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Children in Foster Care: Multidisciplinary Models for Addressing Their Health Care Needs. Celeste R. Wilson, MD 1 Wendy Lane, MD MPH 2 Allison Scobie-Carroll, LICSW MBA 1 Beth Holleran, MSW LICSW 1 Karen Powell, LCSW-C 3 Michele Burnette, RN 4 1 Children’s Hospital Boston

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children in foster care multidisciplinary models for addressing their health care needs

Children in Foster Care: Multidisciplinary Models for Addressing Their Health Care Needs

Celeste R. Wilson, MD1

Wendy Lane, MD MPH2

Allison Scobie-Carroll, LICSW MBA1

Beth Holleran, MSW LICSW1

Karen Powell, LCSW-C3

Michele Burnette, RN4

1Children’s Hospital Boston

2University of Maryland School of Medicine

3Maryland Department of Human Resources

4Maryland Foster Parent Association

objectives
Objectives
  • Understand key steps in developing a program to care for children transitioning into foster care
  • List factors contributing to unrecognized health vulnerabilities for children in foster care
  • Recognize common unmet needs in the foster care population
  • Outline approaches for addressing medical, dental, and psychosocial problems
background
Background
  • Nearly 1 million children are maltreated each year
  • An estimated 423,773 children are in foster care
  • Most are placed because of abuse or neglect in the context of:
    • Parental substance abuse
    • Extreme poverty
    • Mental illness
    • Homelessness
    • Parental chronic illness
placement settings
Placement Settings

Percent

US Dept. of Health and Human, Child Welfare Information Gateway 2011

health status of foster youth
Health Status of Foster Youth
  • Higher rates of:
    • Medical concerns
    • Mental health issues
    • Developmental delays
    • Dental problems
  • Compared to children & youth not in foster care
children entering foster care
Children Entering Foster Care

Pediatrics 1994;93;594.

identification of health care needs
Identification of Health Care Needs
  • Failure to address medical and mental health problems may adversely affect child’s quality of life
  • AAP recommends children in foster care receive:
    • Initial physical exam on entering placement
    • Comprehensive physical, mental health, and developmental evaluations within one month
    • Ongoing primary care and health monitoring
    • Efficient transfer of health information

Pediatrics 2002; 109;536.

aap standards for meeting health care needs
AAP Standards for Meeting Health Care Needs

Comprehensive & coordinated treatment approach

Continuity of care

Assessment of each child’s unique needs

8

fostering connections to success and increasing adoptions act of 2008 h r 6893
Fostering Connections to Success and Increasing Adoptions Act of 2008 (H.R. 6893)

Title I: Connecting and Supporting Relative Caregivers

Title II: Improving Outcomes for Children in Foster Care

Continuing Federal Support for Children in Care After Age 18

Transition Plan for Children Aging Out

Expanding IV-E for Private Agency Training

Promoting Educational Stability

Health Oversight and Coordination Plan

Sibling Placement

Title III: Tribal Foster Care and Adoption Access

Title IV: Improvement of Incentives for Adoption

fostering connections health care requirements
Fostering Connections Health Care Requirements

Develop plan for the ongoing oversight and coordination of health care and services

Develop in collaboration with state Medicaid agency, pediatricians and other appropriate experts

10

coordinated health plan requirement under fostering connections
Coordinated Health Plan RequirementUnder Fostering Connections

Health screenings

Monitoring & treatment of identified health needs

Update & share medical information

Continuity of health care services

Oversight of prescription medications

11

models for meeting health care needs
Models for Meeting Health Care Needs

Specialized foster-care clinic

Community-based care in medical home

Agency-based care

12

slide13
Improving Health Care Outcomes for Children in Foster Care…The Children’s Hospital Boston Experience

