPE||ENTITIES PERFORMING THE REVIEW||ENTITIES REVIEWED||PURPOSE OF REVIEW||FREQUENCY OF REVIEW||CASE FILE REVIEW INCLUDED||PSYCHOTROPIC MEDICATIONS AND FOSTER CARE INCLUDED AS PART OF REVIEW||RESULTS OF REVIEW|
|California Child and Family Services Review||Collaboration between the California Department of Social Services (Social Services) and county child welfare departments and probation placement agencies.||County child welfare departments and probation placement agencies.||To strengthen the accountability system used in the State to monitor and assess the quality of services provided on behalf of maltreated children.||Ongoing. However, counties are to prepare and submit self‑assessments and system improvement plans every five years and progress reports annually.||Yes, starting in 2015.||Yes, starting in 2008 and expanded in 2014.||County self‑assessments, system improvement plans, and annual progress reports linked on Social Services’ website.|
|Program Oversight and Compliance Review||Department of Health Care Services (Health Care Services).||County Medi‑Cal mental health plans.||Verify that county Medi‑Cal mental health plans provided medically necessary services in compliance with state regulations and the contract between Health Care Services and the plan.||Triennial.||Yes.||Yes, starting in fiscal year 2015–16.||County Medi‑Cal mental health plans’ submissions to Health Care Services of plans of correction for any items out of complance.|
|External Quality Reviews||Health Care Services, via contracts with private vendors.||County Medi‑Cal managed care plans and county Medi-Cal mental health plans.||To evaluate the quality, access, and timeliness of health care services offered to Medi‑Cal beneficiaries through Medi‑Cal plans.||Annual.||No.||Not substantively.||Annual reports linked on Health Care Services’ website.|
Sources: Federal and state laws and regulations, documents obtained from Social Services and Health Care Services, and interviews with staff of Social Services.
One of the State’s oversight mechanisms is Social Services’ California Child and Family Services Review (California review). Social Services implemented the California review in 2004 in response to a state law requiring it to monitor county child welfare systems’ performance, including foster care. According to Social Services, this review is an enhanced version of the federal Child and Family Services Review, through which the U.S. Department of Health and Human Services reviews each state’s child welfare system to ensure that it provides quality services to children and families. The California review contains more measures than the federal review and has a primary focus on measuring each county child welfare system’s performance in the areas of safety, permanence, and family well‑being. The State’s goal for the California review is to strengthen the accountability system it uses to monitor and assess the quality of services provided to maltreated children. According to Social Services, the review establishes core outcomes that are central to maintaining an effective system of child welfare services.
The California review is an ongoing, cyclical process that requires counties every five years to submit self‑assessments in which they review their child welfare and probation office placement programs to determine the effectiveness of their current practices, programs, and resources. They must also submit system improvement plans every five years, which are operational agreements between the counties and Social Services that outline how counties plan to improve their system of care for children and families and address priority needs within the child welfare services system. Finally, the counties must prepare and submit annual progress reports to Social Services that provide a written analysis assessing whether their system improvement plans are achieving the desired results.
As part of the California review, the California Child Welfare Indicators Project publishes on its website data on all 58 counties’ child welfare systems’ performance related to specified outcome measures. Social Services also makes the data available on its website. With these measures, counties can identify areas in which they could improve performance. Currently, only one measure—Measure 5F—addresses the number of foster children authorized to receive psychotropic medications. As previously discussed, we found a number of weaknesses in the information this measure provides.
Further, until 2014, the county self‑assessment component of Social Services’ California reviews did not specifically address psychotropic medications prescribed to foster children other than what was required for Measure 5F. As of January 2014, Social Services expanded the self‑assessment reporting requirements to include a description and analysis of how the counties monitor the appropriate administration of prescription medications, including psychotropic medications for foster children. The most recent self‑assessment reports for the four counties we visited are all dated before 2014, before implementation of the new requirement. Although the four counties have yet to fulfill this specific requirement, all have written procedures associated with the court’s consideration of requests to authorize prescriptions of psychotropic medications to foster children.
