Seven Years Later: States Working Toward Promise of a Medical Home for Every Foster Youth

by Jane Krienke

Seven years after President George W. Bush signed the landmark Fostering Connections to Success and Increasing Adoptions Act of 2008 (FCSA) into law, 26 states have introduced bills to improve the oversight of healthcare resources for foster youth, according to the National Conference of State Legislatures State Actions.

States have taken varied paths to address Fostering Connections’ mandate to establish medical homes using a mix of city, county and statewide pilot programs and initiatives. The concept of a medical home has been evolving since the late 1960s. Basically, a medical home is a one-stop shop where all of a patient’s medical records are easily accessible and the patient is guaranteed continuity of care.

In North Carolina, the state’s chapter of the American Academy of Pediatrics is working toward a state-wide implementation of a medical home model for foster youth. Adam Svolto, the program director for Fostering Health NC, said one of the top goals is to increase contact with primary care providers, particularly early in the child’s foster care experience.

By monitoring simple things, such as weight change, Svolto said physicians are able to proactively address the high level of stress and traumatic experiences youth in care often face. Weight loss could be a sign that something needs to change, such as the child’s placement or medications.

“We’ve found if contact is made quickly, if the child has appropriate support and is seen frequently, [he or she] is less likely to experience a psychological crisis that would thrust them into a residential care facility or hospital,” Svolto said. ”This reduces costs over time and also proxies for better outcomes”.

Fostering Health NC sponsored a pilot project at Wilmington Health, a clinic in New Hanover County. From October 2012 to September 2013, the trauma-informed physicians cared for 222 foster youth. They adhered to the American Academy of Pediatrics’ recommended periodicity schedule.

The clinic and local Department of Social services also had access to a common online portal where they could access information about each child. At the conclusion of the study, they reported a reduction in emergency room utilization rates from 20 per year to five. This resulted in a $200 per member per month reduction in cost, and they also reported a 98 percent compliance with the recommended periodicity schedule.

Youth in foster care generate three times the costs compared with youth utilizing Medicaid in the general population, Svolto said. A majority of the expenses come from ER visits and inpatient hospitalizations resulting from medical and mental health illnesses.

Since all 100 counties in North Carolina operate independently, Svolto said a library of resources is available online to promote local partnerships between primary care physicians, the managed care networks and the Department of Social Services.

“I think that many counties in their leadership are coming around to an understanding of why improved standards would be good for this population given the challenges of their movement, and the medical conditions they often experience, especially with respect to mental health,” Svolto said.

The goal in the next two years, according to Svolto, is for one-third of the counties to be using new health summary forms and signing the technology-enabled care coordination agreement so physicians and the local Department of Social Services can access a common portal. Currently, 12 counties have signed onto the technology agreement. Five to seven counties are have been in conversation with local partners about writing collaboration procedures. Two counties are now using new health summary forms and several other counties are in the transition process of using them, too.

In two years’ time, the goal is to shift the oversight responsibility to the state and release a program evaluation comparing the outcomes between counties. Svolto said a statewide implementation rate of 75 to 80 percent is likely within five years. This would translate to an estimated annual cost savings of $16.2 million.

Some states are experimenting with operating medical homes within counties. In Ohio, the Cleveland-based MetroHealth Medical Home for Children in Foster Care was formed through a partnership between MetroHealth, a non-profit county operated health system, and Cuyahoga County Division of Children and Family Services (DCFS).

Ann Forster, a nurse practitioner with the program, said prior to implementation youth often waited for hours in an Emergency Room before receiving their initial exam.

“In our county, we insist on seeing the youth before they are placed in a foster home,” Forster said. “DCFS calls one number to let us know they have a kid who needs to be triaged. We make arrangements, give them an appointment time and meet them to do their triage.”

After the initial exam, youth are automatically enrolled into the medical home program. They are expected to follow up in 30 days at the main campus or at one of the satellite locations. Care coordinators maintain communication with foster parents to remind them of upcoming appointments.

From its inception in November 2013 to May 2014, the staff has conducted an initial exam on 802 children, completed 406 thirty-day comprehensive exams, and has continued tracking 793 patients.

In St. Louis County, Missouri, Dr Katie Plax, pediatrician and member of the state’s Health Oversight and Coordination planning committee, is personally working to reduce healthcare challenges for foster youth.

In 2008 Plax helped found The SPOT (Supporting Positive Opportunities for Teens), a drop-in youth center offering free medical services. Almost four years ago, Plax and her staff decided a clinic devoted to foster youth was a necessity. Many of the SPOT’s clientele were former foster youth who did not have access to a primary care provider.

The St. Louis City and St. Louis County Children’s Division directly refers youth ages 13 to 17 to the COACH clinic (Creating Opportunities and Choosing Health). Here trauma-informed providers perform the state mandated 30-day comprehensive exam. After the 30-day initial exam, youth are eligible for medical, mental, dental and case management services until age 25. The SPOT also offers a place to do laundry, watch TV and take a hot shower.

Missouri’s Health Oversight and Planning committee has been in conversation with state legislators and the Department of Social Services to have a budget item for a foster care medical home in the future, Plax said.

“I am a big advocate for what I call a center of excellence, where people really know what life is like for kids in foster care and understand the impact of trauma on child development and the brain,” Plax said. “Coming at this from a trauma-informed perspective is really different. Just understanding the foster care system – not everyone knows what a family support team is- is just one more thing the patient doesn’t have to explain to you, just one less demand.”

Many states across the country are working to improve health outcomes for foster youth through collaborative projects and initiatives, while other states are continuing to improve the systems they already have in place. Study after study confirms the American Academy of Pediatrics’ designation that youth in care have special healthcare needs, requiring more frequent attention and care than their peers outside of the system.

The system is moving in the right direction, but far from the grand goal of establishing a medical home for every child in foster care.

Correction: The author stated that The Spot opened in 2006, but it opened in 2008.

Jane Krienke wrote this story while taking the Journalism for Social Change Small Private Online Course. 

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