Letter to the Honorable Lynn Johnson, Assistant Secretary for Family Support of the Department of Health and Human Services - Grassley, Kaine Urge HHS to Move Forward on Recommendations to Help Foster Youth

Letter

Dear Ms. Johnson,

We are concerned to learn that the Department of Health and Human Services Office of Inspector General (OIG) determined that thirty-four percent of children in foster care who have been prescribed psychotropic medications did not receive treatment planning or medication monitoring. Children in foster care are more susceptible to potentially inappropriate prescribing and treatment with psychotropic medications.

These children are often prescribed antipsychotic medications at far higher rates than non-foster care children. Side effects of psychotropic medications can be severe, and should be carefully considered against the benefits. Foster youth are more likely than the general population to have severe mental health conditions that may require the use of psychotropic medications. However, it is clear that treatment planning and monitoring are crucial to ensuring the safety and long-term health of these children.

In September 2018 the OIG published a report demonstrating that states do not have adequate processes in place to ensure children in foster care who are prescribed psychotropic medications have proper treatment planning and monitoring. The OIG report further found that twenty percent of children in foster care on psychotropic received no treatment planning. Of the children who did receive treatment planning, fifty-two percent did not have a complete treatment plan. As you know, treatment planning is imperative to ensure continuity of care and reduce the risk of harmful side effects, especially among foster youth who are subject to frequently changing caseworkers, foster parents, and health care providers. Without adequate treatment planning, it is difficult for a child's caregivers to understand why medication has been prescribed, or the potential side effects or benefits of each medication.

Additionally, this report found that twenty-three percent of children in foster care who were prescribed psychotropic medications did not receive medication monitoring. It also found that professional practice guidelines were inconsistently incorporated in state monitoring requirements. Medication monitoring is crucial to preventing inappropriate dosing and adverse side effects from certain combinations of medications, and to ensuring successful longer-term management of the underlying condition.

The OIG report indicates that state-level officials recognize challenges in implementing state plans related to treatment planning and medication monitoring, and requested that the Administration for Children and Families (ACF) provide additional guidance and technical assistance, including national data for states to use as benchmarks, examples of successful strategies that other states have used, and assistance in improving communication between child welfare systems and Medicaid.

Accordingly, we request a response to the following questions:

Does the ACF intend to implement all of the recommendations of the OIG report?

If ACF does not intend to implement all recommendations, please provide a detailed explanation as to what recommendations ACF will implement and why. Please also provide a detailed explanation of what recommendations will not be implemented and why ACF has reached this decision.
ACF noted that there is already a "well-established approach to program implementation." However, the OIG report indicates that this approach is not sufficient to ensure state compliance with requirements related to treatment planning and medication monitoring. What steps does ACF intend to take to improve compliance with these requirements?

ACF noted that the OIG's recommendation would require statutory and regulatory changes to implement. What changes to law or regulation would be required to implement the OIG's recommendations to improve states' compliance with treatment planning and medication monitoring requirements?

What additional statutory authorities or monetary resources does ACF need to implement all of the OIG's recommendations?

Are there other changes to law that would allow ACF to be more effective in improving states' compliance with treatment planning and medication monitoring requirements?

The recommendation to assist states in developing monitoring requirements that incorporate professional practice guidelines recommends publishing a memorandum with specific mechanisms for child-level treatment planning and monitoring. Does ACF intend to publish this memorandum, and if not what does ACF intend to do to assist states in implementing child-level monitoring consistent with professional practice guidelines?

Does ACF intend to provide additional training or technical assistance for states related to incorporating professional practice guidelines beyond what is already available?

When children are removed from their homes and placed into foster care, the government is accepting, at minimum, the responsibility of providing a safe environment. It is critical that the Administration for Children and Families immediately take steps to ensure that states are providing treatment planning and monitoring to ensure that children are being prescribed psychotropic medications safely and appropriately.