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FOSTER AND KINSHIP CARE: A HOME AWAY FROM
HOME?
Legislative AdvocacyElShadey Bekele, MD & Caitlin Haxel,
MDMonday December 3, 2012
Epidemiology
3.3 million child abuse & neglect reports in 2010 436,321 (22%) substantiated 254,000 removed to foster care
408,425 children & adolescents resided in foster care in 2010 26% in relative (kinship) foster home 48% in non-relative foster home 9% in group home or residential care 4% in pre-adoptive family 5% on trial discharge with their parents 2% “run-away”
Epidemiology continued
Minorities represented prominently in foster care In 2010: 29% African American, 21% Hispanic,
41% white, 5% of two or more races Approximately 50% of children &
teenagers will experience more than one foster care placement
Approximately 25% having three or more placements
The Foster Care System
Federal legislation determines patterns of funding and regulatory guidelines
State social service agencies implement foster care programs
Daily management may be delegated to county or private child welfare agencies
The Foster Care System
Caseworkers Engage parents around care of child Coordinate educational, medical, mental
health services for children Secure educational or service resources for
family Support foster parents in their care Recruit, train, monitor and annually recertify
foster parents
The Foster Care System
Legal System Every child in foster care represented in court
by a law guardian Court may also designate a special advocate on
behalf of the child Family court judges
Whether child remains in out-of-home placement after removal
Order services for biological parents Rehearing case to determine continued placement
or alternative permanency arrangement
The Foster Care System
Foster parents Generally married, lower middle income, at least high
school educated, employed, children of their own 5% undergo specialized training to act as resources for
severely emotionally disturbed or medically fragile children
Reimbursement Board subsidy – for food, shelter, personal needs, recreation,
most transportation and education costs Based on child’s age, health needs, complexity of parenting
tasks Cover approximately two thirds of cost
Recruitment, education and retention of suitable foster families is challenging
Group care
Processes in Foster Care
Visitation Recidivism Termination of parental rights Adoption out of foster care
Length of Stay
In 2010, average length of stay 25 months Median 14.5 months Factors
Birth family’s cooperation with case plan for family
Availability of appropriate extended family to care for the child
Diligence in permanency planning by child welfare
Challenges of finding adoptive resources for older children, minority children, large sibling groups, children with significant behavioral and developmental problems
AAP Vision Statement
“We have a dream that foster care will be valued, healing, healthy, and empowering resources for children, teens, families, and
communities, so that every child and teen in foster care will thrive in a forever family.
We will achieve this by engaging communities and their leaders in supporting
children, teens and their families with an effective, multidisciplinary, integrated, and
comprehensive continuum of care.”
Health Issues of Children in Foster Care
HEALTH PROBLEM % OF POPULATION
Chronic medical problems
Complex medical/developmental
Mental health Developmental delay Educational issues
Dental problems Family dysfunction
30-45%
10%
48-80% 60% of children <6yo 45% in special
education or w/IEP 35% 100%
The Medical Home
Pediatric care is accessible and continuous over the child’s time in foster care, regardless of placement
Health-care coordination exists that ensures that all of a child’s health-care needs are identified and addressed
Compassionate care is given that includes and understanding of the impact of childhood trauma and loss on children and families
The Medical Home
Care is culturally competent and includes understanding of the micro-culture of foster care and it’s impacts
Communication amongst all caregivers to collaborate, when appropriate and safe, in planning for child’s health needs
Comprehensive high quality pediatric care provided according to AAP health-care standards
Foster Care Specific Health Visits
AGE OF CHILD TIMING OR FREQUENCY
Admission health screen
Comprehensive health assessment
Follow-up health visit Infants to 6 months 21 months 2 to 21 yrs
Within 72 hrs of placement
Within 30 d of entry to foster care
60-90 d after entry Monthly (btwn
preventive) Extra visit Semiannual (btwn
annual preventive health-care visits)
Anticipatory Guidance
Focusing on child’s strengths Positive parenting strategies Impact of trauma on child behavior Supporting children through transitions Significant sleep disorders Confused loyalties Attachment issues Need for normalizing activities Working with birth parents to reduce
conflict and coercion
Early and Periodic Screening, Diagnostic and Treatment Program
Federal mandate requiring states to provide comprehensive medical services to children enrolled in Medicaid or who are Medicaid eligible
Services include screening, diagnosis and prevention services to ameliorate or treat conditions and to promote healthy development
States have flexibility determining frequency of EPSDT screenings
Comprehensive Health Care
Comprehensive admission Enhanced well-child care Extra visits that occur
related to foster care issues Discharge health planning Child abuse and neglect
issues Mental health services Inpatient hospital and
mental health services Medical transport Optometry and corrective
lenses Dental evaluation and
orthodontic services
