Medical Homes For Children in Foster Care: A Proposal for CCNC Consideration

1. Medical Homes For Children in Foster Care: A Proposal for CCNC Consideration Proposal collaboratively developed by: NC Pediatric Society Foundation & Benchmarks August 2, 2012

2. Population Characteristics • 14,266 children served in foster care during SFY 2010-11 • 4,700 entered; 3,400 exited; 9,000 on any given day • Age Distribution (end of month for 2010-2011) • 38% 0-5 years old • 30% 6-12 years old • 25% 13-17 years old • 60% leave within 1.5 years

3. Population Needs • American Academy of Pediatrics: children in foster care have higher prevalence of physical, developmental, dental and behavioral health conditions than any other group of children • Children in foster care cost Medicaid more than three times what non-disabled, Medicaid-eligible children cost due to their complex physical and behavioral health needs (2008, Center for Health Care Strategies)

4. Buncombe County • PRTF – 14 Children • Age range: 7.5 yrs – 18 yrs • Length of Time in PRTF Range: 3 mo – 12 mo. • Median Length of Time in PRTF: 6.5 mo • Median # of MH Placements: 8 (range: 2-13) • Median # of Hospital: 2 (range: 0-8) • 8 out of 14 (57%) entered DSS custody when they were 5-8 yrs old and have been in custody for a median of 8 yrs • 6 out of 14 (42%) entered DSS custody when they were 11-16 yrs old • ESTIMATED COST FOR PRTF CARE: $1.475 million Level III/IV Therapeutic Foster Care Level I Group Care Family Foster Care 204 Children in DSS Custody (2/29/2012)

5. Importance of Medical Home • Linking children to Carolina Access II homes is first step • As of Dec 2011, 63% of 0-4 years enrolled and 52% for 0-20 (this includes adopted children) • Enhancing capacity of medical homes to serve this high need population is the next step • Challenges include complex coordination needs; confidentiality issues; transience of the population; and the need for a “trauma lens” in assessment and service delivery

6. Proposed Medical Home Functions • Collaboration with local Department of Social Services • Coordination or provision of brief health screenings within 7 days of entering care • Coordination or provision of more comprehensive health, behavioral health, developmental, and substance abuse screenings/assessments within 30 days • Ongoing coordination of referrals to and communications with array of service providers • Coordination with LME-MCO to ensure care coordination of behavioral health services • Education of caregivers (e.g. foster and kinship parents) • Provision/receipt of t.a. and consultation within CCNC network on serving this population (clinically, administratively)

7. Quality Improvement Initiative • Provide support to pilot primary care practices in select CCNC networks: • Professional education on trauma and the unique health/behavioral health needs of children in foster care; • Clarification of confidentiality issues; • Training and support for appropriate billing; • T.A. and support in the development of screening, assessment, and service delivery strategies aligned with the requirements of the foster care system

8. Proposed Performance Indicators • Comparison of cost PM/PM of CCNC enrolled foster children vs. other Medicaid child pop. • Decreased use of high-end services including Emergency Department visits and hospitalizations • Decreased use of psychotropic medications • Increased compliance with Health Check well-child periodicity schedules • Increased timely compliance with the ACIP immunization schedule • Increased rate of annual dental visits • Continued use of same health care providers/practice during foster care placement • Levels of physician, patient and caregiver satisfaction • Impact of provider education on Medicaid coding strategies for assessing and treating children in foster care to ensure financial sustainability