Foster and Kinship Care: A Home Away from Home?

1. Foster and Kinship Care: A Home Away from Home? Legislative Advocacy ElShadey Bekele, MD & Caitlin Haxel, MD Monday December 3, 2012

2. Epidemiology • 3.3 million child abuse & neglect reports in 2010 • 436,321 (22%) substantiated • 254,000 removed to foster care • 408,425 children & adolescents resided in foster care in 2010 • 26% in relative (kinship) foster home • 48% in non-relative foster home • 9% in group home or residential care • 4% in pre-adoptive family • 5% on trial discharge with their parents • 2% “run-away”

3. Epidemiology continued • Minorities represented prominently in foster care • In 2010: 29% African American, 21% Hispanic, 41% white, 5% of two or more races • Approximately 50% of children & teenagers will experience more than one foster care placement • Approximately 25% having three or more placements

4. The Foster Care System • Federal legislation determines patterns of funding and regulatory guidelines • State social service agencies implement foster care programs • Daily management may be delegated to county or private child welfare agencies

5. The Foster Care System • Caseworkers • Engage parents around care of child • Coordinate educational, medical, mental health services for children • Secure educational or service resources for family • Support foster parents in their care • Recruit, train, monitor and annually recertify foster parents

6. The Foster Care System • Legal System • Every child in foster care represented in court by a law guardian • Court may also designate a special advocate on behalf of the child • Family court judges • Whether child remains in out-of-home placement after removal • Order services for biological parents • Rehearing case to determine continued placement or alternative permanency arrangement

7. The Foster Care System • Foster parents • Generally married, lower middle income, at least high school educated, employed, children of their own • 5% undergo specialized training to act as resources for severely emotionally disturbed or medically fragile children • Reimbursement • Board subsidy – for food, shelter, personal needs, recreation, most transportation and education costs • Based on child’s age, health needs, complexity of parenting tasks • Cover approximately two thirds of cost • Recruitment, education and retention of suitable foster families is challenging • Group care

8. Processes in Foster Care • Visitation • Recidivism • Termination of parental rights • Adoption out of foster care

9. Length of Stay • In 2010, average length of stay 25 months • Median 14.5 months • Factors • Birth family’s cooperation with case plan for family • Availability of appropriate extended family to care for the child • Diligence in permanency planning by child welfare • Challenges of finding adoptive resources for older children, minority children, large sibling groups, children with significant behavioral and developmental problems

10. AAP Vision Statement “We have a dream that foster care will be valued, healing, healthy, and empowering resources for children, teens, families, and communities, so that every child and teen in foster care will thrive in a forever family. We will achieve this by engaging communities and their leaders in supporting children, teens and their families with an effective, multidisciplinary, integrated, and comprehensive continuum of care.”

11. Health Issues of Children in Foster Care Health Problem % of Population • Chronic medical problems • Complex medical/developmental • Mental health • Developmental delay • Educational issues • Dental problems • Family dysfunction • 30-45% • 10% • 48-80% • 60% of children <6yo • 45% in special education or w/IEP • 35% • 100%

12. The Medical Home • Pediatric care is accessible and continuous over the child’s time in foster care, regardless of placement • Health-care coordination exists that ensures that all of a child’s health-care needs are identified and addressed • Compassionate care is given that includes and understanding of the impact of childhood trauma and loss on children and families

13. The Medical Home • Care is culturally competent and includes understanding of the micro-culture of foster care and it’s impacts • Communication amongst all caregivers to collaborate, when appropriate and safe, in planning for child’s health needs • Comprehensive high quality pediatric care provided according to AAP health-care standards

14. Foster Care Specific Health Visits Age of Child Timing or Frequency • Admission health screen • Comprehensive health assessment • Follow-up health visit • Infants to 6 months • 21 months • 2 to 21 yrs • Within 72 hrs of placement • Within 30 d of entry to foster care • 60-90 d after entry • Monthly (btwn preventive) • Extra visit • Semiannual (btwn annual preventive health-care visits)

15. Anticipatory Guidance • Focusing on child’s strengths • Positive parenting strategies • Impact of trauma on child behavior • Supporting children through transitions • Significant sleep disorders • Confused loyalties • Attachment issues • Need for normalizing activities • Working with birth parents to reduce conflict and coercion

16. Early and Periodic Screening, Diagnostic and Treatment Program • Federal mandate requiring states to provide comprehensive medical services to children enrolled in Medicaid or who are Medicaid eligible • Services include screening, diagnosis and prevention services to ameliorate or treat conditions and to promote healthy development • States have flexibility determining frequency of EPSDT screenings

