Gabriel Myers Workgroup by pnq48299

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									                                Gabriel Myers Workgroup
                                       July 6, 2009
                                  Tallahassee, Florida


Workgroup Members and Advisors Present:              Jim Sewell, Chairman
                                                     Robin Rosenberg
                                                     Rajiv Tandon
                                                     Anne Wells
                                                     Bill Janes
                                                     Mike Haney
                                                     Theresa Flury
                                                     Betty Busbee

CALL TO ORDER

The fourth meeting of the Gabriel Myers Workgroup was called to order at 9:08 a.m.
Chairman Sewell welcomed meeting attendees and introduced Steve Holmes, newly
appointed Regional Director for the Department of Children and Families, Northwest
Region.

WORKGROUP INTRODUCTIONS

Chairman Sewell asked the workgroup members and advisors to introduce themselves.

UNIVERSITY OF FLORIDA CONTRACT FOR MEDCONSULT AND PRE-
CONSENT SERVICES

Dr. Jane Streit, Senior Psychologist, Department of Children and Families, Mental Health
Program Office, was recognized and provided a PowerPoint presentation regarding the
University of Florida MedConsult and PreConsent Services contract.

Dr. Streit advised that, in the 1990s, numerous studies raised concerns regarding the
increase in the rates of prescriptions for psychotropic medications for all children
nationwide. The finding that was most concerning was the higher rate for children in the
child welfare system in all states. As a result, advocates in Florida called for increased
oversight.

Dr. Streit continued that in July 2003, the Florida Statewide Advocacy Council issued the
Red Item Report on Psychotropic Drug Use in Foster Care, and made a number of
important recommendations. Those recommendations included:

   Develop and implement a quality assurance program for monitoring the use of these
    drugs in children.

   Develop a plan of care to include counseling for anger, self-esteem, positive
    reinforcement, dealing with fear and attitude, and character building traits.

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   Ensure that appropriate standardized written informed consent is obtained prior to
    starting any child on psychotropic medication. This consent should include
    information about any risks and expected benefits, including possible side effects and
    alternative treatments.

   Ensure that everyone who administers psychotropic medications to children in a
    foster care setting is trained to recognize the side effects of medications.

   Ensure that pediatric psychiatrists perform medical examinations prior to
    implementation of these drugs.

   Ensure that foster care records for each child contain organized information and that
    medical records are easily found.

   Ensure when more than one physician is ordering medications that Medical Passports
    are current and made available to each physician.

Dr. Streit outlined Department of Children and Families Initiatives that occurred
following the recommendations of the Statewide Advocacy Council. Those initiatives
included:

   In June 2003, the Mental Health Program Office published the first edition of
    Medication for Children and Youth with Emotional, Behavioral, and Mental Health
    Needs: A Guidebook for Parents, Guardians, and Others.

   In 2004, the Department contracted with the Department of Psychiatry at the
    University of Florida for a “MedConsult” line.

   PreConsent service was added in May 2005.

   In 2004-2005, Department staff reviewed Agency for Health Care Administration
    (AHCA) claims for psychotherapeutic medication to track changes and trends.

   Language specific to psychotherapeutic medications was added to Chapter 39, Florida
    Statutes, in 2004.

   Additional guidance was provided in Judicial Rule 8.350.

Dr. Streit continued that the purpose of the MedConsult line is to assist decision makers
who give express and informed consent for psychotropic medication for dependent
children or children enrolled in the Behavioral Health Network (BNET). It is not a
second opinion, and participation is voluntary.

Dr. Streit added that parents and children receiving services from the dependency system
or BNET, physicians, case managers, DCF staff, Children’s Legal Services, court
personnel, and Guardians or Attorneys Ad Litem may call the MedConsult line.


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Dr. Streit advised that, for fiscal year 2008-2009, the majority of callers were Guardians
Ad Litem (66.75 percent) and Attorneys (24.31 percent). Also, callers represented fifteen
of the 18 circuits. Suncoast Region had the greatest percentage at 42 percent, followed
by Circuit 18 at 13 percent and Circuit 8 at 7 percent.

