Foster Care: State Practices for Assessing Health Needs, Facilitating Service Delivery, and Monitoring Children's Care
Published: 2009-02-06T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Providing health care services for foster children, who often have significant health care needs, can be challenging. The Administration for Children and Families (ACF) oversees foster care, but state child welfare agencies are responsible for ensuring that these children receive health care services, which are often financed by Medicaid. In light of concerns about the health care needs of foster children, GAO was asked to study states' efforts to improve foster children's receipt of health services. This report has four objectives. It describes specific actions that some states have taken to (1) identify health care needs, (2) ensure delivery of appropriate health services, and (3) document and monitor the health care of children in foster care. It also describes the related technical assistance ACF offers to states. To address these objectives, GAO selected 10 states and interviewed state officials and reviewed related documentation regarding the nature and results of the states' practices. To describe ACF's technical assistance, GAO interviewed officials and reviewed documents from ACF, states, and relevant technical assistance centers.
section_title: What GAO Found
paragraphs: To identify the health needs of children entering foster care, all 10 states we studied have adopted policies that specify the timing and scope of children's health assessments, and some states use designated providers to conduct the assessments. All of the states we selected for study required physical examinations, most states we studied required mental health and developmental screens, and several of them required or recommended substance abuse screens for youth shortly after entry into foster care. Preventive health examinations for foster children were required at regular intervals thereafter, in line with states' Medicaid standards. Limited research has suggested that having assessment policies and using designated providers who have greater experience in the health needs of foster children may permit fuller identification and follow-up of children's health care needs. To help ensure the delivery of appropriate health care services, states have adopted practices to facilitate access, coordinate care, and review medications for children in foster care. Some states used specialized staff to quickly determine Medicaid eligibility; others issued temporary Medicaid cards to prevent delays in obtaining treatment. In addition, certain states had increased payments to physicians serving children in foster care to encourage more physicians to provide needed care. Nurses or other health care managers were given roles in coordinating care to help ensure that children received necessary health care services. Six states we studied also reported monitoring the use of various medications, including psychotropic medications intended for the treatment of mental health disorders. To document and monitor children's health care, several states we studied had shared data across state programs and employed quality assurance measures, such as medical audits, to track receipt of services. One state has developed a foster care health "passport" that electronically compiles data from multiple sources, including the state's immunization registry, and this passport can be accessed and updated by responsible parties through a secure Web site. Other states used electronic databases to obtain more complete and timely medical histories than otherwise available but provided more limited access to these and continued to update them through use of paper records. ACF's network of 25 technical assistance centers is intended to improve state performance in meeting children's needs, including their health care needs, by increasing the capacity of state agencies to ensure safety, wellbeing, and availability of permanent homes for children in their care. According to ACF officials, the centers are not intended to provide medical expertise, but to help state child welfare agencies collaborate with others involved with health programs. One center in ACF's network focuses exclusively on children's mental health and several others have also assisted in identifying some practices to improve the health of children in foster care. Five of the centers are newly funded and are expected to provide long-term help in implementing plans to improve agency performance in meeting children's needs.

section_title: Letter
paragraphs: Some of our nation’s most vulnerable children are those who have been  removed from their homes and placed in foster care, often due to abuse or  neglect. Of the nearly 500,000 children in foster care at the end of fiscal  year 2007, 80 percent are estimated to have significant health care needs,  including chronic health conditions, developmental concerns, and mental  health needs. Treatment for the health care needs of children in foster care  is generally financed through states’ Medicaid programs. In addition to the  extent of foster children’s health care needs, the disruptions associated  with foster care—such as having to leave home and experiencing several  changes in placement—may increase the challenges of ensuring that these  children receive health care services. However, conditions left untreated  can impede children’s ability to realize their potential or become self- sufficient later in life.
States are responsible for ensuring that children in foster care receive  necessary health care services. The Administration for Children and  Families (ACF) within the Department of Health and Human Services  (HHS) provides funding for state child welfare programs, including foster  care. In exchange for this funding, states agree to meet basic federal  requirements. However, they also have flexibility in how they design and  implement their programs. In its past reviews of state agencies’  performance, ACF determined that children under agency supervision,  including those in foster care, may not all receive appropriate physical or  mental health care services. For example, ACF found that about 30  percent of children sampled either did not have their health needs  assessed or did not receive treatment during the period reviewed. In these  cases, states were required to develop and implement improvement plans,  and ACF monitored their implementation.
In October 2008, Congress expanded the federal requirements related to  foster children by mandating that states explicitly plan for the ongoing  oversight and coordination of health care services for children in foster  care. The state practices described in this report, although in use before  the expansion of federal requirements, address some of the new  requirements and, thus, may be helpful to other states as they consider  changes in their plans. Specifically, this report addresses four objectives. It  describes practices that selected states have adopted to address the  challenges of (1) identifying health care needs, (2) ensuring delivery of  appropriate health services, and (3) documenting and monitoring the  health care of children in foster care. In addition, the report describes the  technical assistance that ACF offers states to help improve their  performance in providing for the health care needs of these children.
