Maine Citizen's Review Panel Recommendations for a Coordinated Health Plan for Children in Foster Care

The Maine Citizen Review Panel (CRP) in discussion with the Office of Child and Family Services (OCFS) staff made a decision in the spring of 2014, to form a work group to develop recommendations for the State of Maine’s coordinated health plan for children in foster care. OFCS has stated they are developing a statewide plan and invited the Panel to make recommendations as to what should be included in such a plan.

The State of Maine, in order to be in compliance, needs to meet the requirements as stated in the Federal Fostering Connections to Success and Increasing Adoptions Act of 2008 as follows:

The Health Oversight and Coordination Plan, section 205; section 422(b) (15) of the Social Security Act (42 U.S.C. 622(b)(15) is amended to read as follows:

‘‘(15)(A) provides that the State will develop, in coordination and collaboration with the State agency referred to in para- graph (1) and the State agency responsible for administering the State plan approved under title XIX, and in consultation with pediatricians, other experts in health care, and experts in and recipients of child welfare services, a plan for the ongoing oversight and coordination of health care services for any child in a foster care placement, which shall 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 shall include an outline of—

(i)  A schedule for initial and follow-up health screenings that meet reasonable standards of medical practice

(ii) How health needs identified through screenings will be monitored and treated

(iii) 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

(iv) Steps to ensure continuity of health care services, which may include the establishment of a medical home for every child in care

(v) The oversight of prescription medicines

(vi) How the State actively consults with and involves physicians or other appropriate medical or non-medical professionals in assessing the health and well-being of children in foster care and in determining appropriate medical treatment for the children

‘‘(B) subparagraph (A) shall not be construed to reduce or limit the responsibility of the State agency responsible for administering the State plan approved under title XIX to administer and provide care and services for children with respect to whom services are provided under the State plan developed pursuant to this subpart[i]

The Child and Family Services Improvement and Innovation Act (P.L. 112-34) amended the law by adding to the requirements for the health care oversight and coordination plan. Whereas the law had previously required that the plan address “oversight of prescription medicines,” the new provision builds on this requirement by specifying that the plan must include an outline of “protocols for the appropriate use and monitoring of psychotropic medications.” In addition, P.L. 112-34 requires that the health care oversight and coordination plan outline “how health needs identified through screenings will be monitored and treated, including emotional trauma associated with a child’s maltreatment and removal from home” (section 422(b)(15)(A) of the Act).[ii],[iii]

Further and in accordance with the federal law, the Child Welfare League of America (CWLA) and the American Academy of Pediatrics (AAP) call for mandatory health assessments and specify an initial health screening and comprehensive examination for children entering foster care. The AAP guidelines also label 3 key features of these mandatory health assessments: 1) assessments should be inclusive of all children entering foster care; 2) assessments should be comprehensive with respect to the identification of possible physical health, mental health, and developmental problems; and 3) assessments should be performed by a clinician who is knowledgeable about the treatment of children in foster care and can provide regular, ongoing primary care services.[iv],[v] It is important to recognize, that policies in many child welfare systems are set up for physical examinations but many do not have policies designed to address dental care, mental health and developmental needs. [vi]

In administering plans to meet compliance the following examples of recommendations from a few fairly well recognized groups is being provided and was captured from the National Screening and Assessment Recommendations for Children and Youth Entering Foster Care. [vii]

The American Academy of Pediatrics recommends:[viii],[ix]

Upon entry into foster care, children and youth should be seen by an appropriate health care professional, and have a health screening within 72 hours of placement.

  •       Within 30 days of foster care placement, children and youth should have a detailed, comprehensive evaluation of:

–     Mental health;

–     Developmental health (if under age 6 years);

–     Educational needs (if over age 5 years); and

–     Dental health.

  •       A follow-up health visit should occur within 60-90 days of placement.

The Council on Accreditation (COA) recommends:[x],[xi]

• Initial screening from a qualified medical practitioner within 72 hours of a child’s entry into foster care to identify the need for immediate medical or mental health care, and to assess for infectious and communicable diseases; and

• Follow-up assessments within 30 days of foster care entry to help child welfare agencies determine the most appropriate placement for a child.

It is prudent to point out that Maine’s most vulnerable population, which includes those children 5 years old and under, is also the same group with the highest number of children entering foster care. Because of this, it is critical that early intervention for this group occur to afford them a comprehensive examination, in order to reduce trauma and thus lessen future health issues. Notably, at this point there are only three clinics statewide that provide a broad range of services which meet the medical criteria outlined in this review but still lack the desired ongoing oversight.

The committeerecommends that members of OCFS work with members of the medical and mental health field familiar with the needs of children in foster care, to support a plan for the State of Maine which would incorporate the resources of the state in effort to effectively provide comprehensive consistent services for children in all areas of the state, initiate such a plan in a timely fashion, integrate collaboration of agencies and provide a source of ongoing oversight to ensure continued success. A careful consideration of employing a systematic approach in amending the state’s current legislation to meet these guidelines seems appropriate.

In gathering information to support the committee’s recommendations 10 States were selected based on material available, which included Texas, Minnesota[xii], Colorado, Oregon[xiii], Indiana, Tennessee[xiv], Alaska, Ohio[xv], Missouri, California and New York. Another source of information that was used to discover methods of state practices for assessing health needs, facilitating service delivery, and monitoring children’s care was the GAO February 2009 FOSTER CARE report [xvi]. Links to these references are found in the endnotes.

Maine statue currently provides the following language relative to a Health Plan for Children in Foster Care:

–     The department shall ensure that a child ordered into its custody receives an appointment for a medical examination by a licensed physician or nurse practitioner within 10 working days after the department's custody of the child commences.

