1. Kentucky’s Commitment to Change “Race, Community and the Child Welfare System” Initiative

2. Commission for Children with Special Health Care Needs 2007 Conference Identified Counties in Most Need (* = Phase II) County % African American Population (Census) % African American OOHC (foster care) Hardin11.918.8 Warren8.622.2 Jefferson*18.953.5 Madison4.413.3 McCracken*10.933.3 Boyle9.730.7 Fayette*13.545.7 Daviess4.319.0 Kenton*3.821.7 Graves4.432.4 Christian*23.748.5

3. Commission for Children with Special Health Care Needs 2007 Conference Evidence demonstrates that children and families of color experience the health care system differently than do white children in terms of access, quality, and outcomes. Health Care Disparities

4. Commission for Children with Special Health Care Needs 2007 Conference Location, hours of operation, and staffing patterns of health care service providers tend to follow racial lines in the U.S.Access

5. Commission for Children with Special Health Care Needs 2007 Conference A recent report by the Agency for Healthcare Research and Quality (AHCRO) concludes that “racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities”. Minorities receive less aggressive treatments and are more likely to be treated by providers with worse performance records or who are less well trained (Bach, 2004). Quality

6. Commission for Children with Special Health Care Needs 2007 ConferenceOutcomes We know that persons of high SES command greater access to resources such as health information, quality healthcare, and healthy social environments... BUT even after controlling for SES, research is unable to statistically eliminate black/white disparities in outcomes such as pre-maturity and low birth weight.

7. Commission for Children with Special Health Care Needs 2007 Conference Because of these disparities, it is time for all institutions to examine the structural and systemic factors that are engrained in their policies and practices that adversely affect the individual health of the clients they serve.

8. Commission for Children with Special Health Care Needs 2007 Conference Because of these disparities, it is time for all institutions to examine the structural and systemic factors that are engrained in their policies and practices that adversely affect the individual health of the clients they serve. We believe that every child that comes into contact with the Cabinet in need of our services should have the SAME experience. OUR RESPONSIBILITY AS HEALTH CARE PROVIDERS

9. Commission for Children with Special Health Care Needs 2007 Conference At the CCSHCN we began by examining… The reason for referral, time until first appointment, diagnosis, services provided, age at referral, course of treatment, reason for discharge, health status at time of discharge and linkage to post-discharge care The reason for referral, time until first appointment, diagnosis, services provided, age at referral, course of treatment, reason for discharge, health status at time of discharge and linkage to post-discharge care The representation of children of color at referral, intake, medical assessment, treatment planning and discharge The representation of children of color at referral, intake, medical assessment, treatment planning and discharge The location of clinics with respect to minority communities, hours of operation of clinics, staff training, and transportation The location of clinics with respect to minority communities, hours of operation of clinics, staff training, and transportation The racial composition of staff The racial composition of staff The commitment of resources (healthcare resource allocation by race) The commitment of resources (healthcare resource allocation by race)

10. Commission for Children with Special Health Care Needs 2007 Conference Results So … what did we do and what did we find:

11. Commission for Children with Special Health Care Needs 2007 Conference White/Cau casian Black/Af rican America n Hispa nic Some Other Race/Com binationAsian America n Indian/A laska Native Native Hawaiia n/Pacific Islander Total # of Referral s Referrals for Outside Services1350113221751614225143917460 % to Total77.33%7.57% 10.03 %3.52%1.29%0.08%0.22% Less: Pop. Distribution by Race82.47%7.74%5.38%3.38%0.81%0.14%0.09% Proportionally Over / Under Served-5.14%-0.17%4.65%0.14%0.48%-0.06%0.14%

12. Commission for Children with Special Health Care Needs 2007 Conference RACIAL DISTRIBUTION OF HEALTHCARE SERVICES PROVIDED BY CCSHCN OVER 4.5 YEAR PERIOD We reviewed health services utilization data from 1/1/03 to the present. A total population of 19,763 children received services in this timeframe. Data delineating client race was available for 63.53% of the total client population.

