FOSTERING CONNECTIONS AND HEALTH: OVERSIGHT COORDINATION OF HEALTH SERVICES SEPTEMBER 21, 2010

1. FOSTERING CONNECTIONS AND HEALTH: OVERSIGHT & COORDINATION OF HEALTH SERVICESSEPTEMBER 21, 2010 Chris Chytraus, Utah�s Fostering Healthy Children program Marci McCoy-Roth, Child Trends/Fostering Connections Resource Center Jackie Scott, National Academy for State Health Policy Sarah Springer, American Academy of Pediatrics� Task Force on Foster Care Betty Ward-Zuckerman, US Government Accountability Office

2. Overview of Webinar Review of webinar features and Q&A tools Overview of Fostering Connections Resource Center Review of Fostering Connections law and health-related provisions of the Act Review of GAO report on foster care and health State perspective: Utah�s Fostering Healthy Children program Resources: American Academy of Pediatrics� Healthy Foster Care America Wrap-up 2

3. Webinar logistics and Q&A Slides will be available at www.fosteringconnections.org after the session Control Panel features �Grab tab�: click on the arrows to open/close control panel throughout the presentation. Questions pane How to ask a question Type a question for presenters into the text box at the bottom of the question pane and hit �SEND� If we are unable to respond to you during the session, we will follow up with you after the presentation 3

4. About the Fostering Connections Resource Center Mission: The Fostering Connections Resource Center is dedicated to providing timely and reliable tools and information on all aspects of the Fostering Connections Act to ensure that state, tribal and local decision makers are well-informed about the new law and that they receive maximum support as they plan for and carry out its implementation. Supported through generous contributions of: The Annie E Casey Foundation Casey Family Programs Dave Thomas Foundation for Adoption Duke Endowment Eckerd Family Foundation Jim Casey Youth Opportunities Initiative Sierra Health Foundation Stuart Foundation Walter S. Johnson Foundation 4

5. What does the Resource Center provide? 5 Nonpartisan data and resources on each section of the bill A user-friendly website at www.fosteringconnections.org serves as a central clearinghouse of customized tools and information, such as policy and budget analyses, an up-to-date list of federal guidance, implementation toolkits, research briefs, and examples of best practices and legislative approaches.�� Individualized technical assistance� The Resource Center responds directly to questions from state and tribal leaders and can connect decision makers with other experts and TA providers � Monitoring of implementation activity Visitors to www.fosteringconnections.org can stay up-to-date on federal regulatory activity on implementation, events in the field, congressional oversight hearings and learn about best practices and state and tribal approaches to implementation Opportunities to communicate with experts and peers� Subscribe to mailing lists, join webinars and online discussion forums; and stay informed about major events and conferences hosted by the Resource Center and its many collaborating organizations.

6. Resource Center Networks & Collaborating Partners 6 Partners play a central role in the efforts of the Resource Center. The Resource Center hosts and manages six national networks of state-based stakeholders who help us stay abreast of key questions and concerns regarding implementation, identify best practices, and assist in the delivery and dissemination of tools and resources. Networks are managed by issue experts at the Resource Center who work with a leading partner organization: Kinship/Guardianship Jennifer Miller/Children�s Defense Fund Education Madelyn Freundlich/ABA Legal Center for Foster Care and Education Adoption Kerry DeVooght/North American Council on Adoptable Children Health Marci McCoy-Roth/National Academy for State Health Policy Older Youth Barbara Langford/National Foster Care Coalition Tribal Madelyn Freundlich/National Indian Child Welfare Association More than 25 national organizations serving as collaborating partners We welcome the opportunity to feature resources by and contact information for state & tribal organizations. Contact us at info@fosteringconnections.org

7. Sweeping federal reforms for children and families The Fostering Connections to Success and Increasing Adoptions Act (P.L. 110-351): Signed into law on October 7, 2008 Most significant federal reforms for abused and neglected children in more than a decade 7