Dr. Streit continued that information given by MedConsult regarding medication
includes:

   Indicated uses/usual and customary practices (ranges, starting dose, etc.).

   Black Box warnings.

   On or off label use.

   Any precautions such as EKGs, lab work, etc.

Dr. Streit presented a chart reflecting the number of the calls to the MedConsult line from
its inception (July 2004) through May 2009. Information on that chart indicates that, by
May 2009, there had been almost as many calls to the MedConsult line as there had been
during all of fiscal year 2007-2008.

Dr. Streit continued that the PreConsent service was added in May 2005 to provide for
increased oversight for children ages 0-5 who were prescribed psychotropic medication.
Training was provided for case workers statewide at the time on the new service. That
training is still available on SkillNet.

Dr. Streit advised that the PreConsent process is detailed in Department of Children and
Families Operating Procedure 175-98. It is also described in 65C, Florida Administrative
Code. The case manager completes the demographic portion of the form and then takes
the form to the doctor’s office. The case manager is responsible for faxing the form to
the University of Florida, and, if the consultant concurs with the plan, they typically
complete and return the form to the case manager within one business day. The case
manager faxes a copy to the prescribing physician, files a copy in the child’s record, and
delivers a copy to the individual with legal authority for providing informed consent or to
the child welfare legal attorney who will file the motion for court authorization for
psychotherapeutic medication treatment.

Dr. Streit continued that there are two other things that happen in the PreConsent process.
If further information is needed or the consultant does not concur with the prescribing
practitioner’s treatment plan, the consultant will contact the prescribing practitioner by
telephone to discuss the treatment plan. If the consultant is unable to obtain the
information needed to provide a completed review, the consultant will note that inability
on the form.

Dr. Streit advised that on the basis of the information provided, the University of Florida
physician either:

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   concurs with the treatment plan,

   concurs with the treatment plan with modifications,

   asks for the specific information to provide an opinion regarding the child’s
    psychotherapeutic medication treatment, or

   does not concur with the identified treatment plan and recommends an alternative
    plan.

Dr. Streit continued that there were a total of 64 PreConsent service consultations for
fiscal year 2008. Fifty percent of the requests came from the Suncoast Region. The
University of Florida consulting psychiatrists did not concur or needed more information
for 22 percent of those consultations.

Dr. Streit shared charts indicating the rate of growth in PreConsent requests from May
2005 to May 2009 and the number of PreConsent requests for 2009. PreConsent requests
for 2009 reflected an increase beginning in May.

Dr. Streit advised the current contract with University of Florida for MedConsult and
PresConsent Services is funded through Children’s Mental Health, and the base cost is
$84,865. The cost per MedConsult averages $100, and the average cost per PreConsent
is $59. If the current demand continues, funding for an additional 7 hours per week
would be required to achieve the contracted response time. Dr. Streit continued that the
concept of clinic hours (a model used at the beginning of the contract) as well as a web-
based application for PreConsent service have been suggested and may be possible in the
future.

Questions/Comments/Discussion

1. With regard to the publication Medication for Children and Youth with Emotional,
   Behavioral, and Mental Health Needs: A Guidebook for Parents, Guardians, and
   Others, Ms. Rosenberg inquired about its original implementation, distribution and
   current status.

    Dr. Streit responded that the publication was updated in 2005. Work is currently
    underway to update the publication to include information on questions to ask about
    medication and additional resources.

    Dr. Tandon added that he understood the initial version was printed and disseminated
    widely, including to all community base care providers. The 2005 version is
    currently available on the Florida Mental Health Institute website (Child Welfare
    Portal).




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2. Dr. Tandon and Colonel Janes both commented on the number of resources available,
   such as the MedConsult and PreConsent service, and the lack of utilization of those
   resources by appropriate parties prior to the death of Gabriel Myers.