17. Comprehensive Health Care • Comprehensive admission • Enhanced well-child care • Extra visits that occur related to foster care issues • Discharge health planning • Child abuse and neglect issues • Mental health services • Inpatient hospital and mental health services • Medical transport • Optometry and corrective lenses • Dental evaluation and orthodontic services • Drug and alcohol evaluation and rehab • Full developmental or educational evaluation • Emergency health services • Respite services • Home health care services • Medical equipment and supplies • Laboratory costs • Medications • Care for acute and chronic illnesses

18. Sources of Healthcare Funding for Children in Foster Care • Medicaid • Title IV-E • Title IV-B • Social Services Block Grant (SSBG) • Temporary Assistance to Needy Families (TANF) • Children’s Health Insurance Program (CHIP) • Supplemental Security Income (SSI)

19. Medicaid • State and federally funded entitlement program authorized by Title XIX of SSA • States have flexibility to set eligibility criteria and reimbursements paid to providers • Eligibility: • If < 6 years old and family income <133% poverty level • If greater than 6 years and income <100% of poverty level (birth parents income for the first month in foster care) • 3.7% of Medicaid population are foster children • 12.3% of Medicaid expenditures are for foster children due to high prevalence of psychiatric conditions and specialist services • Federal-state match varies with federal share of 50-83% • Can be billed retroactively for 90 days

20. Medicaid waivers • Provide states with more flexibility to provide services, cover services that aren’t already covered and can be targeted towards specific populations • Types of waivers • 1) Section 1115 Research and Demonstration Projects- test new or existing strategies in delivering and financing services • 2) Section 1915(b) Managed Care- funds to be used for managed care services to specific populations • 3) Section 1915(c) HCBS- long-term care services in a home or community setting who would otherwise be in an institution • New York’s Bridges to Health Program

21. Medicaid Rehabilitation Services Option • Provides reimbursement for diagnostic, screening, preventative, rehabilitative services provided in a facility, home or other setting • Can be used to address physical and/or mental health needs of children in foster care in a community based setting • Services can be offered to children in foster care who are Title IV-E eligible

22. Medicaid Payment Methods Managed care Fee for Service • Per member capitated payment creates incentive to control use of mental health services • Improved access to PCP services • Increasingly more common among states • Difficult to continue across different foster care placements • Restrictions placed on mental health visits • Potential for cost savings for states • Waivers required for children with special health care needs and those in foster care • Lower reimbursement rates to providers • Few physicians who accept FFS • Allows for more flexible access to mental health services • Reimbursement for dental services are low

23. Temporary Assistance to Needy Families • Federal block grant to assist families with little or no income • Provides cash and other assistance to help with financial needs • Possible uses for child welfare services: • Family preservation, foster care, kinship care support, employment programs for foster youth • Funding availability based on budget priorities at federal, state and local level

24. Social Services Block Grant aka Title XX • Mandatory capped entitlement program • Purpose is to achieve five social policy goals: • Prevent, reduce or eliminate dependency • To achieve or maintain self-sufficiency • To prevent neglect, abuse, or exploitation of children and adults • To prevent or reduce inappropriate institutional care • To secure admission or referral for institutional care when other forms are not appropriate • Can be used for children in foster care • Availability subject to budgeting priorities

25. Children’s Health Insurance Program (CHIP) • Administered by states, jointly funded by federal and state government • Program is for families with incomes too high for Medicaid and have no health care coverage • Federal matching rate is typically 15 percent higher than Medicaid

26. Supplemental Security Income (SSI) • Administered by Social Security Administration • Foster children are eligible if they have physical or mental impairment resulting in marked or severe functional limitation that is expected to or has lasted for at least 12 months

27. Title IV-E • Largest source of funding for child welfare services. Authorized by SSA and administered by Administration for Children and Families • $6.75 billion in 2011 • Used for out-of-home care and placement. Cannot be used for direct health care services • States receive reimbursement for child welfare services based on eligibility criteria • Administrative activities, short & long-term training, adoption assistance, foster care maintenance payments • 50% of children in foster care not eligible

28. Title IV-B • Alternative for children ineligible for Title IV-E • Funded at $709 million in 2011 • Supports foster care and families to prevent children from entering foster care • No income eligibility criteria

29. Legislature • Foster Care Independence Act of 1999 • Expand independent living programs for youth aging out of foster care and increased funding. Offered educational opportunities, employment training and prevention services. • Chafee Option- extend Medicaid coverage to youth up to age 21 • Fostering Connections to Success and Increasing Adoptions Act of 2008 • Extended Medicaid eligibility to children receiving kinship care assistance payments. Require states to work with pediatricians to develop oversight plan and coordination of services.

