Transcript Healthcare Services for Children in Foster Care

Healthcare Services for
Children in Foster Care
Vince Champagne, M.H.A.
Health Services Manager – Cook County
Office of Health Services, Division of Service Intervention
Illinois Department of Children and Family Services
Paula Kienberger Jaudes, M.D.
Medical Director, Illinois Department of Children and Family Services
Professor of Pediatrics, University of Chicago
President & CEO, La Rabida Children’s Hospital
“Children In Foster Care Are
Among The Most Unhealthy
In America”
(Pinkney, AMA News 1994)
Health Status Prior To Coming
Into Child Welfare System
CATEGORIES OF PRIMARY DIAGNOSIS OF NEWBORNS
ENTERING FOSTER CARE COMPARED TO NEWBORNS IN
AFDC 1995
Odds Ratios of Newborns Entering
Primary Diagnosis
DCFS vs. AFDC Population___
Low Birth Weight
2.76**
Respiratory Distress Syndrome
1.98**
Congenital Anomalies
1.47**
Substance Exposed Infants
32.43**
Seizures
1.79
Not Significant:
 Birth Trauma/Intrauterine Hypoxia
 Hereditary/Degenerative Condition
AFDC: Aid to Families With Dependent Children
**P<0.0001
(Bilaver, Jaudes, Social Service Review, 1999)
CATEGORIES OF PRIMARY DIAGNOSIS OF
CHILDREN ENTERING FOSTER CARE COMPARED
TO CHILDREN IN AFDC 1995
Primary Diagnosis
Odds Ratios of Children Entering
DCFS vs. AFDC Population
All Chronic Conditions
Chronic Physical Conditions
Psychiatric Conditions
Developmental Disorder
1.27**
0.91**
2.40**
1.40**
Not Significant: Lead, Anemia
AFDC: Aid to Families With Dependent Children
**P<0.0001
(Bilaver, Jaudes, Social Service Review, 1999)
COMPARISON OF THE ILLINOIS FOSTER CARE
POPULATION AND THE GENERAL AFDC
POPULATION FOR SELECTED HEALTH STATUS
INDICATORS USING 1995 MEDICAID CLAIMS DATA
HEALTH STATUS INDICATOR
AFDC POP.
FOSTER CARE POP.
21.4%
42.7%
Behavioral/Psychiatric Health Issues
5.9%
25.6%
Developmental Delays
3.6%
8.1%
Chronic Conditions
AFDC: Aid to Families With Dependent Children
(Bilaver, Jaudes, Social Service Review, 1999)
Healthcare of Children
In Foster Care
Foster Care In Three Urban Areas
Findings from a U. S. General Accounting
Office Report
Children >3 years
3 Urban Areas (Los Angeles, New York City,
Philadelphia County)
Source: U. S. General Accounting Office. (1995) Foster Care: Health needs of many young children
are unknown and unmet (GAO/HEHS 95-114). Washington, DC: U. S. General Accounting Office.
Foster Care In Three Urban Areas



12 percent received no routine health care
34 percent received no immunizations
32 percent continued to have at least one unmet
health need after placement

78 percent of the children were at high risk for HIV,
but only 9 percent had been tested for the virus

Less than 10 percent received services for development delays

Children placed with relatives received fewer healthrelated services of all kinds than children placed with
non-relative foster parents
Source: U. S. General Accounting Office. (1995) Foster Care: Health needs of many young children
are unknown and unmet (GAO/HEHS 95-114). Washington, DC: U. S. General Accounting Office.
Historical Context

Health care provisions in B.H. Consent Decree, signed
in December 1991

HealthWorks designed in accordance with American
Academy of Pediatrics (AAP) and Child Welfare League
of America (CWLA) guidelines, and Early Periodic
Screening, Diagnosis & Treatment (EPSDT)
requirements

Illinois was the first state in U.S. to implement a statewide health care system for all children in state custody

Preferred Provider Organization Model, NOT Capitated
HealthWorks
Of
Illinois
Historical Context - Consent Decree Requirements

