Minnesota Chapter of the American Academy of Pediatrics Foster Care Health Learning Collaborative

Minnesota Chapter of the American Academy of Pediatrics Foster Care Health Learning Collaborative Comments on Minnesota s services 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, June 30, 2013 Amelia Burgess, MD, MPH, FAAP Amelia.burgess@parknicollet.com May 16, 2014

Minnesota Foster Care Health Learning Collaborative Minnesota Chapter of the American Academy of Pediatrics Lead physician: Amelia Burgess, MD, MPH, FAAP Park Nicollet Pediatrics 2001 Blaisdell Avenue South Minneapolis, MN 55116 Lydia Caros, MD Chief Executive Officer Native American Community Clinic 1213 E Franklin Avenue Minneapolis, MN 55404 Kathy Hakanson, MD Pediatric Clinic Hennepin County Faculty Associates 7th floor Purple Building 701 Park Avenue Minneapolis, MN 55415 Elsa Keeler, MD, FAAP Health Partners -White Bear Lake Pediatric and Adolescent Medicine 1430 Highway 96 White Bear Lake, MN 55110 Laina Nast, RN Pediatric Care Coordinator Park Nicollet Pediatrics 2001 Blaisdell Avenue South Minneapolis, MN 55116 Dawn Petroskas, PhD, RN Director of Health Services Catholic Charities of St. Paul and Minneapolis 1276 University Ave. St. Paul, MN 55104 Mary Jo Spencer, MPH, CPNP St. Joseph's Home for Children Community Clinic Minnesota Organization on Fetal Alcohol Syndrome University of Minnesota Physicians 1121 E. 46th St. Minneapolis, MN 55407 Anne Sweeney, MS, CPNP North Point Health and Wellness 1313 Penn Ave N Minneapolis, MN 55411 Project Coordinator: Gregory Burgess, MPH 55 Lexington Parkway North St. Paul, MN 55404

CONTENTS Introduction 1 Mental Health Care 2 Medication Management 4 Documentation and Oversight 5 Health Surveillance 6 Summary 7 Appendix: Activities of a pediatric care coordinator regarding the health of children in foster care 8

Introduction The Minnesota Chapter of the American Academy of Pediatrics Foster Care Health Learning Collaborative is a coalition of pediatric clinicians (pediatricians, nurses, and nurse practitioners) who met regularly from October 2013 thru April 2014 to discuss the health of children in foster care and ways to improve health services to these children. Our coalition included clinicians from Hennepin County Medical Center, North Point Health and Wellness, Park Nicollet pediatrics, the Native American Community Clinic, 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 American Academy of Pediatrics Council on Foster Care, Adoption and Kinship Care. We met seven times to discuss 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. Our final meeting on April 25, 2014, was focused on advocacy. We were very grateful to have Mary Doyle from the Department of Human Services Division of Child Safety and Permanency in attendance. At this 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 [Minnesota Department of Human Services, June 30, 2013]. The Minnesota plan for the oversight of healthcare for children in foster care is based on the current child and teen checkup (C&TC) network, 1 collaboration with the AMBIT Network, 2 promotion of the Mental Health Integration and Transformation coalition, 3 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 the child welfare services to collaborate with the Department of Human Services healthcare home network. 4 Pediatric healthcare homes serve children with special health needs, performing all of the oversight required by legislation and by principles of good pediatric care. 1 http://www.health.state.mn.us/divs/fh/mch/ctc/ 2 http://www.cehd.umn.edu/fsos/projects/ambit/ 3 http://www.prairie-care.com/resources/mental-health-integration-and-transformation-coalition-mhint 4 Minnesota Healthcare Programs Healthcare Homes. http://www.dhs.state.mn.us/main/idcplg?idcservice=get_dynamic_conversion&revisionselectionmethod=lat estreleased&ddocname=dhs16_151292 1

