NATIONAL CORE INDICATORS DATA FOR SYSTEMS CHANGE USE OF MEDICATIONS TO ADDRESS MOOD, ANXIETY, PSYCHOSIS AND BEHAVIOR AND STATE EFFORTS TO ADDRESS MARCH.

NATIONAL CORE INDICATORSDATA FOR SYSTEMS CHANGE USE OF MEDICATIONS TO ADDRESS MOOD, ANXIETY, PSYCHOSIS AND BEHAVIOR AND STATE EFFORTS TO ADDRESS

MARCH 29, 2013

A Collaboration of State Members, NASDDDS & HSRI

Overview of National Core Indicators NCI Data Sources NCI Data on Utilization of Medication for Anxiety, Mood disorders, Behavior challenges and Psychotic

disorders NCI Findings and Recommendations on Medication Utilization Significant State Efforts to Address Overuse of Psychotropic Medications State Activities to Monitor and Reduce Unnecessary Medications

Agenda

Overview of NCI

National Core Indicators “NCI”

NCI is a voluntary effort by public developmental disabilities agencies to measure and track systemic performance.

Collaboration began in 1997

Coordinated by HSRI and NASDDDS

Currently 35 states participate plus 23 sub-state entities.

NCI was awarded a contract from the Administration on Intellectual and Developmental Disabilities (AIDD) with goal to increase participation to all 50 states and District of Columbia within 5 years.

NCI Goals

Establish a nationally recognized set of performance and outcome indicators for DD service systems

Develop and maintain reliable data collection methods and tools

Report state comparisons and national benchmarks of system-level performance

What is an “Indicator”?

A standard measure used across states to assess the outcomes of services provided to individuals and families.

Indicators address key areas of concern including employment, rights, service planning, community inclusion, choice, and health and safety.

Indicators and data collection instruments are reviewed regularly to update and reflect best practice in service delivery.

NCI Data Sources and Reports

NCI Data Sources

Adult Consumer Survey

In-person conversation with a sample of adults receiving services to

gather information about their experiences

Keyed to important person-centered outcomes that measure system-

level indicators related to: employment, choice, relationships, case

management, inclusion, health, etc

Adult Family, Child Family, and Family/Guardian Surveys

Mail surveys – separate sample from Adult Consumer Survey

Other state system data: Mortality, Staff Stability

NCI Reporting & Resources

NCI website is a public data source for: Annual national reports Annual state reports Publications: Data used by researchers for journal articles NCI Data Briefs: Medications, Employment Outcomes,

Autism, Dual Diagnosis, Living Arrangement, etc. Webinars: Managed Care, Interviewer Training Chart function for customized data analysis

http://www.nationalcoreindicators.org/

Ways States Use NCI Data

CMS Waiver Assurance Evidence Reports

Quality Assurance and Improvement

State by State Comparisons

Assist with Community Transition

DD Councils

Reports to State Legislatures

Demographic differencesWhat medications are taken forHealth differences

NCI Medication Data Brief: Findings

Source of Information

Adult Consumer Survey

Background Section

“Does the person take medications to address”:

Mood disorder

Anxiety

Psychotic disorder

Behavior

Who takes these medications?

Slightly older Slightly less racially diverse Less likely to live with

parents or relatives Less likely to be diagnosed

with profound level of ID Less likely to be diagnosed

with cerebral palsy and Down syndrome

Less likely to have a physical disability

More likely to be white More likely to live in group

homes More likely to be

diagnosed with mild level of ID

More likely to be diagnosed with Autism Spectrum Disorder

Residence Type and Medications

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

6%

35%

6%

18%22%

7%

1%5%

0%

6%

19%

3%

17%

47%

5%

1%3%

0%

At least one med

No meds

Other Disabilities

0%

5%

10%

15%

20%

25%

30%

ASD CP Seizure disorder/

neurological problem

Physical disability

Alzheimer's/ dementia

Down syndrome

13%

10%

23%

8%

2%5%

7%

20%

25%

12%

1%

13%

At least one med

No meds

Takes Medications to Address

53% of people with IDD receiving services are taking medications for at least 1 of these conditions: mood disorders anxiety behavior challenges psychotic disorders

Most common condition medications are taken for is mood disorders (38%).

14% of those taking at least one medication are taking them for all 4 conditions.

39%

29%

18%14%

Takes medications for….1 condition 2 conditions 3 conditions 4 conditions

Takes Medications to Address

88% of those with a co-occurring psychiatric diagnosis were taking medications for mood, anxiety or psychotic disorders.

However, 30% of people without a psychiatric diagnosis were also taking medications for mood, anxiety or psychotic disorders.

What Health Differences Exist?

Those who take at least one medication are:Less likely to be in very good or excellent health

More likely to use tobacco products

More likely to be obese / less likely to be of normal weight

0%

5%

10%

15%

20%

25%

30%

35%

40%

Underweight Normal Overweight Obese

4%

29% 30%

37%

8%

35%

28%29%

At least one med

No meds

Overuse of Psychotropic Medications: Not just a DD service system concern

Mental Health Aging Service System Initiatives Courts are involved in ensuring due process protections for people

recommended to take certain medications. Advance Directives for medication consent now are used.

