Healthcare Services for Children in Foster Care

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Healthcare Services for Children in Foster Care

• Vince Champagne, M.H.A.
• Health Services Manager Cook County
• Office of Health Services, Division of Service
  Intervention
• Illinois Department of Children and Family
  Services
• Paula Kienberger Jaudes, M.D.
• Medical Director, Illinois Department of
  Children and Family Services
• Professor of Pediatrics, University of Chicago
• President CEO, La Rabida Childrens Hospital

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3
Children In Foster Care Are Among The Most
Unhealthy In America
(Pinkney, AMA News 1994)
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Health Status Prior To Coming Into Child Welfare
System
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CATEGORIES OF PRIMARY DIAGNOSIS OF NEWBORNS
ENTERING FOSTER CARE COMPARED TO NEWBORNS IN AFDC
1995

• Odds
  Ratios of Newborns Entering
• Primary Diagnosis DCFS vs. AFDC
  Population___
• Low Birth Weight 2.76
• Respiratory Distress Syndrome
  1.98
• Congenital Anomalies 1.47
• Substance Exposed Infants 32.43
• Seizures 1.79
• Not Significant
• Birth Trauma/Intrauterine Hypoxia
• Hereditary/Degenerative Condition

AFDC Aid to Families With Dependent
Children Plt0.0001
(Bilaver, Jaudes, Social Service Review, 1999)
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CATEGORIES OF PRIMARY DIAGNOSIS OF CHILDREN
ENTERING FOSTER CARE COMPARED TO CHILDREN IN AFDC
1995

• Odds Ratios of Children Entering
• Primary Diagnosis DCFS vs. AFDC Population
• All Chronic Conditions 1.27
• Chronic Physical Conditions 0.91
• Psychiatric Conditions 2.40
• Developmental Disorder 1.40
• Not Significant Lead, Anemia

AFDC Aid to Families With Dependent Children
Plt0.0001
(Bilaver, Jaudes, Social Service Review, 1999)
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COMPARISON OF THE ILLINOIS FOSTER CARE POPULATION
AND THE GENERAL AFDC POPULATION FOR SELECTED
HEALTH STATUS INDICATORS USING 1995 MEDICAID
CLAIMS DATA

• HEALTH STATUS INDICATOR AFDC POP.
  FOSTER CARE POP.
• Chronic Conditions 21.4 42.7
• Behavioral/Psychiatric Health Issues 5.9
  25.6
• Developmental Delays 3.6 8.1

AFDC Aid to Families With Dependent Children
(Bilaver, Jaudes, Social Service Review, 1999)
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Healthcare of Children In Foster Care
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Foster Care In Three Urban Areas

• Findings from a U. S. General Accounting Office
  Report
• Children gt3 years
• 3 Urban Areas (Los Angeles, New York City,
  Philadelphia County)

Source U. S. General Accounting Office. (1995)
Foster Care Health needs of many young children
are unknown and unmet (GAO/HEHS 95-114).
Washington, DC U. S. General Accounting Office.
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Foster Care In Three Urban Areas

• 12 percent received no routine health care
• 34 percent received no immunizations
• 32 percent continued to have at least one unmet
  health need after placement
• 78 percent of the children were at high risk for
  HIV,
• but only 9 percent had been tested for the
  virus
• Less than 10 percent received services for
  develop-
• ment delays
• Children placed with relatives received fewer
  health-
• related services of all kinds than children
  placed with non-relative foster parents

Source U. S. General Accounting Office. (1995)
Foster Care Health needs of many young children
are unknown and unmet (GAO/HEHS 95-114).
Washington, DC U. S. General Accounting Office.
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Historical Context

• Health care provisions in B.H. Consent Decree,
  signed in December 1991
• HealthWorks designed in accordance with American
  Academy of Pediatrics (AAP) and Child Welfare
  League of America (CWLA) guidelines, and Early
  Periodic Screening, Diagnosis Treatment (EPSDT)
  requirements
• Illinois was the first state in U.S. to implement
  a state-wide health care system for all children
  in state custody
• Preferred Provider Organization Model, NOT
  Capitated

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• HealthWorks
• Of
• Illinois

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Historical Context - Consent Decree Requirements

• Creation of health services management unit (now
• Office of Health Services)
• Hiring of independent Medical Director
• Hiring of nurses as child welfare consultants in
  each
• DCFS region
• Use of Medicaid presumptive in component of HW
• eligibility from the date of custody
• Development of lead agency concept, hybrid of
• ASO (Administrative Service Organization) to
  
