The Health of Children in Utah’s Child Welfare System

1. The Health of Children in Utah’s Child Welfare System Chris Chytraus R.N., BSN, CPM Program Manager Utah Department of Health Fostering Healthy Children

2. At the completion of this presentation, the attendee will be able to: • Summarize the history of health care tracking for Utah’s foster children. • Understand the SAFE database and what data can be obtained. • Recognize challenges faced in obtaining medical care and specialized testing for a foster child. • Apply what was learned during the presentation to a case study and through group discussion, determine appropriate data requests.

3. Utah’s Child Welfare History Related to Health • 1994 Center for Youth Law Settlement Agreement. • Safety and Welfare were major issues. • Health and Well-being Criteria established.

4. Adoption and Safe Families Act (ASFA 1997) • Federal legislation that holds child welfare agencies accountable for children’s well-being. • Extends beyond the traditional focus of child welfare agencies on safety and permanence.

5. ASFA Well-Being Outcomes • Families have enhanced capacity to provide for their children’s needs. • Children receive appropriate services to meet their educational needs. • Children receive adequate services to meet their physical and mental health needs.

6. New Federal Legislation: • The Fostering Healthy Successes legislation sponsored by Representative McDermott from the state of Washington now mandates all states must track the health and medications for all children in foster care. • Utah has been consulted by many states on our process as other states work to implement a system.

7. Fostering Healthy Children Program A contract was written in 1997 between the Department of Human Services/Division of Child and Family Services (DCFS) and the Department of Health/Children with Special Health Care Needs (CSHCN) Bureau, which established the Fostering Healthy Children (FHC) Program.

8. Funding for the FHC Program • Medicaid “Administrative Case Management” option allows an approximate 3 to 1 federal to state funds match. • Provides for coordination of health services to Medicaid eligible children. • Funding was in jeopardy in 2008.

9. Fostering Health Children Program Today • Nurses are co-located in DCFS offices across the state. • Nurses provide medical, dental, and mental health consultation; caseworkers provide case management.

10. FHC Program today: • Identify the child’s medical home (primary medical care provider) and work with the eligibility worker to place the child in the appropriate health plan. • Monitor to make sure the child receives eligible services through the Medicaid program.

11. R.N. Placement and Foster Care Caseloads: Region R.N.’s Number of Children Northern 7 706 Salt Lake 12 1011 Western 5.5 535 Eastern 3 272 Southwestern 2.5 278 8/10/10 from SAFE database

12. Health Care Requirements for Children in Utah’s Foster Care Within 24 hours Emergency Visit, if indicated for • Sick child • Chronic Medical Condition • Signs of Abuse/Neglect

13. Health Care Requirements, cont. Within 30 days of custody date Well Child Exam • Completed by Primary Care Provider. Dental Exam • Includes x-rays, cleaning and fillings. Mental Health Exam • For children 4 months to 5 years, Ages and Stages Developmental Screening tool is completed. • Full Mental Health Assessment completed on children over 5 years old.

14. Health Care Requirements, cont. Annually and/or at transitions • Well Child Examination according to the American Academy of Pediatrics (AAP) recommendations. • Dental Examination for those 3 and older unless identified needs for children younger than 3. • Mental Health Examination or Ages and Stages Developmental Screening tool for those ages 4 months to 5 years.

15. Continuity of Health Care • All follow-up care requested by the physician, dental provider or mental health provider is tracked. • Post cards are mailed when the exam is overdue and the family receives these on a monthly basis.

16. Drug Endangered Children • Vulnerable to drug exposure, criminal activity, sexual abuse. • Many will have developmental delays due to neglect. • Drug Endangered Child examination recommended to identify all health issues.

17. Evaluation of Health Care • Nurses gather, evaluate and document the health history of each child in foster care. This history is obtained from: • The biological parents • Medical providers • Family/friends that know the child • The child themselves depending on their age • On-going health care is tracked by the nurse based on the assessment requirements, the health needs of each child and the AAP recommendations.

18. Training and Consultation • Nurses are available for both foster and biological parents to address their child’s health care issues. • Nurses attend the Child and Family Team Meetings to address health care concerns. • FHC and DCFS collaborate in training foster parents, new caseworkers and providers on the importance of the health care for this vulnerable population.

19. Health Status Outcome Measure (HSOM) • Unique to the State of Utah, however is beginning to evolve to other states. • Provides an additional health care tool to assess acuity and track the health care needs of children in foster care and whether they are being met. • First developed in 1997 • Added to the SAFE database in 2003, many improvements since then.

20. Health Status Outcome Measure • Allows the R.N. to assess the health (medical, dental, and mental health) status of each child and assign an acuity score. • Tracks whether program interventions are making a difference from the time they enter custody to when they leave custody. • Provides justification for increased reimbursement for the foster family that manages the medically fragile client.