Creation of health services management unit (now
Office of Health Services)

Hiring of independent Medical Director

Hiring of nurses as child welfare consultants in each
DCFS region

Use of Medicaid presumptive in component of HW
eligibility from the date of custody

Development of “lead agency” concept, hybrid of
ASO (Administrative Service Organization) to
administer the HealthWorks program
Components of Illinois Model of Health Care for
Children in Foster Care
HEALTHWORKS OF ILLINOIS




Comprehensive system of health care for all children in
substitute care
Access to quality primary and specialty health care
Provider Networks – PPO Model: Initial Health
Screenings, Comprehensive Health Evaluations, Primary
Care
Documentation of health needs
Implementation

HealthWorks implementation began in Cook County in
1993; rollout to Downstate completed in 1995

In 1997, over 52,000 children in state custody, majority in
Cook County

In August 2007, less than 17,000 children in care, majority
now are Downstate
HealthWorks Is A Collaborative Effort
Of Three Illinois State Agencies

Department of Children and Family Services

Department of Healthcare and Family Services
(formerly the Department of Public Aid – DPA)

Department of Human Services
HealthWorks Structure

Twenty Lead Agencies: 1 in Cook County
and 19 Downstate

Medical Case Management agencies covering
every county
Financing For HealthWorks

All health care services are Medicaid
covered services

Annual State funding of $3.5 million for
administrative support for HealthWorks
lead agencies
HealthWorks Services
Core Components






Initial Health Screenings, within 24 hours of PC
Comprehensive Health Evaluations, within 21 days of TC
Linkage to a “medical home” with a qualified primary care
provider
Current (2007) PCP Network: 640 in Cook County; 2000+
Downstate
Standardization of Medical Records, including Health
Passport
Medical Case Management Services
Initial Health Screenings (IHS)
Purpose:

To identify and treat any acute medical
issues, including any infectious or
communicable disease

Document any signs of maltreatment

Provide the case worker with medical
information that can be used in making
placement decisions
Initial Health Screenings (IHS)
Timeframe:
Receive placement IHS within 24 hours,
preferably before placement
Goal:
95% of new children receive IHS within 24
hours
Initial Health Screenings (IHS)
Implementation Strategies:

24 hour Health Line (Cook County)

Transporters, DCP aides

Network of ED, Urgent Care Centers

Enhance Payment – in/out 1 hour
Initial Health Screenings (IHS)
Lessons Learned:

Quality of Exam

Documentation

Timely Movement Through ED
Initial Health Screenings (IHS)

Design One Form

Quality Review of Documentation

Training

11 Preferred Sites (Cook County)
Initial Health Screenings (IHS)
Performance Measure:
Cook County
February 1995
December 1997
February 2001
February 2003
February 2005
February 2007
33%
53%
79%
77%
76%
87%
Downstate
N/A
N/A
N/A
June 2003
June 2005
June 2007
76%
85%
86%
Comprehensive Health
Evaluations (CHE)
Purpose:

Comprehensive health evaluations, including
screening tests (e.g., HIV, hearing, vision)
Timeframe:
Within 21 days of temporary custody
Goal:
95% of new wards will receive CHE within 21 days
Comprehensive Health
Evaluations
Implementation Strategies:

Interim Case Management

Primary Care Providers

Initiate Health Passport

Case Worker Retrieves Prior Health
Information
Comprehensive Health
Evaluations
Lessons Learned:

Primary Care Physicians DO NOT Perform
CHE

Timeliness (Case Worker)

Transportation Problems

Past Health Information Frequently Not
Available
Comprehensive Health
Evaluations
Interventions:
Regionalized CHE sites (FQHC)
 Critical Path Analysis to Identify Time
Consumed To Complete Each 4 Critical
Tasks
 Clear Expectations, Training
 Reminder Recall For CHE’s with Case
Workers and Foster Parents

Comprehensive Health
Evaluations
Interventions Continued:

