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The Health Care Needs of Children in Foster Care: A Research Agenda.

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Title: The Health Care Needs of Children in Foster Care: A Research Agenda.
Language: English
Authors: Simms, Mark D., Halfon, Neal
Source: Child Welfare. Sep-Oct 1994 73(5):505-524.
Peer Reviewed: Y
Page Count: 20
Publication Date: 1994
Document Type: Reports - Descriptive
Opinion Papers
Journal Articles
Descriptors: Child Health, Child Welfare, Childhood Needs, Foster Care, Foster Children, Health Needs, Health Programs, Health Services, Program Improvement, Research Needs, Standards
ISSN: 0009-4021
Abstract: Reviews the unique health care needs of children in the out-of-home care system and the standards developed over the past decade to deliver comprehensive health care services to this population. Raises key policy and practice questions for each standard to facilitate effective implementation of recommendations makes suggestions for future research efforts. (TJQ)
Entry Date: 1995
Accession Number: EJ489909
Database: ERIC
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  Value: <anid>AN0024227351;cwf01sep.94;2007Mar05.12:16;v2.2.460</anid> <title id="AN0024227351-1">The Health Care Needs of Children in Foster Care: A Research Agenda </title> <rj>Health and mental health considerations present many challenges to</rj> <rj>the child welfare system and play a significant role in the care of</rj> <rj>children in out-of-home care. This paper reviews the unique health care</rj> <rj>needs of children in the out-of-home care system and the standards</rj> <rj>developed over the past decade to deliver comprehensive health care</rj> <rj>services to this population. Key policy and practice questions are</rj> <rj>raised for each standard to facilitate effective implementation of the</rj> <rj>recommendations. Future research efforts should concentrate on</rj> <rj>collecting and evaluating data from existing programs to aid in refining</rj> <rj>and directing policy and practice in the field of child welfare.</rj> <p>Most children enter out-of-home care in a poor state of health. For many, placement in a stable environment with competent foster caregivers can be a positive, nurturing, and healing experience. Over time, the children may show significant improvements in physical, emotional, and intellectual development [Kent 1976; Fanshel and Shinn 1978; Palmer 1979; White and Benedict 1986]. The out-of-home care system, however, is often unable to respond appropriately to the needs of children with multiple chronic or complex health problems. Although children's health often plays a significant role in determining the course and/or success of social service interventions, it has not been a primary focus of the child welfare field. With rare exceptions, child welfare agencies lack specific policies on health care to guide workers and have few staff members with sufficient training in matters of health [Halfon and Klee 1991]. Furthermore, administrative structures to ensure that children's health needs are identified and treated are generally nonexistent.</p> <p>State child welfare agencies are increasingly being held legally liable to ensure that the complex physical, emotional, and developmental needs of the children are met while in stale care and custody (Halfon and Klee 1987]. To meet these expanded responsibilities for children's health, child welfare agencies must often increase their personnel and financial allocations, change their basic service goals and policies, and in some cases, create new organizational structures and delivery mechanisms. This is not an easy task, and agencies experience difficulties as they attempt to incorporate ideas and beliefs that are not part of the normal social work approach, and forge new models of service delivery that represent an amalgam of social work and health care practices and procedures. Ultimately, the key to successfully meeting these challenges will lie in the ability of child welfare and health care professionals to work together effectively to meet the needs of these children and their families.</p> <p>This paper discusses some significant issues that complicate the delivery of health care services to children in the out-of-home care system, reviews recommended health care standards, and suggests key areas for additional research and program development. We begin with a brief discussion of the unique health care needs of children in care and why these needs are difficult to meet. We then turn to the normative standards developed over the past decade to focus on service delivery from the perspective of individual children and families (individual level), agencies and interagency procedures (systems level), and policies (policy level).</p> <hd id="AN0024227351-2"> The Health Care Needs of Children in Out-of-Home Care </hd> <p>It is not surprising that children entering out-of-home care have complex physical, emotional, and developmental problems. Several studies have documented that children in care have high rates of chronic medical, mental health, and developmental problems [Schor 1982; Kavaler and Swire 1983; Moffatt et al. 1985; Hochstadt et al. 1987; Simms 1989]. These children frequently have multiple health problems affecting many aspects of functioning. Most often they come from very poor, minority, single-parent families, whose members suffer from high rates of mental illness, substance abuse, homelessness, and chronic physical disability. Many parents of these children were themselves abused and neglected, and their capacity to provide for their children has been further compromised by impediments to educational and intellectual achievement. Additionally, the children often come from the most impoverished urban areas that have the highest rates of crime, violence, and drug abuse.</p> <p>The chronic neglect and abuse that most often result in out-of-home placement often includes neglect of basic preventive and primary health care. In fact, the relationship between health problems and placement is a complex one. For example, the health problems seen in these children may either be the result of physical or medical neglect by the parents or one of the significant factors that overtaxed the family's resources and, as a consequence, led to out-of-home care.</p> <hd id="AN0024227351-3"> Obstacles to Health Care </hd> <p>The emerging literature suggests that health care services for children are most effective when they arc available without obstacles to access, are comprehensive, allow continuity with a primary care provider, coordinate and integrate different functions, are developmentally appropriate, and are community-based and culturally competent [Starfield 1992; Halfon and Berkowitz 1993]. These health care delivery goals and system attributes are similar to the normative goals and system attributes of the child welfare system. In practice, however, the structure and function of both the out-of-home care and health care systems impose a variety of obstacles to achieving tangible benefits from placement.