Drug and alcohol evaluation and rehab
Full developmental or educational evaluation
Emergency health services
Respite services Home health care services Medical equipment and
supplies Laboratory costs Medications Care for acute and chronic
illnesses
Sources of Healthcare Funding for Children in Foster Care
Medicaid Title IV-E Title IV-B Social Services Block Grant (SSBG) Temporary Assistance to Needy Families
(TANF) Children’s Health Insurance Program
(CHIP) Supplemental Security Income (SSI)
Medicaid
State and federally funded entitlement program authorized by Title XIX of SSA
States have flexibility to set eligibility criteria and reimbursements paid to providers
Eligibility: If < 6 years old and family income <133% poverty level If greater than 6 years and income <100% of poverty level (birth parents income for the first month in foster care)
3.7% of Medicaid population are foster children 12.3% of Medicaid expenditures are for foster children due
to high prevalence of psychiatric conditions and specialist services
Federal-state match varies with federal share of 50-83% Can be billed retroactively for 90 days
Medicaid waivers
Provide states with more flexibility to provide services, cover services that aren’t already covered and can be targeted towards specific populations
Types of waivers 1) Section 1115 Research and Demonstration Projects-
test new or existing strategies in delivering and financing services
2) Section 1915(b) Managed Care- funds to be used for managed care services to specific populations
3) Section 1915(c) HCBS- long-term care services in a home or community setting who would otherwise be in an institution
New York’s Bridges to Health Program
Medicaid Rehabilitation Services Option
Provides reimbursement for diagnostic, screening, preventative, rehabilitative services provided in a facility, home or other setting
Can be used to address physical and/or mental health needs of children in foster care in a community based setting
Services can be offered to children in foster care who are Title IV-E eligible
Medicaid Payment Methods
MANAGED CARE FEE FOR SERVICE• Per member capitated
payment creates incentive to control use of mental health services
• Improved access to PCP services
• Increasingly more common among states
• Difficult to continue across different foster care placements
• Restrictions placed on mental health visits
• Potential for cost savings for states
• Waivers required for children with special health care needs and those in foster care
• Lower reimbursement rates to providers
• Few physicians who accept FFS
• Allows for more flexible access to mental health services
• Reimbursement for dental services are low
Temporary Assistance to Needy Families
Federal block grant to assist families with little or no income
Provides cash and other assistance to help with financial needs
Possible uses for child welfare services: Family preservation, foster care, kinship care
support, employment programs for foster youth
Funding availability based on budget priorities at federal, state and local level
Social Services Block Grant aka Title XX
Mandatory capped entitlement program Purpose is to achieve five social policy
goals: Prevent, reduce or eliminate dependency To achieve or maintain self-sufficiency To prevent neglect, abuse, or exploitation of
children and adults To prevent or reduce inappropriate
institutional care To secure admission or referral for institutional
care when other forms are not appropriate Can be used for children in foster care Availability subject to budgeting priorities
Children’s Health Insurance Program (CHIP)
Administered by states, jointly funded by federal and state government
Program is for families with incomes too high for Medicaid and have no health care coverage
Federal matching rate is typically 15 percent higher than Medicaid
Supplemental Security Income (SSI)
Administered by Social Security Administration
Foster children are eligible if they have physical or mental impairment resulting in marked or severe functional limitation that is expected to or has lasted for at least 12 months
Title IV-E Largest source of funding for child
welfare services. Authorized by SSA and administered by Administration for Children and Families $6.75 billion in 2011
Used for out-of-home care and placement. Cannot be used for direct health care services
States receive reimbursement for child welfare services based on eligibility criteria Administrative activities, short & long-term
training, adoption assistance, foster care maintenance payments
50% of children in foster care not eligible
Title IV-B
Alternative for children ineligible for Title IV-E
Funded at $709 million in 2011 Supports foster care and families to
prevent children from entering foster care No income eligibility criteria
Legislature
Foster Care Independence Act of 1999 Expand independent living programs for youth
aging out of foster care and increased funding. Offered educational opportunities, employment training and prevention services.
Chafee Option- extend Medicaid coverage to youth up to age 21
Fostering Connections to Success and Increasing Adoptions Act of 2008 Extended Medicaid eligibility to children receiving
kinship care assistance payments. Require states to work with pediatricians to develop oversight plan and coordination of services.
Patient Protection and Affordable Care Act of 2010
Extends Medicaid coverage to age 26 for former foster care youth
Increase funding for expansion of early childhood home visitation programs for families at risk including those involved in the child welfare system. Hx of abuse and neglect are priority groups. $1.5 billion over 5 years to prevent placement of children in foster care.