13

the process
The Process
  • Proposal to alter the clinic model
  • Approval from internal stakeholders
  • Reactions to change in service by community providers
  • Multiple meetings with state child protection agency stakeholders at Central and Regional level
  • Literature Review
the process15
The Process
  • Informational interviews with representatives from foster care clinics throughout the country
  • New staff hires
  • Administrative and operational processes solidified
  • Presentations to local area offices of state child protection agency
  • Open for business on April 1, 2008
obstacles
Obstacles
  • Staff ambivalence
  • Limited space/ clinic hours
  • 7/30 day policy adherence
  • State protection agency workers’ preferences for other providers
  • Foster parents work schedules
  • Prior affiliations with other providers
eligibility criteria
Eligibility Criteria
  • Any child, ages 0-18 years who is newly placed in foster care in Boston or Metro Region offices. Referrals are made to the clinic within seven days of placement.
  • Children who have been placed in foster care significantly beyond 7 days and children requiring an inpatient level of care are not appropriate for the service.
referral source and requirement
Referral Source and Requirement
  • Social workers from state child protection agency or foster parents
  • Basic medical information
  • Completion of all necessary consents/releases of information prior to the initial visit
the model
The Model
  • 7-day and 30-day visit model
  • Multi-disciplinary approach
  • Comprehensive medical, developmental, behavioral, and dental assessments
  • Intended to address the immediate medical, dental and psychiatric needs of children entering into foster care
7 day visit
7-day Visit
  • Patient examined by a physician specializing in child maltreatment
  • Acute medical needs addressed and referrals for further interventions provided
  • Dental screening
7 day visit21
7-day Visit
  • Foster parents meet with a behavioral health clinician to discuss any psycho-social issues requiring immediate intervention.
  • Foster parents receive two behavioral checklists, one to be completed by the patient’s teacher (if applicable) and one to be completed by the foster parent. These are to be returned at the 30-day visit.
30 day visit
30-day Visit
  • Medical exam, immunizations and labs if clinically indicated
  • For children ages 0-7.5 years, a developmental screening performed
  • The behavioral checklists that were completed by the foster parent and teachers are scored
  • Results discussed with foster care providers
30 day visit23
30-day Visit
  • Recommendations and referrals for primary care, psychiatric services, Early Intervention, further developmental testing or any other clinically indicated service provided
  • Any dental follow up interventions
unrecognized health care needs
Unrecognized Health Care Needs
  • Not surprising that children entering foster care may be in very poor health
  • Challenges faced by state protection workers’ limited ability to communicate with the family
  • Parents unwilling to offer pertinent medical information
  • Through diligence and persistence, clinicians are frequently able to identify pieces of medical information
what did you say
What did you say?
  • 4 year old boy with history of maternal substance abuse
  • “Very hyper” and “does not speak”
  • No medical information provided by state worker
  • Review of our electronic record revealed:
    • Failed newborn hearing test
    • “No show” to audiology evaluation appointment
  • Audiology evaluation revealed moderate to severe hearing loss
i don t eat meat
I don’t eat meat!
  • 12 year old boy placed in care with three younger siblings for concerns of child neglect
  • Rastafarian family
    • “Do not eat products from animals”
    • “Do not cut their hair”
    • “Do not take shots because people get sick from shots”
    • Home schooled
    • No routine medical care
i don t eat meat27
I don’t eat meat!
  • Ordered general screening labs
    • Calcium critically low (6.9)
    • Vitamin D low (<2)
    • PTH elevated (244)
  • Admitted to hospital
  • Mother insisted that Vit D supplementation therapy not be an animal product derivative
  • Version of Vit D replacement suitable by mother and endocrine team identified
looking ahead
Looking Ahead
  • 16 year old girl with longstanding involvement with state protection agency
  • Mother abusing drugs; Grandmother abusive
  • Miscarriage one year prior
  • History of sexually transmitted disease
  • Sexually active
    • No birth control
    • No barrier protection
  • Death of mother from cancer this year
  • Wearing button of deceased fetus
looking ahead29
Looking Ahead
  • Follow up visit 2 months later
  • Pregnant
  • Giddy to excitement
  • “Plan to keep the baby”
  • Visit for prenatal care arranged
  • Sense of hope tempered by uncertain living situation
aspirations of college
Aspirations of College
  • 17 year old boy
  • Originally from Uganda, brought by father at 9 years of age
  • Mother deceased
  • Father with substance abuse
  • Guardianship granted to a relative
  • Financial difficulties and housing concerns, state took custody
aspirations of college31
Aspirations of College
  • 10th grader; star member of football team
  • Endorsed alcohol and marijuana use
  • Actively cutting back on substance use
  • “Doing better than ever…because I’m concentrating”
  • “Likes helping people”
  • Entertained a career in psychology or psychotherapy
meeting the needs
Meeting the Needs
  • Moving from the policy to the practice
  • Respecting the individual child’s experience and responding to the needs of this vulnerable group
  • Examining what we provide
  • Paying attention to the trends
screening
Screening
  • At the time of initial intake, screen for known psychiatric diagnoses, hospitalizations, medications, treatment history
  • Screen patients for physical/emotional safety at visits
  • Administer behavioral checklists
  • Anticipate issues related to lapsed treatment, prescriptions
  • Facilitate referral to prescribing physician, mobile crisis team, community service agency, on-call psychiatry
most common diagnoses
Most Common Diagnoses
  • Of those children referred to our clinic, the most common psychiatric diagnoses include:

