Children's Health

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A SYSTEM OF CARE GIVERS --
CARING FOR CHILDREN'S HEALTH

Primary care physicians are the critical ingredients in the provision of health care services for children in foster care.

doctor holding a baby The U.S. General Accounting Office (GAO) reports, "Foster children are among the most vulnerable individuals in the welfare population. As a group, they are sicker than homeless children and children living in the poorest sections of inner cities." (1995, p. 1). It is well documented that children in foster care as a group have significantly higher rates of serious mental health conditions, chronic illnesses and disabilities, birth defects, and developmental delays relative to other groups of children of comparable socioeconomic backgrounds (AAP, 1997: CWLA, 1988; Silver, Haecker, & Forkey, 1999).

The American Academy of Pediatrics (AAP) is promoting the medical home approach to providing health care services for children with special health care needs. A medical home is not a building, house, or hospital, but rather an approach to providing health care services in a high-quality and cost-effective manner. When children have extraordinary health care needs, having a medical home can ensure that those needs are met. Pediatricians and parents act as partners in a medical home to identify and access all the medical and non-medical services to help children and their families achieve their maximum potential. (AAP, 1997)

Could this approach to the provision of comprehensive health care services be adopted by the system responsible for ensuring services for children in foster care? A precedent for mandated care assurances already exists. Children in foster care are eligible for the Early and Periodic Screening Diagnosis and Treatment Program (EPSDT). This federally mandated program was initiated to ensure that all children from birth to 21 who are covered by Medicaid, receive comprehensive well-child care, medical histories, physical exams, developmental assessments, laboratory screening and immunizations. Unfortunately, only one percent of children surveyed received EPSDT services. (GAO, 1995)

stack of boxes and clipboard How can a community establish a comprehensive health care system that promotes positive outcomes for children in foster care? Many barriers within the system interfere with the provision of needed services. Those barriers include:

Fragmentation and lack of communication.
Lack of complete medical records.
Low reimbursement rates.
Complicated paperwork.
Numerous placement and provider changes.
Judgments and myths about foster parents, biological parents, and children in foster care.

These obstacles need not represent the future picture of health care service delivery for children in foster care. Increasing the likelihood of resilience or positive outcomes for children in foster care is the goal of ALL of the dedicated members of this complex system of service providers. This system has the potential to become a caring community for all children in foster care. Each member of the caring community has an important role in the care and treatment of children in foster care. No one provider can do it alone.

The Caring Communities for Foster Care Project is exploring ways to promote a community-based model for providing comprehensive health care for children in foster care, which incorporates the critical elements of a medical home approach. In 1988, the Child Welfare League of America (CWLA) in consultation with the American Academy of Pediatrics (AAP), developed Standards for Health Care Services for Children in Out-of-Home Care. Those guidelines remain intact today, though incongruence and fragmentation within the "system" often interfere with achieving these service goals. A caring community surrounding children in foster care can work together to ensure that children are being cared for in the most proactive fashion in order to ensure positive physical and mental health outcomes.

Caring Communities diagram of foster care system with a child and birth family in the center surrounded by medical providers, social providers, attorneys, foster family, and teachers

The AAP (2000) recommends that pediatricians serve as the primary health care provider for children in foster care and as consultants to child welfare agencies. Working in concert with social workers, foster parents and other members of the caring community, physicians can ensure that care reflects the components of a medical home for all children in foster care. The medical home approach shows tremendous promise in addressing complex issues present for children with special health care needs.

Medical Home Critical Elements

Accessible

· Care is provided in the child’s community

· Accepts all insurance, including Medicaid

· Insurance changes accommodated
Family-Centered

· Recognizes family as principal caregiver and center of strength and support for children

· Shares all information on ongoing basis
Continuous

· Pediatrician available through adolescence

· Assistance with life transitions
Comprehensive

· Health care available 24 hours, 7 days a week

· Preventive, primary and tertiary care needs addressed
Coordinated

· Families linked to support, educational, and community-based services

· Information centralized
Compassionate

· Concern for child and family well-being is expressed and demonstrated
Culturally-Competent

· Family’s cultural background recognized, valued, and respected

(AAP, 1995)

Phoenix Pediatrics, LTD. provides a medical home to many children with complex health care needs, including a large number of children in foster care. As specialists for children with special health care needs, Phoenix Pediatrics has established relationships with a large number of specialists. As part of their model, a Clinical Care Coordinator serves as a service coordinator for the children and their families and also represents the liaison between parents/foster parents, primary care physicians and medical specialists. All records are compiled and maintained by this office. Dr. Hirsch of Phoenix Pediatrics believes that the care coordinator is critical to providing comprehensive services. "It is so important to have somebody that knows the system."

Programs such as Project ENHANCE (Excellence in Health Care for Abused and Neglected Children) are beginning to explore the effectiveness of a medical home approach for children in foster care.

Project ENHANCE is the result of a collaboration between the Department of Pediatrics and the Division of Child Psychiatry at the State University of New York Health Science at Syracuse and the Onondaga County Department of Social Services. This comprehensive, multi-disciplinary approach to providing health care for children in foster care attributes it’s success to a good fit with the community, the participation of mental health professionals and the focus placed on establishing relationships and effective communication among all parties caring for children in foster care. A written summary of each visit is provided so that caseworkers, foster parents, biological parents, lawyers and judges have access to a clear and concise record of each child to assist in evaluating cases and obtaining services.

A medical home approach to providing comprehensive, accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally-competent care for every child in foster care may increase the likelihood of positive outcomes for more children. Caring communities have the capacity to ensure that all children in foster care have access to a medical home.