</p> <hd id="AN0024227351-4"> Lack of Health Care Policies </hd> <p>Few child welfare agencies at the federal, state, or local level have specific policies or programs to address children's health care needs. This frequently results in poor quality, crisis-oriented care. With rare exceptions, foster care agencies have no means of monitoring whether children in their care receive even basic routine health care services. Despite the high prevalence of chronic and complex health, mental health, and educational problems, many children who are in need of special services do not receive them. Inadequate training of social workers and foster parents also contributes to the lack of recognition of the children's problems. Unless all children entering care are screened systematically, only those with the most severe and obvious problems receive attention [Frank 1980].</p> <hd id="AN0024227351-5"> Health Care Financing </hd> <p>Most of the children in out-of-home care in the United States are eligible for health care coverage under state-administered Medicaid programs, although the exact number of children in placement who are actually enrolled is not known [Halfon and Klee 1987]. Ironically, the Medicaid program itself has proved to be a significant obstacle to access for many poor children, including those in out-of-home care [Halfon and Klee 1987]. Even though states have wide discretion in establishing both eligibility criteria and levels of benefits, many do not elect to provide broad enough coverage for children in care. Additionally, because of a variety of factors (including low reimbursement rates, restrictions of benefits, and increased complexity of claims procedures), the number of physicians participating in Medicaid programs nationally decreased significantly from 1978 through 1989 [Yudkowsky et al. 19901. In a survey of 14 counties in California, Halfon and Klee [1987] found that foster parents and social workers reported great difficulty in finding appropriate health care providers for children in their care. Additionally, there were frequent delays in obtaining Medicaid cards and appropriate authorization for health care services.</p> <hd id="AN0024227351-6"> Lack of Continuity of Health Care </hd> <p>Ongoing care by the same health care providers is critically needed when children have complex and chronic health problems. Children often require immediate medical attention at the time of placement, yet reliance on inappropriately restrictive public health clinics and providers accepting Medicaid reimbursement can needlessly delay care. As a result, foster parents frequently rely on emergency rooms or hospital outpatient departments for care — places where follow-up and continuing health care services may not be provided. Additionally, because these children often received limited or fragmented health care before placement, it is often difficult for health care providers to assemble a complete medical record. Biological parents are often either unavailable or cannot provide adequate information about their children, and as a result, preexisting health conditions may not be adequately recognized or treated until the children show symptoms while in placement. Even when social workers obtain previous medical records, there is often no one available within the agency who can correctly interpret the information. The role of an ongoing health care provider has an added value for children in out-of-home care who may move from placement to placement. A "medical home" and relationship with the same provider can reduce the trauma of establishing more new relationships. Continuity with a health care provider can also improve the overall quality of the assessment process by building a longitudinal perspective from which to evaluate changes in status.</p> <hd id="AN0024227351-7"> Complexity of Required Services </hd> <p>Although foster parents can generally meet the basic needs of the children in their care, most are ill prepared to manage the complex health problems of these children without professional guidance and support. Typically, the children require multiple evaluation and treatment services from a variety of community providers. There is often little communication among these professionals, and the foster parent may be given conflicting recommendations. The number of appointments the foster parents are required to keep for each child frequently places a great burden on their personal resources. Additionally, the foster parents are usually not empowered to make substantial decisions regarding special medical treatments or evaluations. At these times, the lines of responsibility and authority may become quite confused, depending on the child's placement status (voluntarily committed or court-ordered), and whether the potential benefits from the procedure or treatment justify the potential risk of harm or injury.</p> <hd id="AN0024227351-8"> Lack of Advocacy by Caring Adults </hd> <p>Administrative procedures, staff turnover, and the exigencies of family foster home care frequently result in a series of social workers being assigned responsibility for a child's case. Nearly a quarter of the children experience three or more family foster home placements, usually involving a change in health care providers as well. Thus, unlike children who live within well-functioning families, children in care typically lack stable and continuing relationships with adults who are familiar with their needs and who can effectively advocate to protect their health and well-being.</p> <hd id="AN0024227351-9"> Current Approaches to Providing Health Care Services for Children in the Out-of-Home Care System </hd> <p>In 1973, Kavaler and Swire conducted one of the earliest studies of the health care of children in foster care in New York City [Kavaler and Swire 1983]. They analyzed the health care needs of 668 children and found inadequate, and often inappropriate, services delivered haphazardly. In 1976 the Chesapeake Health Plan, a health maintenance organization, was developed to deliver comprehensive health care services for foster children in Baltimore, Maryland [Schor et al. 1984]. Although generally successful in meeting its service goals, this program retained its unique focus on foster children for only a few years. During the 1980s several health care projects were started through the collaborative efforts of health care providers and public child welfare agencies to provide comprehensive diagnostic and treatment services for children in out-of-home care [Simms 1989; Halfon et al. 1993]. As interest in this population has grown, additional programs have developed (figure 1). All provide some direct services to children and agencies and some arc actively conducting research.