Medical homes are critical components of comprehensive care systems for children and youth with special health needs (CYSHCN). They can reduce costs and improve outcomes and care experiences for CYSHCN and their families. This new report, State Strategies to Advance Medical Homes for Children and Youth with Special Health Care Needs, examines effective strategies used by 16 states to advance a medical home model of care for CYSHCN and their families, as part of the Maternal and Child Health Bureau, Health Resources and Services Administration’s State Implementation Grants to Enhance Systems of Services for CYSHCN through Systems Integration. Read the report.
Oklahoma uses focus groups to identify ways to improve treatment guidelines, communication, and medication monitoring for foster care youth enrolled in Medicaid.
May is National Foster Care Month and for the fourth consecutive year the number of children in foster care nationwide has climbed, fueled in part by the opioid epidemic, according to the Adoption and Foster Care Analysis and Reporting System’s most recent report.
|Oklahoma’s focus groups recommended:
Oklahoma is no exception, and recently it used some of its Children’s Health Insurance Program (CHIP) dollars to organize focus groups to identify ways to improve treatment guidelines, communication, and medication monitoring to better serve the needs of foster care youth enrolled in Medicaid.
As the number of youth in foster care rises nationwide, affecting multiple public service systems and programs including Medicaid, many state agencies are working together to ensure that their foster care youth receive appropriate health and support services.
State officials are acutely aware that these youth are more likely than others to be prescribed psychotropic medications. However, foster care youth are also more likely to have experienced one or more adverse childhood experiences or trauma that must be carefully considered in treating their behavioral health needs. While there are resources for states and new evidence from patient-centered research emerging, states may also be interested in conducting their own analyses, as Oklahoma recently did, to identify ways to improve services for this population.
The Oklahoma Health Care Authority (OHCA) used a Health Services Initiative (HSI) as a way to leverage its CHIP dollars to fund its innovative research. HSIs give states flexibility to use a portion of their CHIP administrative dollars to improve the health of low-income children through a range of different activities other than health insurance assistance.
In partnership with the Oklahoma Department of Human Services (DHS), OHCA contracted with Pharmacy Management Consultants to first conduct an extensive data analysis on the use of psychotropic medications and mental health services among the state’s foster care youth. Researchers used administrative paid claims data to measure how many different classes of psychotropic medications were prescribed to foster care youth and whether they also received psychotherapy.
Researchers Examine the Use of Psychotropic Medications in Foster Care Youth
Oklahoma’s quantitative analysis found that compared to the general Medicaid population, the foster care population had a higher proportion of prescription medication and targeted psychotropic medications use, including antipsychotics and anxiolytics, as well as drugs to treat attention deficit hyperactivity disorders, depression, and mood disorders. In addition, the presence of poly-class, meaning one or more classes of mental health medications used on the same day for 90 consecutive days, was significantly higher. Despite the higher medication use by the foster care population, the researchers reported that foster care youth on psychotropic medications were also more likely to have received targeted mental health services, such as psychotherapy, mental health assessment, and prescription management. However, use of psychotherapy was not consistent, especially among individuals with high poly-class use.
These findings led to the second stage of Oklahoma’s project. The state formed a planning team from OHCA and DHS to identify stakeholders engaged in the foster care system who might participate in focus groups and develop questions to help guide the focus group discussions. The primary aim of the focus groups was to better understand the experiences of different care providers—legal professionals, health care providers, social workers, and parents–who regularly interact with children in the foster care system in order to gather their perspectives on how to improve services. The focus groups sought to identify specific strategies to enhance collaboration, communication, and information-sharing among these different stakeholders. The state convened 11 focus groups with more than 72 participants.
Focus Groups Recommend Areas for Improvement
There was a wide range of perspectives across the focus groups on psychotropic medication use by foster care youth, but all expressed concern about over-prescribing. In particular, many thought medication was used before or instead of employing therapy, and was used to treat behaviors rather than the underlying medical condition. For instance, parent group members noted that trauma-related behaviors can present similar to ADHD, leading to misdiagnosis and inappropriate medication. One potential contributing factor identified by the focus groups was the shortage of psychiatric care providers, especially in rural areas. This shortage poses a burden on primary care providers to address the complex care issues of foster care youth.
The focus groups also highlighted communication issues and uneven access to information across stakeholders. When a child transitions to a new home, provider, or DHS case worker, it can result in a gap in care and incomplete information shared about a child’s medication and social history. Participants expressed the need for easily accessible electronic case records that include a child’s complete history and the creation of checklists to ensure that medications and personal property accompany a child during transitions. Participants also noted that medication changes and diagnoses are not consistently shared among all parties caring for the child, and when parties do collaborate the process is often disjointed or incomplete. In particular, the parent group expressed the desire for more information from providers about why a child is treated with a certain medication.
Interventions and Improvements
The focus groups also explored potential interventions to improve care for foster care youth enrolled in Medicaid. The proposed solutions were grouped into four main categories: education, guideline development, communication improvements, and psychotropic medication monitoring. Some of the suggestions include:
- Education across all stakeholder groups on the complex care needs of foster care youth;
- Development of diagnosis and treatment guidelines that include cognitive or behavioral therapy options before psychotropic medications;
- A team approach to care to increase consistency in communication including regular meetings between all members caring for the child; and
- Increasing the number of mental health care providers, especially in rural areas, to provide specialized care
These recommendations provide important insights into the unique care needs of the Medicaid foster care population. The use of focus groups added valuable perspectives from those who regularly interact with this population as well as helped identify key ways to improve the delivery of care to children in the foster care system.