13. Commission for Children with Special Health Care Needs 2007 Conference CCSHCN’S STATEWIDE DISTRIBUTION Racial representation of this population is Caucasian – 82.47%; African American – 7.74%; 5.38% Latino, and 4.41% Other.

14. Commission for Children with Special Health Care Needs 2007 Conference DATA ANALYSIS We were able to extract good information from our existing database in the following areas: 1) Length of service by race 2) Number of services received by race 3) Referrals to outside services by race 4) Insurance utilization by race 5) Racial distribution of clients by county

15. Commission for Children with Special Health Care Needs 2007 Conference Length of Services Received by Race* When length of total time receiving services is distributed by race, we find that African Americans have a shorter average length of services than whites (15.01 months vs. 20.24) and Hispanics had the longest average length of services (24.03 months). African Americans received more services than whites over a shorter period of time. When length of total time receiving services is distributed by race, we find that African Americans have a shorter average length of services than whites (15.01 months vs. 20.24) and Hispanics had the longest average length of services (24.03 months). African Americans received more services than whites over a shorter period of time. *Time from acceptance until discharge

16. Commission for Children with Special Health Care Needs 2007 Conference Number of Services Received by Race When the number of health service providers seen by clients is broken down by race, we find that people of color receive disproportionately more services than whites (Caucasians – 7.78%, African Americans 10.20%, and Hispanics – 10.48% on average) – this is true for both clinic and augmentative services.

17. Commission for Children with Special Health Care Needs 2007 Conference Successful Referral to Outside Providers by Race* When successful referral to external service providers is broken out by client race, we find no significant differences (Caucasians – 84%, African Americans – 83%, Hispanics – 88%, and Asians – 89%). * Successful means client received the service for which they were referred.

18. Commission for Children with Special Health Care Needs 2007 Conference Insurance Utilization Patterns by Race Uninsured: The % of African Americans that were uninsured was less than their representation in the client population as was the case with whites. Hispanics had the highest percentage of uninsured and their percentile was about four times their representation in the total client population. Of those that were uninsured, 67% were white, 6.6% African American, and 22.51% Latino.

19. Commission for Children with Special Health Care Needs 2007 Conference Insurance Utilization Patterns by Race Public Insurance: Health insurance distribution by race shows no racial difference in the numbers of those who have public insurance, fewer African Americans with private insurance than whites and far fewer Hispanics with private insurance than either whites or blacks.

20. Commission for Children with Special Health Care Needs 2007 Conference Racial Distribution of Clients in DCBS Target Areas In the ten counties with disproportionate representation of blacks in the Child Welfare System in Kentucky, all but one county CCSHCN served had a higher percentage of African Americans than are represented in the county census. The exception was Christian County where health services are also available on the military base at Ft. Campbell.

21. Commission for Children with Special Health Care Needs 2007 Conference Racial Representation of Providers We looked at racial representation of our providers, but the available data were incomplete and our numbers too small to analyze. We do know, however, …

22. Commission for Children with Special Health Care Needs 2007 Conference Racial Representation of Providers (cont’d.) Because of the “Common Lens” we share, provider race does not impact service outcomes. However, positive role models are critical for our children and, therefore, racial diversity among providers is desirable.

23. Commission for Children with Special Health Care Needs 2007 Conference What are the explanations for the things we are finding… Is it a good thing or a bad thing when people get referred for more services, stay in our care longer, or are discharged earlier?