</p> <hd id="AN0024227351-10"> Legal Efforts to Reform the Child Welfare System </hd> <p>Over the past decade, class action lawsuits have been brought against 25 states, counties, and cities in an effort to reform the child welfare system [Halfon and Klee 1991]. In seven of these suits (Alabama, Connecticut, Illinois, Maryland, Missouri, New York City, and West Virginia), health care was one of the particular problems emphasized by the plaintiff; in two others (North Carolina and Vermont), educational problems were a central focus [Institute for Health and Human Services 1992], These suits are currently at varying stages of settlement. To date, no formal evaluation has been made of the impact of these actions on services received by children in the out-of-home care system.</p> <hd id="AN0024227351-11"> Standards of Health Care for Children in Placement </hd> <p>In 1986, the Hasboro Children's Foundation sponsored a colloquium on health care for children in out-of-home care. This conference brought together representatives of the Child Welfare League of America (CWLA) and the American Academy of Pediatrics (AAP) to identify the special health care issues of foster children and the difficulties in the delivery of health care services to them [Child Welfare League of America 1987J. Two years later CWLA published Standards for Health Care Services for Children in Out-of-Home Care, based in pan on the findings and recommendations of the Hasboro colloquium [Child Welfare League of America 1988]. More recently, AAP published a revised position statement on the health care of children in out-of-home care [American Academy of Pediatrics 1994]. Despite general praise for these recommendations and extensive circulation, there is little evidence that they have been widely implemented. In pan, limitations in funding and staffing continue to impede change. Two other interrelated factors may explain the limited implementation of these standards: lack of a persuasive research literature to justify these recommendations and a general lack of understanding of their rationale.</p> <p>The CWLA Standards encompass eight aspects of care: initial health screening; establishment of health care records; comprehensive health assessment; developmental, educational, and mental health assessment; ongoing primary health care services; health information management; centralized agency structures to organize and administer health care services; coordination of other state and local agencies; and education and training of foster parents, caseworkers, and health care professionals. The following sections discuss each component in detail, and suggest important questions pertaining to each of the standards.</p> <hd id="AN0024227351-12"> Initial Health Screening </hd> <p>Just before, or shortly after, the first feister home placement, children should receive an initial health screening examination. During this examination, the physician has an opportunity to identify any health problems that require immediate treatment and to alert the foster parents and the caseworker to other obvious and significant health conditions. Particular attention should be paid to diagnosing infections and communicable diseases and to evaluating injuries or other signs of neglect or abuse. The importance of the initial examination was shown by Flaherty and Weiss [1990], who evaluated 5,181 children entering state custody in Illinois over a 22-month period beginning in 1987. Forty-four percent of the children were found to have at least one medical condition requiring treatment. The most common problems were anemia, urinary tract and ear infections, bruises and fractures resulting from abuse, sexually transmitted diseases, pregnancy, and lead poisoning. It was not uncommon for children to require referral to surgical specialists, and approximately 8% were hospitalized for further diagnosis and treatment.</p> <p>The optimal site for the initial health screening has not been determined. A physical examination is often an important part of a complete evaluation of the abuse or neglect associated with the decision to place the child. In other situations, however, as when children are taken into placement because they are abandoned, the parents are arrested, or a sibling was harmed, a physical examination may not be requested unless the child appears ill. In our experience, objections have been raised to the recommendation that all children receive a screening assessment out of fear that a physical examination may inflict "additional trauma" on the child at a time of crisis and confusion. Others have raised a concern that hospital emergency departments are not appropriate places for children to receive initial intake screening examinations because they lack pediatric staff, expose children to seriously ill individuals, have long waiting times, and cannot ensure adequate follow-up care. An innovative program in St. Paul, Minnesota, however, is attempting to deal with some of these problems. The Emergency Department staff of St. Paul Children's Hospital has started a special program to evaluate children entering out-of-home care and has developed a training curriculum for postgraduate fellows in this function [Hall 1991]. In other settings, with prior planning, it is possible for child welfare agencies to make arrangements with community ambulatory clinics or private physicians to evaluate these children on short notice as necessary [Simms and Kelly 1991]. Questions for this standard involve the content and timing of initial screening exams. What should be included in this initial screening battery? Where should it be done? Are there measurable differences in outcomes when children receive a comprehensive intake exam by well-trained providers in contrast to being examined haphazardly in an emergency room?</p> <hd id="AN0024227351-13"> Health Care Records </hd> <p>At the outset of placement, the caseworker should obtain a complete health history from the child's parents or caregivers and health care records should be requested from previous health care providers. A separate health care record should be established and maintained by the agency, and information about the child's health care should be included as part of the overall social service case plan. This past health care information is the crucial database for any kind of reasonably comprehensive health assessment. Questions include: What is the most effective and efficient means of collecting and transmitting such information? What should be the extent and content of the information collection process? What is the marginal gain from having a better history of past health conditions and care patterns? Does this gain justify the expense and trouble? Are there procedures, methods, and information management technology that can improve the collection and distribution of this important background information?