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 MethodsMANAGED 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??