24. Commission for Children with Special Health Care Needs 2007 Conference This is the process an agency should go through to be responsive to this issue… We just discussed what the Commission has done… What will we do next…

25. Commission for Children with Special Health Care Needs 2007 Conference Next Steps… Raise awareness (discuss types… referral sources/ community/ providers/ parents…)– Who are the Commission partners- where do our referrals come from? Raise awareness (discuss types… referral sources/ community/ providers/ parents…)– Who are the Commission partners- where do our referrals come from? Provide staff training Provide staff training Educate referral sources Educate referral sources

26. Commission for Children with Special Health Care Needs 2007 Conference Next Steps (cont’) Satisfaction survey of our clients- this would be one way to determine an outcome for the “length of service” question presented earlier by Dr. Foster. (More/ better services in less time? Were the services responsive to client needs?- Client perspective) Satisfaction survey of our clients- this would be one way to determine an outcome for the “length of service” question presented earlier by Dr. Foster. (More/ better services in less time? Were the services responsive to client needs?- Client perspective) Develop Parent Advocacy Program Develop Parent Advocacy Program

27. Commission for Children with Special Health Care Needs 2007 Conference Next steps (cont’) Improve Access (location, hours of service, transportation, outreach) Improve Access (location, hours of service, transportation, outreach) Provide culturally sensitive care management Provide culturally sensitive care management Establish Team to strategically address Establish Team to strategically address Address structural racism/ how can the Commission structure its services to ensure equality at every level of care? (Reviews/ analyzes/ develops outreach) Address structural racism/ how can the Commission structure its services to ensure equality at every level of care? (Reviews/ analyzes/ develops outreach)

28. Commission for Children with Special Health Care Needs 2007 Conference Next Steps (cont’) Empower minority community to shape policy and practices (minority representation on Board, Parent Advisory Council, Youth Advisory Council) Empower minority community to shape policy and practices (minority representation on Board, Parent Advisory Council, Youth Advisory Council) Post secondary education- lesson plans and coursework that focus on minority health and disparities to make providers aware Post secondary education- lesson plans and coursework that focus on minority health and disparities to make providers aware

29. Commission for Children with Special Health Care Needs 2007 Conference Every child that comes into contact with the Cabinet in need of our services should have the SAME experience.

30. Commission for Children with Special Health Care Needs 2007 Conference What can I do?

31. Commission for Children with Special Health Care Needs 2007 Conference What you can do…

32. Commission for Children with Special Health Care Needs 2007 Conference What does it take???   Commitment to social justice   Ability to collect and use data to demonstrate racial disparities in health   Willingness to ask questions and listen to answers   Tools for understanding and assessing how racism is manifested

33. Commission for Children with Special Health Care Needs 2007 Conference What does it take???   Ability to shift from a focus on individual personal health behaviors to a focus on institutions and systems (requires “training” and “skill building”)   Community leadership/coalitions addressing racism   Desire to work “across issues”   Willingness to shift existing resources to support anti-racism work

34. Commission for Children with Special Health Care Needs 2007 Conference What can you do? Commit to equity Attend community workshops and conference (s) Become a community sponsor Provide funding Provide funding Staff participation Staff participation Collect and analyze data by race Review policies and procedures Change practice Evaluate practice changes

35. Commission for Children with Special Health Care Needs 2007 Conference Future Workshops 9/25/07 - 9/27/07 Home of the Innocents 1100 E. Market St., Louisville, KY 40203 No workshop will be held in October 11/6/07 - 11/8/07 Seven Counties Services, Inc. Commonwealth Business Center 11001 Bluegrass Parkway, Suite 200 Louisville, KY 40299 12/4/07 - 12/6/07 YMCA Safe Place Services, Conference Rooms B-D 2400 Crittenden Drive Louisville, KY 40217

36. Commission for Children with Special Health Care Needs 2007 Conference Recommended Reading and Viewing List www.jointheconversation.net Casey Family Programs http://www.casey.org/OurWork/Disproportionality/ Race Matters Consortium http://www.racemattersconsortium.org/index.htm People’s Institute (delivers Undoing Racism Workshops) http://www.pisab.org/ Alliance for Racial Equity in Child Welfare http://www.cssp.org/major_initiatives/racialEquity.html

37. Commission for Children with Special Health Care Needs 2007 Conference Thank you for attending this presentation. Please feel free to contact us with questions or ideas. Have a great day!