Results of this project have recently been finalized, but with long-term federal CHIP funding now secured, Oklahoma is considering other ways to continue work in this area. This project and Oklahoma’s creative approach of leveraging HSI funding may provide a potential model for other states interested in pursuing a short-term project aimed at improving the health of foster care children.
Medicaid managed care provides a unique opportunity for states to strengthen the structure and delivery of care for children and youth with special health care needs (CYSHCN). The National Academy for State Health Policy (NASHP), studied how six states (Arizona, Colorado, Minnesota, Ohio, Texas, and Virginia) designed their managed care systems to serve CYSHCN and examined some of their best practices and strategies to meet the unique needs of these children in three reports:
- How States Structure Medicaid Managed Care to Meet the Unique Needs of Children and Youth with Special Health Care Needs and an accompanying chart that provides an Overview of Selected State Medicaid Managed Care Programs
- Structuring Care Coordination Services for Children and Youth with Special Health Care Needs in Medicaid Managed Care: Lessons from Six States
- State Strategies to Enhance Medicaid and Title V Partnerships to Improve Care for Children with Special Health Care Needs in Medicaid Managed Care
These studies reveal that while there is variation among states in the design, scope of services, and targeted populations, there are strategies that states can employ in Medicaid managed care to ensure delivery of quality care for CYSHCN, including:
- Assessing the needs of CYSHCN to better coordinate care;
- Establishing network requirements for specialty providers;
- Promoting continuity of care during transitions; and
- Creating quality measures around processes and outcomes.
These three studies build on NASHP’s 50-state scan of Medicaid managed care systems serving CYSHCN and states’ use of Medicaid quality metrics for CYSHCN.
These resources were developed with support from the Lucile Packard Foundation for Children’s Health and the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number UC4MC28037 Alliance for Innovation on Maternal and Child Health.
As states and juvenile justice stakeholders work to facilitate health coverage and access for system-involved youth, they can draw upon the experiences of their counterparts across the country to improve eligibility, enrollment, and outreach processes. Medicaid eligibility strategies in several states have already facilitated seamless coverage for juvenile justice-involved youth, and consumer assistance programs created by the Affordable Care Act (ACA) will provide additional resources to support continuity of care. Key to the success of these strategies will be ongoing collaboration between the multiple state and federal agencies that interact with the juvenile justice population.
The federal and state strategies outlined in this report were informed by policy research conducted by NASHP through its Models for Change project, funded by the MacArthur Foundation, and by discussions from an in-person meeting held in July 2013.
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In May 2006, the National Research Council/Institute of Medicine’s (NRC/IOM’s) Board on Children, Youth and Families (BCYF) convened the Committee on Adolescent Health Care Services and Models of Care for Treatment, Prevention, and Healthy Development. With funding from The Atlantic Philanthropies, the committee conducted a study of health services for adolescents ages 10-19 in the United States and issued a report, Adolescent Health Services: Missing Opportunities. The National Academy for State Health Policy has written this paper based upon that report to highlight aspects of the publication most relevant for and applicable to state policymakers, who play an important role in improving adolescent health.
The adolescent health care system suffers from problems similar to the rest of the U.S. health care system, including a heightened focus on acute and episodic care, and fragmentation that causes specialty services to be unaffordable or inaccessible. States, in their roles as purchasers, regulators, and coordinators, have the opportunity to improve the adolescent health care system in a variety of ways to better meet the unique needs of this population.
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This report examines both why and how state Medicaid programs can support children’s healthy mental development and includes a discussion of how states can use Medicaid to better support young children’s social/emotional development even in the current economic climate. It includes specific strategies Medicaid agencies can use (and have used) to support young children’s healthy mental development.
This brief summarizes presentations made at NASHP’s 2004 annual state health policy conference during a session on “Promoting Young Children’s Healthy Mental Development.” The session focused on the evidence base, state program highlights, a discussion of the ABCD program, and ways to use the Medicaid program to better support early childhood social and emotional development.
This paper examines issues related to screening children for developmental disabilities and problems. It examines the ways in which screening tools differ from one another and the challenges that are often faced by those working to integrate screening tools in medical practices. The paper is designed to provide states with a framework for evaluating developmental screening tools for young children so that state officials are equipped to make informed decisions and to work with pediatricians, parents, and other stakeholders in strengthening services to young children. The paper also includes summary information on 17 different tools.
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This report examines how states are addressing the healthy mental development of children ages birth to 3 and is based on a survey of Medicaid, maternal and child health, and children’s mental health agencies in all 50 states and the District of Columbia. The report addresses critical issues confronting states, common approaches to addressing them, and promising new initiatives that states have undertaken to improve systems of care for young children’s social/emotional development.
This paper summarizes the results of a meeting convened as a means of engaging state, federal, provider, and consumer experts from the child mental health and maternal child health fields in a conversation about how to develop stronger collaborative approaches to improve systems for child and adolescent mental health.
The meeting was based on the premise that meeting child and adolescent mental health needs requires a continuum of services. This continuum includes promotion of social and emotional health and development, as well as prevention, early intervention, and care for mental health conditions affecting children and adolescents. While the discussion broadly considered the continuum of services for child and adolescent mental health, it had a strong focus on the promotion and prevention end of the continuum.
The paper examines the four primary discussion themes, discusses elements of a pathway toward better systems, and looks at next steps to move ahead.