On March 4, 2014, President Obama's administration announced a new five-year program intended to reduce the over-prescription of psychotropic medications to children in the foster care system. [i] Recent research from Rutgers University and its six partner states addresses the issue of over-prescribing in the Medicaid population. Lessons from their work can be found in a new resource guide, and may be instructive for other states seeking to affect similar changes.

The resource guide titled, Implementing a State-level Quality Improvement Collaborative: A Resource Guide from the Medicaid Network for Evidence-based Treatment, aims to provide state agencies and policymakers with guidance on how to implement a quality improvement collaborative to address a clinical concern, such as the one President Obama included in his 2015 budget. This resource guide outlines the core components of such a collaborative, including the importance of collaborative learning and making policy decisions based on evidence and sound data.

As the resource guide describes, one of the first steps towards building a quality improvement collaborative is identifying and describing the issue at hand. This collaborative, which began as a collaboration of the Medicaid Medical Directors Learning Network (MMDLN), and now the Medicaid Medical Directors Network,[ii] offers the opportunity to disseminate lessons learned and collaborate on specific clinical topics and review policy solutions.[iii] Specifically, the MMDLN conducted a study of 16 states’ data in 2010 and found that 193,178 children or adolescents enrolled in Medicaid in 16 states received antipsychotic (AP) medications, which are used to treat serious mental illnesses (a 10 percent relative increase since 2004). The study also found that children in foster care (12.4 percent) were prescribed AP medications at much higher rates than those who were not in foster care (1.4 percent).[iv] Given the serious potential side effects and significant cost of these medications, many were concerned that the expanded use of these medications, frequently off-label, often outpaced the evidence base.[v]

In response to this need, Rutgers University’s Institute for Health, Health Care Policy, and Aging Research (IHHCPAR) and AcademyHealth coordinated MEDNET, a three-year, multi-state consortium that focused on increasing the utilization of evidence-based clinical and delivery system practices in mental health treatment for Medicaid beneficiaries. The learning collaborative included California, Maine, Missouri, Oklahoma, Texas, and Washington.

This guide provides a much needed "how to" and can be used by others in the field that aim to improve the delivery of care. Highlights from the resource guide include:

  1. Develop and Implement a Stakeholder and Data-Driven Quality Improvement Initiative: This section provides a step-by-step description of each stage of developing a collaborative with guiding questions at each stage.
  2. Identify a Champion, Project Lead, and Core Staff Team: This section describes what management resources are needed for strong teams, and as a result, successful programs.
  3. Engage Stakeholders and Partners: This section describes the importance of engaging key stakeholders and how to involve them in the activities throughout the collaborative.
  4. Ensure a Data-Driven Process: Data and information sharing are critical for quality improvement collaboratives to identify the issue, measure progress and provide evidence to stakeholders to initiate action.
  5. Develop a Data-Driven, Iterative and Actionable Quality Improvement Plan: This section goes into the specifics of how to develop a quality improvement plan.
  6. Implement Policy and Quality Interventions: This section provides examples of policy and quality interventions employed by states in this area that can inform other programs.
  7. Host Collaborative Activities: This section provides practical information on how to convene participants since regular communication is essential to successful programs.
  8. Disseminate: This section describes how to share information gathered and work products developed from the initiative.
  9. Bonus: Cross-State Collaboratives: This section provides an example of cross-state collaboratives as a potential mechanism to address issues that affect states broadly.

As this resource guide describes, developing a successful quality improvement collaborative is a significant investment and its success requires thoughtful implementation.

You can download a copy of the report here.

Acknowledgement: Both the Medicaid Medical Directors Learning Network (MMDLN) and the Medicaid Network for Evidence-Based Treatment (MEDNET) were funded by the Agency for Healthcare Research and Quality.


[i] Cheney, Kyle. Obama Budget Funds New Initiative to Limit Psychotropic Drugs for Foster Kids. Politico Pro. Accessed at: https://www.politicopro.com/healthcare/whiteboard/?wbid=29550.

[ii] In 2013, the MMDLN moved under the auspices of the National Association of Medicaid Directors as a clinical arm of the national association of state Medicaid programs and became the Medicaid Medical Directors Network.

[iii] Medicaid Medical Directors Learning Network Fact Sheet. Agency for Healthcare Research and Quality. Accessed April 2014. Available at: http://www.ahrq.gov/policymakers/measurement/quality-by-state/mmdln.html.

[iv] Medicaid Medical Directors Learning Network and Rutgers Center for Education and Research on Mental Health Therapeutics. Antipsychotic Medication Use in Medicaid Children and Adolescents: Report and Resource Guide from a 16-State Study. MMDLN/Rutgers CERTs Publication #1. July 2010. Distributed by Rutgers CERTs at http://rci.rutgers.edu/~cseap/MMDLNAPKIDS.html.

[v] Crystal S, Olfson M, Huang C, Pincus H, Gerhard T. Broadened use of atypical antipsychotics: safety, effectiveness, and policy challenges. Health Affairs. Sep-Oct 2009;28(5):w770-781.

By: Emily Moore, Research Assistant , AcademyHealth

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