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CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS

Office of the Chief Medical Officer
Clinical Operations

Juvenile Court Mental Health Services (JCMHS) Review of Psychotropic Medication Authorization Forms

Med-9

Category: Medication Use
Published Date: December 2023

TERMINOLOGY and Acronyms:
1. Juvenile Court Mental Health Services (JCMHS)
2. Psychotropic Medication Authorization Form (PMAF)
INTRODUCTION
1. These parameters define:
  1. The general categories of Juvenile Court Mental Health Services (JCMHS) findings after reviewing Psychotropic Medication Authorization Forms (PMAF); and,
  2. The specific fact patterns that trigger a categorical finding by JCMHS of:
    1. Recommend Approval of submitted medication requests on PMAF for 45 days only or
    2. Do not recommend approval of submitted medication requests on PMAF
2. Forms are required by the Court when prescribers would like to initiate or continue psychotropic medications for youth in state custody while dependents of:
  1. The Probation Department; or
  2. The Department of Children and Family Services
3. In order to permit JMHCS to make recommendations to the Court regarding approval of submitted requests, JCMHS must have a sufficient level of confidence in any given prescriber’s PMAF based upon:
  1. The provider’s history of medication requests;
  2. Accompanying clinical data; and
  3. Cooperation with the review process.
CATEGORIES OF RECOMMENDATIONS:
1. JCMHS generally will make three different recommendations regarding PMAFs they have reviewed:
  1. Recommend approval for six months:
    1. Information supplied was adequate and
    2. Medication clearly safe and effective for long-term use
  2. Recommend approval for 45 days only:
    1. More information needed.
  3. Do not recommend approval.
CATEGORIES OF APPROVALS
1. General rationale for the approval decision:
  1. Made after review of PMAF only and
  2. Based on scientific literature, training, and clinical experience.
  3. Note that any combination of IV.B.2, 3, and/or 4 can be checked.
2. Approval rating:
  1. Safe and effective
    1. Recommend Approval
  2. Not clearly safe for long-term use, i.e. greater than 45 days
    1. Recommend approval for 45 days only with expectation that regimen will be changed; or,
    2. Do not recommend approval.
  3. Not clearly effective
    1. Recommend approval for 45 days only with expectation that regimen will be changed; or
    2. Do not recommend approval.
  4. Inadequate information supplied, e.g. if diagnosis supplied is consistent with medication proposed, but specific symptoms not listed.
    1. Recommend approval for 45 days only, or
    2. Do not recommend approval.
AUTOMATIC TRIGGERS for Finding Categories of Not Clearly Safe for Long-term Use or Not Clearly Effective
1. Youth aged 9-17 years:
  1. ≥ 4 psychotropic medications (benztropine excepted)
  2. ≥ 2 antipsychotics (any combination of atypical and typical)
  3. ≥ 2 mood stabilizers (atypical anti-psychotics not included)
  4. ≥ 2 anti-depressants (trazodone as hypnotic excepted)
  5. ≥ 2 stimulant medications (this does not include a long-acting stimulant and immediate-release stimulant that is the same chemical entity [e.g., methylphenidate-OROS and methylphenidate])
  6. ≥ 2 hypnotics (including trazodone, diphenhydramine, zolpidem, melatonin, benzodiazepines; not including clonidine, guanfacine, prazosin)
  7. Medication dose(s) exceeds the usual recommended dose(s) as defined in the most recent version of the Los Angeles County Department of Mental Health’s Parameters for Use of Psychotropic Medication for Children and Adolescents.
2. Youth age 6-8 years:
  1. ≥ 3 psychotropic medications
  2. All other restrictions from Youth aged 9-17 years above.
3. Youth age 0-5 years:
  1. ≥ 2 psychotropic medications
  2. Any psychotropic medication other than a stimulant, atomoxetine, guanfacine, clonidine, or risperidone (for Autistic Spectrum Disorders and associated aggression)
  3. All other restrictions from Youth aged 9-17 years above.
JCMHS RECOMMENDATION PROCESS:
1. JCMHS recommendation to Court:
  1. Do not recommend approval – the Court can:
    1. Follow the JCMHS recommendation, or
    2. Order/request more information from:
      1. The prescribing provider
      2. Probation
      3. DCFS and/or
      4. Other sources
  2. Recommend Approval for 45 Days only with the expectation that the regime will be changed – the Court can:
    1. Order/request additional information from:
      1. The prescribing provider
      2. Probation
      3. DCFS and/or
      4. Other sources