- ADHD

- Depression

- Mood Disorder

- PTSD

- Bipolar Disorder

- Oppositional Defiant Disorder

- Substance Abuse

common challenges
Common Challenges
  • Proper assessment of the etiology of the mental health issue is lacking
  • Little to no information known regarding the child’s mental health treatment
  • Children are taking several medications without the benefit of ongoing treatment
  • Delays in the start of treatment due to the transiency of the placement
dental access
Dental Access
  • Oral health is an important part of overall health
  • The CDC reports dental caries as perhaps the most prevalent infectious disease in the children (5x rate of asthma)
  • 40% of children have tooth decay by kindergarten
  • Pain, swelling, decline in growth are risks
  • Dental Home is an important part of care
  • Initial oral exam at time of eruption of 1st tooth but no later than one year of age (American Academy of Pediatric Dentistry, 2008)
dental access37
Dental Access
  • Referred patients receive a comprehensive dental evaluation in the CHB Dental Clinic
  • Unique concerns are communicated in advance to Dental Clinic
  • Results of the dental evaluation are communicated directly with providers and in the summary report to allow for proper dental follow up
developmental screening
Developmental Screening
  • The Brigance is utilized as a basic screening tool for children birth to age 7 years
  • Approximately 70% of those screened were referred for further evaluation
  • Recommendations included: EIP, CORE, Developmental Evaluation, Preschool
behavioral screening
Behavioral Screening
  • Foster parents are given the CBCL to complete and return in postage-paid envelope
  • Discussion takes place with foster parents at each visit regarding the child’s adjustment, behavioral/emotional issues
  • Teacher Report Forms and Youth Self-Report (YSR) forms are provided
  • Higher rate of return when the patient completes the YSR form while in clinic
  • Respond to acute mental health and behavioral concerns
maintaining medical home
Maintaining Medical Home
  • Who is the primary care provider (PCP)?
  • How connected is the child to that PCP?
  • What do you do if you don’t know?
    • Does the child have a MR# with us?
    • Massachusetts health database
    • DCF Medical Services Unit
    • School nurses
    • Ask the child/family
  • How do we build a bridge to primary care?
tracking health care information
Tracking Health Care Information
  • Communicate verbally with the state child protection agency worker the salient points – may require MD-worker contact
  • MD report gets faxed directly to PCP
  • Send a copy of the Summary Report to the state child protection agency worker
  • Send separate Recommendation report to the foster parent to ensure follow up
  • Include specific findings, recommendations, and plan for follow up
  • Reconnect/refer the patient to primary care
conclusions
Conclusions
  • The educational, psychiatric and medical needs of foster children are unique
  • The clinical presentation of our Foster Care Clinic patients mirrors the findings in the literature
  • Placement instability and the increased health care needs of foster children are interrelated
conclusions43
Conclusions
  • Despite CBHI, access to psychiatric care continues to present serious challenges
  • The need for vigilant coordination, consistent communication and the provision of medical consultation to state child protection agency workers is essential to improved outcomes
  • A medical home that responds to the unique needs of foster children is invaluable
the process role of the aap
The Process - Role of the AAP

Task Force on Foster Care (TFOFC)

2008 – Planning Grants – State Systems of Health Care for Children and Youth in Foster Care

State System of Health Care =

Coordinated health system

Child welfare, judicial, pediatric, mental, dental health professionals & foster parents work collaboratively to respond to manage, and improve the health and well-being of foster youth

the process aap grant activities
The Process - AAP Grant Activities

Needs Assessment – 18 month process

Identification of key informants

Surveys of professionals – medical, mental health, social service, child welfare, legal

Surveys of foster parents

Focus group with foster youth

Analysis of responses  Key focus areas

the process needs assessment findings
The Process - Needs Assessment Findings

Primary Care

Access to providers mostly good

Many primary care providers not addressing specific needs of foster youth

Mental health

Mental health problems are common among foster youth

Access to mental health care is problematic

needs assessment findings
Needs Assessment Findings

Dental health

Many youth enter foster care with preventable dental problems

Access to dental care for foster youth is problematic – orthodontics especially a problem

