Abusive Head Trauma Evaluation and Management by cuiliqing


									     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
        2Universityof Maryland School of Medicine
        3Maryland Department of Human Resources
           4Maryland Foster Parent Association
   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
   Nearly 1 million children are maltreated each
   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


      US Dept. of Health and Human, Child Welfare Information Gateway 2011
Health Status of Foster Youth
   Higher rates of:
    •   Medical concerns
    •   Mental health issues
    •   Developmental delays
    •   Dental problems

   Compared to children & youth not in foster
Children Entering Foster Care
                    Diagnosis/Problem               N=1407
Abnormality in at least one body system              91%
Weight <5th percentile (<2yrs old)                   15%
Height <5th percentile (<2yrs old)                   27%
Failed vision screen                                 25%
Failed hearing screen                                15%
Family hx of mental illness or drug/alcohol abuse    75%
Suicidal ideation                                    15%
History of behavioral problems                       36%
History of sexual abuse                              18%
Homicidal ideation                                    7%
Abdnormal/suspect developmental screen               23%
                                                    Pediatrics 1994;93;594.
    Identification of Health Care Needs

   Failure to address medical and mental health
    problems may adversely affect child’s quality of
   AAP recommends children in foster care
     •   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
   Comprehensive & coordinated treatment

   Continuity of care

   Assessment of each child’s unique needs

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
           Sibling Placement
   Title III: Tribal Foster Care and Adoption Access
   Title IV: Improvement of Incentives for Adoption
          Fostering Connections
         Health Care Requirements
   Develop plan for the ongoing oversight
    and coordination of health care and

   Develop in collaboration with state
    Medicaid agency, pediatricians and other
    appropriate experts
    Coordinated Health Plan Requirement
       Under Fostering Connections
   Health screenings
   Monitoring & treatment of identified health
   Update & share medical information
   Continuity of health care services
   Oversight of prescription medications

Models for Meeting Health Care Needs

   Specialized foster-care clinic

   Community-based care in medical home

   Agency-based care

Improving Health Care Outcomes
  for Children in Foster Care…

The Children’s Hospital Boston

                 The Process
   Proposal to alter the clinic model
   Approval from internal stakeholders
   Reactions to change in service by community
   Multiple meetings with state child protection
    agency stakeholders at Central and Regional
   Literature Review
                 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
   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

   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

   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
   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
   Patient examined by a physician
    specializing in child maltreatment

   Acute medical needs addressed and
    referrals for further interventions

   Dental screening
                  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
   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 Visit
   Recommendations and referrals for
    primary care, psychiatric services, Early
    Intervention, further developmental testing
    or any other clinically indicated service

   Any dental follow up interventions
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
   Through diligence and persistence, clinicians
    are frequently able to identify pieces of medical
             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!
   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
    •   Home schooled
    •   No routine medical care
                 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
   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 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
        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 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
   “Likes helping people”
   Entertained a career in psychology or
          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
   At the time of initial intake, screen for known psychiatric
    diagnoses, hospitalizations, medications, treatment

   Screen patients for physical/emotional safety at visits

   Administer behavioral checklists

   Anticipate issues related to lapsed treatment,

   Facilitate referral to prescribing physician, mobile crisis
    team, community service agency, on-call psychiatry
     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
   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
   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

   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 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
     Developmental Screening
   The Brigance is utilized as a basic
    screening tool for children birth to age 7

   Approximately 70% of those screened
    were referred for further evaluation

   Recommendations included: EIP, CORE,
    Developmental Evaluation, Preschool
          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

   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
   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
   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
   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

   Placement instability and the increased health
    care needs of foster children are interrelated
   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
Improving Health Care Outcomes
  for Children in Foster Care…
    The Maryland Experience

    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
   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
   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
   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 Findings
   Knowledge about special needs of foster
       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
                                    Physician Discussion of
                                      Healthcare Topics
                               45          42.4

      never/rarely discussed
       Percent stating topic

                               25                            23.3
                                                                            19.4           19.1                           19.2




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                           e in           ar             e ed             e ed              ed             ee              ed          ee
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                 Tr                     r   A                    Percent Citing as a Barrier
                   av                           pp
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                                                                                                                                               Barriers to Healthcare



Group Home/TFC
Caregiver Receipt of Information

Percent Stating Rarely/Never

                               50                46.9                         46.1
                                    35.6                                             35.9



                                                        8.3          13.1                          12.7


                                    Physical     Mental       Dental        Development Educational
                                    Health*      Health*      Health*                     Needs*

                                                        Type of Information

                                                 Foster Parent              Group Home/TFC
   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
   Access to Medical & Dental Care

   Access to Mental Health Care

   Medical Home & Tracking Health

   Training
        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
   Provider has medical record – knows
    medical history, health & psychosocial

   Child knows, comfort with provider

   Continuity of care with reunification
Medical Home Model - Challenges
    Non-local placements
    Homes with multiple foster youth, each
     with different PCP
    Doesn’t assure knowledge of foster care
    Doesn’t assure quality of medical care
     Workgroup Planning Process
   Workgroup assignments

   Facilitated brainstorming discussion
       Preliminary strategies
       Short and long term goals

   Ongoing meetings & progress post retreat
         Past Medical History ??
   3 year old boy
   Mother’s whereabouts unknown. Dad left
    boy in care of girlfriend for afternoon. Didn’t
   Placed in foster care.
   Screening exam by local doctor.
   Health Passport:
Workgroup Efforts – Immunization

    ImmuNet – State Immunization registry

    Working on DSS password-protected
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
      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 Passport

     No $ to develop electronic health passport

     Use of existing data system – cumbersome

     Rollout/implementation
        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 Sharing

Workgroup Efforts – Info Sharing

Challenges in Using
 Caretaker Order

   Education of judges
   Oversight of judges
Workgroup Efforts – Info Sharing

                 Letter to Providers

                 Laws/regs allowing
                 Information sharing
Workgroup Efforts – Info Sharing
                 Challenges to
                 Information Sharing

                 •   HIPAA phobia
                 •   18-21 year olds
                 •   Mental health
                 •   Reproductive health
        HIPAA Won’t Let Me
   DSS worker asks judge to issue caretaker
   Caretaker order sent to pediatrician
    documenting DSS custody

   Letter sent to pediatrician with regs about
    information sharing

   Medical records released
   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.
   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.

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