   Ms. Flury responded that the Guardian Ad Litem Program has a statewide protocol
   requiring a second opinion, and, many times, the MedConsult line is used. She noted
   that it is difficult to get through to the MedConsult line and that often one is required
   to wait a week or more for a response. She added that many of the Guardian Ad
   Litem Circuit Directors have engaged local pediatricians and child psychiatrists as
   volunteers and Guardians and call upon their expertise for second opinions.

   Dr. Streit commented on the increased demand on the MedConsult line since the
   Gabriel Myers incident and stated that discussions are occurring with the University
   of Florida regarding possible enhancements/improvements. She added that, at the
   present time, the MedConsult line is scheduling in August for calls from June, and the
   PreConsent requests are not far behind.

3. Colonel Janes asked how the activity of the MedConsult line and the PreConsent
   service is monitored.

   Dr. Streit responded that the Department receives a monthly report from the
   University of Florida on the number of calls, as well as a copy of all the MedConsults
   that are completed. The University of Florida also provides quarterly and yearly
   reports on utilization, recommendations made, etc.

4. Colonel Janes asked if the PreConsent process detailed in CFOP 175-98 is working as
   it should.

   Dr. Streit responded that it is not working as it should consistently.

5. Ms. Rosenberg asked for the required response time for the MedConsult line and
   PreConsent service under the contract.

   Dr. Streit advised that the contract provides for a 5-day response time for MedConsult
   and 1-day response time for PreConsent service when there is agreement. If there is
   not agreement, the response time is 3 days from the date of contact with the physician
   if more information is needed.

GUARDIAN AD LITEM PROGRAM

Theresa Flury, Executive Director of the Statewide Guardian Ad Litem Office, was asked
to address the workgroup regarding psychotropic medication. She advised that the
Guardian Ad Litem Program has been more reactive than proactive in the past regarding
psychotropic medication. Ms. Flury is taking actions to reverse this trend. She is
working to make each of her Circuits ensure that a Guardian is appointed to every child
that is on medication. The Program has developed a visitation form, now incorporated
into their training, which is completed at every home visit. The form requires the

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volunteer to ask questions, including is the child on medication. If the child is on
medication, the volunteer has to look at the container and note the prescribing physician
and dosage information. She noted that she does not believe it is appropriate for the
Program to wait on notification from the community based care case manager that a child
is prescribed a psychotropic medication.

Ms. Flury continued that it would be helpful if the Guardian Ad Litem Program was
copied on consents and that consents/orders include a list of all medications a child is
taking. This would enable the Guardians to be aware of medication status. Ms. Flury
added that the Guardians are not necessarily as concerned about making sure the
informed consent/court order procedures are followed, but rather with ensuring that the
medication is appropriate for the child. She continued that this is extremely difficult
when you are not a medical professional, and that it is a fine line for all involved to walk
in just gathering information that questions a medical professional. She added that
Guardians are asked to gather as much information as possible in talking to either the
MedConsult line or volunteers with medical expertise and share it among all the parties.

Questions/Comments/Discussion

1. Dr. Streit suggested that it would probably be helpful to have target symptoms listed
   as well.

2. Robin Rosenberg suggested that the Guardian Ad Litem visitation form, as well as the
   medication log that is maintained in the home, should include the name/location of
   the pharmacy used for each prescription.

3. Dr. Tandon commented on the importance of the prescribing physician having
   adequate information and the need for a system to ensure that the information is
   provided.

   Ms. Flury responded that the Guardian Ad Litem Program is trying to get the
   Guardians to not just rely on calling the MedConsult line or other experts, but to talk
   with teachers, caregivers, family members, etc., to get their understanding of
   behaviors being demonstrated. She stressed the importance of a communication
   protocol between the Guardians and the case workers, noting that the Guardians often
   have more time to gather information from other sources than case workers. She
   added that there needs to be a stronger working relationship between all parties
   involved.

4. Dr. Tandon asked Ms. Flury for her thoughts on the role of the Guardian.

   Ms. Flury responded that the Guardian’s only focus is the child, and that she thinks
   the Guardian should be as involved as the case worker, including talking to teachers,
   family members, foster parents, and the child to get an understanding of what is
   occurring in the child’s life.