Sharing of medical information

A problem for all groups of respondents

Often not enough info to determine needs

needs assessment findings49
Needs Assessment Findings

Knowledge about special needs of foster youth

Many professionals could benefit from additional training

For example:

Training of mental health professionals in trauma-based therapy

Training of judges to better understand the special needs of foster youth

recommendations
Recommendations

Create a better system for obtaining and sharing health information for Maryland Foster youth

Implement additional training for professionals to better address the needs of foster youth

Offer additional training/education for foster parents and group home providers to address behavioral and mental health concerns

Identify ways to increase number of health providers who accept Medical Assistance

key issues to address
Key Issues to Address

Access to Medical & Dental Care

Access to Mental Health Care

Medical Home & Tracking Health Information

Training

the model medical home
The Model – Medical Home

Continuity of care with primary care provider

Initial site: Baltimore City

MATCH program

Care coordination –

Nursing & social work care coordinators

Oversight by pediatrician and psychiatrist

medical home model benefits
Medical Home Model - Benefits

Provider has medical record – knows medical history, health & psychosocial concerns

Child knows, comfort with provider

Continuity of care with reunification

medical home model challenges
Medical Home Model - Challenges

Non-local placements

Homes with multiple foster youth, each with different PCP

Doesn’t assure knowledge of foster care issues

Doesn’t assure quality of medical care

workgroup planning process
Workgroup Planning Process

Workgroup assignments

Facilitated brainstorming discussion

Preliminary strategies

Short and long term goals

Ongoing meetings & progress post retreat

past medical history
Past Medical History ??

3 year old boy

Mother’s whereabouts unknown. Dad left boy in care of girlfriend for afternoon. Didn’t return.

Placed in foster care.

Screening exam by local doctor.

Health Passport:

workgroup efforts immunization records
Workgroup Efforts – Immunization Records

ImmuNet – State Immunization registry

Working on DSS password-protected access

workgroup efforts medical home
Workgroup Efforts – Medical Home

Identification of medical home

Initial & Comprehensive medical evaluations done in medical home

Provider aware of health history

Asthma

Infants and Toddlers

workgroup efforts health passport
Workgroup Efforts – Health Passport

Old passport:

Plastic billfold

Little or no information

Blank forms – no instructions

Passport in progress

Problem & provider lists

Visit focused forms with checkboxes

Provider instructions

Information form for providers

workgroup efforts health passport64
Workgroup Efforts – Health Passport

Challenges:

No $ to develop electronic health passport

Use of existing data system – cumbersome

Rollout/implementation

hipaa won t let me
HIPAA Won’t Let Me

12 year old – placed in foster care because of maternal substance abuse

History of asthma, lead exposure

DSS requests medical records from primary care provider

Doctor’s office “HIPAA regs say I can’t share this information.”

workgroup efforts info sharing67
Workgroup Efforts – Info Sharing

Challenges in Using Caretaker Order

Education of judges

Oversight of judges

workgroup efforts info sharing68
Workgroup Efforts – Info Sharing

Letter to Providers

Laws/regs allowing

Information sharing

workgroup efforts info sharing69
Workgroup Efforts – Info Sharing
  • Challenges to
  • Information Sharing
  • HIPAA phobia
  • 18-21 year olds
  • Mental health
  • Reproductive health
hipaa won t let me70
HIPAA Won’t Let Me

DSS worker asks judge to issue caretaker order

Caretaker order sent to pediatrician documenting DSS custody

Letter sent to pediatrician with regs about information sharing

Medical records released

references
References

American Academy of Pediatrics. Committee on Early Childhood, Adoption, and Dependent Care. Health care of young children in foster care. 2002;109(3):536.

Child Welfare Information Gateway. (2011). Foster care statistics 2009. Washington, DC: US Department of Health and Human Services, Children’s Bureau.

Child Welfare League of America. (2007). Standards of Excellence for Health Care Services for Children in Out-of-Home Care. Washington, DC:CWLA.

Chernoff R, Combs-Orme T, Risley-Curtiss C, Heisler A. Assessing the health status of children entering foster care. Pediatrics. 1994;94:594.

Jee SH, Szilagyi M, Ovenshire C, Norton A, Conn A, Blumpkin A, Szilagyi PG. Improved detection of developmental delays among young children in foster care. Pediatrics 2010;124:282.

Simms MD, Dubowitz H, Szilagyi MA. Health care needs of children in the foster care system. Pediatrics. 2000;106:909.