In addition, Sonoma County was the only county of the four to address psychotropic medications as an area of needed improvement in its most recent system improvement plan for 2014 to 2019. In the plan, Sonoma noted that, with the exception of two counties with very small populations of foster children, it had the highest rate of foster children authorized for psychotropic medications: more than 24 percent in the fourth quarter of 2012, or nearly double the statewide rate at that time. Consequently, the plan stated that Sonoma’s child welfare department would identify the causes of the high rate and develop monitoring processes to reduce by 5 percent the number of youth authorized for psychotropic medications. Although a subsequent annual progress report did not identify the causes for its high rate, it mentioned that Sonoma was implementing a number of steps to reduce the number of foster children prescribed psychotropic medications. These steps included engaging county partners in conversation about the problem, implementing an internal review process for court authorization requests for psychotropic prescriptions, and providing training on the issue for all its social workers.
The State also monitors county mental health care plans (Medi‑Cal mental health plans) through triennial program oversight and compliance reviews. Health Care Services conducts these triennial reviews, which verify that the Medi‑Cal mental health plans provide medically necessary services to beneficiaries in compliance both with the terms of their contracts with Health Care Services and with state and federal laws and regulations. However, the review protocol for fiscal year 2014–15—which was essentially a checklist more than 90 pages long containing questions for which Health Care Services seeks answers—did not include any questions regarding psychotropic medications for foster children. Health Care Services recently took a step toward ensuring that its triennial reviews better address this issue in the future. Specifically, its review protocol for fiscal year 2015–16 includes three questions on the prescription of psychotropic medications to foster children.
A third state mechanism for monitoring counties’ provision of health care is Health Care Services’ annual external quality review (external review) of local Medi‑Cal health plans. In accordance with federal law and regulations, Health Care Services must contract with third‑party vendors to conduct external reviews that examine Medi‑Cal beneficiaries’ access to timely health care services as well as the quality of their outcomes under county mental health care plans and county Medi‑Cal managed care plans (Medi‑Cal managed care plans). Health Care Services contracts with two organizations to conduct these external reviews and includes links to the organizations’ reports on its website. However, the reports for the most recent annual external reviews for the Medi‑Cal mental health plans and Medi‑Cal managed care plans for the four counties we visited did not include substantive information regarding psychotropic medications prescribed to foster children.
Although external reviews annually examine the counties’ Medi‑Cal mental health plans and Medi‑Cal managed care plans, the assistant chief of the Medical Review Branch within Health Care Services’ Audits and Investigations Division indicated that the State has no similar oversight mechanism in place for health professionals who provide psychosocial services and then bill Medi‑Cal via the fee‑for‑service approach. While more Medi‑Cal beneficiaries are enrolling in managed care plans, foster children have the option to receive health care services from fee‑for‑service providers instead. Health Care Services is responsible for signing up and screening these providers. However, according to the assistant chief of the Medical Review Branch, the only oversight Health Care Services performs related to this type of provider involves identifying appropriate billing based on medical necessity criteria and federal and state reimbursement guidelines.
The three types of county‑level reviews that Social Services and Health Care Services perform present an opportunity for the departments to gather first‑hand information regarding the counties’ administration of psychotropic medications to foster children. These reviews could allow Social Services and Health Care Services to identify relevant deficiencies in this area and work with counties to resolve those deficiencies. Further, using the relevant results of these reviews in conjunction with complete and accurate state data, Social Services, Health Care Services, and their county partners could consider whether to modify their oversight structures to better ensure that providers only prescribe psychotropic medications to foster children when reasonably necessary.
The State Has Not Proactively Overseen Physicians Who Prescribe Psychotropic Medications for Foster Children
Although the State has mechanisms in place for reacting to complaints about physicians who may have inappropriately prescribed psychotropic medications to foster children, it does not currently take routine proactive steps to identify and correct inappropriate prescribing practices. The State oversees physicians through the Medical Board, which is responsible for issuing physicians’ licenses, investigating complaints, and imposing discipline. Its disciplinary actions may include administrative citations, fines, or license revocation. However, as of February 2016, its executive director stated that the Medical Board had not received any complaints against physicians for inappropriately prescribing psychotropic medications to foster children. Given the nature and extent of the issues we identified in Chapter 1 related to psychotropic medications, we believe that the lack of complaints to the Medical Board may suggest that this reactive approach alone is not sufficient to help ensure that physicians properly prescribe psychotropic medications to foster children.