    2. Request a targeted JCMHS Safety Consultation for purposes of determining degree of range (low, moderate, or high) clinical risk of continuing the medication regimen, which may include:
      1. Record review
      2. Contact with collateral sources of information and/or
      3. Face-to-face evaluation of the youth by a clinician and/or a JCMHS child psychiatrist.
2. Face to Face evaluation of youth process prior to or at the end of the initial 45-day approval period:
  1. Upon submission of the new PMAF, JCMHS will not recommend approval of the new PMAF, presuming the medication regimen is substantively unchanged.
  2. If, after further investigation, JCMHS initially determines that the medication regimen is clearly safe for long-term use, effective, and appropriate, and that other potential medication regimens that comport with these parameters are not feasible to utilize, upon submission of the new PMAF, the following will occur:
    1. JCMHS will forward both the initial and newly submitted PMAF and associated collateral information supporting the tentative recommendation for continued approval of the medication regimen to the Juvenile Justice Mental Health Program (JJMHP) Medical Director or designee for review.
    2. The JJMHP Medical Director or designee will have two business days to review this information and to consult with JCMHS in order to determine JCMHS’ ultimate recommendation to the Court regarding the medication regimen’s long-term safety, efficacy, and appropriateness.
    3. If, after this consultation, JCMHS and the JJMHP Medical Director or designee conclude that the medication regimen is not clearly safe for long-term use, effective, or appropriate, or that other potential medication regimens that comport with these parameters are feasible or preferable to utilize, JCMHS will not recommend approval of the new PMAF (presuming the medication regimen is substantively unchanged).
    4. If, after this consultation, JCMHS and the JJMHP Medical Director or designee conclude that the medication regimen is clearly safe for long-term use, effective, appropriate, and that other potential medication regimens that comport with these parameters are not feasible to utilize, JCMHS will recommend approval of the new PMAF for six months presuming the medication regimen is substantively unchanged.
      1. In this situation, the prescribing provider shall be required to submit every 45 days to JCMHS documentation of the medication regimen’s continuing safety, efficacy, and appropriateness, and that other potential medication regimens that comport with these parameters are not feasible to utilize. JCMHS briefly will review this information and provide input to the Court regarding the medication regimen as needed or appropriate.
LEVEL OF CONVIDENCE DETERMINATION for Recommendations based on PMAF Submissions (05/01/2015)
1. Purpose: To help ensure that Department of Mental Health (DMH) has a sufficient level of confidence in the overall prescribing practices and reporting of prescribers to permit the making of recommendations to the Juvenile Court regarding approval of medications for youth in state custody based upon prescriber-reported clinical information.
2. Background:
  1. In accordance with the Superior Court Juvenile Division's Psychotropic Medication Protocol, judicial approval is generally required for provision of medications to youth in state custody.
  2. Prescribers petition the court to authorize administration of psychotropic medications to youth in state custody via the PMAF also know as JV-220A.
  3. JCMHS, a division of the Juvenile Justice Mental Health Program (JJMHP), reviews all PMAFs and makes a recommendation regarding approval to the court.
  4. Based upon its review, JCMHS makes recommendations to the court regarding court approval or non-approval of the proposed regimen.
  5. Occasionally, there may be prescribers for whom JCMHS has an insufficient level of confidence in their prescribing practices and/or ability or willingness to relay complete and accurate information to JCMHS via the PMAF or by other means.
  6. If JCMHS has insufficient confidence in a prescriber, it is unable to render a recommendation to the court regarding approval of a proposed medication regimen.
3. Factors for a Determination of Insufficient Level of Confidence - JCMHS may identify a prescriber who demonstrates anyone (1) or combination of the following:
  1. A pattern of submitting PMAFs that do not comport with existing DMH parameters for prescribing of psychotropic medications to youth in state custody.
  2. A pattern of submitting PMAFs that trigger unsupportive secondary reviews, i.e., recommendation to court of Do Not Approve by JCMHS.
  3. A pattern of submitting PMAFs that are incomplete or inaccurate.
