Overview
The Department of Children and Families (DCF), established by Section 1 of Chapter 18B of the Massachusetts General Laws, provides services to children ages 0 through 21 who are at risk or who have been victims of abuse or neglect, as well as their families.
According to its website, DCF “works in partnership with families and communities to keep children safe from abuse and neglect.”
DCF services include adoption, guardianship, foster care, housing stabilization, and family support and stabilization. DCF has a central office in Boston and four regional offices administered by regional directors who oversee 29 local-area offices.
In fiscal year 2020, DCF provided support and services to approximately 48,000 children between the ages of 0 and 21. DCF had an annual appropriation of approximately $1.05 billion for fiscal year 2020 and an annual appropriation of approximately $1.09 billion for fiscal year 2021.
Federal law requires Massachusetts to have a plan for overseeing and coordinating healthcare services for any child in foster care placement. According to Section 422(b)(15)(A)(v) of the Social Security Act, this plan must include “an outline of the oversight of prescription medicines, including protocols for the appropriate use and monitoring of psychotropic medications.”
DCF’s Protective Custody
Children are referred to DCF for services in several ways. Section 51A of Chapter 119 of the General Laws requires professionals whose work brings them into contact with children to be designated as mandated reporters. Mandated reporters are required to make an immediate oral report, and a subsequent written report (called a 51A report), to DCF when, in their professional capacity, they have reasonable cause to believe that a child under the age of 18 is suffering from abuse and/or neglect. If DCF considers the report to have merit, it conducts what is called a 51B investigation. For children who are in immediate danger, DCF can file a care and protection case in the Juvenile Court and request that a judge order the child’s immediate removal from a household into DCF’s protective custody. Children and families may also come to DCF’s attention from sources other than 51A reports, including cases referred by the Juvenile Court, cases referred by the Probate Court, instances of infants surrendered under the Safe Haven Act, and parents’ or other relatives’ requests for DCF services.
When a child is removed from a household and is in DCF’s protective custody, they are placed in DCF-contracted or DCF-operated settings, such as foster care, a shelter, a short-term or group care program, or a community residential care facility.
During fiscal years 2020 and 2021, a total of 17,891 children under the age of 18 were in DCF’s protective custody.
DCF’s iFamilyNet
DCF implemented the Statewide Child Welfare Information System, known as FamilyNet, in February 1998. In 2009, DCF moved FamilyNet functionality to the web-based application, iFamilyNet (iFN). iFN is the system of record for DCF. Starting in May 2016, DCF hired 29 medical social workers—one for each local-area office—who are responsible for ensuring that each child’s healthcare records, such as medical appointment information or medical passport information, remain up-to-date in the medical section of iFN. Social workers input healthcare information for children, including their healthcare providers, appointment dates, medical conditions, and medications, in the medical section of iFN. In addition, social workers can upload healthcare records directly to iFN. These electronic healthcare records enable the social worker to review a child’s healthcare information at any time.
Pediatric Behavioral Health Medication Initiative
The University of Massachusetts Chan Medical School leads the MassHealth Pharmacy Program in collaboration with DCF and the Department of Mental Health. In 2014, this partnership created the Pediatric Behavioral Health Medication Initiative to ensure safe and effective prescribing of behavioral health medications, including psychotropic medications, for MassHealth members who are 18 years old and younger. This initiative requires prior authorizations from MassHealth for certain behavioral medication classes and/or specific medication combinations that have limited evidence for safety and efficacy within the pediatric population. For example, pharmacy claims with any combination of four or more behavioral health medications within a 45-day period require a prior authorization from MassHealth.
Psychotropic Medications
Psychotropic medications are provided to patients with diagnosed mental health disorders. These medicines may be prescribed to children in protective custody. During the audit period, 3,899 (22%) of the 17,891 children in DCF’s protective custody were prescribed at least one psychotropic medication.
