CHAPTER IV:
HEALTH CARE FOR FOSTER CHILDREN

Children in the Foster Care System Have Overwhelming Health and Emotional Needs.

Children in foster care are some of the most vulnerable children we can imagine -- abused, neglected and abandoned. They're now in the care of the state, and it has the responsibility of ensuring that these kids get the health care and other services they need.

Children and adolescents in foster care typically suffer serious health, emotional and developmental problems. As wards of the state, foster care children are dependent on government-funded health services to respond to their often complicated health conditions. As a group, children in foster suffer high rates of serious physical or psychological problems compared with other children from the same socioeconomic backgrounds.

Nearly 50 percent suffer from chronic conditions such as asthma, cognitive abnormalities, visual and auditory problems, dental decay and malnutrition, as well as birth defects, developmental delays or emotional and behavioral problems. Approximately 40-72 percent require ongoing medical treatment, and studies indicate that 50-60 percent have moderate to severe mental health problems. The cause of these conditions are multiple and stem from exposure to alcohol and drugs, lack of medical care, poor parenting, domestic violence, neglect, and unstable living conditions prior to family removal. The trauma of family separation, frequent moves and the stress and disruptions brought about by impermanent placements in the foster care system compound these conditions. Given their overwhelming and complex needs, foster children require and use health services more than other children.⁽⁷⁰⁾

The California Foster Children's Health Project Task Force

For six months of 1997-98, more than 30 of the state's top experts on California's foster care system have engaged in intense discussions and debates, working to develop recommendations to improve the delivery of health services to children in foster care.⁽⁷¹⁾ They listed the following obstacles to adequate health care for foster children.

Numerous Obstacles Limit Health Care

The foster care health system is really not a system at all. It is a piecemeal and disjointed set of departments that rarely communicate with one another about the ... needs of the children they are charged with protecting.

Despite extreme need, children and youth in foster care often fail to receive preventive and consistent health services due to the following:

• Constant mobility of foster children impedes continuity of care

• Medi-Cal reimbursement cards are not always available immediately to children who require urgent services and are not universally accepted by physicians

• Thorough screening and assessment does not always occur

• Comprehensive care for this special needs population is not always available

• Many physicians do not accept Medi-Cal patients, including foster children, because of red tape and low reimbursement rates

• Foster care providers do not typically receive training on how to gain access to complex county-based health services

• Many health (care) providers have not been trained to deal with the complex physical, mental, and developmental health issues faced by foster children

• Social workers are typically overburdened with high case loads and lack medical training

• Lack of adequate medical records often results in over-immunization and under-treatment of chronic conditions

• Insufficient coordination among health care providers and agencies can limit access to, and quality of, services.⁽⁷²⁾

Administration of Drugs to Children in Foster Care

A lot of these kids suffer from a deficit in attention, not attention deficit disorder.

Recent articles in the press have focused on the lack of proper monitoring and possible inappropriate administration of mood-altering drugs to children in foster care. Although there are laws on the books to require careful control and monitoring of administration of drugs to children under state care, those who are designated to do the monitoring: judges, social workers and county agencies do not have the resources to do this adequately. The staff of smaller group homes that receive a lower reimbursement from the state are poorly paid and often inadequately trained to properly supervise the children. Foster parents are given inadequate support. Children receiving mood-altering drugs are supposed to be diagnosed and monitored by psychiatrists whose reimbursement is so low that it is difficult to find enough of them to provide this service.⁽⁷³⁾ The same problems with lack of individual medical histories and changes of medical care providers, as mentioned above, affect the proper administration of these drugs.⁽⁷⁴⁾

We are increasingly alarmed at the severity and complexity of issues faced by the damaged children who come to us for help. In years past, many would have been in psychiatric hospitals. The beds have gone away, but the children have not. For some, the use of a carefully monitored medication program is critical.

At the same time, it must be realized that there are many responsible residential treatment centers who have appropriate psychiatric services for their charges. The director of one of them was quoted in the press recently, see text box to the left.⁽⁷⁵⁾

Foster nurses report that it is often difficult to find psychiatrists to provide the required evaluation and prescription drugs for foster children when they move from one county to another. The young people are often put on waiting lists even though the drugs they need had been appropriately administered at their previous placement.⁽⁷⁶⁾

The Situation

In researching and evaluating the available health services for foster children, the Task Force found that:

• Policymakers have not dealt effectively with the harsh realities confronting foster families and group homes trying to obtain health care for foster children.

• A system of health care for foster children has never been proactively designed. In most cases, foster children have been "fit in" to existing programs, which almost always do not have the flexibility, resources or expertise to deal with the complex physical, mental, developmental and dental needs of children living without their parents.

• There is no agency or department within state government that has the authority to:
  • design an effective system,
  • make changes to improve what presently exists, or
  • coordinate the multiple entities within the state that provide or regulate health services for foster children.