–     If the physician or nurse practitioner who performs a physical examination and determines that a psychological assessment of the child is appropriate, the department shall ensure that an appointment is obtained for such an assessment within 30 days of the physical examination.

–     Whenever a child is ordered into the custody of the department and the child is not expected to be returned to the home within 21 days, the department shall obtain counseling for the child as soon as possible, unless the department finds that counseling is not indicated.[xvii]

PANEL RECOMMENDATIONS

  1.     We recommend that the Maine Department of Health and Human Services collaborate with professionals in the field to develop a plan to meet the health care needs of children in foster care in a timely fashion.
  2.     We recommend that the plan should cover every child in every county in the state.
  3.     We recommend that the plan include ongoing oversight to see that all children are receiving comprehensive medical evaluations by providers who are familiar with the needs of children in foster care, as well as the care that is recommended in the evaluation. The plan should include measures to ensure that the medical records of children in foster care are available to providers and updated appropriately.
  4.     We recommend that a comprehensive examination plan should include evaluations for developmental needs and mental health needs. Children should be referred to trauma informed mental health services in a timely fashion, when indicated through evaluation by a qualified mental health professional. Young children should be enrolled in developmental services, with a thorough evaluation by a qualified Early Childhood evaluation team.
  5.     We recommend that the plan should include guidelines to ensure that complete mental health evaluation occur by a qualified mental health provider before any psychotropic medications are prescribed.
  6.     We recommend that the comprehensive evaluation include screening for oral health concerns and that the plan includes recommendations for dental care services.
  7.     We recommend that the plan include steps to ensure that every child in foster care has a medical home[1].
  8.     We recommend that the plan include ongoing oversight to ensure compliance, such as, an evaluation to be completed on the entire foster care system and a report generated and delivered to the legislature or an advisory group in order to support continuous quality improvements
  9.     In preparing the plan the committee recommends coordination of funding and services for children in foster care should be reviewed, specifically the Early Periodic Screening, Diagnosis and Treatment Program (EPSDT)[2] ,Maine Care services, Behavioral Health home services and Case Management services.
  10. Finally, the committee recommends that work be done to update the current legislation in Maine to include all aspects required by the federal law, and recommended by CHCS, AAP, CWLA and COA.

ENDNOTES

 


[1] A "medical home," is an approach to primary care in which providers, families and patients work in partnership to improve health outcomes and quality of life for individuals, especially those with chronic health conditions and disabilities, and ultimately contain or reduce health care costs

[2] EPSDT program is the child health component of Medicaid. It's required in every state and is designed to improve the health of low-income children, by financing appropriate and necessary pediatric services.

[i]http://www.gpo.gov/fdsys/pkg/PLAW-110publ351/html/PLAW-110publ351.htm

[ii] CHCS – Center for Health Care Strategies Health Screening and Assessment for Children and Youth Entering Foster Care: State Requirements and Opportunities, Kamala Allen, Center for Health Care Strategies, Inc. November 2010.

[iii]http://aaicama.org/cms/federal-docs/CRS_PL_112_34.pdf

[iv] Child Welfare League of America. Standards for Health Care Services for Children in Out-of-Home Care, Washington, DC: Child Welfare League of America, Inc; 1988

[v] American Academy of Pediatrics, Committee on Early Childhood Adoption and Dependent Care. Policy statement: health care of children in foster care. Pediatrics. 1994;93:335–338. [PubMed]

[vi]Comprehensive Assessments for Children Entering Foster Care: A National Perspective

Laurel K. Leslie, Michael S. Hurlburt, John Landsverk, Jennifer A. Rolls, Patricia A. Wood, Kelly J. Kelleher

Pediatrics. Author manuscript; available in PMC 2006 July 25. Published in final edited form as: Pediatrics. 2003 July; 112(1 Pt 1): 134–142.

[vii] CHCS – Center for Health Care Strategies Health Screening and Assessment for Children and Youth Entering Foster Care: State Requirements and Opportunities, Kamala Allen, Center for Health Care Strategies, Inc. November 2010.

[viii]Comprehensive Assessments for Children Entering Foster Care: A National Perspective

Laurel K. Leslie, Michael S. Hurlburt, John Landsverk, Jennifer A. Rolls, Patricia A. Wood, Kelly J. Kelleher

Pediatrics. Author manuscript; available in PMC 2006 July 25. Published in final edited form as: Pediatrics. 2003 July; 112(1 Pt 1): 134–142.

[ix] For more information about the AAP guidelines, visit: http://www.aap.org/fostercare/health_care_ standard.html.

[x]Comprehensive Assessments for Children Entering Foster Care: A National Perspective

Laurel K. Leslie, Michael S. Hurlburt, John Landsverk, Jennifer A. Rolls, Patricia A. Wood, Kelly J. Kelleher

Pediatrics. Author manuscript; available in PMC 2006 July 25. Published in final edited form as: Pediatrics. 2003 July; 112(1 Pt 1): 134–142.

[xi] Note: COA is an international, independent, not-for-profit, child- and family-service and behavioral healthcare accrediting organization. For more information about COA accreditation standards, visit: http://www.coastandards.org/standards.php?

navView=public&core_ id=253

[xii]http://www.health.state.mn.us/divs/fh/mch/ctc/factsheets.html

[xiii]http://www.oregon.gov/dhs/children/publications/cfsp/cfsp-2010-2014.pdf

[xiv]http://www.state.tn.us/youth/fostercare.htm

[xv]http://www.metrohealth.org/upload/docs/Medical%20Services/Pediatrics/MH%20Medical%20Home%20for%20Children%20in%20Foster%20Care%200714.pdf

[xvi]http://www.gao.gov/new.items/d0926.pdf

[xvii]http://www.mainelegislature.org/legis/statutes/22/title22ch1071sec0.html


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