FaCES Clinic and Evaluation

1. FaCES Clinic and Evaluation A Collaborative Effort….

2. Agenda • The Need & Recommendations • FaCES (Foster Care Evaluation Services) Clinic Overview & Goals • Evaluation Plan • Programmatic Data • Caseworker Survey • Discussion

3. The Need and DSS Recommendations

4. The Need: Health of children in foster care • Children tend to enter foster care in a poor state of health: • exposure to poverty • poor prenatal care/ prenatal maternal substance abuse • prenatal infection • inadequate preventative health interventions • family and neighborhood violence • parental mental illness. • Children coming into foster care have multiple physical problems: • failure to thrive (10% to 50% of these children suffer from growth retardation) • up to 80% have at least one chronic medical condition • nearly one-quarter have 3 or more chronic conditions • increased likelihood of delays in cognitive, language, and fine and gross motor skills development • Recent studies found that children with multiple chronic problems at entry into care were more likely to remain in foster care.

5. DSS Health Screening Recommendations • 7 Day Initial Screen • 30 Day Comprehensive • 2001 Study on Screening Compliance • Overall rates for 7 and 30 day visits were approximately 10% and 25% respectively. • Worcester Office rates: 9.5% (7 day) and 22.2% (30 day).

6. 7 day components • History taking • Brief physical exam • Evaluate for communicable diseases • Evaluate for signs of physical/sexual abuse • Evaluate for life threatening illness • Discuss findings with caseworker and/or foster parents

7. 30 day components • Medical record review • History taking with all parents if possible • Immunization assessment • Nutritional assessment • Oral health screening • Physical exam • Developmental assessment • Assess need for behavioral and other services/referrals • Lab testing and lead screening • Discuss findings with relevant stakeholders

8. FaCES (Foster Care Evaluation Services) Clinic Overview & Goals

9. FaCES Clinic Overview and • Clinic started as model program based on prior research and program findings and 2001 data analysis • November 2003: FaCES opens in Pediatric Department of UMass Medical School • Began with children ages 0-5, expanded to now see children up to age 9 • Only for foster care children referred by the Worcester DSS office.

10. FaCES Clinic Project Goal • Goal: To provide medical assessments for all children from birth to five years of age who have been placed in foster homes under the auspices of Worcester DSS. • Objectives: • Improve compliance with recommended screenings • Improve exchange of medical information during assessment period • Assure uniformity of assessment • Provide medical case management and facilitate finding a medical home • Assess caseworker perception of benefit/effectiveness

11. FaCES Clinic: Unique Features • Administrative Case Management • Medical Case Management • Data Management • Collaboration between DSS & referral locations, collaboration between FaCES and medical homes/referrals

12. FaCES Clinic: Programmatic Information, Year 1 • First year: 94 children seen (11/2003-12/2004) • 0-5 years of age • Generated 149 Referrals • Wide range of diagnoses • Wide range of medication gaps

13. Evaluation Plan

14. Evaluation Plan • Research Questions: • Did project increase the rate of achievement of the 7 and 30 day screenings as compared to 2001 data? • Did the project increase the rate of achievement of the 7 and 30 day screenings as compared to comparison group/Medicaid claims?

15. Additional Evaluation Questions: • Did the project achieve its goals? • Improve exchange of medical information during assessment period • Assure uniformity of assessment • Provide medical case management – immunizations, laboratory tests, referrals • Assess case worker perception of benefit/effectiveness

16. Evaluation Plan Data Sources: • FaCES database • Comparison group: Statewide foster care population Medicaid claims, excluding Worcester DSS kids

17. Programmatic Data

18. Most Common Diagnosis Seen at FaCES Clinic • Asthma • Speech dysfluency • Eczema • Dermatitis Note: The most frequent diagnosis noted is “well-child”

19. Separate Study on Medication and Information Gaps • Identified the frequency with which foster care children were placed in homes without access to necessary chronic medications for pre-diagnosed problems (75 patients) • Chronic conditions/medications most frequently identified: • Preventive health (fluoride) • Eczema (topical steroid and immunomodulators) • Asthma (beta agonists and inhaled steroids)

20. Results of Medication Gap Study • 75% of children required at least one chronic medication • 82% of those requiring the medication did not have the medication in the home of the foster parent • 90% did not have medication for eczema • 79% did not have medication for asthma

21. 76 80 70 60 50 Number of Referrals 31 40 25 30 11 20 3 3 10 0 Other Dental Audiology MD Specialist Early Intervention Mental Health Services Type of Referral FaCES Database: ProgrammaticNumber and Types of Referrals

22. FaCES Database: Programmatic Diagnosis “Found” at FaCES Clinic • Hepatitis C (two cases) • Object blocking nasal passages • Genetic conditions (2): Branchio-oto-renal syndrome & Fragile X • Atypical febrile seizures requiring diagnostic work up • Abuse

23. FaCES Database: Programmatic Types of Medical Records Received

24. Caseworker Survey

25. Caseworker Survey • June and July 2005 • Worcester DSS Area Office • 45 respondents (out of approximately 75) • Working on a comparison group survey right now in Northeast region of Massachusetts

26. Caseworker Survey Results • 61% of those surveyed reported they had been caseworkers five or more years • 80% of those surveyed knew the required time frame of 7 days for a foster child to get their initial health care screening following placement. • 72 %of those surveyed thought that 30 days subsequent to placement was the required time frame for a foster care child to receive their comprehensive health care evaluation

27. Caseworker Survey, con’t • 82% of those surveyed felt the clinic made their job easier. • Of those, 26 % of those surveyed found that the FaCES clinic makes it easier to find a child a doctor. • 59% found it easier in terms of getting children health access • 7% found that it makes their job more difficult

28. Conclusion and Discussion

29. Discussions / Questions • Evaluation of programs is key • Difficulty around cost/benefit analysis • Funding is an ongoing issue • Programmatically • Evaluation

30. Cui bono? • “Good for whom?” — a maxim which suggests that considering who will benefit is likely to reveal who is responsible for an unwelcome happening…$$$. • Who is responsible for the health outcomes of these children? Pay now or pay later?