• administer the HealthWorks program

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Components of Illinois Model of Health Care for
Children in Foster Care

• HEALTHWORKS OF ILLINOIS
• Comprehensive system of health care for all
  children in substitute care
• Access to quality primary and specialty health
  care
• Provider Networks PPO Model Initial Health
  Screenings, Comprehensive Health Evaluations,
  Primary Care
• Documentation of health needs

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Implementation

• HealthWorks implementation began in Cook County
  in 1993 rollout to Downstate completed in 1995
• In 1997, over 52,000 children in state custody,
  majority in Cook County
• In August 2007, less than 17,000 children in
  care, majority now are Downstate

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HealthWorks Is A Collaborative Effort Of Three
Illinois State Agencies

• Department of Children and Family Services
• Department of Healthcare and Family Services
  (formerly the Department of Public Aid DPA)
• Department of Human Services

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HealthWorks Structure

• Twenty Lead Agencies 1 in Cook County
• and 19 Downstate
• Medical Case Management agencies covering every
  county

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Financing For HealthWorks

• All health care services are Medicaid covered
  services
• Annual State funding of 3.5 million for
  administrative support for HealthWorks
• lead agencies

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HealthWorks ServicesCore Components

• Initial Health Screenings, within 24 hours of PC
• Comprehensive Health Evaluations, within 21 days
  of TC
• Linkage to a medical home with a qualified
  primary care provider
• Current (2007) PCP Network 640 in Cook County
  2000 Downstate
• Standardization of Medical Records, including
  Health Passport
• Medical Case Management Services

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Initial Health Screenings (IHS)

• Purpose
• To identify and treat any acute medical issues,
  including any infectious or communicable disease
• Document any signs of maltreatment
• Provide the case worker with medical information
  that can be used in making placement decisions

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Initial Health Screenings (IHS)

• Timeframe
• Receive placement IHS within 24 hours, preferably
  before placement
• Goal
• 95 of new children receive IHS within 24 hours

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Initial Health Screenings (IHS)

• Implementation Strategies
• 24 hour Health Line (Cook County)
• Transporters, DCP aides
• Network of ED, Urgent Care Centers
• Enhance Payment in/out 1 hour

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Initial Health Screenings (IHS)

• Lessons Learned
• Quality of Exam
• Documentation
• Timely Movement Through ED

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Initial Health Screenings (IHS)

• Design One Form
• Quality Review of Documentation
• Training
• 11 Preferred Sites (Cook County)

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Initial Health Screenings (IHS)

• Performance Measure

Cook County Downstate February
1995 33 N/A December 1997 53
N/A February 2001 79
N/A February 2003 77 June
2003 76 February 2005 76 June
2005 85 February 2007 87 June 2007 86
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Comprehensive Health Evaluations (CHE)

• Purpose
• Comprehensive health evaluations, including
  screening tests (e.g., HIV, hearing, vision)
• Timeframe
• Within 21 days of temporary custody
• Goal
• 95 of new wards will receive CHE within 21 days

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Comprehensive Health Evaluations

• Implementation Strategies
• Interim Case Management
• Primary Care Providers
• Initiate Health Passport
• Case Worker Retrieves Prior Health Information

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Comprehensive Health Evaluations

• Lessons Learned
• Primary Care Physicians DO NOT Perform CHE
• Timeliness (Case Worker)
• Transportation Problems
• Past Health Information Frequently Not Available

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Comprehensive Health Evaluations

• Interventions
• Regionalized CHE sites (FQHC)
• Critical Path Analysis to Identify Time Consumed
  To Complete Each 4 Critical Tasks
• Clear Expectations, Training
• Reminder Recall For CHEs with Case Workers and
  Foster Parents

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Comprehensive Health Evaluations

• Interventions Continued
• Provision of Transportation As Needed
• Improved Method of Documentation Retrieval

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Comprehensive Health Evaluations

• Performance Measures

CHEs Completed Cook County Downstate June
2000 34.1 N/A June 2003
32.6 81.5 June 2005 48.0
84.9 June 2007 87.8 89.5 CHEs
Completed Within 21 Days of TC June 2000
52.3 N/A June 2003 25.5
N/A June 2005 36.1
N/A June 2007 78.5
N/A
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Primary Care Provider (PCP)Medical Home

• Purpose
• Foster Parent Chooses From Network Providers
• If PCP is not in Network Enroll
• Goal
• 95 of all wards linked to qualified PCP

