Health Oversight and Coordination Plans Fostering Connections to Success and Increasing Adoptions Act

1. Health Oversight and Coordination PlansFostering Connections to Success and Increasing Adoptions Act Jim Pawelski, Director Division of State Government Affairs 9.1.09 CWLA Community Forum

2. Welcome to Chicago! About the AAP • The American Academy of Pediatrics (AAP) was founded in June 1930 by 35 pediatricians who met in Detroit in response to the need for an independent pediatric forum to address children’s needs. • The AAP is nonprofit professional organization, headquartered in the Chicago area, of more than 60,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to attaining optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. • The AAP has 59 chapters in the US and 7 chapters in Canada. US chapters are 1 per state, except California and New York, due to population have more than 1 chapter. In addition, 2 chapters serve pediatricians in the uniformed services (east and west, divided by the Mississippi River) and the District of Columbia and Puerto Rico also have chapters. • In addition, the Academy’s governance structure includes 30 committees, 49 sections, 6 councils, and 3 task forces, including a Task Force on Foster Care.

3. Fostering Connections Act • The AAP worked closely with Congress to develop Section 205: Health Oversight and Coordination Plan (HOCP) of Public Law 110-351. • Evidence and experience tell us that the health care needs of children in foster care continue to go unmet. • The new Fostering Connections law specifically requires state child welfare and Medicaid agencies, in consultation with pediatricians, other experts in health care, and experts in and recipients of child welfare services, develop a plan for the ongoing oversight and coordination of health care services for any child in a foster care placement.

4. Health Oversight and Coordination Plan Plan must ensure a coordinated strategy to identify and respond to the health care needs of children in foster care placements, including mental health and dental health needs, and must include an outline of: • a schedule for initial and follow-up health screenings that meet reasonable standards of medical practice • how health needs identified through screenings will be monitored and treated • how medical information for children in care will be updated and appropriately shared, which may include the development and implementation of an electronic health record • steps to ensure continuity of health care services, which may include the establishment of a medical home for every child in care • the oversight of prescription medicines • how the state actively consults with and involves physicians or other appropriate medical or nonmedical professionals in assessing the health and well-being of children in foster care and in determining appropriate medical treatment for the children

5. Schedule for Initial and Follow-Up Health Screenings Standards for health screenings are issued by the AAP and CWLA along with other partner organizations. • A medical/developmental/mental health screening within 72 hours of entering the child welfare system. • A comprehensive assessment, including review of physical, mental, developmental, and dental health, within approximately 30 days after entering the child welfare system. • Additional visits as appropriate during the first 60-90 days of entering the child welfare system to assess the child in the process of transition, monitor the adjustment to care, identify evolving needs, and continue information-gathering. • Preventive health care in accord with an enhanced schedule of well-child visits, immunizations, and related care developed by authoritative professional organizations to meet the special needs of children in child welfare system.

6. Monitoring and Treating Health Needs Identified Through Screenings • AAP recommends that health needs identified during the screening and comprehensive assessment, and other visits should be monitored, treated, and addressed in accordance with Early and Periodic Screening, Diagnosis and Treatment (EPSDT) requirements by pediatricians, other health care clinicians, caseworkers, and the judicial system in the medical home. • AAP is advising that state HOCPs include steps for ensuring that the individuals involved in a child’s care each know exactly what their responsibilities are and how to fulfill them (eg, social worker is responsible for ensuring that appropriate medical exams or screenings are scheduled and appointments kept; judge is responsible for ensuring that the child is receiving regular medical care).

7. Medical Information/Records • The AAP is aware that some states, most notably Texas, with involvement of the AAP Texas Chapter, are already developing electronic health records for children in foster care. • States should be incentivized to examine ways to improve the collection, maintenance, and sharing of such information. • A strong state-federal partnership on this issue will ensure interface among such records as a child may move across the country and is cared for by another pediatrician in a different state. • State plans should address access to necessary medical information for others involved in the care of children in foster care beyond the physician and other health care clinicians (eg, social workers, judges, foster parents, educators). • State plans should address provision of appropriately detailed medical information to a foster family upon placement or placement change; to the biological family upon reunification; to a prospective adoptive family who is seriously considering adoption of a particular child; to the adoptive family upon adoption; and to the youth upon aging out of the system.

