A Promising Approach: Integrated Health Care with Foster Care Children

1. A Promising Approach: Integrated Health Care with Foster Care Children Rick Ybarra, MA, Program Officer, Hogg Foundation for Mental Health (Austin, TX) Alejandra Posada, MEd, Chief Program Officer, Mental Health America of Greater Houston (Houston, TX) Toni Watt, PhD, Professor of Sociology, Texas State University (San Marcos, TX) Session #B2, #8474907 CFHA 18th Annual Conference October 13-15, 2016  Charlotte, NC U.S.A.

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Objective 1: Identify three aspects of how the care delivery system in structured in foster care settings. • Objective 2: Describe three characteristics of the HCPS IHC program for children in State custody care that differ from usual care. • Objective 3: List three recommendations for future design and implementation of practice, program and policy considerations of IHC with foster care children.

4. Bibliography / Reference Asarnow, J., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated Medical-Behavioral Care Compared with Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. JAMA Pediatrics, 169(10), 929-937. doi:10.1001/jamapediatrics.2015.1141. Lin, C. (2014). Evaluating Services for Kinship Care Families: A Systematic Review. Children and Youth Services Review, 36 (2014) 32–41. Pires, S., Grimes, K., Gilmer, T., Allen, K., Mahadevan, R., & Hendricks, T. (2013). Identifying Opportunities to Improve Children’s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, Inc. Faces of Medicaid Data Brief. Sakai, C., Lin, H., & Flores, G. (2011). Health outcomes and family services in kinship care: Analysis of a national sample of children in the child welfare system. Archives of Pediatrics & Adolescent Medicine, 165(2), 159–165. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau (2012). The AFCARS Report: Preliminary FY 2011 estimates as of July 2012. Washington, DC.

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. Speed Dating! NOT!!!! • 30 seconds each person • Introduce self: name, state, setting (FQ, CHC, MH/BH setting, foster care, pediatrics, academic setting, etc) • Why are you here? • One thing you hope to learn or take-away from the session?

7. Children in State Custody: A High-Need Population • Uniquely vulnerable group • Abuse and/or neglect, trauma • Life disruption (removed from parent/s, siblings, friends, schools, neighborhoods) • Substantial health needs compared with children from similar socioeconomic circumstances • Behavioral health issues (40% - 60%) • Physical health concerns • Developmental delays • High level of comorbidity • Example – Texas Medicaid • Children in state custody represent 3% of children with Medicaid • Account for 29% of Medicaid expenditures for behavioral health

8. An Underserved Population • Insufficient access to care • Only 25% - 50% receive needed behavioral health services • Kinship care vs. foster care placements – Kinship placements, while beneficial in many regards, may provide less access to behavioral health treatment • Inadequate, substandard care • Lack of coordination of services • Poor communication among providers • Failure to include biological family members • Narrow treatment protocol – Overreliance on psychotropic medications

9. A Role for Integrated Health Care? • Few studies of IHC among pediatric populations, and no studies of children in state custody served with IHC • Complexities that any IHC model must take into account • Complicated child welfare system • Different types of placements (e.g., kinship care, foster care) and multiple placements • History of trauma • Disentangling child’s reaction to a new placement from symptoms of mental health disorders

10. Structure and Components of Harris County Protective Services IHC program • While Child Protective Services (CPS) in Texas is a state-managed program through the Texas Department of Family and Protective Services (DFPS), in a unique governmental collaboration, protective services for children and adults in Harris County are provided by DFPS and Harris County through Harris County Protective Services for Children and Adults (HCPS) • HCPS provides direct services to children not served by DFPS through Youth Services Center, Community Youth Services and the Prevention Program • BEAR...BE A Resource for CPS Kids, Children's Crisis Care Center, Medical and Dental Clinic • Bringing enhanced alignment to systems touched by the child & family/care giver

11. Structure and Components of Harris County Protective Services IHC program • Child-Centered Medical Home • CM and psychiatric consultation embedded in clinic & workflow; referrals to therapist (in same building) • CM helps children access needed specialty services, schedules appts for on-site psych services, makes referrals for therapy when needed; offers children/ families emotional support, guidance, and assistance obtaining other community resources; tracks children’s wellbeing; maintains the majority of the data collection for the initiative • Two peer navigators added Q1 of 2015 to provide caregivers with a connection to other families who have been through the system and can offer support and guidance www.hc-ps.org/services_provided.aspx

12. Evaluation Design • Process and Outcome • Mixed Method • Field Research • Qualitative-In-Depth Interviews • Kinship caregivers and key stakeholders • Quantitative Data • StarHealth service data • Clinic screening data • Child well-being (BERS-2)

13. Evaluation Highlights: The Case for Care Management • Care Coordination • “Trying to get services was just a mess….I had to search for a therapist and a psychiatrist and didn’t even know where to start from. A lot of parents like me that don’t know where to start from. They say ‘go to the internet’. But what if I don’t have internet?” • Social Support • “I think she really sincerely cares. ….In our situation, we’re so rattled, here we were almost empty nesters, and then we were just in this situation. Every contact (with her), it matters more to me than the case workers.” • Tracking • “On a bad week you think I can’t do this I’m a failure… It does make you feel good when a therapist or the care manager says you are doing good. It gives you strength to go on, hearing that the outcomes are improving.”

14. Pre to Post Change in Child/Adolescent Well-Being: Effect Size

15. Pre to Post Change in Well-Being

16. Care Management: IHC Opportunities • Early Childhood Interventions and Referrals • Trauma • Screening • Training caregivers • Trauma services

17. Foster Care and IHC: A Mutually Beneficial Partnership • Filling gaps in services for foster youth • Complex health problems • Strained caregivers navigating complex systems • Lack of attention to outcomes • Expanding integrated care • Prevention and early intervention • Biopsychosocial model of mental health

18. Q&A/Audience Engagement • Thoughts/Reactions? • Was there anything new presented to you? • What’s missing from what we covered? • For those working with foster care youth or child serving agencies, can you share what’s working or not in your setting? What have you learned? • What components are doable which are not? Why not? What are the barriers that would prevent implementing components or this program?

19. Session Evaluation Please complete and return the evaluation form before leaving this session. Thank you!