</p> <hd id="AN0024227351-14"> Comprehensive Health Assessment </hd> <p>Within one month of placement the child should have a comprehensive health assessment, preferably completed by a team of community professionals who can provide follow-up and treatment services, if necessary. By the time this evaluation takes place, the caseworker should have gathered any available information from the child's parents and previous caregivers, as well as previous medical records. In addition, sufficient time should have elapsed to allow the foster parents to observe the child's health, development, and behavior; the foster parents may also have specific questions about the care of the child. It is best for both the foster parents and the caseworker to be present for this visit to provide detailed information about the child's behavior and progress in the foster home. When appropriate, the biological parents should be encouraged to attend and to participate in these assessments.</p> <p>A careful physical examination may reveal medical conditions that require further evaluation or referral. In our clinical experience, many children who enter out-of-home care have congenital problems and birth defect syndromes that may not have been adequately evaluated before placement [Simms 1989]. The child's immunization history should be reviewed and screening tests should be performed for common medical conditions such as anemia, lead poisoning, and so on, according to AAP's Recommendations for Preventive Pediatric Health Care [American Academy of Pediatrics 1988]. This is also an excellent time to discuss health education matters with the foster parents and to work with the caseworker to ensure that appropriate support services are in place to help in the care of the child's medical problems. With respect to these standards, the following questions require further study: What should be the content of this examination? What is the optimal timing of such a comprehensive examination? How best should information from this examination be reported to foster parents, social workers, and other providers?</p> <hd id="AN0024227351-15"> Developmental, Educational, and Mental Health Assessment </hd> <p>Developmental, behavioral, and emotional disturbances are frequently encountered in children entering out-of-home care placement [Schor 1982; Moffatt et al. 1985; Hochstadt et al. 1987; Simms 1989]. For example, Halfon et al. [1992] found that, although foster children made up only 4% of the population of children enrolled in the California state Medicaid program in 1988, approximately half of all visits to psychologists and psychiatrists were made by children in out-of-home care. Other studies, however, have shown that, for various reasons, many children in out-of-home care with significant mental health problems do not receive proper evaluation and assistance during their placement [Frank 1980]. Sometimes this occurs because caseworkers do not recognize the existence of the problems, or they consider the symptoms to be part of a normal pattern of adaptation to placement, or they feel that, because the placement is only going to be "short term," it is not appropriate to initiate evaluation or treatment services. In other instances, because the child is not creating a threat to the placement by disruptive behavior, it is believed that the child is receiving adequate care. Finally, some children may simply fall through the cracks of a bureaucracy in which caseworkers and foster parents change so often that identified problems are not followed up.</p> <p>Functional developmental delays are the most common findings, particularly in the preschool age group. These problems are frequently responsive to a variety of community-based early intervention services. In older children, educational difficulties are often the eventual outcome of chronic neglect or abuse, inadequately treated developmental delays, or congenital or hereditary difficulties. Despite a formal structure within the public education system to "protect" the right to appropriate educational treatment (P.L. 92-142), many children in the out-of-home care system fail to receive needed remedial education services, often for the same reasons they fail to receive mental health services.</p> <p>The consequences to both the children and the child welfare system are probably much greater than has been generally recognized. The presence of physical, developmental, emotional, and behavioral problems strongly influences the child's course in care. For example, several investigators have found that children with developmental delays and/or behavioral disturbances have a longer length of placement compared to children free of these problems [Benedict and White 1991; Horwitz et al. 1994]. Furthermore, clinical experience suggests that the burden of caring for a child with multiple physical problems or overwhelming emotional or behavioral problems underlies the reason for children moving from one foster home to another, particularly when the foster parents perceive that they are not receiving adequate assistance with the child. These problems can threaten the ability of foster parents to care for the child, lead to longer stays in care, and have been documented as a cause of a disproportionate use of mental health services by children in care.</p> <p>Although the importance of these problems and the clear opportunity to employ a more preventive approach exist, little work has been done to clarify how best to assess children, which measures should be used, where children should be assessed, and how often measurement is necessary to ensure appropriate monitoring. In addition to questions about how best to assess children for mental health problems, a similar long list of questions must be confronted regarding what constitutes effective preventive mental health interventions. How can the therapeutic potential of family foster homes be optimized? Who should receive preventive mental health services?</p> <p>Although mental health and developmental services are essential for this population, it is often difficult to obtain sufficient Medicaid reimbursement for such services, thereby limiting the availability of providers. Given the plan to transform Medicaid from a fee-for-service system to managed care, it will be critical to determine how mental health services can be paid for and efficiently organized in a reformed health care system. The following questions arise from a health services viewpoint: How can the range of mental health services that most foster children need be effectively organized? How can these services be incorporated into a managed care format?</p> <hd id="AN0024227351-16"> Ongoing Primary Health Care Services </hd> <p>Monitoring of children's health care by a single provider, or group of providers, is an extremely important component of a comprehensive system of care for several reasons. Although many significant health problems may be obvious and easily detected at the time of the initial exam or one month later, other more subtle health or developmental problems may become known only after a prolonged period of observation. For example, the impact of prenatal or perinatal health complications may not become evident until the child is six months or older. Other chronic preexisting health conditions, such as seizures, asthma, and allergic disorders, may not be known at the time of placement, especially if the parents or the previous health records are not available for questioning or review. Furthermore, behavioral and emotional responses to placement and adaptation to the foster home may change over time [Simms 1991]. Maladaptive patterns frequently manifest in young children as somatic stress symptoms, such as eating disorders, compulsive water-drinking, and poor physical growth, and are identified only by careful monitoring of the child's health.