30. Patient Protection and Affordable Care Act of 2010 • Extends Medicaid coverage to age 26 for former foster care youth • Increase funding for expansion of early childhood home visitation programs for families at risk including those involved in the child welfare system. Hx of abuse and neglect are priority groups. $1.5 billion over 5 years to prevent placement of children in foster care. • Extends home and community based services (HCBS) to those with higher incomes other than Medicaid beneficiaries

31. Patient Protection and Affordable Care Act of 2010 • States can create primary care health homes for children with chronic illness who are Medicaid beneficiaries, providing financial incentives for designated providers • Requires transition planning for those aging out of foster care to include health care insurance information and identification of a health care proxy • Extends CHIP funding until 2015 and increases the federal matching rate to 93%

32. Access to Care • Lack of providers accepting Medicaid recipients • High turnover rate of children in and out of foster care • Difficulty identifying health care needs • Inability to obtain health history • Lack of understanding of the type of services needed • Lack of resources to ensure delivery of health services • Lack of documentation and monitoring of health care • High turnover of case workers and support professions • Difficult to track medical care when multiple foster and medical homes involved

33. Actions to Improve Health Care • States have implemented important measures to prevent custody relinquishment by: • Amending policies that require state custody in order for children to have access to mental health services; • Allowing child welfare agencies to set up voluntary agreements with parents for out-of-home placement without custody relinquishment • Giving juvenile courts jurisdiction to order mental health treatment for children in out-of-home placement. • Some states have started using designated providers to perform the initial and comprehensive evaluations with some evidence that there has been increased consistency

34. Actions to Improve Health Care • States can request Title IV-E child welfare waiver demonstrations from HHS • Allow more flexibility for use of funds from the title to get welfare services • Using waivers for intensive preventive services, substance abuse services for parents, subsidized guardianships, mental health and post adoption services • As of March 2012, 6 states had waivers

35. Finance Reform Recommendations • Remove income restrictions that limit access for children to obtain services • Title IV-E is attached to outdate income standards and less than half of children in foster care are supported under this title • Increase funding to prevention services and in home care to better outcomes for children • $4 billion for Title IV-E vs $800 million for Title IV-B program

36. Innovative Programs • Special Kids Special Care Program- MA • Children who have complex medical conditions and are in DCF custody or foster care • Receive intensive medical case management and coordination of care by a NP with development of individualized health care plan • Funded by MassHealth • Key Clinic of Penobscot Pediatrics- Maine • Children in custody of child welfare system and live in specified counties • Provides medical assessment with 72 hrs of entering custody, compile medical records, work with foster family, comprehensive medical eval, labs, screening tests • Funded by MaineCare and nurse by grant from PCHC • Thomas H. Pinkstaff Medical Home Clinic- Kentucky • Children with Medicaid and mainly children in out of home care • Provide well child and sick visits for foster children. Team is made up of an APRN, LSW, and a therapist • Funded by a grant through Kentucky Commission for CSHCN and Medicaid

37. The Pediatrician as Child Advocate • Work with states to ensure that child welfare agencies are aware of and promote health-care standards • Partner with state and local child welfare agencies, departments of public health, and mental health organizations to develop evidence-based mental health-care resources in their community • Partner with state and local child welfare agencies, departments of health, and dental organizations to increase access to dental care • Partner with state and local EI and school/preschool special education programs to develop strategies to assess the needs of children in foster care and ensure access to needed services

38. The Pediatrician as Child Advocate • Advocate for services and policies at the federal and state level that serve children/teens in foster care • Volunteer or work with agencies that serve children or teens in foster care • Become a mentor

39. The Pediatrician as Child Advocate • Start a “backpack” program so that children in foster care have items for school • Donate to a fund to enroll children in foster care in extracurricular activities • Teach independent living skills • Advocate for teens transitioning out of foster care including a permanent home

40. References • Committee on Child Health Financing. “Medicaid Policy Statement.” Pediatrics; July 2005, Vol. 116, No 1. • Committee on Early Childhood, Adoption and Dependent Care. “Developmental Issues for Young Children in Foster Care.” Pediatrics; November 2000, Vol. 106, No 5. • Committee on Early Childhood, Adoption, and Dependent Care. “Health Care of Young Children in Foster Care.” Pediatrics; March 2002, Vol. 109, No 3. • Fostering Health: Health Care for Children and Adolescents in Foster Care. New York: American Academy of Pediatrics, 2005. • Phicil, Sheila. “Financing the Special Health Care Needs of Children and Youth in Foster Care: A Primer." Catalyst Center. Sept. 2012. Web. <http://hdwg.org/sites/default/files/Foster-Care-Primer.pdf>. • Szilagyi. Moira, MD. “Pediatric Role in the Care of Children in Foster and Kinship Care.” Pediatrics in Review; November 2012, Vol. 33, No 11.

41. Questions??