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Primary Care Provider (PCP)Medical Home

• Implementation Strategies
• Interim Case Manager Contacts Foster Parents
• Foster Parents Chooses PCP For Child
• Enhanced Rate Monthly Management Fee
• PCPs Credentialed Every 2 Years

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Primary Care Provider (PCP)Credentialing

• Training In Pediatrics (Pediatrician,
• Family Physician)
• 24 Hour Coverage
• Hospital Admitting Privileges
• Medicaid
• Licensed In State
• Professional Regulations
• Standardized Medical Records

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Primary Care Provider (PCP)Medical Home

• Lessons Learned
• Difficulties Enrolling Non-Network PCP Into
  Network
• - Medicaid Payments, Forms
• Form Documentation

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Primary Care Provider (PCP)Medical Home

• Intervention
• On-going Process of Enrolling
• Targeting Non-Enrolled Physicians With
• Most Children
• Increase Medicaid Rate (Federal Decree)
• Simplify Documentation for IHS CHE

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Primary Care Provider (PCP)HealthWorks Enrollment

• Performance Measures
• Cook County Downstate
• 1992 0 0
• (No documentation of linkage to PCPs for
  children in foster care)
• October 1997 46 N/A
• July 1998 93 98
  (2002)
• 2003 to Present 97
  98
• Change in definition of HealthWorks enrollment.

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Standardized Medical Records

• Purpose
• Unified Health Records
• Passport Of Child Kept By Foster Parent
• Goal
• All Children Have Health Passports
• Process
• Standardized Forms Given To PCP In Network
• Design Health Passport
• Form Stays With Physicians For Own Records
  Copy of Form To Case Manager

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Standardized Medical Records

• Lessons Learned
• PCP did not want to fill out forms
• Health Passport Lost, not dynamic
• Medical Records Kept at case management, not
  shared with need-to-know parties
• Performance Measures
• None No Health Information System!

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Medical Case Management (MCM)

• Purpose
• Facilitate access to primary and specialty care
• Develop individualized health care plan
• for Client Service Plan and for ACRs
• Track immunizations and Well Child Exams

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Medical Case Management (MCM)

• Goal
• 90 of all wards will be current with immun-
• izations and Well Child Exam requirements
• Target Population
• Children in DCFS legal custody between the ages
  of 0 5 years
• Pregnant wards
• Children (0 5 years) of parenting wards

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Medical Case Management (MCM)

• Implementation Strategies
• Oversight by DHS (state Title V MCH Agency)
• Selection of DHS-certified providers
• Use of local public health departments Public
• Health Nurses for high-risk (APORS) children

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Medical Case Management (MCM)

• Interventions
• Monitoring Issues of MCM Providers
• by DHS
• Funding Rate Low

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Medical Case Management (MCM)

• Interventions
• Discontinue use of MCM providers with low per-
• formance for Immunizations and Well Child
• Exams
• Increase use of MCM providers with high perfor-
• mance for Immunizations and Well Child Exams

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Medical Case Management (MCM)

• Performance Measures
• Immunizations
• Cook County Downstate
• June 1999 32 N.A.
• June 2003 70
  90
• June 2005 76 93
• June 2007 80 92

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Medical Case Management (MCM)

• Well Child Exam
• Cook County Downstate
• June 1999 23 N.A.
• June 2003 42
  83
• June 2005 70 93
• June 2007 75 89

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Does HealthWorks Work?
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• Application of Continuous Quality Improvement
  (CQI)
• Concepts and Principles to Measure Improvements
  in the Receipt of Health Services
• for Children in Foster Care

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• Basic CQI Tools
• Know Thy Customer For every process or service,
  we must determine who is the customer
• Do It With Data Decisions must be based on facts
  and reliable data
• PDSA (Plan, Do, Study, Act) Cycle For
• Quality Improvement

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• Basic CQI Tools Continued
• PDSA Involves a circular approach to
  improvement
• Plan a change
• Implement the change on a small scale
• Study the results of the change
• Act either to standardize the change or to begin
  the cycle of improvement again with new
  information

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• Application Of CQI To HealthWorks
• Monthly CQI meetings reviewing aspects of the
  HealthWorks Program in Cook County (see monthly
  summary of performance indicators handout)
• Tri-annual CQI meetings for downstate HealthWorks
  lead agencies reviewing various aspects of the
  HealthWorks Program
• Quarterly CQI meetings with key DCFS and DHS
  staff reviewing aspects of the HealthWorks
  Program and systemic issues of access to health
  care services for children in foster care
  

