DISCUSSION:

The purpose of this memorandum is to introduce Mandatory Reviews, discuss Secondary and Automatic Reviews of Psychotropic Medication, and notify staff of a new form, the Denial Notification Letter of Center for Excellence Findings, CD-280.

There are new types of clinical consultation reviews that will be necessary to complete in order for case managers to make the best informed consent decisions for children in alternative care and to ensure that their medical/mental health needs are being addressed appropriately.

The Center for Excellence in CHILD Well-Being (The Center) is serving as the Statewide Clinical Consultant who completes Mandatory, Secondary, and Automatic Reviews. Staff may be familiar with Secondary and Automatic Reviews, discussed more fully below, but Mandatory Reviews are now required in certain specific instances BEFORE informed consent may be given for administration of a psychotropic medication.

Mandatory Review

BEFORE informed consent for psychotropic medications may be given, CD shall determine if a mandatory review by the Statewide Clinical Consultant (The Center) is required.

A mandatory review is required in the following instances:

• Before a child age three (3) or younger is prescribed any psychotropic medication
• For a child age four (4) or older: 
  • Before starting a 3rd (or more) psychotropic medication;
  • Before starting a 2nd (or more) antipsychotic;
  • Before a psychotropic medication is started by a second prescriber;
  • Before starting a psychotropic medication that exceeds dosage guidelines

Referrals for Mandatory Reviews shall be made by the Health Information Specialist (HIS) to The Center as soon as practicable. The case manager needs to make contact with the HIS as soon as possible upon receiving a recommendation for psychotropic medication to notify the HIS to request a referral for a mandatory review. Consent cannot be given or medication administered until after the recommendations and findings of the mandatory review are received and considered by the case manager.

Secondary Review  

• A referral for a secondary review shall be submitted to The Center if any of the following occur: 
  • The case manager has concerns about psychotropic medications being prescribed, or any other recommended physical or behavioral health intervention. 
  • The parent or child disagrees with a case manager’s informed consent decision. 
  • Other members of the child’s FST, including the child’s GAL or CASA, the child’s resource provider, or the Juvenile Officer have submitted a request to CD to refer the case for secondary review of the child’s psychotropic medications or any other recommended physical or behavioral health intervention. Case managers shall ensure that all such requests are referred for secondary review, except that CD may, in its discretion, decline to perform more than one (1) review for a child within the same sixty (60) day period. 
• The HIS will make the referral to The Center. The case manager needs to make contact with the HIS as soon as possible once a decision has been made that a secondary review is necessary based upon the criteria listed above, clearly documenting why the review is being requested. The online referral form shall be submitted within five (5) business days. Medical records to include in the referral: current diagnosis, prescriber notes, current medication list including dose and frequency, lab results, psychiatric evaluation, therapy reports and other records related to the child’s behavior or diagnosis. 
• The Center shall, within five (5) business days of receiving the request for consultation, review the pending prescription and provide an opinion and recommendation as to the appropriateness and timing of the prescription (including but not limited to whether the child should begin taking the proposed medication immediately). Documentation of the request and the recommendation shall be included in the child’s case record. 
• The individual authorized to provide informed consent shall consider the recommendation and collaborate with the prescriber if necessary prior to providing an informed consent decision. 
• The findings and recommendations of The Center shall be provided to the child’s parent or legal guardian; the individual authorized to provide informed consent for the medication (if an alternative consenter has been appointed by the court), child’s resource provider, and any other person or entity authorized to receive the recommendation by order of the court.
• The findings and recommendations of The Center may be provided to other individuals as determined appropriate, who would include: GAL, CASA, other members of the FST, and medical providers. 
• If a parent or child does not agree with the recommendation from The Center, the parent or child may: 
  • Within five (5) business days, initiate a service delivery grievance, or 
  • At any time, file an appropriate motion with the juvenile court

If The Center has recommended immediate administration of a psychotropic medication, the case manager may follow that recommendation, regardless of any pending service delivery grievance or juvenile court motion filed by the parent. 

If The Center recommends that immediate administration of a psychotropic is NOT REQUIRED, the case manager will not consent to the medication until any service delivery grievance or juvenile court motion has been resolved.

Automatic Reviews 

Staff will be notified when a child’s case has been identified for automatic review by The Center. These reviews will be completed on a quarterly basis for cases meeting identified criteria. The case manager shall have ten (10) business days from the date of receiving notice to collect the materials or documents that The Center requests to complete the review. The Center has five (5) business days to complete the review process.

Denial Notification Letter of Center for Excellence Findings, CD-280 

After a review is completed by The Center, the findings and recommendations are provided to the case manager. In the event that CD declines to share the findings and recommendations of The Center with the child’s parent or legal guardian, CD shall notify the individual in writing of the reason for denial using the Denial Notification Letter of Center for Excellence Findings, CD280. 

CD may only decline to share the findings and recommendation if at least one of the following criteria applies:

• The Court has entered an order limiting access to certain information about the child; 
• Sharing information is not in the best interest of the child or could endanger the health, safety, and welfare of the child or another person; 
• Sharing the information may interfere with a child abuse, child neglect, or a child investigation; or 
• Providing information is contrary to law.

The CD-280 will explain the individual’s right to seek a review by completing a service delivery grievance of that decision or to file an appropriate motion with a juvenile court. 

The Denial Notification Letter of Center for Excellence Findings, CD-280, as well as the Spanish version, can be accessed through E-Forms located on CD intranet.

Questions regarding the Psychotropic Medication Settlement Agreement can be sent to PsyMedSettle@dss.mo.gov.