Children’s Health & Development Program

1. Children’s Health & Development Program Wake County Human Services Raleigh, North Carolina Jean C. Smith, MD jcsmith@co.wake.nc.us CityMatCH Albuquerque, NM September 22, 2008

2. “When I was little I would think of ways to kill my daddy. …But I did not kill my daddy. He drank his own self to death the year after the County moved me out.” Ellen Foster

3. Background/Purpose

4. Health Needs of Children in Foster Care Children and adolescents in foster care have higher prevalence of - • Physical • Developmental • Dental & • Behavioral – health conditions

5. “…my teacher noticed a bruise he put on my arm and they all had a field day over it in the school nurse’s office. Calling in everybody but the janitor to look at it. I had rather nobody saw my business.”

6. Health Status of Children & Adolescents Entering Foster Care • More than 90% have abnormality in at least 1 body system • Vision & hearing problems common • Suboptimal growth 5 times expected (Large cohort study of children entering foster care - Baltimore, MD)

7. Health Status of Children & Adolescents Entering Foster Care • < 20% had NO medical conditions • >20% had growth abnormalities • 30% had neurological disorders • 16% had asthma (~3 times national ave.) (Large cohort study of children in foster care in Oakland, CA)

8. Health Status of Children & Adolescents Entering Foster Care • High incidence of anemia • High incidence of infectious diseases • Increased risk for vertically transmitted infections (HIV, hepatitis B & C, syphilis, herpes simplex)

9. “I try not to leave her by herself with him.”

10. Other problems • >80% exposed to domestic and/or community violence • High risk behaviors in adolescents in foster care with risk for STD’s, etc. • No cohesive system of care for this vulnerable population • Little tracking or monitoring of care that does exist.

11. “When they came back in they said they had decided what to do with me. It’s about time I thought. Yes Lord it’s about time.”

12. Fostering Health: Health Care for Children & Adolescents in Foster Care Task Force on Health Care for Children in Foster Care American Academy of Pediatrics, 2005

13. Child Welfare League of America • Standards for Health Care Services for Children in Out-of-Home Care Washington, DC: Child Welfare League of America; 1988

14. Evaluating Quality of Care for Children in Foster Care -CWLA Seven criteria • Access to care • Appropriateness of services • Comprehensiveness of care • Coordination

15. Quality of Care Criteria Continued • Continuity • Relation to the community • Family-centered service

16. Health Care Delivery Models for Children in Foster Care • Agency-based care • Specialized foster care clinics • Community-based care

17. “Since my first day here all I felt is luck coming my way. I never thought I could have it this good.”

18. Components of Health Care Services • Initial health screening • Comprehensive health assessment • Developmental & mental health evaluation

19. Components of Health Care Services • Primary health care and monitoring health & developmental status • Transfer of medical information

20. “All I did was wish him dead real hard every now and then. And I can say for a fact that I am better off now than when he was alive.”

21. Children's Health and Development Program: A collaboration of John Rex Endowment and Wake County Human Services

22. Wake County Human Services (WCHS) is a consolidated agency including health, mental health and social services.

23. Children's Health and Development Program Staff • Assessment Coordinator – BSW,QMHP 1.0 FTE • Developmental Specialist – BA,MA 0.5 FTE • Pediatric Nurse Practitioner – 0.5 FTE • Mental Health Specialist – LCSW-P 0.5 FTE • Pediatrician Director – 0.05 FTE

24. Objectives of CHDP • Provide medical, mental health, and developmental assessments for children birth to 18 years of age entering foster care and children 3 to 10 years of age in CPS treatment in Wake County. • Share assessment information and plans of care with those responsible for the child’s care and well being • Identify health, developmental and behavioral problems and/or needs of children in foster care and CPS treatment.

25. Objectives of CHDP(2) • Develop individualized plans of care with recommendations for each child • Identify the medical home for each child to provide continuity of care and monitoring of ongoing health and developmental care and needed services. • Assist DSS, guardians, and families in accessing appropriate referrals or services for children.

26. Program Standards The Children’s Health & Development Program uses: • State of the art screening and assessment tools and community referral networks for early intervention services including Child Service Coordination • Incorporates best practices in developmental and behavioral screening into each assessment • Assists parents/foster parents in anticipation of strengthening of their children’s developmental skills

27. Program Standards(2) • Collaborates with families to strengthen ties and or link families to medical home • Assists families and medical home in securing developmental and behavioral services outlined in the plan of care • Provides assistance in continued monitoring of health and development

28. “..there have been more than a plenty days when she has put both my hands in hers and said if we relax and breathe slow together I can slow down shaking. And it always works.”