Extends home and community based services (HCBS) to those with higher incomes other than Medicaid beneficiaries
Patient Protection and Affordable Care Act of 2010
States can create primary care health homes for children with chronic illness who are Medicaid beneficiaries, providing financial incentives for designated providers
Requires transition planning for those aging out of foster care to include health care insurance information and identification of a health care proxy
Extends CHIP funding until 2015 and increases the federal matching rate to 93%
Access to Care Lack of providers accepting Medicaid recipients High turnover rate of children in and out of
foster care Difficulty identifying health care needs Inability to obtain health history Lack of understanding of the type of services
needed Lack of resources to ensure delivery of health
services Lack of documentation and monitoring of health
care High turnover of case workers and support
professions Difficult to track medical care when multiple
foster and medical homes involved
Actions to Improve Health Care States have implemented important measures to
prevent custody relinquishment by: Amending policies that require state custody in
order for children to have access to mental health services;
Allowing child welfare agencies to set up voluntary agreements with parents for out-of-home placement without custody relinquishment
Giving juvenile courts jurisdiction to order mental health treatment for children in out-of-home placement.
Some states have started using designated providers to perform the initial and comprehensive evaluations with some evidence that there has been increased consistency
Actions to Improve Health Care
States can request Title IV-E child welfare waiver demonstrations from HHS Allow more flexibility for use of funds from the title
to get welfare services Using waivers for intensive preventive services,
substance abuse services for parents, subsidized guardianships, mental health and post adoption services
As of March 2012, 6 states had waivers
Finance Reform Recommendations
Remove income restrictions that limit access for children to obtain services
Title IV-E is attached to outdate income standards and less than half of children in foster care are supported under this title
Increase funding to prevention services and in home care to better outcomes for children $4 billion for Title IV-E vs $800 million for Title
IV-B program
Innovative Programs
Special Kids Special Care Program- MA Children who have complex medical conditions and are in DCF custody
or foster care Receive intensive medical case management and coordination of care by
a NP with development of individualized health care plan Funded by MassHealth
Key Clinic of Penobscot Pediatrics- Maine Children in custody of child welfare system and live in specified counties Provides medical assessment with 72 hrs of entering custody, compile
medical records, work with foster family, comprehensive medical eval, labs, screening tests
Funded by MaineCare and nurse by grant from PCHC Thomas H. Pinkstaff Medical Home Clinic- Kentucky
Children with Medicaid and mainly children in out of home care Provide well child and sick visits for foster children. Team is made up of
an APRN, LSW, and a therapist Funded by a grant through Kentucky Commission for CSHCN and
Medicaid
The Pediatrician as Child Advocate
Work with states to ensure that child welfare agencies are aware of and promote health-care standards
Partner with state and local child welfare agencies, departments of public health, and mental health organizations to develop evidence-based mental health-care resources in their community
Partner with state and local child welfare agencies, departments of health, and dental organizations to increase access to dental care
Partner with state and local EI and school/preschool special education programs to develop strategies to assess the needs of children in foster care and ensure access to needed services
The Pediatrician as Child Advocate
Advocate for services and policies at the federal and state level that serve children/teens in foster care
Volunteer or work with agencies that serve children or teens in foster care
Become a mentor
The Pediatrician as Child Advocate
Start a “backpack” program so that children in foster care have items for school
Donate to a fund to enroll children in foster care in extracurricular activities
Teach independent living skills Advocate for teens
transitioning out of foster care including a permanent home
References Committee on Child Health Financing. “Medicaid Policy Statement.”
Pediatrics; July 2005, Vol. 116, No 1. Committee on Early Childhood, Adoption and Dependent Care.
“Developmental Issues for Young Children in Foster Care.” Pediatrics; November 2000, Vol. 106, No 5.
Committee on Early Childhood, Adoption, and Dependent Care. “Health Care of Young Children in Foster Care.” Pediatrics; March 2002, Vol. 109, No 3.
Fostering Health: Health Care for Children and Adolescents in Foster Care. New York: American Academy of Pediatrics, 2005.
Phicil, Sheila. “Financing the Special Health Care Needs of Children and Youth in Foster Care: A Primer." Catalyst Center. Sept. 2012. Web. <http://hdwg.org/sites/default/files/Foster-Care-Primer.pdf>.
Szilagyi. Moira, MD. “Pediatric Role in the Care of Children in Foster and Kinship Care.” Pediatrics in Review; November 2012, Vol. 33, No 11.
QUESTIONS??