I. Mental health care Current plan: The state is collaborating with the University of Minnesota AMBIT Network to promote trauma-sensitive care, including increased screening of children for trauma and increased training for therapists in Trauma- Focused Cognitive Behavioral Therapy (TF-CBT). 5 Advantages: The AMBIT Network is a leader in care for traumatized children, and TF-CBT is the gold standard treatment for post-traumatic stress disorder. Disadvantages: In the United States, rates of witnessing community violence range from 39% to 85%, and rates of victimization approach 66%. Youths exposure to sexual abuse is estimated to be 25 to 43%. 6 In foster care, these figures can be expected to be higher. Children removed from their homes by child protection should be expected to have been traumatized screening may only delay care. TF-CBT is not effective for young children, or for chronic trauma. Recommendations: Therapy. Children in foster care should have a prompt mental health evaluation by a therapist trained in children s mental health and in trauma-sensitive care. To increase access, the Department of Human Services can promote priority scheduling for children and adolescents in foster care, so that they can be evaluated around 30 days after removal from home. This evaluation should be scheduled at the time of removal, at the same time that health and dental services are arranged. That evaluation will determine which children go on to ongoing treatment to stabilize the child and the placement, and which children can reasonably be expected to adapt and function in a well-trained foster home. Coordination of these initial evaluations can be performed by the care coordinator (see appendix). In addition to TF-CBT, the Department of Human Services should promote the dissemination of Parent-Child Interaction Therapy (PCIT), 7 an evidence-based therapy for children with oppositional and conduct problems. The skills are parent-based. Once a foster parent has learned the skills, they can be transferred to future foster children. Foster Care as a Health Intervention. It is our belief that foster parents provide the primary intervention aimed to normalize the behaviors and developmental trajectories of abused and neglected children in out-of-home care. They should receive standardized, specific training to prepare them for the problems these children commonly present. It is our belief that 5 See http://www.nrepp.samhsa.gov/viewintervention.aspx?id=135 6 American Psychological Association, 2014. 2008 Presidential Task Force on PTSD and Trauma in Children and Adolescents. https://www.apa.org/pi/families/resources/children-trauma-update.aspx 7 See www.pcit.org 2

appropriately training foster parents will decrease placement disruptions and reunification disruptions. Therefore, the Department of Human Services should promote evidence-based parent training for foster parents, to ensure that foster homes can be expected to provide appropriate developmental environments for abused and neglected children. Evidence-based parent training programs that are already taught in Minnesota include Parent Management Training of Oregon/Parenting through Change 8 or Incredible Years. 9 8 See http://evidencebasedprograms.org/1366-2/parent-management-training-the-oregon-model-pmto-near-toptier, http://www.isii.net/ 9 See http://incredibleyears.com/programs/ 3

II. Medication Management Current plan: The state s out-of-home placement plan requires the local agency to ensure oversight and continuity of health care services and prescription medications. The Mental Health Integration and Transformation coalition and the DHS pharmacy program are developing policies and procedures for psychiatric consultation and prescription oversight for primary care clinicians. Advantages: The plan provides a statewide standard of care. Disadvantages: The plan doesn t identify an individual in the care team who is responsible for medication oversight, and doesn t make use of the child s primary care clinicians. Recommendations: In a healthcare home, the care coordinator works with the clinician to obtain psychiatric consultation and medication management (see appendix). 4

III. Documentation and oversight Current plan: Information about a child s physical and mental health, dental care, immunizations, medications and treatment monitoring are entered into their case record in SSIS. Foster parents also keep a health record for each child. Advantages: Records are kept centrally and with the child, facilitating quality management and access. Disadvantages: Records may not be kept or maintained by individuals with health expertise. Recommendations: A care plan created in a healthcare home contains all of the information required for SSIS. Children should receive their care in a certified healthcare home 10. 10 For further information about care coordination and healthcare homes, see Appendix: Activities of a pediatric care coordinator regarding the health of children in foster care and Minnesota Health Programs Healthcare Homes http://www.dhs.state.mn.us/main/idcplg?idcservice=get_dynamic_conversion&revisionselection Method=LatestReleased&dDocName=dhs16_151292 5

IV. Health Surveillance Current plan: Minnesota s Title IV-B health care oversight plan for children in foster care is based on the existing framework of identification and outreach through the C&TC program. Advantages: C&TC coordinators are familiar with local resources for at-risk populations. Disadvantages: The C&TC schedule of screenings does not reflect the American Academy of Pediatrics recommendations for the health surveillance of children in foster care. 11 The abuse and neglect that lead to foster care placement also lead to neurodevelopmental damage, abnormal growth, and increased medical disease. The standardized screening tools used in the C&TC program are likely to under-identify mental and developmental disorders, especially when the reporter (foster parent or caseworker) is unlikely to know the child well. The usual schedule of well child visits (1 week, 2,4,6,9, 12, 15, 18, 24, 36, 38, 60 months; annually or biannually thereafter) is not adequate to catch existing or emerging conditions as these highrisk children transition between homes. For children in foster care, the American Academy of Pediatrics recommends monthly visits during the first 6 months of life, every 3 months from 6 to 24 months and every 6 months thereafter. Recommendations: All children in foster care should receive their health care in a certified pediatric healthcare home. The existing C&TC coordinators can facilitate linking foster families to healthcare homes. Pediatric healthcare homes already provide care planning, integration of behavioral, developmental, educational and oral health services in the care plan, and medication management for children with special health care needs. The Department of Human Services should advocate that certified pediatric healthcare homes must state their plan for providing care coordination for the special population of children that is in foster care. Health care for children in foster care should follow the enhance surveillance guidelines recommended by the American Academy of Pediatrics Council on Foster Care, Adoption, and Kinship Care. However, many pediatric and family practice clinicians are not aware that there are guidelines for children in foster care. The Department of Human Services can promote the enhanced guidelines through child protection, C&TC and healthcare home networks. 11 American Academy of Pediatrics Healthy Foster Care America, http://www.aap.org/en-us/advocacy-andpolicy/aap-health-initiatives/healthy-foster-care-america/pages/health-care-standards.aspx 6