29. Methods 1. Children come into DSS care 2. Court Day One conference 3. Appointment for medical assessment Completed for all children unless a CME (Child Medical Exam) or SICC exam (Special Infant Care Clinic) is done.

30. Methods(2) 4. Appointment for developmental assessment (Completed for all children 10 years and under.) 5. Appointment for mental health assessment (Children 3 mos. – 4 years with concerning score on ASQ-SE are assessed. All children ages 4 – 18 get a screening or review of current mental health services.)

31. Methods(3) 6. Complete needed referrals 7. Develop Plan of Care (POC) with team 6. Review POC with Social Worker 7. Assure follow-up services are secured.

32. Services • A comprehensive health assessment within a month which will include gathering and reviewing all past medical records, school/child care information, immunization status, etc. • A developmental and mental health evaluation (which may occur in the home) * A review of all medical, school, and mental health records are done for children not receiving direct assessment by the CHDP. • A plan of care to include identification of a medical home, special health needs, specific behavioral/developmental concerns, and assistance for families in securing needed referrals.

33. Medical Exam • Review all medical history and request records for review • Full comprehensive PE • Required state DSS PE form sent • Assess if HIV testing or other lab work needed • Skeletal survey done per protocol for children < 2 years of age

34. Developmental Assessment • Review developmental history, school history, and any interventions including IFSP/IEP • Developmental screening for all children less than 5 years of age • Neurodevelopmental screening for school age children who have not had psychoeducational testing at school. • Review school records for those children with IEP’s to determine the need for changes and/or updating.

35. Mental Health Assessment • Review mental health history and prior MH services/assessments. • MH evaluations for all children ages 4 – 18 years if not currently in treatment • MH evaluation may include observation of child in the home, daycare, or office setting along with collateral contacts with those working with child • Complete a Doctor’s order for services and provide level of care information for indicated therapeutic services

36. “Every Tuesday a man comes and gets me out of social studies and we go to a room and talk about it all. ..He spread out pictures of flat bats for me to comment on. I mostly saw flat bats. Then I saw big holes a body could fall right into.”

37. “..he tells me I’m scared. I used to be but I am not now….I might be a little nervous but I am never scared.”

38. Features of CHD Program: Direct Benefits • Comprehensive and Coordinated screening and treatment plan for children in foster care or in families in need of child protective services. • Coordinated individualized plan of care to increase parents/caregivers understanding of their children’s developmental and mental health status. • Assist parents/caregivers to use resources in medical home and early intervention programs to optimize their children’s development.

39. Features of CHD Program: Health Care Management • Information gathering • Ensuring appropriate medical consents • Coordination of health care services • Educating child welfare staff, courts, GALs, foster & birth parents, educators, and health care professionals • Ensuring Plans of Care are provided to all medical homes and child welfare staff

40. Referrals & Secured Care January 2004 through December 2005 All children are referred to a medical home for ongoing health care - 412 • Medical referrals (specialized) – 27 • Developmental referrals – 90 • Mental Health referrals – 158

41. Outcomes • January 2007 through December 2007 Medical/Physical Exams – 132 Developmental screenings – 105 Mental Health evaluations – 79 (foster care only – no CPS)

42. Outcomes Totals for 4 years of program: 811 children seen 670 referrals 1,879 assessments

43. Lessons Learned • Public health and child welfare agencies have a significant responsibility to assure comprehensive care for children in foster homes. • Families and DSS staff prefer regionalization of services. • Protocols (skeletal surveys, HIV screening, etc.) need to be followed.

44. Lessons Learned • More children were found in need of developmental and/or mental health services than DSS had previously anticipated. • Children are receiving services in a timelier manner than previously.

45. “The CHDP has offered comprehensive health services to all children entering foster care each year. The program has offered a resource that was not available previously and assures an individual plan of care addressing health, development, behavioral, and mental health needs. Foster children generally come from a background of poor or inconsistent health care; records are frequently scarce. The CHDP is invaluable in providing a complete and thorough health view of these children who may be vulnerable to delays, emotional problems or other medical concerns.” Elaine Rakouskas, WCHS Program Manager for Foster Care Services

46. “Sometimes …I count up what I like about the way I’m living now. ….And the best one number four is my new mama saying good morning to me like she means it.”