Foster Care: HHS Has Taken Steps to Support States' Oversight of Psychotropic Medications, but Additional Assistance Could Further Collaboration

What GAO Found

State child welfare and Medicaid officials in seven selected states reported a variety of practices to support the appropriate use of psychotropic medications, which affect mood, thought, or behavior, for children in foster care. Practices include screening for mental health conditions, developing prescription guidelines, and monitoring a child's health while on medication. Additional state efforts aim to increase mental health knowledge among stakeholders and improve access to mental health services. However, officials in four selected states and from five national mental health organizations said limited access to mental health services was a challenge. Five of the selected states have begun offering remote consultation services that connect patients with mental health specialists. State officials said strong interagency collaboration and outreach to stakeholders helped them implement practices more effectively.

While some selected states have reduced medication use among these children, states focused on other measures to gauge the results of their efforts. Four of the seven selected states reduced medication use from 2011 through 2015, two states had steady rates, and the remaining state did not have data during this time period. These data, however, cannot be compared across states because states use different methodologies to collect data. Officials in three selected states said reducing medication use may not be appropriate for every child, and officials in all seven states said they focus instead on measures such as tracking the use of medications that can have negative side effects and the use of psychosocial services (e.g., therapy) for children in foster care. Officials in most selected states discussed limitations with gathering data needed to oversee medication use, such as disparate data systems, resource constraints, and privacy concerns related to data sharing among state child welfare and Medicaid agencies and with managed care organizations. Officials in some states that shared data said they overcame privacy concerns through written interagency agreements and educating stakeholders.

The Department of Health and Human Services (HHS) has taken steps to help state child welfare and Medicaid agencies support the appropriate use of psychotropic medications and identify mental health needs and treatments for children in foster care. HHS has focused its efforts on practices for prescribing, screening and diagnosis, and access to trauma-related services. HHS is also working with states to implement voluntary measures to track medication use, other mental health treatments, and a child's overall health. In 2012, HHS hosted a meeting for state leaders to help them establish effective medication oversight practices. Despite the positive outcomes resulting from this meeting, and HHS guidance that says an agency goal is to facilitate cross-system collaborations, such as in the oversight of psychotropic medications, it has not convened meetings with all stakeholders together since 2012. Though HHS has conducted webinars, created learning communities, and convened smaller meetings, HHS officials said it has no plans to convene all stakeholders as it did in 2012 due to resource constraints. Officials in three selected states said more federal support to bring together state stakeholders could help address ongoing issues, such as privacy concerns around data sharing.

Why GAO Did This Study

GAO previously reported that children in foster care in five selected states were prescribed psychotropic medications at higher rates than other children on Medicaid. GAO also reported that some prescriptions were not supported by research and could pose health risks. GAO was asked to study efforts to oversee psychotropic medications for children in foster care since GAO last reported on the issue in 2014.

GAO examined (1) how child welfare and Medicaid agencies in selected states ensure the appropriate use of psychotropic medications for children in foster care, (2) what is known about the results of their efforts, and (3) the extent to which HHS helps states support appropriate medication use. GAO reviewed relevant federal laws, regulations, and guidance; visited a nongeneralizable group of seven states and five counties in two of those states, selected by foster care population and diversity of location; analyzed selected states' data on medication use in foster care populations; and interviewed officials from federal, state, and county child welfare, Medicaid, and other agencies, as well as officials from nine relevant national organizations selected to represent a variety of views.