Childrens Health

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Childrens Health Development Program

• Wake County Human Services
• Raleigh, North Carolina
• Jean C. Smith, MD
• jcsmith_at_co.wake.nc.us
• CityMatCH
• Albuquerque, NM
• September 22, 2008

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• When I was little I would think of ways to kill
  my daddy. But I did not kill my daddy. He
  drank his own self to death the year after the
  County moved me out.
• Ellen Foster

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Background/Purpose
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Health Needs of Children in Foster Care

• Children and adolescents in foster care have
  higher prevalence of -
• Physical
• Developmental
• Dental
• Behavioral
• health conditions

5

• my teacher noticed a bruise he put on my arm
  and they all had a field day over it in the
  school nurses office. Calling in everybody but
  the janitor to look at it. I had rather nobody
  saw my business.

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Health Status of Children Adolescents Entering
Foster Care

• More than 90 have abnormality in at least 1 body
  system
• Vision hearing problems common
• Suboptimal growth 5 times expected
• (Large cohort study of children entering foster
  care - Baltimore, MD)

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Health Status of Children Adolescents Entering
Foster Care

• lt 20 had NO medical conditions
• gt20 had growth abnormalities
• 30 had neurological disorders
• 16 had asthma (3 times national ave.)
• (Large cohort study of children in foster care
  in Oakland, CA)

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Health Status of Children Adolescents Entering
Foster Care

• High incidence of anemia
• High incidence of infectious diseases
• Increased risk for vertically transmitted
  infections (HIV, hepatitis B C, syphilis,
  herpes simplex)

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• I try not to leave her by herself with him.

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Other problems

• gt80 exposed to domestic and/or community
  violence
• High risk behaviors in adolescents in foster care
  with risk for STDs, etc.
• No cohesive system of care for this vulnerable
  population
• Little tracking or monitoring of care that does
  exist.

11

• When they came back in they said they had
  decided what to do with me. Its about time I
  thought. Yes Lord its about time.

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Fostering Health Health Care for Children
Adolescents in Foster Care

• Task Force on Health Care for Children in Foster
  Care
• American Academy of Pediatrics, 2005

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Child Welfare League of America

• Standards for Health Care Services for Children
  in Out-of-Home Care
• Washington, DC Child Welfare League of America
  1988

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Evaluating Quality of Care for Children in Foster
Care -CWLA

• Seven criteria
• Access to care
• Appropriateness of services
• Comprehensiveness of care
• Coordination

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Quality of Care Criteria Continued

• Continuity
• Relation to the community
• Family-centered service

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Health Care Delivery Models for Children in
Foster Care

• Agency-based care
• Specialized foster care clinics
• Community-based care

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• Since my first day here all I felt is luck
  coming my way. I never thought I could have it
  this good.

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Components of Health Care Services

• Initial health screening
• Comprehensive health assessment
• Developmental mental health evaluation

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Components of Health Care Services

• Primary health care and monitoring health
  developmental status
• Transfer of medical information

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• All I did was wish him dead real hard every now
  and then. And I can say for a fact that I am
  better off now than when he was alive.

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Children's Health and Development Program A
collaboration of John Rex Endowment and Wake
County Human Services

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• Wake County Human Services (WCHS) is a
  consolidated agency including health, mental
  health and social services.

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Children's Health and Development Program Staff

• Assessment Coordinator BSW,QMHP 1.0 FTE
• Developmental Specialist BA,MA 0.5 FTE
• Pediatric Nurse Practitioner 0.5 FTE
• Mental Health Specialist LCSW-P 0.5 FTE
• Pediatrician Director 0.05 FTE

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Objectives of CHDP

• Provide medical, mental health, and developmental
  assessments for children birth to 18 years of age
  entering foster care and children 3 to 10 years
  of age in CPS treatment in Wake County.
• Share assessment information and plans of care
  with those responsible for the childs care and
  well being
• Identify health, developmental and behavioral
  problems and/or needs of children in foster care
  and CPS treatment.

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Objectives of CHDP(2)

• Develop individualized plans of care with
  recommendations for each child
• Identify the medical home for each child to
  provide continuity of care and monitoring of
  ongoing health and developmental care and needed
  services.
• Assist DSS, guardians, and families in accessing
  appropriate referrals or services for children.

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Program Standards

• The Childrens Health Development Program uses
• State of the art screening and assessment tools
  and community referral networks for early
  intervention services including Child Service
  Coordination
• Incorporates best practices in developmental and
  behavioral screening into each assessment
• Assists parents/foster parents in anticipation of
  strengthening of their childrens developmental
  skills

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Program Standards(2)

• Collaborates with families to strengthen ties and
  or link families to medical home
• Assists families and medical home in securing
  developmental and behavioral services outlined in
  the plan of care
• Provides assistance in continued monitoring of
  health and development

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• ..there have been more than a plenty days when
  she has put both my hands in hers and said if we
  relax and breathe slow together I can slow down
  shaking. And it always works.

