Oklahoma Uses Focus Groups to Identify Strategies to Better Serve Foster Care Youth

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:

  • Educating all stakeholders about the complex care needs of foster care youth;
  • Developing diagnosis and treatment guidelines that include cognitive or behavioral treatment before psychotropic medications are prescribed;
  • Promoting team approaches to care to improve communication; and
  • Increasing mental health care providers, especially in rural areas, to provide specialized care

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.