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 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 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 Percent 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 care 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 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 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) 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 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 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 Specialized foster-care clinic Community-based care in medical home Agency-based care 12 Improving Health Care Outcomes for Children in Foster Care… The Children’s Hospital Boston Experience 13 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 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 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 provided 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 provided 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 information Through diligence and persistence, clinicians are frequently able to identify pieces of medical information 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 shots” • 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 situation 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 concentrating” “Likes helping people” Entertained a career in psychology or psychotherapy 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 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 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 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 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 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 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 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 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 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 Improving Health Care Outcomes for Children in Foster Care… The Maryland Experience 44 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 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 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 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 Physician Discussion of Healthcare Topics 45 42.4 38.3 40 35 never/rarely discussed Percent stating topic 30 23.3 25 23.3 19.4 19.1 19.2 20 15 10 4.3 5 0 g e s s s ds s ds e in ar e ed e ed ed ee ed ee ll B rC N N Ne N lN e N e te lth n g l th l th ta al /W Fo s a ri ea a en n th He ea He tio ea l tt o ta l n/ H lH ta l pm ca ra lo du H en De n io io en e E rall tm V is h av M D ev e us Be Ov A dj W ai tT im e fo Tr r A Percent Citing as a Barrier av pp el oi 10 15 20 25 30 35 40 0 5 Ti nt m m e en to t* A 11 pp o in N 30.2 o tm Pr en M t D ov 6.7 W id on er 7.9 't in Se A e re a 6.1 Fo st M er D 11.1 Yo W ut on h 't A M cc D 5.5 6.3 ep W tM on A* 't 10.3 Se Lo e ng N 36.5 ew W M ai A tf 9.8 C or hi ld M A 19 N C ot ar El d* ig 4.2 Tr ib an le Foster Parent sp fo 23.8 or rM ta A tio * 1.2 n Barriers to Healthcare Pr ob 6.3 le m s 1.2 4.8 Group Home/TFC Caregiver Receipt of Information 60 52.2 Percent Stating Rarely/Never 50 46.9 46.1 40.8 40 35.6 35.9 Receive 30 20 8.3 13.1 12.7 10 4.8 0 Physical Mental Dental Development Educational Health* Health* Health* Needs* Type of Information Foster Parent Group Home/TFC 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 Access to Medical & Dental Care Access to Mental Health Care Medical Home & Tracking Health Information 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 concerns 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 issues 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 return. Placed in foster care. Screening exam by local doctor. Health Passport: Workgroup Efforts – Immunization Records ImmuNet – State Immunization registry Working on DSS password-protected access 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 Challenges: 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 Caretaker order 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 order Caretaker order sent to pediatrician documenting DSS custody Letter sent to pediatrician with regs about information sharing Medical records released 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.
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