Texas Department of Family and Protective Services
Council Meeting

January 21, 2011

The Texas Department of Family and Protective Services (DFPS) Advisory Council meeting was held in the John H. Winters Building Public Hearing Room, 125-E, 701 West 51st Street, Austin, Texas. Members present were Chair Gigi Edwards Bryant, Vice Chair Imogen Papadopoulos, Past Chair Ommy Strauch, Debbie Epperson, Paul Furakawa, Tina Martin, Linda Bell Robinson, and Scott Rosenbach . Also present were Commissioner Heiligenstein and department staff. Council member Mamie Salazar-Harper was absent.

Agenda Item 1 Call to Order

Chair Bryant called the meeting to order at 9:02 a.m.

Agenda Item 2 - Reading, Correction, and Approval of Minutes of October 15, 2010, regular meeting

Chair Bryant called for approval of the minutes. Ms. Papadopoulos moved acceptance of the minutes as written; Ms. Strauch seconded. The minutes needed no corrections and were approved as presented.

Agenda Item 3 - Agency Briefings

3.a. Psychotropic Medication for Texas Foster Children - James Rodgers, MD

Commissioner Heiligenstein introduced Dr. James Rogers, child psychiatrist and DFPS Medical Director, who presented an agency briefing on psychotropic medication for Texas foster children.

Dr. Rogers described progress made over the past six years, In March 2004 Dr. Charles Bell, HHSC Assistant Commissioner, asked that a committee address the use of psychotropic medication for foster children. By February of 2005, the HHSC committee had recommended a statewide system to monitor the medication of foster children and developed guidelines resulting in a significant decrease of utilization of the medications within the first seven months. In addition, House Bill 6, implemented in September 2005, sponsored by Senator Nelson, set the stage for having regional nurses and a medical director, and for the implementation of STAR Health.

STAR Health was fully implemented in April 2008, to provide oversight to the use of medications. The features of STAR Health include immediate enrollment and coordination of a broad range of providers to serve children's needs, including medical and behavioral health problems. The program provides a 24-hour nurse helpline, which is particularly helpful during a child's transition into foster care and between placements.

Many children entering foster care have significant medical needs as well as behavioral health problems. About 15 percent of the children entering care who are already on Medicaid are already taking psychotropic medications when they enter care. Ninety percent of the psychotropic medications prescribed to children are prescribed by psychiatrists or child psychiatrists. The system ensures foster children are seen by psychiatrists and behavior health providers who are clinically privileged by STAR Health. Health assessments, which include telephone screening and detailed questioning by service managers, are performed when the child is coming in and out of care and during transitions from one setting to another.

The medical passport, another beneficial feature of STAR Health, is an electronic health record that includes up to two years of Medicaid data if the child has been on Medicaid and contains visit history, prescription and immunization data. The health passport is made available to the parent or adult child when the child leaves foster care. Behavioral health assessments and reviews of psychotropic medications are included, as well as vital signs and allergies to medicines.

In February 2005, the Psychotropic Medication Utilization Parameters for Foster Children was released. The parameters were updated in 2007, again in December 2010, and is available on the public website. The parameters include eight criteria for review of a child's medications.

Ms. Strauch asked if health managers are physicians. Dr. Rogers responded that health managers are nurses or social workers who are trained to conduct health assessment questionnaires. If a child's medications fall outside the eight criteria, a Psychotropic Medication Utilization Review (PMUR) is performed by STAR Health child psychiatrists who consult with the prescribing psychiatrist.

The automated pharmacy data on the Health Passport has also proved valuable and serves as a real time review of each child's prescription regimen. Reviews from STAR Health can be requested by others involved in a child's treatment, including the caseworker, supervisor, judge, foster parent, or facility caring for the child.

Data is collected through HHSC on an annual basis. Close to 20 percent of foster children are on psychotropic medication. Ten percent of the general population has serious mental illness; therefore, ten percent is the general community goal. Dr. Rogers noted that children living in foster care are different than the general Medicaid population, so we may expect to see a higher percentage of children in foster care on psychotropic medication.

DFPS has decreased overall utilization of psychotropic medications and will strive to bring the numbers down even further. The Texas Medical Association has posted the parameters on their website.

Ms. Papadopoulos commented about Dr. Rogers's recent interview on the television program, Need to Know (aired January 27, 2011 on PBS) and asked how the agency responds to a doctor's overuse of psychotropic medications. Dr. Rogers answered that a quality of care review is requested. Ms. Papadopoulos then asked about the care of children who are prescribed psychotropic medication while living in residential treatment centers but then age out of the agency's care. Dr. Rogers answered that there are times when treatment does not continue because some will no longer qualify for Medicaid once they are adults. Coverage and treatment is maintained for those children who are eligible for SSI. Commissioner Heiligenstein reminded the Council that almost all of the children that age out of care are entitled to receive Transitional Medicaid coverage through their 21st birthday. Only children with other medical coverage or income and resources above the program limits would not be entitled to this program. A child does not have to remain in DFPS' care to receive this benefit.