</p> <p>To be effective, monitoring must account for the dynamic changes in the child's life, and must be able to deal with those transactions that influence a child's health and behavior. Since children in out-of-home care are living in tumultuous and often chaotic environments, the amount of change in behavior and health status, and the need for ongoing supervision, may require monitoring intervals and activities that are more frequent than those required for typical pédiatrie care. Since monitoring intervals for routine pédiatrie care are based more on the schedule for immunizations than on the need for therapeutic services, need-based monitoring criteria may be quite different for children in care. Therefore, it will be important to study the following: What constitutes appropriate monitoring intervals for children with different types of problems? When is more frequent or different monitoring warranted? Are there automated techniques and case management mechanisms to assist with monitoring? How can multiple consultative services be effectively monitored?</p> <hd id="AN0024227351-17"> Health Care Information Management </hd> <p>Medical passports — abbreviated child health care records held by foster parents — are currently being used in California, Connecticut, Maryland, and Massachusetts. These booklets or forms are kept by the foster parent and brought to each health care visit. When used faithfully by foster parents, and kept current by both caseworkers and health care providers, medical passports have the potential to provide a much-needed written communication link among all of the parties involved in the child's care. Furthermore, the passport can be transferred to new foster parents in the event of a change of placement and, at the end of the foster care placement, given to either the biological or adoptive parents. These forms generally contain the schedule of preventive well-child visits, routine screening tests, and immunizations recommended by the AAP.</p> <p>In this manner, the form serves as a statement of the expected frequency of health care visits and a reminder of the agency's standard of health care for its children.</p> <p>Although parent-held health care records have been used successfully outside the U.S. in many other settings [Morley 1973], there are several practical problems with their use in the foster care setting. Among the most significant is the inability of the agency to use the record for tracking information. For this reason, medical passport programs usually include a separate encounter form that the physician completes, indicating the date, diagnosis, and treatment. Following each health care visit the encounter form is mailed back to the caseworker for inclusion in the child's social service case record. Another major concern is the possible lack of confidentiality of the foster parent-held record, especially when sensitive information is recorded on the passport. Finally, this approach has the potential for incomplete recording of data if it is not used consistently. To date, no formal study of the impact of the medical passport on the delivery of health care has been undertaken.</p> <p>Recently, the paper medical passport has been expanded to include a computerized database — an electronic medical passport. When linked to the state Medicaid database from which location, visit date, diagnosis, and treatment information can be regularly downloaded, a variety of specially tailored and continually updated reports can be made available to appropriate health care providers, caseworkers, and administrators. Confidentiality is easier to control, health care utilization patterns are easier to monitor, and quality assurance activities are possible. A prototype program of this nature is currently being implemented in San Diego, California [Lindsay et al. 1993]. Important questions include: Do automated data systems or medical passports make a difference in the effectiveness and efficiency of care provided? What kinds of systems and what kinds of data have the most impact on how agencies function? Do medical passports increase access and improve health autonomy?</p> <hd id="AN0024227351-18"> Centralized Agency Structures to Organize and Administer Health Care Services </hd> <p>CWLA has recommended that public and private child welfare agencies develop so-called Health Management Units to direct and support caseworkers and foster parents, to be a liaison with health care providers, and to monitor the care given [Child Welfare League of America 1988]. These units should include appropriately trained health care professionals, either directly employed by the agency or under a purchase-of-service contract. The medical staff should set health care standards and policies for the agency, provide training and consultation for the staff, and carry out a program of health care quality assurance [Bell 1976]. Activities of these units should be thoroughly integrated at all levels of the agency to ensure that the health of the children is being taken care of in the most efficient manner possible. Child welfare agencies may elect to operate their own health care programs directly or contract with outside providers. Through the efforts of these units, health care information will be consistently collected by caseworkers, recorded in the case record, and included in all case planning and treatment plans and activities of the agency. A variety of models of service delivery are emerging around the country, largely based on the perceived needs of the child population, and the available resources (capacity) of a particular community (figure 1). These systems range from centralized delivery models (Los Angeles, Rochester and Syracuse) where regionalized delivery centers provide all services for a geographic region, to more decentralized models where central coordination and case management integrates a geographically diverse set of providers (Waterbury, San Diego, and Oakland). It is not clear how well these different service delivery models function or how they can be made maximally effective. Research is clearly necessary to examine whether these emerging models can increase the allocative efficiency of services, improve effectiveness, and lead to better health outcomes.