According to the American Academy of Child and Adolescent Psychiatry’s (AACAP’s) 2005 “Position Statement on Oversight of Psychotropic Medication Use for Children in State Custody: A Best Principles Guideline,” “Many children in state custody benefit from psychotropic medications as part of a comprehensive mental health treatment plan.” For example, these medications can help control mental health symptoms such as mood swings, anger outbursts, hallucinations, and delusions. Although there are benefits to prescribing children in protective custody psychotropic medication, it is important that the medication is only a part of an overall health treatment plan, which should include monitoring the side effects of these medications and providing mental health services.
According to the US Food and Drug Administration’s (FDA’s) Approved Drug Products with Therapeutic Equivalence Evaluations, referred to as the Orange Book,3 psychotropic medications can have potentially serious side effects associated with them, including drowsiness, upset stomach, increased appetite and weight gain, other metabolic abnormalities, allergic reactions, mania, seizures, low sodium, serotonin syndrome, and suicidal ideation. According to AACAP’s 2015 Recommendations about the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems, healthcare professionals should routinely monitor children receiving this class of medication for adverse side effects like these and avoid prescribing children too many medications.
We used the MassHealth Pediatric Behavior Health Initiative Medication List4 to determine what specific psychotropic medications were prescribed to children in DCF’s protective custody. These medications included the following:
- antianxiety and antidepressant medications, such as Zoloft, which are used to treat anxiety or depression;
- antipsychotic medications, such as Haldol, which are used to treat symptoms of some mental disorders, including schizophrenia;
- mood stabilizing medications, such as lithium, which are used to treat mood disorders, such as bipolar disorder;
- stimulants, such as Adderall, which are used to treat attention deficit / hyperactivity disorder; and
- other medications, such as Armodafinil, which are used to treat excessive drowsiness and/or narcolepsy.
The table below shows the breakdown of psychotropic medication types and how many prescriptions for each were filled for children in DCF’s protective custody who were in a fee-for-service (FFS) plan.
| Medication Type | Number of Prescriptions Filled |
|---|---|
| Antianxiety | 1,065 |
| Antidepressant | 21,585 |
| Antipsychotic | 10,564 |
| Mood stabilizer | 10,776 |
| Stimulant* | 48,453 |
| Other | 1,244 |
| Total | 93,687 |
* Stimulants in this list included some hypertension medications that are also used to treat attention deficit / hyperactivity disorder. These medications were listed on the MassHealth Pediatric Behavior Health Initiative Medication List for this reason.
Psychotropic Medication Consent
When a healthcare provider recommends prescribing psychotropic medication(s) to a child in DCF’s protective custody, DCF must consent to the prescription. A social worker engages with the child in protective custody and the foster family or residential facility providing care regarding the prescribing provider’s recommendations, and the social worker, doctor, and caregiver (i.e., foster family or program provider) together develop a plan for the child’s well-being. Additionally, the social worker should document DCF’s consent for the use of psychotropic medications, should ensure that the prescription(s) are filled, and should document the consent in iFN throughout the child’s time in DCF’s protective custody.
Rogers Guardianship Order
Rogers guardianship order proceedings are named for the 1983 Massachusetts court case, Rogers v. Commissioner of Mental Health, in which the court stated that antipsychotic medications are so intrusive, and their side effects are potentially so severe, that a court must review the treatment plan and approve their prescription and use for children in DCF’s protective custody.
In order to apply for a Rogers guardianship order, DCF must present the court with a Clinician’s Affidavit as to Competency and Proposed Treatment Plan from the healthcare professional for the prescription and administration of the proposed antipsychotic medication. This treatment plan includes the name of the antipsychotic medication, the dosage, the dosage range, proposed alternative medications, risks of potential side effects and/or adverse reactions, and the benefits of the medication.
If the judge approves the Rogers guardianship order, the treatment plan presented to the judge remains in effect for a specified amount of time. After the specified amount of time has lapsed, or at least annually, the Rogers guardianship order must be reviewed and renewed.