Mr. Rosenbach inquired about the 20.6 percent of children on medication, asking how much of that was for children with ADHD or attention deficit disorder. Dr. Rogers responded that ADHD is the most commonly occurring psychiatric condition in children, and possibly in adults as well. Mr. Rosenbach also asked if the percentage of children taking the medicines could be a result of adverse selection. Dr. Rogers stated genetic loading, stressful upbringing, nutritional differences, and more can contribute to psychiatric needs.

Gerry Williams, General Counsel, commented that other states are looking to Texas since Texas has this medical data.

Chair Bryant asked if there is an attempt to control some children's conditions with diet. Dr. Rogers indicated that it is important to take into consideration diet, behaviors and the child's activity level. Chair Bryant then asked if diet is looked at in the 30 day assessment. Dr. Rogers said it is not assessed.

Ms. Heiligenstein encouraged the council to watch the program Need to Know and thanked Dr. Rogers for his work.

3.b. Improving the Quality of Infant and Toddler Child Care Programs – Implementation Update - Sasha Raco

Chair Bryant called on CCL Assistant Commissioner, Sasha Rasco to speak about quality of child care programs. Ms. Rasco introduced Dr. Stephen Green with Texas A&M University. Ms. Rasco described the three goals of using the one-time federal funding to improve care of infants and toddlers: education of consumers, education of child care providers, and staff education and training. The Safe Sleep and Don't Be in the Dark campaigns were introduced and materials have been redesigned and redistributed. Training modules have been developed for parent and providers, and an online orientation for providers has been designed.

Dr. Green discussed how Texas A&M University has assisted with the online library. He talked about online training for parents and providers and showed sample slides of online courses available in English, Spanish and Vietnamese. Costs for the courses are minimal, and completion certificates are available.

Statistical analyses are run on pre-training versus post- training scores. Pre-test average is about 69 percent and post-test average knowledge is about 84 percent. Dr. Green provided a handout with course titles and hours available for courses for childcare providers. Course evaluations rate the overall quality of the courses at 92 percent good or excellent and content at over 90 percent good or excellent.

Ms. Martin asked how different regions become aware of course availability. Courses are marketed online through infanttoddler.tamu.edu and through the larger extension system and at conferences across the state. Additionally, an informational email and library link has been sent to licensed childcare providers. The link has also been posted on the agency's public website and on Facebook.

Ms. Epperson expressed that first-time parents could also use the training. Dr. Green indicated that a number of courses would be helpful for parents and a second series is under development.

Dr. Robinson asked if there would be a press release for the general public. Dr. Green replied this could be done in conjunction with CCL and utilizing networks. He also mentioned that online training was less costly than face-to-face training.

Commissioner Heiligenstein spoke about the one-time money awarded last session and the need to have it spent wisely. This online training will provide long-term benefits. Ms. Rasco acknowledged others who contributed to this program, including the steering committee and licensing staff. Chair Bryant expressed appreciation to all who contributed to the effort.

4.c. Commissioner's Report to include: Agency Administrative Changes and Acknowledgements, CPS Initiatives, Attorney General's Opinion on Training Hour Requirements, Legislative Session, Savings Request for FY 2011, and Notification of Rule Adoptions - Anne Heiligenstein

Commissioner Heiligenstein announced Ann Strauser assumed the role of Director for the Center for Consumer and External Affairs. The commissioner also recognized Sasha Rasco for her work as Assistant Commissioner for Child Care Licensing and announced that Ms. Rasco has made the decision to step down as Assistant Commissioner to spend time with her family.

Commissioner Heiligenstein called on Audrey Deckinga to give updates on CPS initiatives. For the last six years, one goal of CPS has been to eliminate disproportionality, the over-representation of a particular group of people in a particular system. In Texas and other states, African American and Native American children are over-represented in the CPS system. Hispanic or Latino children are not overrepresented in the system statewide; however, this particular group is slower to reach permanency, which leads to disparate outcomes. Disproportionality issues for African American and Hispanic children and families are being considered in every initiative that DFPS implements in an attempt to improve the outcomes for these children and families. The agency has engaged in staff and leadership training and in-depth analyses of the agency's policies and procedures. This work of addressing disproportionality will continue, as staff moves toward embedding the work into each program's day-to-day practices. Ms. Deckinga introduced Tanya Rollins, the newly-hired State Disproportionality Manager. Ms. Rollins has experience as a caseworker, statewide intake specialist, and academy training manager.