8. Consider American Indian/Alaskan Native Children & Families 8 Fostering Connections provides federally-recognized Tribes direct access to the Title IV-E program. In addition, each of the provisions of Fostering Connections applies to tribal children. We urge states to take a new look at the needs of American Indian/Alaskan Native children, youth and families as they implement the Fostering Connections Act. Relevant information is available at www.fosteringconnections.org or by contacting us at info@fosteringconnections.org or the National Indian Child Welfare Association at www.nicwa.org

9. Fostering Connections and Health: Developing Oversight and Coordination of Health Provisions Jacqueline Scott, JD, ML Senior Program Director National Academy for State Health Policy 9

10. Who Are We? 22 year old non-profit, non-partisan organization Academy members Peer-selected group of state health policy leaders Commitment to identifying state needs and guiding our work Working together across states, branches, and agencies to advance, accelerate, and implement workable policy solutions that address major health issues 10

11. NASHP and Fostering Connections NASHP is the lead partner for the Health Network in the Fostering Connections Resource Center NASHP�s previous work includes: Improving systems of care for vulnerable children and youth Addressing health and human services needs for children in juvenile justice systems and foster care 11

12. Key State Policy Areas to Address 1) Support for kinship care and family connection 2) Support for older children 3) Coordinated health services 4) Improved educational stability and opportunities 5) Incentives and assistance for adoption 6) Direct access to federal resources for Indian Tribes 12

13. State Requirements: Health Oversight and Coordination Planning 13

14. Sec. 205. Health Oversight and Coordination Plan States required to coordinate with Medicaid agencies to develop plans to identify and respond to children's health needs in foster care 14

15. Sec. 205. Health Oversight and Coordination Plan Coordination plans should include: 1) A schedule for initial and follow-up health screenings, as well as how the identified health needs will be monitored and treated. 2) An outline of how medical information will be updated and appropriately shared, may include the development and implementation of an electronic health record 3) Steps to insure continuity of health care services, which may include establishment of a medical home for every child in care 4) Oversight of prescription medicines 5) How the state actively consults with and involves physicians or other appropriate medical and non-medical professional in assessing the health and well-being of children in foster care should be outlined. 15

16. Fostering Connections and Health Reform Issued June 7, 2010 Provides guidance for States and American Indian Tribes on compliance with the Act with regards to: Transition Planning Health Care Oversight and Coordination Plans Foster Care Independence Program 16

17. Fostering Connections and Health Reform Transition Planning Personalized transition plans for youth 18 years and older may include information on designating a health care advocate, health care power of attorney, or health care proxy under State law Effective Date: October 1, 2010 Action Required: December 31, 2010 17

18. Fostering Connections and Health Reform Health Care Oversight and Coordination Planning Transition plan development process to include health care options for children aging out of the foster care system Updated Plans Submitted to Regional Offices: June 30, 2010 Effective Date: October 1, 2010 18

19. Fostering Connections and Health Reform Foster Care Independence Program Adolescents participating in the Chafee Foster Care Independence and/or Education and Training Voucher Program will be educated on the importance of designating a health care representative Effective Date: October 1, 2010 Action Required: September 30, 2010 19

20. Fostering Connections and Health Reform Medicaid Coverage for Former Foster Children States required to extend Medicaid coverage up to age 26 for youth who have aged out of the foster care system Effective Date: January 1, 2014 20

21. Jacqueline Scott Senior Program Director jscott@nashp.org Phone: 202-903-0101 www.nashp.org 21

22. Foster Care: State Practices for Assessing Health Needs, Facilitating Service Delivery and Monitoring Children�s Care (GAO-09-26) Describes selected state practices for: Identifying foster children�s health care needs, Ensuring delivery of appropriate health services, and Documenting and monitoring foster children�s health care. 22

23. State Initiatives Specific Requirements for Assessments and Use of Designated Providers Practices to Enhance Access to Services, Coordinate Care, and Monitor Use of Medications Mechanisms for Data Management and Quality Assurance for Documenting and Monitoring Children�s Health 23