Provision of Transportation As Needed

Improved Method of Documentation
Retrieval
Comprehensive Health Evaluations
Performance Measures:
CHE’s Completed
June 2000
June 2003
June 2005
June 2007
Cook County
34.1%
32.6%
48.0%
87.8%
Downstate
N/A
81.5%
84.9%
89.5%
CHE’s Completed Within 21 Days of TC
June 2000
June 2003
June 2005
June 2007
52.3%
25.5%
36.1%
78.5%
N/A
N/A
N/A
N/A
Primary Care Provider (PCP)
Medical Home
Purpose:

Foster Parent Chooses From Network
Providers

If PCP is not in Network – Enroll
Goal:
95% of all wards linked to qualified PCP
Primary Care Provider (PCP)
Medical Home
Implementation Strategies:

Interim Case Manager Contacts Foster Parents

Foster Parents Chooses PCP For Child

Enhanced Rate – “Monthly Management” Fee

PCP’s Credentialed Every 2 Years
Primary Care Provider (PCP)
Credentialing
Training In Pediatrics (Pediatrician,
Family Physician)
 24 Hour Coverage
 Hospital Admitting Privileges
 Medicaid
 Licensed In State
 Professional Regulations
 Standardized Medical Records

Primary Care Provider (PCP)
Medical Home
Lessons Learned:

Difficulties Enrolling Non-Network PCP
Into Network
- Medicaid Payments, Forms

Form Documentation
Primary Care Provider (PCP)
Medical Home
Intervention:

On-going Process of Enrolling

Targeting Non-Enrolled Physicians With
Most Children

Increase Medicaid Rate (Federal Decree)

Simplify Documentation for IHS + CHE
Primary Care Provider (PCP)
HealthWorks Enrollment
Performance Measures:
Cook County
Downstate
1992
0%
0%
(No documentation of linkage to PCPs for children in foster care)
October 1997
July 1998
46%
93%*
N/A
98% (2002)
2003 to Present
97%
98%
* Change in definition of HealthWorks enrollment.
Standardized Medical Records
Purpose:
Unified Health Records
Passport Of Child Kept By Foster Parent
Goal:
All Children Have Health Passports
Process:
 Standardized Forms Given To PCP In Network
 Design Health Passport
 Form Stays With Physicians For Own Records;
Copy of Form To Case Manager
Standardized Medical Records
Lessons Learned:

PCP did not want to fill out forms

Health Passport – Lost, not dynamic

Medical Records – Kept at case management, not
shared with “need-to-know parties”
Performance Measures:
None – No Health Information System!
Medical Case Management (MCM)
Purpose:

Facilitate access to primary and specialty care

Develop individualized health care plan –
for Client Service Plan and for ACR’s

Track immunizations and Well Child Exams
Medical Case Management (MCM)
Goal:
90% of all wards will be current with immunizations and Well Child Exam requirements
Target Population:



Children in DCFS legal custody between the
ages of 0 – 5 years
Pregnant wards
Children (0 –5 years) of parenting wards
Medical Case Management (MCM)
Implementation Strategies:
• Oversight by DHS (state Title V MCH Agency)
• Selection of DHS-certified providers
• Use of local public health department’s Public
Health Nurses for high-risk (APORS) children
Medical Case Management (MCM)
Interventions:
• Monitoring Issues of MCM Providers
by DHS
• Funding Rate Low
Medical Case Management (MCM)
Interventions:
• Discontinue use of MCM providers with low performance for Immunizations and Well Child
Exams
• Increase use of MCM providers with high performance for Immunizations and Well Child Exams
Medical Case Management (MCM)
Performance Measures:

Immunizations
June 1999
Cook County
32%
Downstate
N.A.
June 2003
70%
90%
June 2005
76%
93%
June 2007
80%
92%
Medical Case Management (MCM)

Well Child Exam
June 1999
Cook County
23%
Downstate
N.A.
June 2003
42%
83%
June 2005
70%
93%
June 2007
75%
89%
Does HealthWorks Work?
Application of Continuous Quality
Improvement (CQI)
Concepts and Principles to Measure
Improvements in the Receipt of
Health Services
for Children in Foster Care
Basic CQI Tools

