1. 1 Meeting the Health Care Needs of Children in Foster Care National Association of State Foster Care Managers Washington, DC – 10/24/05 Jan McCarthy National TA Center for Children’s Mental Health Georgetown University

2. 2 The Health and Mental Health Discussion – Why It’s Important Health Care Needs of Children in Foster Care Needs similar among all children: Well-child care Immunizations Treatment for acute illnesses Treatment for chronic medical problems

3. 3 Unique Needs of Children in Foster Care: High prevalence of medical, dental, developmental, mental health, and behavior problems, conditions and disabilities Substance use disorders Need for ongoing treatment for these conditions

4. 4 Unique Experiences of Children in Foster Care Children’s vulnerability and risk Prior life experiences Often previous lack of attention to health care Trauma of separation from family Ongoing issues of loss while in foster care – multiple placements Impact on child health and well being

5. 5 Link to Safety, Permanency and Well-Being Appropriate health, developmental and mental health care: Enhances child’s chance for healthy development Reduces stress on caregivers Helps families care for their children Stabilizes families and placements Provides information needed to make permanency/placement decisions Improves child’s school performance Increases chance of achieving permanency

6. 6 A Comprehensive Framework Specific components for creating a comprehensive community-based health care system for children in FC Rarely are all components implemented in one site Framework provides issues to consider in assessing current system and prioritizing Implementation of components also requires strong child welfare and cross-system policies

7. 7 “CRITICAL COMPONENTS” OF A COMPREHENSIVE FRAMEWORK Initial Health Screening and Comprehensive Assessment Access to Health Care Services and Treatment Management of Health Care Data Coordination of Care Collaboration Among Systems Family Participation Attention to Cultural Issues Monitoring & Evaluation Training & Education Funding Strategies Managed Care Strategies

8. 8 Initial Health Screening and Comprehensive Assessment Initial Screening – for all children as they enter care Comprehensive Assessment – within 30 days, at regular intervals and transitions

9. 9 Access to Health Care Services and Treatment Access Issues – immediate eligibility for Medicaid, transportation, location of care, adequate providers, medical necessity criteria, waiting lists Services – comprehensive array, prevention to intensive intervention, primary care and specialty care, mental health,dental, developmental, family support services

10. 10 Management of Health Care Data and Information Multiple strategies – both paper and electronic Tasks are to: Gather Organize Retain Share Update regularly Aggregate data of individual children

11. 11 Coordination of Care Coordination assigned to specific person (e.g., health care coordinator) or unit (e.g., health care management unit) Health plan for every child Health plan addressed at all court and review hearings

12. 12 Collaboration Among Systems Cross-system responsibility to meet health care needs of children in foster care Families and community-based organizations involved in planning and implementing Some strategies – co-location, blending funds, cross-system training, interagency structures and agreements

13. 13 Family Participation All families (BPs, FPs, APs, Kin) partners in assuring health care for child Roles – sources of information/history, obtaining on-going care, ensuring continuity of care when child moves Child’s health care viewed in context of family strengths, needs, culture, environment BPs included in ongoing health care of child Families receive services to enhance their capacity to provide health care for child Families provide system level input

14. 14 Attention to Cultural Issues Knowledge of child/family culture influences health care design and delivery, creation of provider network, training Knowledge of how culture and beliefs shape child/family view of health and illness incorporated in approach Traditional and non-traditional approaches used

15. 15 Monitoring and Evaluation Ensure that established health care procedures are followed Track health outcomes (individual and aggregate) Assess family, child and provider satisfaction and cost effectiveness Make improvements based on data and outcomes

16. 16 Training and Education Training for parents, caregivers, providers, social workers, other systems, and youth May address multiple issues such as – general health and development special, individualized health care needs navigating health care system how child welfare system works… Parents/caregivers as co-trainers