  4. A pattern of submitting PMAFs that are unsupportable because of concerns about clinical quality. Examples of this may include, but are not limited to:
    1. The proposed medication’s lack of efficacy in treating the youth’s diagnosis as listed on the PMAF.
    2. Not adhering to recommended dose ranges or lab monitoring as defined in existing DMH parameters or other relevant practice parameters from recognized professional organizations, e.g., the American Academy of Child and Adolescent Psychiatry.
    3. Changing diagnoses to ones unsupported by clinical data to justify a particular medication regimen.
  5. A pattern of failing to follow standardized administrative procedures involving the PMAF submission and review process. Examples of this may include, but are not limited to:
    1. Failure to return phone calls or other communications from JCMHS (which generally request clarification of the submitted PMAF) within 72 business hours.
    2. Failure to submit PMAFs for youth on whom they are required.
  6. For purposes of a making an “insufficient level of confidence” determination, “pattern” shall be defined as “three or more occasions in a two-year period.”
4. Notification of Prescriber:
  1. If a prescriber demonstrates anyone (1) or a combination of the listed factors for a preliminary determination of insufficient level of confidence, the JCMHS Medical Director may notify their immediate supervisor, the Juvenile Justice Mental Health Program (JJMHP) Medical Director. The JJMHP Medical Director and JCMHS Medical Director will meet to review the prescriber’s submitted PMAFs, and any assessments completed by JCMHS. The JJMHP Medical Director will notify the prescriber of their intent to make a final insufficient level of confidence determination.
  2. Within 10 days of notification, the prescriber may request to meet with the JCMHS and relevant Medical Directors in the Division of Forensic Psychiatry at Edmund D. Edelman Children’s Court in order to jointly review the PMAF protocol, practice parameters, and other information relevant to the prescribing review and approval process for dependency and delinquency youth.
  3. The Chief Medical Officer, with input from the JCMHS Medical Director and relevant Medical Directors in the Division of Forensic Psychiatry, will consider whether or not to make a final insufficient level of confidence determination for that prescriber based on the factors for the preliminary insufficient level of confidence determination that had been demonstrated by the prescriber prior to the meeting, the results of the meeting with the prescriber, the prescriber's overall prescribing practices, and adherence to standardized administrative procedures and the PMAF protocol during the 30-day period after the meeting.
5. Notification of Court and Other Agencies:
  1. If an insufficient level of confidence determination is ultimately made, JCMHS will immediately notify the prescriber, all delinquency and dependency court judicial officers, and the supervising agency (the Department of Children and Family Services (DCFS) or the Probation Department) of youth for whom the individual has prescribed.
  2. Thereafter, any time a PMAF is submitted by the identified prescriber, JCMHS will notify the prescriber, the judicial officer presiding over the youth’s case, and the youth’s supervising agency (DCFS or the Probation Department) of the insufficient level of confidence determination.
6. Effect of an Insufficient Level of Confidence Determination:
  1. In order to ensure the well-being of children and adolescents, for a period of one year following a determination of an insufficient level of confidence by the Chief Medical Officer, JCMHS will note on any PMAFs submitted by that prescriber that JCMHS cannot provide a recommendation to approve due to a lack of sufficient confidence in the quality of the associated clinical work.
  2. After one year, the provider may request to meet with the JCMHS Medical Director and relevant Medical Directors in the Division of Forensic Psychiatry at Edmund D. Edelman Children’s Court in order to jointly review the PMAF protocol, practice parameters, and other information relevant to the prescribing approval process for youth in state custody. After such a meeting has been completed, the insufficient level of confidence determination will be deemed to have lapsed, and JCMHS will resume review of PMAFs from that prescriber and make recommendations regarding approval. If JCMHS identifies, in the course of these new PMAF reviews, that the same or new factors exist for a determination of an insufficient level of confidence in that prescriber's practices, the relevant Medical Directors may make a new insufficient level of confidence determination.