Know Thy Customer: For every process or
service, we must determine who is the
customer

Do It With Data: Decisions must be based on
facts and reliable data

PDSA (Plan, Do, Study, Act) Cycle For
Quality Improvement:
Basic CQI Tools Continued
PDSA Involves a circular approach to
improvement

Plan a change

Implement the change on a small scale

Study the results of the change

Act either to standardize the change or to begin
the cycle of improvement again with new
information
Application Of CQI To HealthWorks

Monthly CQI meetings reviewing aspects of the
HealthWorks Program in Cook County (see monthly
summary of performance indicators handout)

Tri-annual CQI meetings for downstate HealthWorks
lead agencies reviewing various aspects of the
HealthWorks Program

Quarterly CQI meetings with key DCFS and DHS staff
reviewing aspects of the HealthWorks Program and
systemic issues of access to health care services for
children in foster care
Application Of CQI To HealthWorks
Of Illinois

Improvement in Immunization Compliance for
Children Enrolled in Chicago Public Schools
DCFS Wards
November 2001
October 2003
October 2005
October 2006
Source: CPS Out of Compliance Report
95.4%
92.4%
96.3%
97.3%
CPS General Pop.
N/A
N/A
N/A
90.1%
Application of CQI to HealthWorks
Of Illinois

Improvement in Well Child Services using ReminderRecall System with caregivers and caseworkers
(Pilot project in Cook County)