</p> <hd id="AN0024227351-19"> Coordination of Health Care Services between State and Local Agencies </hd> <p>The Medicaid (Title XIX) program is the principal funding source for most children in out-of-home care. Health care coverage is mandated for all children eligible for AFDC, for Title IV-E foster children, for pregnant women, and for children under age six from households with incomes below 133% of the poverty level. States may opt, however, to cover all children in state care without regard to the parents' income eligibility. Beyond a mandated list of services, many optional services can be provided, including case management for children with multiple health care needs, rehabilitative services, home-based nursing care, respite care, transportation, and medical supplies [Halfon and Klee 1991].</p> <p>In addition to Medicaid, many other federal programs can be tapped to provide support for the health care, psychological, educational, and social services that children in care frequently require. These include Title V (Maternal and Child Health Programs), P.L. 94-142 (Education for the Handicapped Act), P.L. 99-457 (Birth to Three Early Intervention Program), Head Start programs. Child Nutrition Act (WIC), Food Stamps, Supplemental Security Income (SSI), Alcohol, Drug Abuse and Mental Health Services Block Grant programs, as well as Family Planning, Child and Adolescent Service System Programs (CASSP), and Juvenile Justice and Delinquency Prevention Programs [Klee et al. 1992]. Because these programs were developed in relation to individual, specific issues, there is no coordination among them. Also, because many of these programs are designated as optional, foster children who might otherwise qualify do not receive services if the services are not included in the stale plan. To improve their ability to provide needed services to children in their care, child welfare agencies must work closely with other state and federal agencies to formulate a strategy to use these current entitlement programs most effectively [Richardson et al. 1989; Halfon and Klee 1991]. What is the best way to organize these various funding and delivery programs? How can Medicaid funds be most efficiently used? What models have been tested to integrate funding with services? Is it possible to decategorize funding streams to create more flexible funding pools?</p> <hd id="AN0024227351-20"> Training and Support Programs </hd> <p>In addition to the wisdom, maturity, patience, and strength that parenting the average child requires, foster parents must become quite expert at caring for children with special physical, medical, emotional, developmental, and social needs. Although most agencies require foster parents to complete a training curriculum of some type before receiving a license, exceptions are often made for relatives who agree to kinship care placements. Furthermore, the content of training varies considerably and may not prepare the foster parents to manage particular medical conditions or to cope with the confusing array of professionals and agencies they may encounter as they try to comply with agency recommendations for the children's care.</p> <p>The quality of the relationship the child forms with his or her foster parents is one of the most important determinants of the child's experience in placement. It is this relationship, rather than any outside professional intervention, that has the greatest potential to promote healthy development in these highly vulnerable and often damaged children [Ruff et al. 1990]. Furthermore, the foster parents' ability to support the children's ties to their biological parents is often critical to helping the children to successfully return home. Few agencies, however, provide formal postlicensing training or support programs for their foster parents to assist them in this task.</p> <hd id="AN0024227351-21"> Research Agenda in Health Care </hd> <p>Over the past 20 years, the types and extent of the health care problems common to children in out-of-home care have been well documented in localized studies conducted at particular health care sites. The types of health care services needed and the administrative tasks and structures necessary to ensure that the services are effectively delivered have been suggested by groups of stature and authority. Presently, only a small number of collaborative projects are attempting to carry out various parts of these recommendations. Systematic evaluation of health care service delivery to children in out-of-home care is generally lacking. The following broad arenas require further study:</p> <hd id="AN0024227351-22"> Clearer Definition of the Health Care Status, Utilization of Health Care Services, and Natural History of Children's Health Care in Out-of-Home Care </hd> <p>Although numerous localized studies have been conducted to define the burden of illness in children in placement, most have not used a population-based approach or examined the utilization and effectiveness of available services to respond to needs. Population-based studies are necessary to better define the nature of health problems affecting children in care, and to determine access to and utilization of health care services, the cost of care provided, and the services' impact on health outcomes.</p> <hd id="AN0024227351-23"> The Current Extent of Health Care Policies and Programs in Public and Private Out-of-Home Care Programs </hd> <p>Very few studies have examined the impact of different health care policies on out-of-home care programs [Kavaler and Swire 1972; Schor 1981; Halfon and Klee 1987]. As noted previously, the extent to which agencies have begun to implement the CWLA Standards is not known. Thus, one of the first tasks should be a nationwide survey of the current health care policies of public and private out-of-home care agencies and how health care services are presently organized, and to measure them against the CWLA and AAP recommended standards. In particular, it will be important to learn:</p> <olist> <item> What specific health care guidelines for foster parents, caseworkers, and health care providers (such as the AAP guidelines, Early Periodic Screening Diagnosis and Treatment schedules, and so on) are being used?</item> <item> How are agency case records organized and do they include a separate section for health care information?</item> <item> What kind of quality assurance mechanisms exist to monitor the delivery of health care services to the children in the agencies' care?</item> <item> How are delivery systems staffed?</item> <item> Is a medical passport or other health care information management program being used to record health care data and facilitate communication among the responsible parties? How effective are these systems?</item> <item> Is there formal liaison with other treatment and support services for children with special needs at the local, regional, or state level?