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Methods

• 1. Children come into DSS care
• 2. Court Day One conference
• 3. Appointment for medical assessment
• Completed for all children unless a CME (Child
  Medical Exam) or SICC exam (Special Infant Care
  Clinic) is done.

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Methods(2)

• 4. Appointment for developmental assessment
• (Completed for all children 10 years and under.)
• 5. Appointment for mental health assessment
• (Children 3 mos. 4 years with concerning score
  on ASQ-SE are assessed. All children ages 4 18
  get a screening or review of current mental
  health services.)

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Methods(3)

• 6. Complete needed referrals
• 7. Develop Plan of Care (POC) with team
• 6. Review POC with Social Worker
• 7. Assure follow-up services are secured.

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Services

• A comprehensive health assessment within a month
  which will include gathering and reviewing all
  past medical records, school/child care
  information, immunization status, etc.
• A developmental and mental health evaluation
  (which may occur in the home)
• A review of all medical, school, and mental
  health records are done for children not
  receiving direct assessment by the CHDP.
• A plan of care to include identification of a
  medical home, special health needs, specific
  behavioral/developmental concerns, and assistance
  for families in securing needed referrals.

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Medical Exam

• Review all medical history and request records
  for review
• Full comprehensive PE
• Required state DSS PE form sent
• Assess if HIV testing or other lab work needed
• Skeletal survey done per protocol for children lt
  2 years of age

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Developmental Assessment

• Review developmental history, school history, and
  any interventions including IFSP/IEP
• Developmental screening for all children less
  than 5 years of age
• Neurodevelopmental screening for school age
  children who have not had psychoeducational
  testing at school.
• Review school records for those children with
  IEPs to determine the need for changes and/or
  updating.

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Mental Health Assessment

• Review mental health history and prior MH
  services/assessments.
• MH evaluations for all children ages 4 18 years
  if not currently in treatment
• MH evaluation may include observation of child in
  the home, daycare, or office setting along with
  collateral contacts with those working with child
• Complete a Doctors order for services and
  provide level of care information for indicated
  therapeutic services

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• Every Tuesday a man comes and gets me out of
  social studies and we go to a room and talk about
  it all. ..He spread out pictures of flat bats for
  me to comment on. I mostly saw flat bats. Then
  I saw big holes a body could fall right into.

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• ..he tells me Im scared. I used to be but I am
  not now.I might be a little nervous but I am
  never scared.

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Features of CHD Program Direct Benefits

• Comprehensive and Coordinated screening and
  treatment plan for children in foster care or in
  families in need of child protective services.
• Coordinated individualized plan of care to
  increase parents/caregivers understanding of
  their childrens developmental and mental health
  status.
• Assist parents/caregivers to use resources in
  medical home and early intervention programs to
  optimize their childrens development.

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Features of CHD Program Health Care Management

• Information gathering
• Ensuring appropriate medical consents
• Coordination of health care services
• Educating child welfare staff, courts, GALs,
  foster birth parents, educators, and health
  care professionals
• Ensuring Plans of Care are provided to all
  medical homes and child welfare staff

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Referrals Secured Care

• January 2004 through December 2005
• All children are referred to a medical home for
  ongoing health care - 412
• Medical referrals (specialized) 27
• Developmental referrals 90
• Mental Health referrals 158

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Outcomes

• January 2007 through December 2007
• Medical/Physical Exams 132
• Developmental screenings 105
• Mental Health evaluations 79
• (foster care only no CPS)

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Outcomes

• Totals for 4 years of program
• 811 children seen
• 670 referrals
• 1,879 assessments

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Lessons Learned

• Public health and child welfare agencies have a
  significant responsibility to assure
  comprehensive care for children in foster homes.
• Families and DSS staff prefer regionalization of
  services.
• Protocols (skeletal surveys, HIV screening, etc.)
  need to be followed.

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Lessons Learned

• More children were found in need of developmental
  and/or mental health services than DSS had
  previously anticipated.
• Children are receiving services in a timelier
  manner than previously.

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• The CHDP has offered comprehensive health
  services to all children entering foster care
  each year. The program has offered a resource
  that was not available previously and assures an
  individual plan of care addressing health,
  development, behavioral, and mental health needs.
  Foster children generally come from a background
  of poor or inconsistent health care records are
  frequently scarce. The CHDP is invaluable in
  providing a complete and thorough health view of
  these children who may be vulnerable to delays,
  emotional problems or other medical concerns.
• Elaine Rakouskas, WCHS Program Manager for
  Foster Care Services

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• Sometimes I count up what I like about the way
  Im living now. .And the best one number four
  is my new mama saying good morning to me like she
  means it.

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