Merge of data from DHS and DCFS

Reminder letters to caregivers, caseworkers, and PCPs

Immunization/Well Child Exam history and forecasts
Application of CQI to HealthWorks
Of Illinois
Results of Reminder-Recall System (Cook County)
June 2004
June 2007
MCM Agency A
Immunizations
Well Child Exams
76%
77%
96%
90%
MCM Agency B
Immunizations
Well Child Exams
91%
93%
93%
92%
MCM Agency C
Immunizations
Well Child Exams
68%
32%
80%
69%
HealthWorks
Percentage of Children Receiving Service by Study Populations, 1997
DCFS Custody
Enrolled
in HealthWorks
General Exams
74.0
Physician Services
71.1
Psychiatric Clinic Services
5.5
Mental Health Services
14.3
Hearing Exams
13.5
Eye Exams
18.9
Lead Screening
18.2
Emergency Room Services
22.8
General Inpatient Hosp.
7.8
Psychiatric Inpatient Hosp.
3.2
DCFS Custody
NOT Enrolled
in HealthWorks__
55.1
50.7
4.1
14.5
10.7
16.8
8.0
20.2
7.7
2.7
AFDC
_Children
38.7
35.7
0.6
0.8
5.1
7.0
8.4
16.4
7.3
0.3
AFDC = Aid to Families with Dependent Children.
(Jaudes, CWLA, 2004)
HealthWorks
Adjusted Odds Ratios of Service Receipt for Children in HealthWorks Compared With
Children Not Enrolled in HealthWorks and in AFDC, 1997
Children in Custody, NOT
Enrolled in HealthWorks
Children In
AFDC
Service Type
General Exams
Physician Services
Psychiatric Clinic Services
Mental Health Service
Hearing Exams
Eye Exams
Lead Screening
Emergency Room Services
General Inpatient Hospitalization
Psychiatric Inpatient Hospitalization
AFDC = Aid to Families w/Dependent Children.
**p<0.01
1.82**
2.20**
1.49**
1.28**
1.22**
1.27**
1.49**
1.12**
1.04**
1.26**
5.15**
5.46**
9.68**
22.31**
2.84**
2.86**
2.27**
1.55**
2.32**
11.11**
(Jaudes, CWLA, 2004)
Trends Of Chronic Conditions Of Children In Substitute Care
35
70,000
60,000
30
55,000
50,000
45,000
25
40,000
35,000
30,000
20
25,000
20,000
15,000
15
10,000
fy95
fy96
fy77
fy98
fy99
fy00
fy01
fy02
fy03
fy04
fy05
Number of Children in DCFS Protective Custody
Percentage of Children with Chronic Conditions
65,000
35
70,000
30
60,000
25
50,000
20
40,000
15
30,000
10
20,000
Children in DCFS Custody
Percentage of Children with Cronic Conditions
Trends Of Chronic Conditions Of Children In Substitute Care
Chronic
DDMR
Asthma
Attention
N in care
5
10,000
0
0
fy95
fy96
fy77
fy98
fy99
fy00
fy01
fy02
fy03
fy04
fy05
Trends Of Physician Services Of Children In Substitute Care
100
90
Percentage of Children Receiving Care
80
70
60
Physician Category
50
Psych Category
40
30
20
10
0
fy95
fy96
fy97
fy98
fy99
fy00
fy01
fy02
fy03
fy04
fy05
Trends Of Services For Children In Substitute Care
40
Percentage of Children Receiving Care
35
30
25
Hearing Exams
20
Eye Exams
15
10
5
0
fy95
fy96
fy97
fy98
fy99
fy00
fy01
fy02
fy03
fy04
fy05
Trends Of Health Services For Children In Substitute Care
35
Percentage of Children Receiving Care
30
25
20
Emergency Room Services
General Inpatient Care
Psychiatric Inpatient Care
15
10
5
0
fy95
fy96
fy97
fy98
fy99
fy00
fy01
fy02
fy03
fy04
fy05
All DCFS Substitute Care Compared To TANF
(where duration > 1 year)
Fiscal Year of Claims
2002
2003
2004
2005
TANF
DCFS
TANF
DCFS
TANF
DCFS
TANF
DCFS
114018
22,145
83,171
19,089
63,579
17,065
58,675
15,059
Chronic Conditions
12
27
13
27
13
29
16
32
DDMR
6
18
6
14
6
14
5
15
Asthma
6
9
6
10
6
11
7
12
Attention
2
13
2
13
3
14
3
15
N of Children with claims
Pct of children with claims with:
Fiscal Year of Claims
2002
2003
2004
2005
TANF
DCFS
TANF
DCFS
TANF
DCFS
TANF
DCFS
114,018
22,145
83,171
19,089
63,579
17,065
58,675
15,059
Hearing Exams
24
24
23
21
19
16
18
18
Eye Exams
34
37
32
36
28
29
27
31
Lead Screening
4
6
1
2
0
1
0
0
N of Children with
claims
Pct of children with claims
with:
Fiscal Year of Claims
2002
2003
2004
2005
TANF
DCFS
TANF
DCFS
TANF
DCFS
TANF
DCFS
114,018
22,145
83,171
19,089
63,579
17,065
58,675
15,059
Emergency Room
Services
16
24
9
14
9
14
8
11
General Inpatient Care
1.6
3.9
1.6
3.6
1.5
3.7
1.6
3.4
Psychiatric Inpatient
Care
0.5
4.3
0.5
5.0
0.6
5.3
0.5
6.1
N of Children with
claims
Pct of children with claims
with:
NEW INITIATIVES
Challenges for the HealthWorks Program
1.
Limitations in health information component of
SACWIS
Strategic Objective: Enhance SACWIS to achieve:
-- sharing of health data from other state agencies
-- producing a dynamic electronic Health Passport
-- providing aggregate data to assess health
outcomes
2.
Coordination with behavioral/mental health system
Strategic Objective: Develop “Consult for Kids” pilot
project for HealthWorks PCPs to request consultation
on behavioral/mental health concerns.
Challenges for the HealthWorks Program
3.
Nearly 50% of wards in substitute care are over 12 years
of age
Strategic Objective: Improve the HealthWorks provider
network and service delivery system to better serve
adolescents’ health care needs.
4.
Statewide disparities in access to dental care
Strategic Objective: Collaborate with DHFS to increase
Medicaid participation statewide by qualified dental
providers.
OTHER STATES
UTAH
RHODE ISLAND
ARKANSAS
MASSACHUSETTS