Although the State also has other reactive methods through which it can monitor physicians who prescribe psychotropic medications to foster children, it is unclear whether these methods provide adequate oversight. For instance, state law requires Social Services to establish a foster care ombudsman’s office to disseminate information on the rights of foster children and to investigate and attempt to resolve complaints made by or on behalf of foster children related to their care, placement, or services. Nonetheless, according to a consultant in the foster care ombudsman’s office, a review of a sample of child welfare complaints over a four‑year period showed that the office had not received complaints regarding children being overprescribed psychotropic medications. Similarly, state regulations allow Health Care Services to designate a Medi‑Cal managed care ombudsman to investigate and resolve complaints between Medi‑Cal beneficiaries and their managed care health plans. However, the chief of Health Care Services’ Managed Care Operations Division told us that the managed care ombudsman’s office does not investigate complaints regarding inappropriate prescribing of psychotropic medications to foster children and would refer any such complainants to another appropriate program.
Consequently, we believe that the State’s reactive approach for overseeing physicians should be supplemented by more proactive steps to better ensure that physicians who prescribe psychotropic medications to foster children adhere to applicable guidelines. Although the Medical Board is trying to take proactive steps, its progress has been slow. Specifically, in April 2015 the Medical Board entered into an agreement with Health Care Services and Social Services to obtain pharmacy claims data for all foster children who were or had been on three or more psychotropic medications for 90 days or longer. The Medical Board’s executive director stated that her staff had planned to analyze these data and investigate those physicians who exhibited inappropriate patterns of prescribing psychotropic medications to foster children. However, even though the Medical Board received these data in May 2015, the executive director explained in February 2016 that the board had not yet been able to use it to identify physicians with potentially inappropriate prescribing habits.
The executive director attributed the delay to a number of causes. Specifically, she stated that the Medical Board was unable to contract with a consultant to analyze the data until November 2015 because it took longer than expected to identify an appropriate, available expert in the Sacramento area. She further stated that in late January 2016, the consultant reported to the Medical Board that the data were inadequate to perform the desired assessment. The consultant presented a list of additional information necessary to perform the desired analysis, such as each child’s targeted diagnosis and weight, and each medication’s dosage and frequency. In February 2016, the Medical Board met with Health Care Services and Social Services to request the additional information. Health Care Services responded in March 2016, stating that its claims system does not capture data for the targeted diagnoses, dosages, or frequency of the medications but that it could provide other data fields as substitutes. Health Care Services also said that Social Services could provide each child’s weight to the extent its data system captured that information. The Medical Board requested these substitute data fields but, according to the executive director, was still waiting as of April 2016 to hear from the two departments.
Because the Medical Board has not yet received the necessary information from Health Care Services and Social Services, it does not know when it will be able to complete this project. However, its executive director asserted that if this project is successful in identifying physicians who may have inappropriately prescribed psychotropic medications to foster children, the Medical Board will continue working with Health Care Services and Social Services to review their data on a regular basis.
Health Care Services Does Not Ensure That Pharmacists Obtain Its Approval Before They Dispense Psychotropic Medications to Foster Children for Off‑Label Uses
Off-Label Use of
Prescription Medications by Children
Prescription Medications by Children
According to studies and other documents that we examined, physicians may prescribe medications for off‑label uses, which are any uses that are not indicated on the medications’ approved drug labels. Federal regulations state that any prescription medication approved by the U.S. Food and Drug Administration (FDA) must contain a drug label that identifies its approved uses, including the target population, diagnosis, dosages, and method of administration. According to the FDA, most medicines prescribed for children have not been tested in children and, by necessity, doctors have routinely prescribed medications for off‑label use in children. However, the safety and effectiveness of a medication may or may not extend to all age groups or diagnoses that were not tested, which could pose additional risks to a patient prescribed a medication for off‑label purposes. Nevertheless, according to the American Academy of Child and Adolescent Psychiatry, it is ethical, appropriate, and consistent with general medical practice to prescribe medication off‑label when clinically indicated.
Sources: California State Auditor’s review of the FDA’s regulations and website and of studies and other documents related to off‑label use of medications.
Health Care Services has not consistently ensured that pharmacists obtain its approval before they dispense psychotropic medications to foster children for purposes other than those indicated on the medications’ product labels. As the text box describes, such uses of prescription medications are considered off‑label because they do not have the approval of the U.S. Food and Drug Administration (FDA). State regulations require pharmacists to obtain approved treatment authorization requests (TARs) before dispensing any medication, including psychotropic medications, to be used for off‑label purposes, except in cases of emergency. According to an American Bar Association 2011 Practice and Policy Brief, more than 75 percent of psychotropic medication use by children and adolescents is likely prescribed for off‑label purposes. However, our review found that few pharmacists had obtained TARs when dispensing these medications to foster children.