17. 17 Funding Strategies Policy makers know how to target different funding sources for different aspects of health care, e.g., treatment/services, care coordination, data management, administration, training Flexibility in funding strategies encouraged Medicaid waivers requested and Medicaid options pursued when needed Interagency agreements about the transfer of funds among child-serving agencies (to maximize funding sources)

18. 18 Designing Managed Care to Fit the Needs of Children in Child Welfare Address special needs of children in custody when designing managed care system, e.g., Developing contracts Setting capitation and case rates Defining makeup of provider networks Ensure that there are mechanisms to: Solve problems (e.g., clinical liaisons) Ensure continuity of care when child changes placements Provide services for family members (in addition to identified child)

19. 19 Managed Care (cont’d) Examples of special provisions for children in custody: Eligibility Enrollment process Authorization of services Priority for receiving services Medical necessity criteria Service array Provider rates Collecting specific data Tracking outcomes

20. 20 A Health Care Delivery Model- Center for Healthier Children, Families and Communities, UCLA (Halfon, et al) Child’s health needs Entry into custody Health Services Delivery Initial health exam Comprehensive assessment Ongoing health care Transition assessments Child welfare Child health Mental health Medicaid Performance monitoring Child’s well-being Care coordination Service integration Intermediate outcomes

21. 21 Foster Care Health Delivery System Model Child Welfare System Organization Procedures Financing Health Outcomes health status child developmental functional clinical Child’s Needs Safety Medical Mental Health Dental Nutritional Developmental Relationships Antecedent Factors prenatal substance exposure abuse and neglect history Intermediate Outcomes % of children receiving appraisal % of children receiving appropriate care Child Health System Organization Procedures Financing Performance Monitoring Performance Measurers (IOM) Effectiveness Access Appropriate quality Acceptability Continuity Quality Critical Management Processes Continuous Quality Improvement Pre-placement Health Exam Comprehensive Health Assessment Continuing Health Care Referrals & Specialty Services Transition Assessments at Placement Change Health Service Delivery Service Integration Coordinated Clinical Management Family Factors Enabling Predisposing Entry into the system From: Neal Halfon, MD, MPH, Victor Perez, MD, MPH, Neal Kaufman, MD, MPH, Providing Health Services to Children in Foster Care

22. 22 New Health Care Delivery Model – Milwaukee, WI Name - Allied Services for Healthy Foster Children Program Goal – improve access, coordination, quality and efficiency of health care services for foster children in Milwaukee Operated by Abri Health Plan, Inc. - managed care organization Anticipated date to implement – February 2006 (3,000 children)

23. 23 Allied Services for Healthy Foster Children (cont’d) Managed care model (1915 B Medicaid Waiver) Health plan at full risk (capitation rate/child) Abri subcontracts with partners to be providers (e.g., Wraparound Milwaukee for BH care)

24. 24 Allied Services for Healthy Foster Children (cont’d) Features: Coordinated system of health care to meet physical, behavioral, developmental and mental health needs of children in out-of- home care Integrated physical and mental health care Health care managers for each child Medical home for each child Health plan and health passport for each child

25. 25 Allied Services for Healthy Foster Children (cont’d) Features (cont’d) Screening, assessment and enhanced services Promotion of preventive care and early intervention Transition planning Quality assurance and utilization management to guarantee access to services

26. 26 Allied Services for Healthy Foster Children (cont’d) Contact Persons: Burnie Bridge, Administrator, Division of Children and Family Services, 608/267-3905 Mike Fox, Division of Health Care Financing (Medicaid), 608/266-7559 Jane Wick, President, Abri Health, 262/834-1120 Bruce Kamradt, Wraparound Milwaukee (behavioral health), 414/257-7531

27. 27 Community Example – Screening and Assessment FaCES (Foster Care Evaluation Services ) Worcester, MA

28. 28 Contact Information Jan McCarthy Director of Child Welfare Policy National TA Center for Children’s Mental Health Georgetown University Center for Child and Human Development 202/687-5062 voice 202/687-1954 fax jrm33@georgetown.edu