While state law and regulations make the Department of Social Services ultimately responsible for accessing medical, developmental, dental and mental health care services for children in out-of-home placement, the Department must rely on existing county-based health care systems to serve foster children and does not have the authority to modify these systems to accommodate their needs.

• No state policy or guidelines exist to guide development of a system of care.

• There is a need to create a coordinated, statewide system of care for children in foster care, but that this system would likely take on various forms within the 58 highly diverse counties that comprise California.

Foster care should help stop child abuse -- not allow the wounds inflicted by abusive parents to fester and spread. We need a system of specialized and compassionate health care to help foster children heal.

As a consequence, the state offers a confusing and often uncoordinated patchwork of programs to serve the health care needs of foster children. Health care providers and foster parents spend inordinate amounts of time trying to understand regulations and obtain care. Changes in placement for a foster child often trigger entirely new sets of providers and rules, beginning the bureaucratic cycle again and sometimes delaying health care for foster children.⁽⁷⁷⁾

Funding of Health Care for Foster Children

Foster children have the same minimum health benefits as children in the Aid to Families with Dependent Children (AFDC) program. At present health care for these children in California is funded by the Federal Government, the state of California and the counties.

Most Federal funds for AFDC and foster children's health care come through Federal Medicaid (Title XIX of the Social Security Act). The state implements Medicaid and matches the federal funds, dollar for dollar, through their Medi-Cal program.⁽⁷⁸⁾ Medi-Cal eligible children are served through the state's Child Health and Disability Prevention (CHAP.) Program. CHAP. administers the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program which provides preventive and diagnostic screening services and treatment for any condition discovered by such a screen. All children entering foster care are entitled to an EPSDT test and the necessary follow-up services. California requires that foster children receive further screening test every two years. Some counties require that these tests occur every year.⁽⁷⁹⁾ The county in which the child entered foster care is responsible for reimbursing the provider, even when the child moves to another county.⁽⁸⁰⁾

Foster Care Nurses in Local Health Departments

Foster care nurses in local health departments administer the county CHAP. program for foster children. They recruit and certify providers, perform direct activities, including outreach, health education, follow-up and support services, such as assistance with transportation and medical appointment scheduling, and finally, handle assessment/claims forms (PM-160s) and submit them to the state for reimbursement. Many counties have one full- or part-time position for this function.⁽⁸¹⁾

School Nurses and Teachers

School personnel play an important role in the detection of abuse and neglect among school children. School nurses also can detect sexual and psychological abuse if they administer a test to young people which asks them about their attitudes to home, school, friends etc.⁽⁸²⁾

Conversion to Managed Care

In 1993 the California Department of Health Services (DHS) announced plans to move all Medi-Cal recipients in certain counties from fee-for-service into managed care plans over the next few years. The theory behind this change was that the fee-for-service system which compensated providers for services provided created a false incentive to over-test, over-prescribe, and over-operate, etc. On the other hand, managed care, it was argued, would encourage prevention services and cut out unnecessary services.⁽⁸³⁾

There will be three alternative managed care arrangements:

1. Some counties will have County Organized Health Systems management, a "quasi-governmental" agency which will arrange providers and manage a program that all those eligible for Medi-Cal must join. San Mateo and Santa Barbara Counties have had such a program for ten years. Solano, Santa Cruz, Orange Co, San Francisco and Contra Costa Counties will adopt the same system.

2. Two counties, Sacramento and San Diego, will use Geographic Managed Care. This system involves county regulation of competing plans without a predetermined limit as to their number. All those covered by AFDC or programs linked to AFDC must enroll with one of the approved competing plans.

3. Twelve counties would adopt the "Two-Plan Model". This option involves two competitive plans -- one a publicly run county "local initiative", and the other a commercial provider. All AFDC-linked beneficiaries must enroll with one of these two plans. Counties using this system are Alameda, Fresno, Kern, Riverside, San Bernadino, San Joaquin, Santa Clara, Stanilaus, and Tulare.⁽⁸⁴⁾ All counties not specifically mentioned here are adopting one of these three alternatives.

Some of the problems in implementing this managed care system are predictable given the enormity of transition involved. Thousands of providers must be organized in some manner to provide a coherent supply of medical services for a large population. Other problems may be inherent in the "incentive not to treat" structure. Eligible children may not be on Medi-Cal long enough for the managed care provider to realize savings from preventive services. Foster parents may need to be powerful advocates for health services, such as check-ups, screenings, and immunizations for their foster children.⁽⁸⁵⁾

Task Force Recommendations

• Develop a system of health care for children in foster care.

• Provide a comprehensive benefit package and ensure timely screens and assessments for foster children.

• Improve coordination and delivery of services in counties.

• Hire foster care public health nurses.

• Cut red-tape in the MediCal eligibility process.

• Increase the pool of providers by reducing barriers to participation.

• Increase training and education for foster and health care providers.⁽⁸⁶⁾

(For more recommendations by the Task Force, see Appendix C: Recommendations of the California Foster Children's Health Project Task Force)

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