Health Care Services’ staff pharmacists review and adjudicate TARs, either approving the requests, denying them, or deferring them in order to gather more information from the health care providers—including the prescribing physicians—before making decisions. According to the chief of its Clinical Assurance and Administrative Support Division, Health Care Services’ staff pharmacists look at the type of medication and the child’s diagnosis, and then evaluate the following questions as part of each TAR review:
• Whether the intended use is FDA‑approved.
• Whether the usage is age‑appropriate.
• Whether the regular and daily dosage amounts are appropriate for a child’s age and size.
• Whether the medication is medically necessary.
• Whether the medication is in the same pharmaceutical class as any other medications the child is receiving.
• In the case of antipsychotic medications, whether the child is receiving metabolic monitoring as part of monitoring side effects.
State regulations allow Health Care Services to authorize the offoff‑label use of medications when that use represents reasonable and current prescribing practice. For example, our review of the case files for 80 foster children at the four counties we visited showed that a number of physicians prescribed trazodone—an antidepressant—to treat insomnia. Although this usage is not indicated on the medication’s FDAoff‑approved label, a 2010 survey of the members of the American Academy of Child and Adolescent Psychiatry found that trazodone was the most commonly prescribed insomnia medication for children with anxiety disorders.14 The results of this survey suggest that prescribing trazodone for insomnia is a reasonable off‑label use.
Although the TARs review process provides an opportunity for the State to ensure that foster children only receive psychotropic medications for appropriate off‑label purposes, our review found that pharmacists rarely obtained approved TARs before dispensing these medications. Specifically, when we reviewed the case files for the 80 foster children, we identified 45 children to whom physicians prescribed at least one psychotropic medication for an off‑label use. However, when we asked Health Care Services to provide approved TARs for the medications prescribed for these 45 foster children, it could not do so for 44 of them—even though some of the children were receiving multiple psychotropic medications for off‑label purposes. In other words, pharmacists failed to submit TARs, as state regulations require, in nearly all instances of off‑label use.
When it does not receive, review, and approve TARs for psychotropic medications prescribed for off‑label use by foster children, Health Care Services has less assurance that physicians have properly prescribed these medications. For example, in April 2014 a physician prescribed Seroquel—an antipsychotic medication that the FDA approved to treat symptoms of bipolar disorder in patients 10 and older or schizophrenia in patients 13 and older—to a 15‑year‑old foster child. However, the physician prescribed Seroquel to treat “mood dysregulation” with symptoms of moodiness, irritability, anger problems, and arguing. Although we concluded that this was an off‑label use because the documents did not mention bipolar disorder or schizophrenia, Health Care Services could not provide an approved TAR.
Pharmacists rarely submitted TARs for off‑label prescriptions in part because Health Care Services has not programmed its claims system to identify medications prescribed for off‑label use in order to prompt pharmacists to submit TARs. According to a section chief in its Clinical Assurance and Administrative Services Division (section chief), Health Care Services relies on pharmacists to voluntarily identify when medications are prescribed for off‑label uses. However, the section chief acknowledged that few dispensing pharmacists devote the time or have the information necessary to determine whether psychotropic medications are prescribed for off‑label purposes.
The chief of Health Care Services’ Pharmacy Benefits Division (chief of pharmacy benefits) indicated that Health Care Services has not programmed its claims system to identify off‑label prescriptions of psychotropic medications using children’s diagnoses because prescriptions do not always include reliable diagnoses that indicate the purposes of the medications. Without a diagnosis, the system cannot determine whether a medication is being prescribed for an off‑label purpose. The chief of pharmacy benefits also stated that for Health Care Services to use diagnoses to enforce the TAR requirement for off‑label purposes through its claims system, it would need to require TARs for all psychotropic medication prescriptions, which would result in the submission of unnecessary TARs and impede foster children’s access to medications they need.
