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Creating a Health Care Home for Children in Foster Care

August 1, 2014

By Amelia Burgess, MD, MPH, FAAP, pediatrician at Park Nicollet

Foster care and the conditions of abuse or neglect that lead to foster care are seen in both rural and urban settings throughout Minnesota. Twenty six percent of all Minnesota’s children in out-of-home care come from counties with fewer than 10,000 children, and they are removed from their homes at rates higher than we see in our most populous counties.

In counties with fewer than 10,000 children, we find that 1 in 100 children is placed in out-of-home care each year. The largest counties (with populations of over 100,000 children), have out-of-home placement rates ranging from 1 in 313 (Dakota) to 1 in 73 (Ramsey).

Foster care placement represents a distinct health disparity. American Indian children are 10 times more likely than white children to be placed in foster care, and African American children are four to five times more likely. However, overall, most of Minnesota’s children placed out-of-home are white.

These statistics demonstrate that foster care, and the abuse and neglect that lead to foster care, are common in all parts of Minnesota and should be anticipated in all practices that care for children.

Health Effects of Abuse and Neglect

Foster care placement is a health intervention. The conditions that lead to out-of-home placement – poverty, medical and mental illness, substance abuse, interpersonal violence – also lead to poor health outcomes in children. These children have higher rates of medical illness, mental illness, developmental delay, oral disease, and educational disruption. Our increasing understanding of adverse childhood events teaches us that these are lifelong effects, and timely interventions can affect the life trajectory of a child exposed to the toxic stress of abuse or neglect. Clinicians who care for children should understand the prevalence of abuse and neglect in their communities, and should be prepared to help families, including foster families, halt the abuse and neglect and mitigate their effects.

MNAAP Foster Care Learning Collaborative

From October 2013 thru April 2014, the Minnesota Chapter of the American Academy of Pediatrics (MNAAP) Foster Care Health Learning Collaborative met to discuss the health of children in foster care and ways to improve health services to these children. The collaborative included clinicians from Hennepin County Medical Center, North Point Health and Wellness, Park Nicollet pediatrics, the Native American Community Clinic, the Minnesota Organization on Fetal Alcohol Syndrome, St. Joseph’s Home for Children Community Clinic and Catholic Charities Health Services, and Health Partners pediatrics.

We structured our meetings around the guidelines of the American Academy of Pediatrics Council on Foster Care, Adoption and Kinship Care. Our collaborative learning focused on the educational health, oral health, mental health, developmental health, physical health, and the epidemiology and legal framework of foster care in Minnesota. Speakers came from the Children’s Law Center, PACER, Children’s Dental Services, and the Alexander Center.

Recommendations for Pediatric Providers

One of the products of our learning collaborative was an electronic resource guide designed for clinicians throughout Minnesota to use when caring for children in out-of-home placement, with the intention that practices would adapt it for local use. This guide can be found at www.mnaap.org/healthcarehome.htm and is summarized with regard to the following four categories:

Mental health care: prompt evaluation and evidence-based therapies are recommended, with emphasis on training of foster parents (using methods like Incredible Years) to assure therapeutic foster home environment

Health Surveillance: frequent visits in a health care home with care coordination, twice as often as current Child and Teen Check-up (C&TC) recommendations, to assure appropriate medical and developmental/behavioral screening.

Medication Management: care coordination within primary care for timely and appropriate psychiatric consultation and medication management.

Documentation and oversight: a comprehensive portable medical/mental health record and care plan within a certified health care home

At our final meeting, we discussed Minnesota’s proposed health services and oversight for children in foster care as outlined in the Minnesota Annual Progress and Services Report for the Stephanie Tubbs Jones Child Welfare Services and Promoting Safe and Stable Families Programs.

The Minnesota plan for health care oversight is based on the current C&TC network, collaboration with the AMBIT Network, promotion of the Mental Health Integration and Transformation coalition, and making use of the existing SSIS database to monitor health care and medication use among children in foster care.

We see a great opportunity for child welfare services to collaborate with the Department of Human Services’ health care home network. Pediatric health care homes serve children with special health needs, performing all of the oversight required by legislation and by principles of good pediatric care. Individual pediatric clinicians can help by using the resource guide to improve their own health care home processes for children in foster care. Our recommendations to the state can be found at:
www.mnaap.org/healthcarehome.htm

Child abuse and neglect bring us despair. We often, as clinicians, feel overwhelmed and inadequate, particularly when faced with “the system.” But children in foster care, more than almost any others, need us as advocates. They do not have effective parent advocates. The role of parent is shared by foster parents with many professionals, all of whom have time-limited relationships and very focused roles. They often believe that the words developmental delay and mental illness will stigmatize children. Therefore they resist early therapy.

We can help them understand that delay and dysfunction can represent normal responses to horrific situations, and guide them to appropriate therapies.

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