SUMMARY Children and adolescents in foster care should receive their health care in a certified healthcare home which provides care coordination and ongoing care planning according to the guidelines of the American Academy of Pediatrics. The care plan created in the clinic will serve all of the planning, oversight, and documentation needs required by law, and will remove that burden from caseworkers. Children and adolescents in foster care should receive mental health and developmental evaluation within 30-60 days of initial placement, with the goal of initiating therapy as soon as possible regardless of planned transitions. The Department of Human Services should promote the dissemination of Parent-Child Interaction Therapy as well as Trauma-Focused Cognitive Behavioral Therapy. The Department of Human Services should promote evidence-based parent training such as Parent Management Training of Oregon/Parenting through Change or Incredible Years for all foster parents, to ensure that they are providing developmentally supportive, therapeutic environments for abused and neglected children. The Department of Human Services should consider creating regional Centers of Excellence in Foster Care Health. Out-of-home care is common, with nearly 1% of children spending time in foster care each year. The 11,453 children and adolescents who spent time in out-of-home care in 2012 are found throughout the state. Many of them see family practice and pediatric clinicians who rarely see children in state custody, and who do not have experience in the health complexity and intra-disciplinary collaboration required to plan appropriately. Regional centers of excellence could provide comprehensive evaluation and ongoing guidance to local primary care clinicians. 7

Appendix Activities of a pediatric care coordinator regarding the health of children in foster care A pediatric care coordinator is a valuable member of the health care team, acting as interface and point of contact among families, primary care clinicians, and specialty consultants, and as an ongoing support to families. When working with children in foster care, the care coordinator must also collaborate with multiple caregivers, children s services/child protection, legal services and the school system. This is because a child in foster care is not represented by a unique parent or guardian, but by a team of caregivers and professionals who may each focus on a different aspect of a child s well-being. This document lists potential activities of a pediatric care coordinator in a foster care-focused healthcare home. Quality Assurance The care coordinator will create and maintain a registry of children and adolescents to facilitate appropriate follow up as well as evaluation of services provided. Proactive management of health surveillance. The care coordinator will call the county intake office on a weekly basis to learn of new foster care placements. The care coordinator would then schedule the initial comprehensive evaluation including mental health, developmental, and oral health evaluations. The care coordinator will develop and monitor a schedule of surveillance visits for each child, based on the age of the child. More visits may be necessary if the child has acute or chronic illness. The care coordinator will update the child s immunization record. The care coordinator will collaborate with the clinician to create a plan for updating immunizations as needed. The care coordinator will seek previous health records, including birth records, growth data, and mental health or developmental health evaluations, and IEPs/504s, in order to create a comprehensive health record for each child. The care coordinator will collaborate with the clinician to keep an updated medical history, family history, and problem list for each child. Care Planning The care coordinator will meet regularly with the clinician to discuss the needs of the children and adolescents on the foster care panel, to develop a care plan that incorporates family needs and preferences and that addresses the five aspects of health: physical, mental, developmental, oral, and educational. The care coordinator will assist the clinician in scheduling meetings that include caseworkers, birth family, foster family, and adoptive family, as indicated by the child s situation and permanency plan. 8

Medication Management The care coordinator (or clinic designee) will assist the clinician in keeping the medication list and history updated. In particular, the care coordinator will assist in identifying patients whose psychotropic medications meet the threshold for mandatory psychiatric consultation, and will assist in accessing the Mental Health Integration and Transformation coalition for consultation. The medication plan will be stated clearly in the care plan. Care Coordination The care coordinator will serve as a first point of contact with the clinician and health system for children enrolled in the healthcare home. The care coordinator will help families fulfill the care plan by assisting in identifying geographically and culturally appropriate specialists and services. The care coordinator (or clinic designee) will help arrange consent for care, transportation, insurance coverage, and prior authorization as needed. The care coordinator will represent the pediatric clinician at case conferences and IEP meetings as needed. Community Engagement The care coordinator will maintain an interdisciplinary list of local consultants who address the needs of children in the five stated areas. The care coordinator will maintain a list of community programs and resources to assist families in integrating children into usual childhood activities (e.g., YMCA, community education and library programs, swim lessons, art/music lessons, sports teams). In a clinic that provides nurse triage services, the care coordinator does not need to be able to provide medical triage. The primary characteristics needed are compassion, communication, problem-solving, and data management. Experience working in or with public health, education (particularly education administration or special education), health education, community health, community mental health or substance abuse care, homelessness, social services, or advocacy will all contribute to the interdisciplinary nature of the position. 9