However, even if Health Care Services cannot reasonably program its claims system to detect prescriptions for off‑label uses based on diagnoses, the claims system could still trigger a TAR requirement for off‑label use for psychotropic medications based on children’s ages, just as it currently does for antipsychotic medications. Specifically, for service dates on or after October 1, 2014, Health Care Services began requiring TARs for antipsychotic medications prescribed to Medi‑Cal beneficiaries under age 18, including foster children. According to the chief of pharmacy benefits, Health Care Services enacted this TAR requirement to ensure the safe and appropriate use of these medications by children given their severe and potentially irreversible side effects. Health Care Services enforces this TAR requirement by having its claims system automatically prompt pharmacists to submit TARs whenever they submit claims for antipsychotic medications prescribed to Medi‑Cal beneficiaries under 18 years old. Health Care Services appears to properly enforce this TAR requirement; it provided approved TARs for the 27 foster children we reviewed who had prescriptions for antipsychotic medications filled after October 1, 2014.
The section chief noted that since implementing the TAR requirement in October 2014, Health Care Services has denied some TARs for antipsychotics that it deemed were medically inappropriate for various reasons, including for too‑high dosages, concurrent use of multiple psychotropic medications, and off‑label uses that were not medically justified. In fact, in April 2015 Health Care Services denied a TAR for the foster child we mentioned previously who had been prescribed Seroquel—an antipsychotic medication—for an off‑label use. According to the section chief, the claims system required the TAR because of the patient’s age, which allowed Health Care Services to request additional information—including the child’s specific diagnosis, the clinical justification for the medication, and evidence of metabolic monitoring—to assess the medication’s appropriateness. According to the section chief, the pharmacist did not provide the requested information within 30 business days, so Health Care Services automatically denied the TAR.
Although Health Care Services may not be able to ensure that it reviews all off‑label uses of psychotropic medications by foster children, we believe it can better oversee the appropriateness of some of these medications by creating a TAR process similar to the one it uses to for antipsychotic medications but focused specifically on children’s ages. Of the 45 psychotropic medications we identified from the case files we reviewed, 19—or 42 percent—were not FDA‑approved for any use by patients under age 18 as of March 2016.
The chief of pharmacy benefits agreed that Health Care Services should consider programming its claims system to trigger TAR requirements for these psychotropic medications based on the patients’ ages. He also stated that Health Care Services should evaluate alternative tools and procedures to identify off‑label use of medications and better enforce compliance with TAR requirements. For example, he stated Health Care Services could consider developing a process through which its Audits and Investigations Division could include off‑label TARs in its retail pharmacy audits.
Finally, as discussed earlier, the Judicial Council recently adopted new and revised forms to request court authorization of psychotropic medications prescribed to foster children. These forms now require physicians to describe why they prescribed psychotropic medications not approved for a child this age. County staff can use this information to better ensure that foster children were properly prescribed psychotropic medications.
To improve the State’s and counties’ oversight of psychotropic medications prescribed to foster children, the Legislature should require Social Services to collaborate with its county partners and other relevant stakeholders to develop and implement a reasonable oversight structure that addresses, at a minimum, the concerns identified in this audit report.
To improve the State’s oversight of physicians who prescribe psychotropic medications to foster children, the Legislature should require the Medical Board to analyze Health Care Services’ and Social Services data in order to identify physicians who may have inappropriately prescribed psychotropic medications to foster children. If this initial analysis successfully identifies such physicians, the Legislature should require the Medical Board to periodically perform the same or similar analyses in the future. Further, the Legislature should require Health Care Services and Social Services to provide periodically to the Medical Board the data necessary to perform these analyses.
California Department of Social Services
To improve the oversight of psychotropic medications prescribed to foster children, Social Services should collaborate with the counties and other relevant stakeholders—including Health Care Services, as necessary—to develop and implement a reasonable oversight structure that ensures the coordination of the State’s and counties’ various oversight mechanisms as well as the accuracy and completeness of the information in Social Services’ data system. This structure should include at least the following items:
• Identification of the specific oversight responsibilities to be performed by the various state and local government agencies.
• An agreement on how county staff such as social workers, probation officers, and public health nurses will use printed Health and Education Passports to obtain foster children’s necessary mental health information—including psychotropic medications and psychosocial services—for inclusion in Social Services’ data system.
• A plan to ensure that counties have sufficient staff available to enter foster children’s mental health information into Social Services’ data system and the resources to pay for those staff.