21. Health Status Outcome Measure Scoring Guidelines • Healthy • Healthy, in counseling No medical/mental health conditions requiring medications. 3. Chronic Condition On preventative medications only. (examples include: hay fever medication, creams for dry skin, contraceptives, fluoride)

22. Outcome Measure Scoring, cont. 4. Acute illness or chronic condition that requires regular on-going follow-up Includes those placed in residential placement, acute care facility and state hospital. Also includes those on psychotropic medications or other medications. 5. Medically fragile child Child has multiple and/or debilitating conditions that require assistance with activities of daily living. At risk for developing an acute condition. 6. AWOL

23. Identifying Unmet Needs A Current on all requirements B Overdue for exam/follow-up C Overdue for immunizations only B/C Overdue for exams or follow-up and immunizations. (This is a snapshot of the health of the child on the day the HSOM is completed. Any item that is overdue will place the child outside of the A category.)

24. HSOM Scores for July2005 - 2010

25. SAFE Information System • All health information on each child in foster care is entered into the SAFE system. • Information can be pulled at any time if the child should return to care. • Placements are provided with health care information along with exams and follow-up that is due.

26. Health Care Screens • Provides data warehouse for all of the child’s health care information. • Nurse maintains an up-to-date medical history on each child that has an open foster care case. • Prompts the nurses and caseworker for policy required exams. • Generates health data report for use by medical providers.

27. SAFE Health Care Screens • Summary of Visits • Mental Health/Treatment • ASQ/ASQ-SE Scores • Health Conditions • HSOM • Medication/Allergies • Immunizations • History - both client and family • MI 706/Medicaid Information • Health Care Professional

28. Current Data: • Medical Conditions: • 13 have a hearing loss • 16 have diabetes • 165 have developmental delays • 6 have sleep apnea • 4 have congenital defects of their heart • 21 have cerebral palsy • 54 have anemia SAFE database 08/10/10

29. Current Data, cont.: • Dental Conditions • Dental carries (cavities) 70 • Mental Health Conditions • 140 have Behavioral Problems • 127 suffer from Anxiety • 42 have Autism SAFE database 8/10/10

30. Current Data, cont.: • Medications being used: • 221 take Albuterol/ProAir for Asthma • 63 take a BenzaClin type medication for Acne • 196 take Claritan or Zyrtec for allergies • 29 take Insulin for their Diabetes • 189 take some type of “Over the Counter” formula/vitamin • 116 take some type of prescription vitamin, fluoride or mineral SAFE database 8/10/10

31. Psychiatric Medication Use: • There were 2,651 children in custody on July 9, 2008. • The total number of unduplicated children prescribed one or more psychotropic medication was 833 out of 2,651 or 31%. • The data shows that there are over 140 licensed providers that prescribed these medications.

32. Sample letter to Provider: Dr. Ben Casey Northeastern Medical Group 210 West 300 North Sandy, Utah 84066 Regarding your Patient: Polly Pill Dear Dr. Casey, The above named patient is currently in the care of the State of Utah, Division of Child and Family Services. Our medical records show that you are currently prescribing Paxil for Polly Pill. Due to the recent information received on the use of Paxil in children under the age of 18, we are asking that you review this child’s case to determine if there may be another drug of choice for use in their care. You will find attached the recent FDA concern along with a Health Visit Report and return envelope to be completed and returned to the R.N. case manager. As temporary guardian of this child, we want to make sure every effort is made to provide a safe and healthy environment. This includes following up on concerns raised related to medications and therapies offered to the children in state custody. We appreciate your immediate assistance in this matter. Please call me if you have any questions or concerns. I can be reached at 801-584-8598 or by pager at 801-249-3851. Sincerely

33. Challenges: • Identify and maintain the child’s primary care provider or medical home. • Access to dental and pediatric sub-specialty providers that accept Medicaid, such as Pediatric Orthodontists, Neurologists, Geneticists. • Wait times to have children seen in pediatric sub-specialty clinics (some are booked out 6-7 months), due to provider shortages.

34. Challenges, cont. • Obtaining medical records due to the interpretation of HIPAA regulations. • Covered services paid for by Medicaid. • Wanting the best for the child within the system limitations.

35. Case Study: • 11 year old male child enters foster care due to poor medical care from biological parents. Child is post liver transplant and has diabetes. Requires anti-rejection medications at the same time each day along with insulin and blood sugar testing. Child is in the United States illegally. He is seen every month at the Diabetic Center and weekly to bi-weekly at the liver transplant clinic. • What considerations might you make in this case?

36. Group Discussion Thoughts • Not eligible for Medicaid • Medically fragile home needed • Mental health needs due to chronic life-threatening illness • Wants to be like “other children”

37. Group Discussion Thoughts • Immigration issues • Placement location • Chronic risk of rejection/infection • Typical teen behavior with lack of compliance

38. Questions, Thoughts and Answers….