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5. Colonel Janes asked Ms. Flury to provide a document or talk with the workgroup
   within a few weeks about where the Guardian Ad Litem is effectively linked and
   what should be looked at to strengthen their role within the context of the
   team/community.

UPDATE ON QUALITY ASSURANCE REVIEW

Dr. Sewell announced that one of the agenda items at each workgroup meeting is an
update on the Department’s Quality Assurance Review. At the last meeting, the report
presented was on the cohort of children 0-5 years old. Dr. Sewell reminded everyone that
the review, when it is completed, will include all children in out-of-home care who are
receiving psychotropic medications.

David Daniels, Family Safety Program Office, provided a PowerPoint presentation on the
findings of the Special Quality Assurance Review of children ages 6 and 7 in out-of-
home care on psychotropic medications.

Mr. Daniels stated that, as a result of Secretary Sheldon’s directive, a review of all
children on psychotropic medications in out-of-home care began on June 3. The first
phase included the cohort of children 0-5 years old. That phase was completed, and the
next phase began on June 10 and concluded on June 23. The review team consisted of
Department of Children and Families and community based care provider staff with
ongoing consultation from Children’s Legal Services. The review team looked
particularly at whether or not cases were compliant with statute and rule and the validity
and reliability of the data in Florida Safe Families Network (FSFN), the Department’s
centralized data system.

Mr. Daniels advised that key findings in this phase of the review include:

   Children ages 6-7 on psychotropic medication represent 14 percent of the total
    population of children in this age group who are in out-of-home care.

   Of the 268 children ages 6-7 years old, 85 percent have a DSM diagnosis of ADHD.

   Parental rights were terminated in 103 (38 percent) of the cases.

   Of the 424 psychotropic medications prescribed, 255 (60 percent) were prescribed by
    a psychiatrist.

   55 percent of the children were prescribed only one psychotropic medication, and 34
    percent were prescribed two psychotropic medications. The remaining 11 percent
    were prescribed more than two psychotropic medications.

   The prescribing practitioner did not complete the Psychotherapeutic Medication
    Treatment Plan as required in 65C-28.016 in 231 cases (86 percent).



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   Informed consent or a court order was absent for 200 (47 percent) of the psychotropic
    medication prescriptions.

   Supervisory discussions with case managers regarding the child’s health care and
    behavioral health care were not documented in 187 cases (70 percent).

   FSFN data errors included: parental consent data were inaccurate in 121 cases;
    dosage errors were noted in 108 cases; and court order data were inaccurate in 76
    cases.

Mr. Daniels shared charts and graphs reflecting various findings of the review team. This
included:

   a depiction of the number and percentage of children ages 6-7 in out-of-home care on
    psychotropic medication by Community Based Care Lead Agency.

   a depiction of the DSM IV-R diagnosis for children age 6-7.

   a break-out of type of practitioner prescribing the medication (60 percent were
    psychiatrists, and seventy percent of the time, the medication was prescribed by a
    board certified practitioner).

   a comparison of children prescribed a psychotropic medication compared to the total
    number of children ages 0-7 in out-of-home care.

   population of children taking psychotropic medication compared to the remainder of
    the children in out-of-home care by race and gender.

   a depiction of the legal status of children ages 6-7 prescribed a psychotropic
    medication.

   a representation of the number of psychotropic medications children ages 6-7 are
    prescribed: 55 percent (147) were prescribed 1 medication; 34 percent (92) were
    prescribed 2; 9 percent (23) were prescribed 3; and 2 percent (6) were prescribed 4
    (there was one child with 5 medication prescribed).

   the current status of children ages 6-7 on psychotropic medication at the time of
    removal: 31 percent (82) were on medication at the time of the most recent removal;
    69 percent (186) were not.

   a depiction of whether or not the medical history was provided to the prescribing
    practitioner: In 25 percent (67) of the cases, the case manager provided medical
    information to the prescribing practitioner; in 75 percent (201), the information was
    not provided.