Ms. Deckinga reported on Foster Care Redesign, which focuses on keeping children in their home communities, placing children with their siblings, and preventing frequent moves. It is a key component to eliminating disproportionality and can improve permanency outcomes for all children. Ms. Deckinga thanked Ommy Strauch, the Council representative on the Public Private Partnership, which contributed to the Foster Care Redesign initiative.

Ms. Deckinga discussed about the Permanency Care Assistance (PCA) Program in Fostering Connections, which allows family members to receive long-term financial assistance for children who cannot return to their families and will not be adopted. PCA focuses on permanency for the child and involves notification of the child's relatives following the removal, diligent searches for relatives of the child, and recruiting kinship to be verified foster homes.

Enhanced Family-Centered Safety Decision Making is an initiative to improve critical thinking skills of front-line staff and management staff in making decisions based on safety, rather than poverty or race. The initiative strives for better decision making that keeps children safe at home with their families.

The diligent recruitment grant application was co-written with CASA and has been funded. Diligent recruitment efforts are finding permanent homes for children in foster care. The department focused in Region 3 Regions 4 and 5 because these regions have the most children of color under permanent managing conservatorship.

Ms. Deckinga discussed the Advisory Committee for Promoting Adoption for Minority Children, the committee charged with studying, developing and evaluating programs and projects related to community awareness and education, family support, counseling, parenting skills and education, and reform of the child welfare system. Bishop Blake and Pastor Russell addressed the Council at the October meeting and requested funding. Casey Family Programs has agreed to fund some activities. The committee plans to partner with CPS, disproportionality committees and faith-based communities to help increase adoptions of children of color.

Ms. Papadopoulos asked if there is a mechanism for keeping judges apprised of department activities. Ms. Deckinga stated she would be giving this update also to the Supreme Court Permanent Judicial Commission for Children, Youth and Families. The Children's Commission is the vehicle for reaching out to judges. There is a joint effort on training CPS staff and judges at the Commission.

Ms. Strauch congratulated the Commissioner and CPS for work on these initiatives. Commissioner Heiligenstein expressed appreciation for Ms. Deckinga's leadership and her team on these initiatives.

Commissioner Heiligenstein introduced APS Assistant Commissioner, Beth Engelking who recognized Patrick Turley, Regional Director for region 10, who has received the FBI's El Paso Division 2010 Director's Community Leadership Award. Mr. Turley is one of 55 people nationwide to receive this award and will travel to Washington D.C. to attend a banquet in his honor. Mr. Turley's work was commended by Commissioner Heiligenstein and the Council. Mr. Turley thanked his staff for their support.

Commissioner Heiligenstein referred to the request for an Attorney General's opinion regarding whether, through rulemaking, the Council could establish training requirements for day care operators or if such requirements had to be set by statute. The Attorney General concluded that in all likelihood a court would determine DFPS does have the ability to set training requirements through rulemaking. The opinion will not preempt actions of the current legislative session which has several bills going through that may affect training requirements.

Commissioner Heiligenstein provided an update on budget concerns. The department has identified an additional $4.3 million to help address the shortfall in the current fiscal year. Staff is analyzing the House Appropriations Committee bill that came out Tuesday evening and will have an update on the senate bill when it is released.

Upon the Council's recommendations to Commissioner Suehs, the following three rules received no public comment and have since been adopted: permanency planning for foster children; determination of eligibility for receipt of enhanced adoption assistance; and the DFPS contract dispute resolution process.

4.d. Chair's Report to include acknowledgement of Loretta Edelen for her commitment to higher education for foster children; and Ommy Strauch, Mamie Salazar-Harper, and Dr. Paul Furukawa for their dedication and service to the DFPS Council - Gigi Bryant

Chair Bryant acknowledged the work of community partners with DFPS, including council members. One community leader, Loretta Edelen, Director of Community Student Affairs at Austin Community College was acknowledged for her work. Ms. Edelen started REACH, a program that educates foster youth about educational opportunities at the college level. REACH held a conference at Texas State University in 2010. The program will be presented at Sam Houston State University this year.

Commissioner Heiligenstein thanked Ms. Edelen and read a letter of appreciation concerning her work. Ms. Edelen responded that the second REACH conference will be held June 2 and 3, 2011, at Sam Houston State University. She also provided a summary of the first conference.

Chair Bryant then recognized the acknowledgements from Governor Perry for three DFPS Council members for their years of service. She presented a letter and proclamation to the following persons: T. Paul Furakawa, Ph.D., 2006-2011; and past Council Chair, Christina Ommy Strauch, 1999-2011. The Governor's Office has also provided proclamation for Mamie Salazar-Harper who was unable to attend this meeting.