</item> </olist> <hd id="AN0024227351-24"> Evaluation of Existing Programs </hd> <p>Presently, a wide range of approaches to health care delivery to this population of children exists. In some programs, health care is delivered by a few designated providers either within the agency or in the community, while in other settings, children are cared for wherever the foster parent chooses. Some of these programs use centralized delivery centers; others use a network of decentralized providers. It is important to study the following issues:</p> <olist> <item> Do different methods of organizing health care services (centralized vs. network model) have different impacts on health status, service utilization, and cost for children in out-of-home care?</item> <item> Are policies and expectations clearly explained to foster parents and caseworkers?</item> <item> What role does health insurance play in the delivery of appropriate health care to children in out-of-home care? What nonfinancial obstacles to receiving adequate care exist?</item> <item> How do physicians and other health care providers communicate information to out-of-home care agencies?</item> <item> How well do new models of service delivery perform?</item> <item> Are children routinely evaluated at the beginning of placement and periodically during care? How comprehensive and how accurate are these assessments? Where and how are they performed? What are the mechanisms that ensure appropriate follow-up and treatment for identified problems?</item> <item> What are the costs of these health care programs and the services they provide? Do certain aspects result in more effective or less costly care?</item> <item> What is the impact on the children of receiving appropriate health care services? For example, do appropriate health care services result in improved overall health status, fewer changes in foster homes, and shorter duration of placement?</item> </olist> <hd id="AN0024227351-25"> Summary </hd> <p>The health and mental health problems of the children in out-of-home care present many challenges to child welfare agencies and demand closer collaborative relationships among a variety of professional groups. Despite generally well-accepted guidelines for action and strong evidence suggesting that appropriate care may result in significant benefit to the children, many questions remain as to the most effective and efficient methods of providing these services at the individual, system, and policy levels. At the present time, a small number of programs are attempting to implement various parts of the CWLA and AAP recommendations for health and mental health services for children in out-of-home care. It is not certain, however, how efforts to reform the health care system may affect the delivery of services to this population. Research efforts should concentrate on collecting and evaluating data from existing programs at all three levels (individual, system, policy) to aid in refining and directing future policy and practice in the field of child welfare.</p> <p>(Address requests for a reprint to Mark D. Simms, Medical College of Wisconsin. Department of Pediatrics. 8701 Watertown Plank Road, Milwaukee, WI 53226.)</p> <hd id="AN0024227351-26">FIGURE 1Health Care Programs for Children in Foster Care[*]</hd> <ct id="AN0024227351-27"> Legend for Chart: A - Location B - Name A: Los Angeles, CA B: Protective Services Child Health System (Los Angeles County Department of Children's Services) A: Oakland, CA B: Foster Care Program (Center for the Vulnerable Child, Children's Hospital Oakland) A: San Diego, CA B: San Diego Foster Children's Health Project (San Diego County Department of Social Services and Children's Hospital Center for Child Protection) A: Waterbury, CT B: The Foster Care Clinic (Department of Children and Families and St. Mary's Hospital) A: Chicago, IL. B: Columbus-Maryville Reception Center (Cook County Department of Social Services and Columbus Hospital) A: St. Paul, MN B: Children's Hospital of St. Paul Medical Assessment Resource Center (Ramsey County Department of Human Services and Children's Hospital of St. Paul) A: Manchester, NH B: Foster Children's Health Care Project (New Hampshire Division of Children and Youth Services and Child and Family Services of Manchester) A: New York, NY B: Drug-Exposed Infant Project (Leake and Watts Children's Home) A: Rochester, NY B: Foster Care Pediatrics (Monroe County Department of Social Services) A: Syracuse, NY B: ENHANCE Services for Children in Foster Care (Onondaga County Department of Social Services) and SUNY Health Sciences Center * Includes programs reporting activity to American Academy of Pediatrics Committee on Early Childhood, Adoption and Dependent Care, October, 1993.</ct> <p>© 1994 Child Welfare League of America</p> <ref id="AN0024227351-28"> <title> References </title> <blist> <bibl id="bib1" type="bt"></bibl> <bibtext>American Academy of Pediatrics, Committee on Early Childhood, Adoption and Dependent Care. (1994). Health care of children in foster care. Pediatrics. 93, 335-338.</bibtext> </blist> <blist> <bibl id="bib2" type="bt"></bibl> <bibtext>American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. (1988). Guidelines for health supervision II. Elk Grove Village, IL: American Academy of Pediatrics.</bibtext> </blist> <blist> <bibl id="bib3" type="bt"></bibl> <bibtext>Bell, J. (1976). Medical consultants: Appropriate selection and utilization in child welfare. Child Welfare, 55, 445-158.</bibtext> </blist> <blist> <bibl id="bib4" type="bt"></bibl> <bibtext>Benedict, M.I., & White, R.B. (1991). Factors associated with foster care length of stay. Child Welfare, 70, 45-58.</bibtext> </blist> <blist> <bibl id="bib5" type="bt"></bibl> <bibtext>Child Welfare League of America. (1987). A white paper on the health care of children in foster care: Summary of a colloquium on health care for children in foster homes (mimeograph). Washington. DC: Child Welfare League of America.</bibtext> </blist> <blist> <bibl id="bib6" type="bt"></bibl> <bibtext>Child Welfare League of America. (1988). Standards for health care services for children in out-of-home care. Washington, DC: Child Welfare League of America.</bibtext> </blist> <blist> <bibl id="bib7" type="bt"></bibl> <bibtext>Fanshel, D., & Shinn, E.B. (1978). Children infester care: A longitudinal investigation. New York: Columbia University Press.</bibtext> </blist> <blist> <bibl id="bib8" type="bt"></bibl> <bibtext>Flaherty, E.G., & Weiss, H. (1990). Medical evaluation of abused and neglected children. American Journal of Diseases of Children, 114, 330-334.</bibtext> </blist> <blist> <bibl id="bib9" type="bt"></bibl> <bibtext>Frank, G. (1980). Treatment needs of children in foster care. American Journal of Orthopsychiatry, 50, 256-263.</bibtext> </blist> <blist> <bibl id="bib10" type="bt"></bibl> <bibtext>Halfon, N., & Berkowitz, G. (1993). Health care entitlements for children: Providing health services as if children really mattered. In S.G. Coffin & M.A. Jensone (Eds.). Visions of entitlement: The care and education of America's children (pp. 175-212). Albany, NY: SUNY Press.</bibtext> </blist> <blist> <bibl id="bib11" type="bt"></bibl> <bibtext>Halfon, N., Berkowitz, G., & Klee, L. (1992). Menial health service utilization by children in foster care in California. Pediatrics, 89, 1238-1244.