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Mr. Daniels continued that there have been several questions about family engagement
requirements, keeping the parents involved, and getting informed consent. He added that
the agency worker is responsible for contacting the child’s parent or legal guardian as
soon as is feasibly possible upon learning of a recommendation for psychotropic
medications, if the parent can be located and parental rights have not been terminated.
Contact may occur in person, via telephone, or via written notice to the parent’s last
known address. He presented charts and graphs representing the following findings
related to family engagement:

   the case manager attempted to contact the parent/guardian 41 percent of the time (67
    cases) and did not 59 percent of the time (95 cases).

   the case manager involved the parents/guardians in the whole decision process 66
    percent of the time (115 cases), and did not 34 percent of the time (68 cases).

   the agency worker ensured that the parent or legal guardian received all written
    information concerning the prescription(s) or that written information was sent to the
    parent’s last known address 24 percent of the time (42 cases), but did not do so 76
    percent of the time (131 cases).

Chairman Sewell asked Mr. Daniels to break from his presentation to allow Secretary
Sheldon to make comments.

COMMENTS BY SECRETARY SHELDON

Secretary Sheldon thanked the workgroup members for their work. He noted that, as he
talks to his counterparts around the country, he believes that the review being conducted
is probably the most comprehensive review of psychotropic medication ever done of the
child welfare population. He noted that as he reviews reports, he is seeing that a certain
consistency is beginning to develop in the entry of the data. The data reflecting the
number of children in the system that are on some form of psychotherapeutic medication
have been consistent for the last 30 days, and the number of children in the system
without consent has dropped from 35 percent when the review began to 16.12 percent.

He also stated that it is important to develop the kind of expertise in our case managers
with the kind of training, experience, and dedication so that the right decisions are made
at that level as opposed to developing another form, rule, or regulation. Secretary
Sheldon advised that Children’s Legal Services is now proactively working with case
managers and community based care providers in terms of the training necessary for front
line staff. He added that he is looking forward to the workgroup’s findings and the
recommendations developed by the Task Force on Fostering Success.

UPDATE ON QUALITY ASSURANCE REPORT - continued

Mr. Daniels continued with presenting charts and graphs representing findings related to
family engagement, court authorization, treatment plans, behavioral health concerns, and
FSFN data errors:

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   Before the agency provides psychotropic medications to a child in its custody, the
    agency must engage the parent or legal guardian concerning express and informed
    consent prior to requesting a court order for psychotropic medications. This occurred
    42 percent of the time (59 cases) and did not occur 58 percent of the time (81 cases).

   The agency worker made concerted efforts to facilitate contact between the parent or
    legal guardian and the prescribing practitioner in order for the parent or legal
    guardian to be as educated as possible regarding their consent for the child’s use of
    psychotropic medication(s). This did occur in 24 percent of the cases (42) and did not
    in 76 percent of the cases (131).

   When express and informed consent could not be obtained from the child’s parents,
    the agency worker submitted a request for court authorization to provide the
    psychotropic medications to Children’s Legal Services within 12 working hours of
    receipt of the prescription. This occurred in 17 percent of the cases (46) and did not
    occur in 89 percent of the cases (214).

   The prescribing practitioner completed the medical sections of the treatment plan 14
    percent of the time (37 cases) and did not complete the medical section of the
    treatment plan 86 percent of the time (231 cases).

   In 30 percent of the cases (81), the required quarterly supervisory review covered the
    psychotropic medication, and in 70 percent of cases (187), it did not mention the
    psychotropic medications.

   FSFN data were accurate for informed consent in 32 percent of the cases (58) and
    was inaccurate in 68 percent of the cases (121).

   FSFN data were accurate for court orders in 64 percent of the cases (133) and
    inaccurate in 36 percent of the cases (76).

   FSFN data were accurate for types and dosages of psychotropic medication in 60
    percent of the cases (160) and inaccurate in 40 percent of the cases (108).