Aging Service System Initiatives In aging services, Massachusetts nursing homes are monitored by state

licensing agency for overuse of these kinds of medications. Children using Medicaid & Foster Care

GAO 2012 report found that 18% of foster children were taking psychotropic medications. Utilization varied widely by the child’s living arrangement.

1.3 % of children in Medicaid took antipsychotic medications, that is twice the rate for privately insured children (0.5%).

Children's Mental Health: Concerns Remain about Appropriate Services for Children in Medicaid and Foster Care. GAO-13-15, December 10. http://www.gao.gov/products/GAO-13-15

Massachusetts Georgia Missouri

State Presentations

DD Service System Initiatives

Statute, policies and procedures in many states affirm that people receiving services cannot be chemically restrained, or prescribed medication that has an impact on behavior, without first conducting an evaluation to determine if there are medical causes for the behavior.

Some states require positive behavior supports be implemented prior to use of medications.

Human Rights Councils review restrictive practices and rights violations, including under what circumstance people can be prescribed multiple psychotropic medications.

Annual service planning allows for review of all treatment regimens and their continued efficacy.

Massachusetts Dept. of Developmental Services3 Tier Approach

DDS concerned about poly-pharmacy, co-occurring medical/psychiatric/behavioral issues; aging population; limited number of practitioners knowledgeable about DD issues

Established a Statewide Medication Review Committee to bring together physicians, psychiatrists, behavioral psychologists, psycho-pharmacologist, neurologist, and nurses

Approaches issue of over-utilization of medications on 3 levels focusing on patterns and trends as well as individual reviews Individual Case Review Targeted Outreach to clinicians utilizing multiple medications based upon

an analysis of Medicaid billing data Broad Outreach and education to clinicians regarding “Consensus

Guidelines

Massachusetts Dept. of DevelopmentalServicesReview Process for Individual Cases

Referrers submit complete package of documentation so that Committee Members can read in advance

All family, staff, clinicians involved are encouraged to come to meeting

Committee sends recommendations to DDS Area Office for distribution to involved parties

Committee may facilitate additional referrals to specialists, and follow up with treating community PCP and psycho-pharmacologist

Committee follows up in 90 days to determine status and next steps

Massachusetts Dept. of DevelopmentalServicesPreliminary Lessons Learned from Individual Case Reviews

Important to stress consultative nature of committee so that it encourages referrals

Individuals referred to committee typically present with multiple issues in addition to poly-pharmacy which may be “tip of the iceberg”

Individuals facing declining health status; outcomes may focus on quality of life issues

Individuals often present with effects of long term utilization of psychotropic medications, which affects individuals with ID differently than general population

Physicians, however well meaning, tend to add medications when an individual is experiencing behavioral or other issues

Physicians try to be responsive to family and or direct support staff who may be having significant challenges with supporting an individual which sometimes leads to increasing medications

Extremely productive to have clinicians from multiple disciplines; enables better coordination and problem solving

Massachusetts Dept. of Developmental Services Next Steps

Further refinement of referral package Broader outreach to DDS community to encourage

more referrals Change of name of committee More in-depth analysis of prescriber practices utilizing

Medicaid data Development of more systemic outreach efforts to

community clinicians Initiation of evaluation component of both process

and outcomes of Medication Committee Reviews

Georgia Dept. of Behavioral Health andDevelopmental Disabilities

Psychotropic & Anti-epileptic Medications Study Purpose of study Olmstead Plan Study participants Data collected and points in time Analysis plan Anticipated action from study findings

Missouri Division of DevelopmentalDisabilities

Identification of Concerns and Development of Strategies NCI data – ensure accuracy Cross –analysis with Medicaid Claims Cross- analysis with HIPS Established threshold for local identifiers as a

result of discussion with Medical Director and Chief Behavior Analyst.

Missouri Division of DevelopmentalDisabilities

Educating and Implementing Strategies Used national and regional

data to present at each Regional Office/ SOP to further educate staff and stakeholders of identified concerns.

Region specific data was prepared for each question related to medication and behavior supports.

Missouri Division of DevelopmentalDisabilities

Next Steps: Using established threshold, continue to identify individuals quarterly

and forward to respective Regional Office teams for individualized review.

Statewide data will be compiled to establish benchmarks for comparison of improvement with current strategies.

Continue to monitor data through current systems and share findings with stakeholders for continued improvement.

Currently working to develop a standardized Developmental Disabilities Medication Administration curriculum, with a component specifically addressing psychotropic medications.

Development of a best practice guide regarding the use of psychotropic medications –currently in development

For more information

NCI website: http://www.nationalcoreindicators.org

NASDDDS: Mary Lee Fay, Director of NCI, [email protected]

Charles Moseley, Associate Executive Director, [email protected]

HSRI:Val Bradley, President, [email protected]

Sarah Taub, Director of NCI, [email protected]

Julie Bershadsky, Research Associate, [email protected]

Josh Engler, NCI Project Coordinator, [email protected]