</bibtext> </blist> <blist> <bibl id="bib12" type="bt"></bibl> <bibtext>Halfon, N., Berkowitz, G., & Klee, L. (1993). Development of an integrated case management program for vulnerable children. Child Welfare, 72, 379-396.</bibtext> </blist> <blist> <bibl id="bib13" type="bt"></bibl> <bibtext>Halfon, N., & Klee, L. (1987). Health services for California's foster children: Current practices and policy recommendations. Pediatrics. 80, 183-191.</bibtext> </blist> <blist> <bibl id="bib14" type="bt"></bibl> <bibtext>Halfon, N., & Klee, L. (1991). Health and development services for children with multiple needs: The child in foster care. Yale Law and Policy Review, 9, 71-96.</bibtext> </blist> <blist> <bibl id="bib15" type="bt"></bibl> <bibtext>Hall, M. L. Personal communication. (1991).</bibtext> </blist> <blist> <bibl id="bib16" type="bt"></bibl> <bibtext>Hochstadt, N. J., Jaudes, P. K., Zimo, D. A., & Schachter, J. (1987). The medical and psychosocial needs of children entering foster care. Child Abuse and Neglect, 11, 53-62.</bibtext> </blist> <blist> <bibl id="bib17" type="bt"></bibl> <bibtext>Horwitz, S. M., Simms, M. D.. & Farrington, R. M. (1994). The impact of developmental and behavioral problems on the exit of children from foster care. Journal of Developmental and Behavioral Pediatrics, 15, 105-110.</bibtext> </blist> <blist> <bibl id="bib18" type="bt"></bibl> <bibtext>Institute for Health and Human Services. (1992. October). Directory of Child Welfare Class Action Lawsuits. (Available from The Institute for Health and Human Services. Inc., 24 Farnsworth Street, Boston. MA 02210).</bibtext> </blist> <blist> <bibl id="bib19" type="bt"></bibl> <bibtext>Kavaler, F., & Swire, M. R. (1972). Health services for foster children: An approach to evaluation. Child Welfare, 51, 574-583.</bibtext> </blist> <blist> <bibl id="bib20" type="bt"></bibl> <bibtext>Kavaler, F., & Swire, M. R. (1983). Foster child health care. Lexington MA: Lexinglon Books.</bibtext> </blist> <blist> <bibl id="bib21" type="bt"></bibl> <bibtext>Kent, J. T. (1976). A follow-up study of abused children. Journal of Pediatric Psychology, 25, 31-40.</bibtext> </blist> <blist> <bibl id="bib22" type="bt"></bibl> <bibtext>Klee, L., Soman, L. A., & Halfon, N. (1992). Implementing critical health services for children in foster care. Child Welfare, 71, 99-111.</bibtext> </blist> <blist> <bibl id="bib23" type="bt"></bibl> <bibtext>Lindsay, S., Chadwick, D., Landsverk, J., & Pierce, E. (1993). A computerized health and education passport for children in out-of-home care: The San Diego model. Child Welfare, 72, 581-594.</bibtext> </blist> <blist> <bibl id="bib24" type="bt"></bibl> <bibtext>Moffatt, M. E. K., Peddle, M., Stuginskas, J., Pless, I. B., & Steinmetz. N. (1985). Health care delivery to foster children: A study. Health and Social Work. 10, 129-137.</bibtext> </blist> <blist> <bibl id="bib25" type="bt"></bibl> <bibtext>Morley, D. (1973). Paediatric priorities in the developing world. London: Butlerworths.Palmer, S. E. (1979). Predicting outcome in long term foster care. Journal of Social Service Research, 3, 201-214.</bibtext> </blist> <blist> <bibl id="bib26" type="bt"></bibl> <bibtext>P.L. 94-142. (1975) Education for All Handicapped Children Act.</bibtext> </blist> <blist> <bibl id="bib27" type="bt"></bibl> <bibtext>Richardson, M., West, J. A., Day, P.. & Stuart, S. (1989). Children with developmental disabilities in the child welfare system: A national survey. Child Welfare, 68, 605-613.</bibtext> </blist> <blist> <bibl id="bib28" type="bt"></bibl> <bibtext>Ruff, H. A., Blank, S., & Barnett, H. L. (1990). Early intervention in the context of foster care. Journal of Developmental and Behavioral Pediatrics, 11, 265-268.</bibtext> </blist> <blist> <bibl id="bib29" type="bt"></bibl> <bibtext>Schor, E. L. (1982). The foster care system and health status of foster children. Pediatrics. 69, 521-528.</bibtext> </blist> <blist> <bibl id="bib30" type="bt"></bibl> <bibtext>Schor, E. L. (1981). Health care supervision of foster children. Child Welfare, 60, 313-319.</bibtext> </blist> <blist> <bibl id="bib31" type="bt"></bibl> <bibtext>Schor, E. L., Neff, J. M., & LaAsmar, J. L. (1984). The Chesapeake Health Plan: An HMO model for foster children. Child Welfare, 63,431-440.</bibtext> </blist> <blist> <bibl id="bib32" type="bt"></bibl> <bibtext>Simms, M. D. (1989). The Foster Care Clinic: A community program to identify treatment needs of children in foster care. Journal of Developmental and Behavioral Pediatrics, 10, 121-128.</bibtext> </blist> <blist> <bibl id="bib33" type="bt"></bibl> <bibtext>Simms. M. D. (1991). Foster children and the foster care system. Part II; Impact on the child. Current Problems in Pediatrics. 21, 345-369.</bibtext> </blist> <blist> <bibl id="bib34" type="bt"></bibl> <bibtext>Simms, M. D., & Kelly, R. W. (1991). Pediatricians and foster children. Child Welfare, 70, 451-461.</bibtext> </blist> <blist> <bibl id="bib35" type="bt"></bibl> <bibtext>Starfield, B. (1992). Primary care: Concept, evaluation, and policy. New York: Oxford University Press.</bibtext> </blist> <blist> <bibl id="bib36" type="bt"></bibl> <bibtext>White, R., & Benedict, M. (1986). Health status and utilization patterns of children in foster care: Executive summary. (Grant No. 90-PD-86509). Washington, DC: U.S. Department of Health and Human Services, Administration for Children, Youth, and Families.</bibtext> </blist> <blist> <bibl id="bib37" type="bt"></bibl> <bibtext>Yudkowsky, B. K., Cartland, J. D. C, & Flint, S. S. (1990) Pediatrician participation in Medicaid: 1978 to 1989. Pediatrics, 85, 567-577.</bibtext> </blist> </ref> <aug> <p>By Mark D. Simms and Neal Halfon</p> <p></p> <p>Mark D. Simms, M.D.. M.P.H., is Associate Clinical Professor of Pediatrics, Yale University School of Medicine, Waterbury Regional Department of Pediatrics, Waterbury, CT.</p> <p>Neal Halfon, M.D., M.P.H.. is Associate Professor of Pediatrics and Public Health, University of California, Los Angeles, CA.</p> </aug>
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  Data: The Health Care Needs of Children in Foster Care: A Research Agenda.
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  Data: <searchLink fieldCode="AR" term="%22Simms%2C+Mark+D%2E%22">Simms, Mark D.</searchLink><br /><searchLink fieldCode="AR" term="%22Halfon%2C+Neal%22">Halfon, Neal</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Child+Welfare%22"><i>Child Welfare</i></searchLink>. Sep-Oct 1994 73(5):505-524.
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  Data: 20
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  Data: Reviews the unique health care needs of children in the out-of-home care system and the standards developed over the past decade to deliver comprehensive health care services to this population. Raises key policy and practice questions for each standard to facilitate effective implementation of recommendations makes suggestions for future research efforts. (TJQ)
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