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• Application Of CQI To HealthWorks
• Of Illinois
• Improvement in Immunization Compliance for
  Children Enrolled in Chicago Public Schools
• DCFS Wards CPS General Pop.
• November 2001 95.4 N/A
• October 2003 92.4 N/A
• October 2005 96.3 N/A
• October 2006 97.3 90.1
• Source CPS Out of Compliance Report

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• Application of CQI to HealthWorks
• Of Illinois
• Improvement in Well Child Services using
  Reminder-Recall System with caregivers and
  caseworkers
• (Pilot project in Cook County)
• Merge of data from DHS and DCFS
• Reminder letters to caregivers, caseworkers, and
  PCPs
• Immunization/Well Child Exam history and
  forecasts

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• Application of CQI to HealthWorks
• Of Illinois
• Results of Reminder-Recall System (Cook County)
• June 2004 June 2007
• MCM Agency A
• Immunizations
  76 96
• Well Child Exams
  77 90
• MCM Agency B
• Immunizations 91
  93
• Well Child Exams 93
  92
• MCM Agency C
• Immunizations 68
  80
• Well Child Exams 32
  69

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HealthWorks

• Percentage of Children Receiving Service by Study
  Populations, 1997
• DCFS Custody DCFS Custody
  Enrolled NOT Enrolled AFDC
• in HealthWorks in HealthWorks__
  _Children
• General Exams 74.0
  55.1 38.7
• Physician Services 71.1
  50.7 35.7
• Psychiatric Clinic Services 5.5
  4.1
  0.6
• Mental Health Services 14.3
  14.5 0.8
• Hearing Exams 13.5 10.7
  5.1
• Eye Exams 18.9
  16.8 7.0
• Lead Screening 18.2 8.0
  8.4
• Emergency Room Services 22.8
  20.2 16.4
• General Inpatient Hosp. 7.8
  7.7
  7.3
• Psychiatric Inpatient Hosp.
  3.2 2.7
  0.3
• AFDC Aid to Families with Dependent Children.

(Jaudes, CWLA, 2004)
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HealthWorks

• Adjusted Odds Ratios of Service Receipt for
  Children in HealthWorks Compared With
• Children Not Enrolled in HealthWorks and in AFDC,
  1997
• Children in Custody, NOT
  Children In
• Enrolled in HealthWorks
  AFDC
• Service Type
• General Exams 1.82 5.15
• Physician Services
  2.20 5.46
• Psychiatric Clinic Services 1.49
  9.68
• Mental Health Service 1.28
  22.31
• Hearing Exams 1.22
  2.84
• Eye Exams 1.27 2.86
• Lead Screening 1.49 2.27
• Emergency Room Services 1.12 1.55
• General Inpatient Hospitalization
  1.04 2.32
• Psychiatric Inpatient Hospitalization 1.26
  11.11

AFDC Aid to Families w/Dependent
Children. plt0.01
(Jaudes, CWLA, 2004)
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Trends Of Chronic Conditions Of Children In
Substitute Care
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Trends Of Chronic Conditions Of Children In
Substitute Care
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Trends Of Physician Services Of Children In
Substitute Care
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Trends Of Services For Children In Substitute Care
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Trends Of Health Services For Children In
Substitute Care
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All DCFS Substitute Care Compared To TANF
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NEW INITIATIVES
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Challenges for the HealthWorks Program

• 1. Limitations in health information component of
  SACWIS
• Strategic Objective Enhance SACWIS to achieve
• -- sharing of health data from other state
  agencies
• -- producing a dynamic electronic Health
  Passport
• -- providing aggregate data to assess
  health
• outcomes
• 2. Coordination with behavioral/mental health
  system
• Strategic Objective Develop Consult for Kids
  pilot project for HealthWorks PCPs to request
  consultation on behavioral/mental health concerns.

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Challenges for the HealthWorks Program

• 3. Nearly 50 of wards in substitute care are
  over 12 years of age
• Strategic Objective Improve the HealthWorks
  provider network and service delivery system to
  better serve adolescents health care needs.
• 4. Statewide disparities in access to dental care
• Strategic Objective Collaborate with DHFS to
  increase Medicaid participation statewide by
  qualified dental providers.

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OTHER STATES

• UTAH
• RHODE ISLAND
• ARKANSAS
• MASSACHUSETTS