8. Establishing Medical Homes and Ensuring Continuity • The “medical home” refers to a system of patient-centered care in which one physician is responsible for coordinating the entire universe of care for the child. • This includes coordinating care plans that may be developed by other physicians, ensuring that the caregiver is equipped to care for the child appropriately, monitoring the number and potential interaction of prescriptions, etc. • The medical home is a critically important concept for children in foster care, given that nearly half of all children in foster care have chronic medical problems, and up to 80% have emotional problems. • These health care challenges require concerted, coordinated efforts on the part of not only health care providers, but the entire child welfare system, to improve the health and well-being of the child. • State plans should seek to establish a medical home for every child in foster care in order to maintain that continuity through placement changes. • For more information on the medical home, please visit: www.medicalhomeinfo.org/

9. Oversight of Prescription Medicines • Failure to coordinate and provide continuity of services and the absence of clear guidelines and accountability to ensure that treatment decisions are in the child’s best interest, create a greater risk that medications will be prescribed to control children’s behaviors in the absence of individualized service plans that might offer the best chance for success. • AAP encourages states to include specific steps for monitoring the prescription of medication to children in foster care in their HOCP. • The Texas Department of State Health Services developed Psychotropic Medication Utilization Parameters for Foster Children in collaboration with Texas Pediatric Society, Federation of Texas Psychiatry, Texas Academy of Family Physicians, Texas Osteopathic Medical Association, Texas Medical Association. • www.dshs.state.tx.us/mhprograms/psychotropicMedicationFosterChildren.shtm

10. State Consultation with Physicians and Others Regarding Medical Treatment • Critical to improving systems of care for children in the child welfare system. • AAP supports and encourages pediatricians and other health care clinicians to collaborate closely with child welfare professionals in improving the health and well being of children in foster care. • Encouraging chapters to work with states to provide a detailed explanation, algorithm, or flowchart of what systems are in place to ensure that medical decisions are made by the appropriate individuals and there is coordination among all parties who are responsible, in whole or in part, for the child’s health and medical care.

11. Guidance from ACF • October 23, 2008 – program instructions issued to states, tribal, and territorial agencies: www.acf.hhs.gov/programs/cb/laws_policies/policy/pi/2008/pi0805.htm • Gave states 30 days to file forms, subject to approval by Children’s Bureau Regional Program Manager, certifying that they would require enactment of state legislation to comply with various provisions of the new law. • Administration transition delays. • June 3, 2009 – program instructions issued addressing 5-year Child and Family Services Plans for FY2010-2014, including HOCP requirements, though no additional guidance on the plans was offered: www.acf.hhs.gov/programs/cb/laws_policies/policy/pi/2009/pi0906.htm • Gave states 27 days to submit numerous reports including a five-year CFSP for FYs 2010 through 2014, which had to include their health oversight and coordination plan as described in Section 205 of Fostering Connections. • Stated effective date for Section 205, with the exception of approved delays for special legislation, was October 7, 2008.

12. Utilization of Plans • AAP urged ACF to examine ways in which state Health Oversight and Coordination Plans can be used by both the agency and the individual states to track and improve care. • On the federal level, our hope that ACF will share the Academy’s recommendations as potential guidelines for states embarking upon the development of plans, just as our state chapters are doing with their states directly. • AAP has requested that ACF highlight particularly innovative plans as models for other states. • Our view is that these plans are not intended to be static documents but dynamic processes that help drive continuous quality improvement. • AAP encourages states to consider using this planning process to help inform their Performance Improvement Plans under Child and Family Service Reviews as well as other periodic efforts to improve child welfare and foster care systems.

13. Progress Report A sample of states in the region: • Illinois - The HealthWorks initiative reportedly addresses some of the HOCP requirements but the program only reaches children younger than 6 years old. Illinois also has an advisory foster care workgroup that has been tapped to review the Fostering Connections provisions for the states. Initial reports noted that the state anticipated minor fiscal impact resulting from the mandatory provisions. • Kansas - The state requested an extension to comply with the mandatory provisions of the law. With regard to the HOCP, collaboration is underway between the Medicaid and child welfare agencies on data coordination and analysis to understand and ensure children’s needs are being met. • Minnesota - At this time the state is reporting that existing laws, policies, and programs related to the HOCP are compliant with the provisions of the federal law. • Ohio - The state’s Office for Children and Families and Ohio Health Plans (Medicaid), is in preliminary discussions with the Ohio Department of Education and the Ohio Department of Health around the educational stability and health oversight provisions. At this time the plan is to have these agencies work in collaboration with state’s Family and Children First Council to ensure children in foster care have a plan for improved oversight of health care and educational stability.

14. Partnership with AAP Chapters • To collaborate with pediatricians on development of a health oversight and coordination plan for children in foster care or other issues, contact your state AAP chapter: • www.aap.org/member/chapters/chaplist.cfm

15. We’re Here to Help • Contact the AAP Division of State Government Affairs for consultation and technical assistance with state advocacy activities: Division of State Government Affairs 141 Northwest Point Boulevard Elk Grove Village, Illinois 60007 1.800.433.9016, extension 7799 stgov@aap.org