24. Specific Requirements for Health Assessments and Use of Designated Providers All 10 states we studied adopted policies that specified the timing and scope of children�s health assessments. All 10 required physical examinations Most required mental health and developmental screens Several required or recommended substance abuse screens for youth shortly after entry Preventive health screens were required at regular intervals after entry, in line with state Medicaid standards Several states used designated providers for assessment Specific research suggests that examination policies and use of designated providers permit fuller identification and follow-up of health care needs 24

25. Practices to Enhance Access, Coordinate Care, and Monitor Use of Medications States took steps to hasten documentation of Medicaid eligibility or enhance compensation to Medicaid providers States used nurses or other health care managers to coordinate care Six states we studied reported monitoring the use of various medications, including psychotropic medications for treatment of mental health disorders 25

26. Data Management and Quality Assurance for Documenting and Monitoring Children�s Health Several states we studied Shared data across state programs Employed quality assurance measures, such as medical audits, to track receipt of services One state had developed an electronic, web-based health care passport for foster children Other states used some electronic databases to obtain more complete and timely medical histories, but continued to use paper-based update processes 26

27. UTAH: Fostering Healthy Children Program Program has been in existence since approximately 1994. Came about after a law suit was filed against the State of Utah by the Center for Youth Law in San Francisco known as the �David C� lawsuit. Founded on children that had been in care that did not get their health care needs met. Exited out of settlement agreement finally in December 2008. 27

28. UTAH: Fostering Healthy Children Program 28 Memorandum of Understanding between Division of Child and Family Services/ Department of Human Services and Children with Special Health Care Needs/Department of Health. R.N.�s co-located with DCFS caseworkers. R.N�s partner with caseworker to provide oversight of health needs of child, caseworker provides case management.

29. UTAH: Fostering Healthy Children Program 29 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 Ongoing health care is tracked by the nurse, based on the assessment requirements, the health needs of each child and the AAP periodicity recommendations.

30. UTAH: Health Requirements 30 Medical: Child seen immediately on entry into care if injured, sick, or visible signs of abuse. Within 24 hours if chronic medical condition or complaints. Within 30 days for Comprehensive Medical exam with medical home.

31. UTAH: Health Requirements, con�t. 31 Dental: Dental exam, x-rays, prophylaxis Mental Health: Ages and Stages and Ages and Stages-Social Emotional for all children 4 months to 5 years. Comprehensive Mental Health Assessment for all children > 5 years of age.

32. UTAH: Annual Health Requirements 32 Well Child Check according to AAP Periodicity schedule. Dental exam MHA or ASQ All follow-up health care referrals and follow-up completed within 90 days

33. UTAH: Health Status Outcome Measure 33 Point in time phone review of child�s current health status with foster parent. Scheduled for completion at one month, 3 months and 6 months in care; then prompted for completion based on child�s score. Healthy done every 6 months, on psychotropic meds every 4 months, medically fragile every 2 months.

34. UTAH: HSOM Scores 34

35. UTAH: Medication Tracking 35 Meds tracked in SAFE. Psychiatrists available to staff concerns. Second opinions an option. 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.

36. 36 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

37. UTAH: SAFE Database Health Tabs 37 Summary of Visits Mental Health AXIS Diagnosis/Treatment ASQ/ASQ-SE Scores Health Conditions HSOM Medication/Allergies Immunizations History - both client and family MI 706/Medicaid Information Health Care Professionals See SAFE Health screen PDF

38. UTAH: Forms 38 HSOM Scoring Sheet Health Visit Report Form Release of Medical Records Health Data Report Letter for health providers on Responsible Party Copy of SAFE Health Screens

39. UTAH: Contact Information Chris Chytraus R.N., BSN, CPM Utah Department of Health 44 N Mario Capecchi Drive P.O. Box 4671 Salt Lake City, Utah 84114-4671 801-584-8598 chrischytraus@utah.gov 39