Mr. Daniels continued that, when Special Quality Assurance Review team found
problems with a case, a Request for Action form was forwarded to case management for
action. He noted that a case could have more than one Request for Action. He presented
a chart indicating the number of Request for Action referrals by type, which indicated the
following:

   9 referrals for child safety

   139 referrals for missing consent or order for any medication

   216 referrals for Missing Treatment Plan form for any medication


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   157 FSFN Data Entry error(s) referrals

   42 “other” referrals

   No RFA required in 19 cases

Mr. Daniels concluded his presentation with the following update of actions underway:

   A Request for Action (RFA), the form used to alert management that follow-up was
    needed, was completed for 582 concerns.

   Cases identified without documentation of informed consent or court orders are
    referred to Children’s Legal Services to notify the court that the Department is
    seeking a valid informed consent or a court order.

   On June 24, the Special Quality Assurance Review was extended to children ages 8-9
    in out-of-home care who are prescribed psychotropic medications. This review
    includes 393 children and will be completed on July 14.

   Quality assurance teams will begin to review cases of children ages 10-11 who are on
    psychotropic medications on July 15.

   A validation review has been established that requires weekly reporting to the Acting
    Assistant Secretary for Operations on the status of corrective action for each
    deficiency noted by quality assurance teams.

Questions/Comments/Discussion

1. Dr. Wells asked, if when a discrepancy is found between the FSFN data and
   information contained in the case file regarding medication dosages, any further
   action is taken to determine what information is correct to actually reconcile the error.
   She also asked if the review team is following up on Requests for Action referrals to
   ensure appropriate action is taken by case management.

    Mr. Daniels responded that follow up on the Request for Action referrals is being
    looked at as the next step once all children in out-of-home care on psychotropic
    medication have been reviewed.

2. Dr. Tandon commented that he thought what Dr. Wells was suggesting by reconciling
   the error with regard to dosage discrepancies is that someone actually looks at the
   bottle of medication or calls the pharmacy to determine the correct dosage.

    Chairman Sewell added that he thought this was good suggestion, and asked that
    Acting Assistant Secretary John Cooper include it in discussion at the next weekly
    psychotropic medication meeting.


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3. Colonel Janes commented that it would be useful to have a one-year snapshot of
   information on how the percentages for children out of the foster care system on
   medication compare to those in out-of-home care on medication. He indicated that
   some of his past reading suggests a higher percentage of emotional disturbances
   among youth in foster care, and, in many cases, a problem of medicating. He added
   that he would also be interested in looking at how many of the children in the child
   welfare system are getting the appropriate care for emotional disturbances and how
   that compares to those children who are not in the state’s custody.

4. Dr. Armstrong stated that prevalent studies conducted nationally indicate that
   between 40 and 60 percent of children who are in the custody of the child welfare
   system have mental health needs. That leaves completely unanswered whether those
   needs were assessed properly and whether the assessment’s recommendations were
   carried out.

CASE MANAGEMENT FOR CHILDREN ON PSYCHOTHERAPEUTIC
MEDICATION

Ms. Daphne Smoker, Lead Dependency Case Manager with Children’s Home Society in
Bay County, which is a Big Bend Community Based Care partner, was introduced to
discuss case management and answer questions from the workgroup.

Ms. Smoker advised that she has worked as a dependency case manager for
approximately 4-1/2 years. She indicated that the pre-service training she completed at
that time did not include training regarding psychotherapeutic medication. She added
that training on family engagement and psychotherapeutic medication has been
developed and is scheduled in her Circuit over the next month and a half.

Ms. Smoker shared that she sees the case manager as the “middle man” or the person
who is responsible for keeping track of what is happening and coordinating the process.
She added that a portion of her workload includes facilitating contact between the
prescribing doctor and the parent; getting information from the prescribing doctor to the
court in cases where parental rights are terminated or the parent is deceased or cannot be
located; securing treatment plans; and creating the Child Resource Record. She noted
that her typical work day varies, but can include sitting in court, being in the office to do
paperwork, and doing field work such as home visits and school or daycare visits. She
added that as a lead dependency case manager, she has a lower case load of 10 children,
while other case managers in her unit have approximately 15.