CWLA and AAP Standards for Health Care in Brief

Initial Health Screening

Identify immediate health care needs in which foster parents and caseworkers should be aware. Conducted before or shortly after placement (within 24 hours) to identify immediate medical needs and includes:

Screening for health, nutrition, and developmental history and assessment,
Complete physical examination,
Screening for vision, hearing and dental status,
Mental health screening.

Developmental and Mental Health Evaluation

Assessment of child’s developmental, educational and emotional status are part of comprehensive health evaluation and each visit thereafter.

Completed within 30 days of placement.
Initial evaluation completed by qualified mental health practitioner.
Results included in child’s social services case plan.

Comprehensive Health Assessment

Address and integrate medical, emotional, educational, developmental, social and cultural aspects of child’s well-being.

Completed within 30 days of placement.
Performed by pediatrician available for regular ongoing primary care services.
Note the presence of acute or chronic medical programs that might suggest need for further evaluation or referral.
Include screening tests recommended for Preventive Pediatric Health Care by AAP.
Consider tests for HIV, Hepatitis or other sexually acquired infections for children in high-risk groups.
Dental examination.
Determine types and number of immunizations.
Produce written summary of medical, mental health, educational, dental, and social needs.

Ongoing Monitoring of Children’s Health Status

Periodic reassessment of health, development and emotional status to determine changes in status and need for additional services and interventions. Conducted every 6 months in first year of placement, yearly thereafter and includes:

Preventative health and health maintenance services incongruent with AAP standards of practice,
Routine health care including dental and eye examinations in accordance with EPSDT standards,
Available mental health services including psychological testing and/or psychiatric services as determined necessary,
Referrals to other specialized services identified as needed by primary care physicians.

Creating a Caring Community

The goal of The Caring Communities for Foster Care Project is to create a family/professional collaborative partnership which will bridge the barriers that prevent children in foster care from obtaining coordinated and comprehensive health care and other needed services. In collaboration with Fairfax County Department of Human Services, a "design team" was established. Key county and state administrators, providers and foster parents collaborated to enhance and merge existing practices on behalf of culturally diverse children in foster care and their families reflecting a medical home approach.

The Caring Communities for Foster Care Project has developed three specific strategies to address barriers to comprehensive health care services for children. The first tool developed: "Don’t Leave Home Without It" was adapted from the Los Angeles County, Department of Children and Family Services, Public Health Nursing Unit (1993) to address difficulties in obtaining information from biological parents, particularly when Child Protective Services are involved in a case.

Recommendations for Infusing a

Medical Home Into Caring Communities

Social workers share information with the physician

• Reasons why child is in foster care.

• Suspicions of physical or sexual abuse.

• Physical and mental health history reported by biological parent.

• Relevant history from medical, educational, developmental, personal, family and social sources. [Guardian Ad Litem can subpoena birth records for a child if needed.]
Foster parents as partners

• Foster parents are present at every visit.

• Foster parents provide detailed important information to physicians.

• Physicians discuss specific care instructions with foster parents.
Written medical information is key

• Written summaries of health assessments and ongoing care are integrated into child’s health record.
Attentiveness to Mental Health

• Include reports from providers, teachers and caretakers.

• Consider multi-disciplinary teams for mental health evaluations.

• Physicians and social workers help foster parents to identify access.
Advocate for Children

• Communication among caring community members is essential for coordinating services, changes in child’s health status or placement changes.

• Pediatricians and social workers advocate for payment of needed specialized services.

The need for comprehensive, accurate medical records for children in foster care, led to the development of a "Child Health Profile." A "medical passport" or "health profile" can assist physicians and families by serving as an ongoing health record for children in foster care. Foster parents maintain the document which follows the child in foster care to reunification or adoption.

Finally, the Caring Communities for Foster Care Project explored the role of mentors to support foster parents in accessing comprehensive, compassionate, family-centered, coordinated services for the children in their care. The foster parent mentors are experienced foster parents whose personal experiences augmented by training and support, can help foster families locate resources and negotiate the foster care system.

The Caring Communities for Foster Care Project offers recommendations to infuse medical home attributes into a caring community. These recommendations are the result of information received from members of caring communities throughout the country working to improve outcomes for children in foster care.

References

American Academy of Pediatrics (1994). Health care of children in foster care. Pediatrics, 93. (2). 335-338.

American Academy of Pediatrics (1997). Health care of children in foster care. Managed care and children with special health care needs. ( p. 54-58). Elk Grove, IL: Author.

American Academy of Pediatrics (2000). Developmental issues for young children in foster care (RE0012). Available Internet: http://www.aap.org/policy/re0012.html.

Blatt, B., Saletsky, S., Meguid, R., Church, V., & Critzet, C. (1997). A comprehensive, multi-disciplinary approach to providing health care for children in out-of home care. Child Welfare, 87 (2), 331-347

Child Welfare League (1998). Standards for health care services for children in out-of-home care. Washington, DC: Author.

Kaye, N., Horvath, J., Booth, M. (1998). Monitoring the quality of health care provided to children in foster care. Portland, ME: The National Academy for State Health Policy.

Rawlings-Sekunda, J. (1999). The state of the states in delivering health care for children in foster care: findings of a state survey. Portland, ME: National Academy for State Health Policy:

Silver J., Haecker T., & Forkey, H. (1999). Health care for young children in foster care. In J. Silver, B. Amster & T. Haecker (Eds.), Young children and foster care: A guide for professionals. (pp. 161-195). Baltimore, MD: Paul H. Brookes.

U.S. General Accounting Office (1995). Foster Care: Health needs of many young children are unknown and unmet. GAP/HES-95-114. Washington, DC: Author.