41. Health Needs of Children & Youths in Foster Care A strategic priority for the AAP Created Task Force on Foster Care to address systems policy, community, & pediatric practice levels Contributed significantly to health portions of HR 6893

42. Educating & Enlisting Pediatricians Access to quality pediatric care identified as a significant issue Empowering pediatricians to feel knowledgeable & competent to meet the often-complex needs of kids in foster care Opening doors of pediatric practices to kids in care Educating pediatricians to collaborate with other child welfare professionals

43. AAP Chapters as Resources to States AAP has at least 1 chapter in every state Currently in the process of identifying �foster care champion� pediatricians in each state To collaborate at state levels on developing health oversight & coordination plans To serve as liaison back to pediatricians & family doctors, encouraging access & quality care for kids & collaboration with state system

44. AAP Chapters as Resources to States Have created resources for Chapters specifying AAP recommendations about how to best implement the health provisions of Fostering Connections. Ongoing efforts to help connect AAP Chapters & state administrators as plans are devised & implemented. These resources are available to state colleagues who are interested: http://www.aap.org/fostercare/policymakers.html

45. www.aap.org/fostercare

46. Expert information on the health issues of children and teens in foster care Downloadable chapters of Fostering Health: Health Care for Children Healthy Foster Care America listserv subscription Customizable forms A Special Place for Children and Families What�s New Resource Library- Coming Soon!

48. Forms, Tip sheets, AAP family materials, other publications, and Web site links Health care standards Addressing barriers to good care Health care management  and coordination Models of health care coordination

50. AAP Task Force on Foster Care Main Contacts: Sarah Springer, MD, FAAP (Chair) sspringer@aap.net Moira Szilagyi, MD, PhD, FAAP (Vice-Chair) mszilagyi@aap.net Mary Crane, PhD, LSW (Staff) mcrane@aap.org

51. We invite your questions 51 The Resource Center is pleased to answer questions about any topic related to implementation. Please email questions to info@fosteringconnections.org The Resource Center can also broker or offer limited technical assistance to agencies. Again, please send inquiries to info@fosteringconnections.org.

52. More than 500 state and national resources available 52 Visit www.fosteringconnections.org to access tools, analyses, and other information on each provision of the Act : Healthy Foster Care America website http://www.aap.org/fostercare/ Fostering Healthy Children website http://health.utah.gov/cshcn/FHCP/ GAO Report: State Practices for Assessing Health Needs, Facilitating Service Delivery, and Monitoring Children�s Care http://www.gao.gov/new.items/d0926.pdf Policy Lab (at Children�s Hospital of Philadelphia) http://stokes.chop.edu/programs/policylab/index.php/research-and-policy/child-welfare.html And much more!

53. Thank you & please come again 53 Copies of this presentation, as well as an audio recording, will be available on www.fosteringconnections.org Next FCRC webinar: Stay tuned for details on an October webinar focused on older youth. Sign up to be notified of this and other upcoming events at www.fosteringconnections.org Discussion forum: We invite you to join a new LinkedIn Group Discussion Forum:� Fostering Connections Implementation Working Group. You can find a user guide to LinkedIn and register for the Fostering Connections Group at: http://www.fosteringconnections.org/resources?id=0007 The Fostering Connections Discussion Group offers subgroups on kinship, guardianship, adoption, older youth, education, health, training and Tribal topics. Contact us: Fostering Connections Resource Center, info@fosteringconnections.org Chris Chytraus, Utah�s Fostering Healthy Children program, chrischytraus@utah.gov Marci McCoy-Roth, Child Trends/Fostering Connections Resource Center, mmcoy-roth@childtrends.org Jackie Scott, National Academy for State Health Policy, jscott@nashp.org Sarah Springer, American Academy of Pediatrics� Task Force on Foster Care, sspringer@aap.net Betty Ward-Zuckerman, US Government Accountability Office, wardzukermanb@gao.gov