Questions/Comments/Discussion

1. Dr. Haney asked Ms. Smoker to help the workgroup members understand obstacles
   the case manager faces in obtaining informed consents.
   Ms. Smoker responded that a lack of understanding of informed consent and the
   informed consent process has been a problem in the past. She also noted sometimes a
   barrier exists when a child is in a specialized therapeutic foster care or SIPP
   placement in another county, and the case manager has to rely on a courtesy worker

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   in the county of the placement. She added that one of the children on her caseload
   on psychotherapeutic medication is in specialized therapeutic foster care in Duval
   County. She noted that she is fortunate in this instance because Duval County has a
   strong system in place and the child has a psychiatrist, a courtesy worker, a therapist,
   and a targeted case manager.

2. Chairman Sewell stated that the workgroup has heard discussions regarding the
   difficulty of adding data regarding psychotherapeutic medication to FSFN and asked
   Ms. Smoker to share her thoughts.

   Ms. Smoker responded that FSFN has become more user friendly as new releases
   have been added, but noted that it has, in the past, been a difficult system to work
   with. She added that a specific problem she is having is actually getting the
   information timely from the foster parent on prescription refills and keeping FSFN
   updated.

3. Colonel Janes asked Ms. Smoker to explain the role of the targeted case manager.

   Ms. Smoker explained that a targeted case manager works directly with the therapist
   and the psychiatrist in implementing the treatment plan.

4. Chairman Sewell asked Ms. Smoker to share what she sees as ideal with regard to the
   to Children’s Legal Services and court orders for psychotherapeutic medication.

   Ms. Smoker responded that ideally it would be that the case manager provides the
   necessary information to Children’s Legal Services and obtaining the court order
   becomes priority. She added that, unfortunately, in the realm of child safety, there are
   other things that take priority in keeping children safe, such as shelter hearings and
   changes in visitation, so the medication issue sometimes gets put on the back burner.

5. Dr. Tandon asked Ms. Smoker if she felt the case manager should attend all medical
   appointments with the child.

   Ms. Smoker responded that attending all medical appointments would be ideal;
   however, it is not always possible, especially in instances when a child is placed out
   of county.

6. Colonel Janes inquired if the psychiatrist routinely participates in multidisciplinary
   staffings, and at what frequency the team should meet for a child that has been
   medicated.

   Ms. Smoker responded that they don’t normally participate; however, she can contact
   him/her if necessary. She added that she believes the team should meet at least once
   every 90 days.




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7. Colonel Janes asked Ms. Smoker what she would estimate to be the highest case load
   a case worker can effectively manage, realizing the complications that differ for each
   child.

    Ms. Smoker responded that, 4-1/2 years ago, her caseload was between 40 and 50
    children. As a Lead Dependency Case Manager, her current case load is 10. She
    added that she would estimate between 20 and 25 as the highest case load a case
    manager can effectively manage.

    Emilio Benitez, Chief Executive Officer of ChildNet, noted that it is also important
    when talking about case loads that it should be in terms of children per case worker,
    and the Children’s Welfare League of America has set a standard that no more than
    20 children per case worker is best practice.

    Mr. Cooper responded that some areas of the state actually have less than 20, but
    statewide the average is about 20.

    Mike Watkins, Chief Executive Officer of Big Bend Community Based Care, added
    that in Bay County, the average is 14-15 children per case load. He added that in all
    Big Bend Community Base Care counties, the number of children per case load is
    under 20, and in some counties that number is well under 20.

CASE PROFILES OF CHILDREN ON PSYCHOTROPIC MEDICATION

Dr. David Fairbanks, Assistant Secretary for Programs with the Department of Children
and Families, was recognized to introduce Dr. Mary Armstrong. Dr. Armstrong is an
Associate Professor and Director of the Division of State and Local Support for the
Department of Child and Family Studies at the Florida Mental Health Institute,
University of South Florida. He added that she is a well-respected national leader as a
researcher, a scholar, and an expert in mental health and social service systems that serve
children and families. He continued that Dr. Armstrong and her research team at
University of South Florida developed 12 individualized child profiles to better inform
the workgroup about the children served in the child welfare system who are also taking
psychotropic medications.