Medical Passport
All children placed in DCF’s protective custody are issued a physical medical passport. A medical passport is a record of healthcare services that a child receives, including current medications, relevant mental health history, known mental health conditions, all treatment programs, and appointments. The medical passport remains with the child and in the possession of the foster family, group home, or residential facility throughout the child’s time in protective custody or foster care placements. DCF requires its social workers to review these physical medical passports every six months to keep the children’s related medical records in iFN updated with their most recent healthcare information.
Psychosocial Services
Psychosocial services are mental health treatment services designed to reduce patients’ emotional or behavioral symptoms and usually include general therapy, group therapy, and behavioral therapy. Such therapies may be used instead of, or in combination with, psychotropic medications to treat children with mental health conditions. AACAP’s 2015 Recommendations about the Use of Psychotropic Medications for Children and Adolescents Involved in Child-Serving Systems recommends, “All youth with complex behavioral needs, including youth in foster care, should receive a combination of evidence-based psychosocial interventions and psychotropic medication when indicated, not just psychotropic medication alone.”
FFS and Managed Care Program
MassHealth members can receive benefits on an FFS basis or through a managed care program. MassHealth directly pays healthcare providers under the FFS model for medical services rendered to an eligible MassHealth member. Healthcare providers can bill MassHealth directly through the Provider Online Service Center, which connects to the Medicaid Management Information System, using its MassHealth-issued provider identification.
MassHealth’s managed care program consists of two managed care organizations (MCOs), Tufts Health Together and Boston Medical Center HealthNet Plan, both of which provide healthcare services to members through MCO plans. Each MCO plan assigns members a group of doctors and other healthcare providers who work together to provide members with coordinated healthcare services. The doctors and other healthcare providers contractually agree to follow certain federal and state requirements about how they provide services. MCO plan enrollees select a primary care physician to provide basic healthcare and make any necessary specialist referrals. MassHealth pays the MCO a capitation payment,5 the amount of which is based on a rating category assigned by the Executive Office of Health and Human Services, for each member enrolled in the MCO plan. Rating categories are based on risk factors for each member, such as whether the member needs facility-based care (e.g., skilled nursing facilities) or behavioral health treatment.
Office of the Comptroller of the Commonwealth’s Pandemic Response Guidance
On September 30, 2020, the Office of the Comptroller of the Commonwealth provided guidance in response to the COVID-19 pandemic for state agencies. This guidance helped state agencies that were experiencing significant changes to identify their goals, objectives, and risks associated with the COVID-19 pandemic. Objectives included the following: telework; return-to-office plans; a risk assessment of the impact of COVID‑19 on department operations; changes to business processes; safety protocols for staff members and visitors; and tracking of COVID-19-related awards and expenditures, which were tracked separately from other federal, state, and local expenditures.
Cybersecurity Awareness Training
The Executive Office of Technology Services and Security (EOTSS) has established policies and procedures that apply to all Commonwealth agencies within the executive branch. Section 6.2 of EOTSS’s Information Security Risk Management Standard IS.010 states,
The objective of the Commonwealth information security training is to educate users on their responsibility to help protect the confidentiality, availability and integrity of the Commonwealth’s information assets. Commonwealth Offices and Agencies must ensure that all personnel are trained on all relevant rules and regulations for cybersecurity.
To ensure that employees are clear on their responsibilities, EOTSS’s policies require that all employees in state executive branch agencies complete a cybersecurity awareness training course every year. All newly hired employees must complete an initial security awareness training course within 30 days of their orientation.
John H. Chafee Foster Care Independence Program Grant
DCF received $7.9 million from the federal government through the John H. Chafee Foster Care Independence Program to give direct financial assistance to help current and former foster children recover from the pandemic. The Supporting Foster Youth and Families through the Pandemic Act prohibited states from allowing children to age out6 of foster care during the pandemic. This law also allocated money to distribute to young people in foster care and to former foster children who had aged out of the system before the pandemic but were still under the age of 26. In the five-year Child and Family Services Prevention Plan that Massachusetts submits to the federal government, the Commonwealth commits to providing support to the child welfare system to promote the safety and well-being of children within the Commonwealth.
| Date published: | November 7, 2024 |
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