• An agreement on the specific information related to psychotropic medication—including but not limited to the medication name, maximum daily dosage, and court authorization date—and psychosocial services and medication follow‑up appointment information that county staff must enter into Social Services’ data system for inclusion in foster children’s Health and Education Passports.
• Specific directions from Social Services regarding the correct medication start dates and court authorization dates counties should include in its data system and foster children’s Health and Education Passports.
• An agreement on the training or guidance Social Services should provide to county staff members working with Social Services’ data system to ensure that they know how to completely and accurately update foster children’s Health and Education Passports.
• An agreement on how the counties will use information on the new authorization forms that the Judicial Council approved to better oversee the prescription of psychotropic medications to foster children.
• An agreement regarding how counties will implement, use, or disseminate the educational and informational materials the Quality Improvement Project has produced, including the California Guidelines for the Use of Psychotropic Medication with Children and Youth in Foster Care, Questions to Ask About Medications, and the Foster Youth Mental Health Bill of Rights.
• An agreement on the specific measures and the best available sources of data the State and counties will use to oversee foster children prescribed psychotropic medications, including psychosocial services and medication follow‑up appointments.
• An agreement on how the State and counties will oversee psychotropic medications prescribed to foster children by fee‑for‑service providers who are not affiliated with county Medi‑Cal mental health plans.
• An agreement on the extent of the information related to psychotropic medications prescribed to foster children that counties will include in their responses to Health Care Services’ reviews, including its county Medi‑Cal mental health plan compliance reviews and external quality reviews.
California Department of Social Services and the Department of Health Care Services
To ensure that the Medical Board can promptly complete its analysis to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, Social Services and Health Care Services should continue to work with the Medical Board and its consultant to meet their data needs. If the Medical Board’s analysis is able to identify these physicians, Social Services and Health Care Services should enter into an agreement with the Medical Board to provide the information the Medical Board needs to perform similar analyses in the future.
Department of Health Care Services
To increase the State’s assurance that foster children do not receive medically inappropriate or unnecessary psychotropic medications, Health Care Services should devise and implement within six months methods to better enforce its prior authorization requirement for the off‑label use of psychotropic medications. For example, Health Care Services should revise its claims system to automatically prompt pharmacists to submit treatment authorization requests when filling prescriptions for Medi‑Cal beneficiaries under age 18 when the prescribed psychotropic medications have no FDA‑approved pediatric uses. Furthermore, as part of its collaboration with Social Services and the counties to develop and implement a reasonable oversight structure, Health Care Services should determine whether information from the Judicial Council’s revised court authorization forms would help it better enforce its prior authorization requirements.
Medical Board of California
To ensure that physicians do not inappropriately prescribe psychotropic medications to foster children, the Medical Board should take the following steps:
• Within 60 days, obtain and analyze the data from Health Care Services and Social Services to identify physicians who may have inappropriately prescribed psychotropic medications for foster children.
• Following the completion of this analysis, take the appropriate follow‑up actions that it deems necessary, including the investigation of physicians identified in its analysis.
• To the extent that its analysis is able to identify physicians who may have inappropriately prescribed psychotropic medications to foster children, the Medical Board should enter into an agreement with Health Care Services and Social Services within six months of completing its initial review to periodically obtain the data necessary to perform the same or similar analyses.
We conducted this audit under the authority vested in the California State Auditor by section 8543 et seq. of the California Government Code and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the Scope and Methodology section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.
ELAINE M. HOWLE, CPA
Date: August 23, 2016
Mike Tilden, CPA, Audit Principal
Dale A. Carlson, MPA, CGFM
Michelle J. Sanders
Oswin Chan, MPP, CIA
Molly Hogan, MPP
IT Audit Support:
Michelle J. Baur, CISA, Audit Principal
Lindsay M. Harris, MBA, CISA
Richard W. Fry, MPA, ACDA
J. Christopher Dawson, Sr. Staff Counsel
For questions regarding the contents of this report, please contact
Margarita Fernández, Chief of Public Affairs, at 916.445.0255.
13 The California Child Welfare Indicators Project is a collaborative venture between the University of California, Berkeley School of Social Work and Social Services that makes available child welfare administrative data to policymakers, child welfare workers, and the public on a website. Go back to text
14 The FDA‑approved label for trazodone lists somnolence, or sleepiness, as an adverse reaction. Go back to text