Dr. Armstrong began that the purpose of the child profiles is to provide real-life
individual case studies of a sample of children in out-of-home care who are on
psychotropic medications. She encouraged workgroup members to read the profiles and
added that they are very elucidating around the range of children, their life experiences,
why they are on psychotropic medication, and how they are doing now.

Dr. Armstrong shared that a purposive sampling methodology was used in developing the
profiles because that method is typically used in qualitative research studies, and a
sample of 16 children (12 plus 4 backup) was drawn. Four sampling criteria were used:

   Geographic location (the state was divided into 3 regions; north, south, and central).



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   The age of the child (the children were divided into 3 age ranges; 5-8 years of age, 9-
    12 and 13-18).

   The number of psychotropic medications the child was on (one medication or more
    than one medication).

   Whether or not the child was receiving mental health treatment (yes/no).

Dr. Armstrong continued that the study team consisted of 7 Florida Mental Health
Institute staff with previous experience as a child protection case manager, clinical
expertise and background, and expertise in the review of case records.

The following guiding rules were established by the study team.

   The focus should be child centered.

   The team would make no clinical judgments.

   The team would not critique the handling of the case, the case manager, or the
    system.

   There would be no identification of patterns, themes, data interpretation, or
    conclusion.

   No recommendations would be made.

   The team would try to paint a picture of each child.

Dr. Armstrong continued that the Department of Children and Families provided FSFN
data for each child in the study team’s sample. The team members reviewed the FSFN
record, developed the profile using a protocol outline, and then contacted the child’s case
manager to verify current status of the child and to capture as much as possible about the
child’s strengths, interests, and skills.

Dr. Armstrong closed her presentation by sharing information from the profile of
Wynona, one of the children in the study team’s sample.

Questions/Comments/Discussion

1. Dr. Tandon asked that Dr. Armstrong to explain the purpose of the records review.

    Dr. Armstrong responded that the purpose was just to let the workgroup have a sense
    of the great variety among the types of children that are on medication, the severity of
    their problems, what kinds of medications they are on, and how they are doing now.

2. Dr. Scott Benson, Child Psychiatrist, was in the audience and commented that, in
   much of his own clinical experience, the therapy that is being provided to children all

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   Dr. Armstrong followed that she agreed with Dr. Benson and added that, in the
   Panhandle, Children’s Home Society has received a grant from the National Child
   Traumatic Stress Network. They are implementing trauma informed cognitive
   behavioral therapy with children in out-of-home care from Families First Network,
   the community based care lead agency in that area. She also mentioned the new
   interagency workgroup that is looking at trauma informed care for all children who
   are out of home in Florida, including the juvenile justice system.

3. Dr. Joseph Chiaro, Deputy Secretary for Children’s Medical Services, advised that
   the Department of Health, in concert with the Department of Children and Families,
   convened an interagency meeting earlier this year and brought in Dr. Abraham
   Bergman, who has looked very carefully at the issue of foster children and what does
   and does not happen to them. He stated that, in Florida, foster children are being
   failed in that a comprehensive evaluation of these children, medically, behaviorally,
   or psychosocially, is not being provided in a timely manner. He added that he
   believes there does need to be a single individual who becomes the parent/responsible
   party for the child, whether it is the foster parent or the Guardian.

   Robin Rosenberg added that currently not every child is eligible for a comprehensive
   behavioral health assessment, and there are issues with the quality of the assessments
   and who gets and uses them. She noted that, in some places the assessments are
   completed within 30 days of entering care. She continued that there are children that
   slip through the cracks at every stage from not being Medicaid eligible, or not being
   in shelter status, or not getting the referral in the time for them to still be in shelter
   status and covered by Medicaid.

ADJOURNMENT

Chairman Sewell advised that the next two workgroup meetings will be held in Tampa on
July 24 and August 5.

The meeting adjourned 2:34 p.m.




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