General Counsel Gerry Williams was introduced and described his work with Ms. Bryant and the Legislature. He acknowledged Phoebe Knauer, attorney, for her work during the legislative session.

Chair Bryant called for reports from council members. Ms. Bryant serves Austin and represents Region 7. She meets with the Commissioner regularly to be updated on the initiative the agency is undertaking.

Dr. Robinson represents Region 6, the Houston area in particular. She expressed thanks for the opportunity to serve and is available to meet with staff and the public.

Dr. Furukawa has represented Region 8, the San Antonio area. He considers the meetings and work sessions a learning experience. He will miss the depth and quality of staff reports, as well as public testimony from both providers and the general public. Dr. Furukawa expressed gratitude for the opportunity to have served on this Council.

Ms. Strauch has also represented Region 8. As of December, she completed her participation on the Foster Care Redesign. She thanked the Council for the opportunity to make a difference in the life of a child or an elderly, vulnerable adult.

Imogen Papadopoulos, representing Region 6, expressed appreciation and admiration for the work of Dr. Furukawa and Ms. Strauch. She addressed Dr. Green to request that online educational opportunities be included for grandparents who are raising grandchildren.

Debbie Epperson, who represents Regions 3 and 4, attended a meeting with CASA and CAC. She will share the infant and toddler child care online training information with programs in the Dallas area.

Tina Martin of Region 11 represents the Rio Grande Valley. She is working on a fundraiser to benefit the Children's Advocacy Center and rainbow rooms. Additionally, she has provided agency brochures on child safety at rehab centers in the Valley. Ms. Martin also attended the HHS All-Councils meeting and the annual conference for quality infant and toddler care. At CCL's conference, she was presented with the concept of the ideal day care center and the emphasis placed on relationships.

Scott Rosenbach represents Region 1 and is from Amarillo, Texas. He expressed thanks to Council members for this learning experience. In Region 1, he continues to work with Adult Protective Services to establish Silver Star Rooms.

Chair Bryant reiterated her thanks to the three Council members finishing their terms of service.

Agenda Item 4 – Council Operations

4.a. Vice Chair Selection - Gigi Bryant

Chair Bryant asked for nominations for Vice Chair of the Council. Ms. Epperson nominated Imogen Papadopoulos. Mr. Rosenbach moved to accept the nomination; Ms. Strauch seconded. The motion was accepted by a voice vote, Ms. Papadopoulos abstaining. Ms. Papadopoulos thanked the Council and will continue in her role as Vice Chair.

Agenda Item 5 - Public Testimony

Judy Powell, co-founder and Communications Director of the Parent Guidance Center, spoke about the death of a child at the Daystar Residential Treatment Center, which has been ruled a homicide. She stated that four children have died at Daystar or related centers. She requested that this facility be closed. Ms. Powell also emphasized that parents need services.

Commissioner Heiligenstein noted that revocation action had already been taken and that there are no children in care at the Daystar facility.

Agenda Item 6 - New Business

6.a. Recommendation to Repeal Existing Rule at 1 TAC, Part 15, Chapter 355, Section 355.9041, Reimbursement of Services - James Jenkins, HHSC

James Jenkins with the Health and Human Services Commission presented the repeal rule. The Centers for Medicare and Medicaid changed the definition of targeted case management, and case management services provided by DFPS no longer meet the definition. The repeal of this rule has no fiscal impact.

Ms. Epperson moved that the Council recommend for proposal by the Health and Human Services Commission the repeal of Section 355.9041, concerning reimbursement services, as reflected in the Council's January 21, 2011 Agenda Item 6(a). Mr. Rosenbach seconded the motion. Ms. Bryant asked for comments and, hearing none, called for a vote. The motion passed by voice vote.

6.b. Recommendation to repeal 40 TAC, Chapter 708, Medicaid Targeted Case Management Program - Cindy Brown, Finance

Cindy Brown, Chief Financial Officer, presented a similar repeal that goes in tandem with the repeal presented by Mr. Jenkins. The DFPS rules regarding Medicaid targeted case management are now obsolete and require deletion.

Ms. Strauch moved that the Council recommend for proposal by the Health and Human Services Commission the repeal of Sections 708.1-708.4, concerning the Medicaid Targeted Case Management Program, as reflected in the Council's January 21, 2011 Agenda Item 6(b). Dr. Furukawa seconded the motion. Ms. Bryant asked for comments and, hearing none, called for a vote. The motion passed by voice vote.

Agenda Item 7 - Adjourn

The meeting was adjourned at 11:30a.m.