To address these objectives, we selected 10 states for in-depth study based  on the information they provided and the variations they represented in  geographic location, foster care caseload, and child welfare administrative  structures. The 10 states selected were California, Delaware, Florida,  Illinois, Massachusetts, New York, Oklahoma, Texas, Utah, and  Washington. (For more information on our state selection, see appendix I.)  We conducted site visits in three of these states to describe state practices  in context and gather views of multiple stakeholders, such as state child  welfare officials, health or Medicaid officials, health care providers, foster  parents, and in two cases (Cook County, Illinois and New York City), the  views of child welfare personnel in major metropolitan areas. In our  interviews with officials of the seven remaining states, conducted by  telephone, we focused primarily on interviewing child welfare and  Medicaid officials regarding certain practices that state agencies  identified. We cannot generalize the results of our review from the 10  states we selected to all states. Although we did not examine the actual  operation of every practice, we reviewed information about states’  practices through such means as discussions with researchers, advocates,  and other parties who had knowledge of these states’ foster care programs  and, where available, we also collected and evaluated research, state data,  and other information on the effectiveness of the practices adopted. In  addition, we reviewed relevant federal laws, policies, and guidance and  research literature on the physical and mental health needs and treatment  of children in foster care. To obtain information on ACF’s provision of  technical assistance, we reviewed documents and interviewed officials at  ACF and six centers participating in ACF’s network of technical assistance  providers, including the two centers jointly funded by ACF and HHS’s  Substance Abuse and Mental Health Services Administration (SAMHSA).  Our work was designed to describe specific state and federal practices,  not to assess compliance with statutory or regulatory requirements. We  conducted our work from November 2007 to January 2009, in accordance  with all sections of GAO’s Quality Assurance Framework that are relevant  to our objectives. The framework requires that we plan and perform the  engagement to obtain sufficient and appropriate evidence to meet our  stated objectives and to discuss any limitations in our work. We believe  that the information and data obtained, and the analysis conducted,  provide a reasonable basis for any findings and conclusions.
subsections: section_title: Background
paragraphs: Children in foster care tend to exhibit more numerous and serious medical  conditions than other children, including mental health problems. Foster  care begins when children are removed from their parents or guardians  and placed under the responsibility of a state child welfare agency.  Removal from the home can occur for several reasons. For example,  parental violence, substance abuse, severe depression, or incarceration  may have led to the children’s removal from the home. Other children and  youth are referred when their own behaviors or conditions are beyond the  control of their families or pose a threat to themselves or the community.
The realities of foster care may further contribute to the challenges in  meeting these children’s health care needs. Once children are removed  from their homes, obtaining information on their health status and health  history from their parents or guardians may be challenging. Also, children  often move to several different foster homes or treatment facilities during  the course of their stay in foster care, which may result in having different  health care providers. Changes in placement pose significant challenges  for agencies, foster parents, and providers with regard to providing  continuity of health care services and maintaining uninterrupted  information on children’s medical needs and course of treatment.
Finally, in addition to specific characteristics or circumstances that  complicate their care, children in foster care encounter some health care  challenges in common with other health care users. Child welfare agencies  generally expect that foster parents or other caregivers will recognize  when children need medical attention and obtain the needed health  services, but such services may be in short supply or difficult to access  because of a lack of providers who serve Medicaid patients—particularly  for some specialties or geographic areas. Children entering foster care  may lack medical care prior to entry, and children with prior medical care  may have experienced disruptions in care, changes in providers, and have  missing or incomplete records.
Figure 1 illustrates the steps that are typically involved in addressing  health needs of children in foster care.
subsections: section_title: State and Federal Funding for Children in Foster Care
paragraphs: All state child welfare agencies receive federal funds from ACF for  children in foster care under two parts of title IV of the Social Security Act.  The larger source of federal funds, under title IV-E, provides open-ended  reimbursement for a portion of states’ foster care expenses for children  meeting federal eligibility criteria, who represented about 43 percent of  children in foster care in 2006. Title IV-E provided $4.8 billion to states in  2007 for the federal share of the expense of housing and feeding these  children. States cover the remaining costs and 100 percent of the costs to  house and feed children in foster care who do not meet federal eligibility  criteria. State child welfare agencies also receive funds under title IV-B to  provide services to children in foster care and to those remaining in their  homes for the purpose of preventing conditions leading to the need to  remove children from their homes. In 2007, about $700 million was  available under title IV-B. State child welfare agencies cannot use title IV-E  or most IV-B funds for the direct provision of health care services. Limited  IV-B funds may be used for some health care services but are intended  primarily for the support and preservation of families, rather than for  children in foster care. Foster children who meet title IV-E eligibility  criteria, on the other hand, are explicitly identified as a group that is  eligible for coverage under Medicaid.
As a condition of receiving federal funds, state child welfare agencies must  agree to meet certain federal requirements, including requirements related  to the health of children in foster care. Under both titles IV-B and IV-E,  states must submit plans to ACF that contain a number of statutorily  required elements. For title IV-E, state agencies must have a written case  plan for each child that includes specific health information, such as  records of immunizations and medications, to be shared with foster care  providers at the time of placement. The agencies must also have standards  to ensure that children are provided services to protect their safety and  health. Because these standards have not been further defined in statute or  regulation, states have some flexibility with respect to their form and  content. For safety and health standards, some states have cited standards  for licensing foster care facilities, training foster care parents, or  credentialing staff.
In recent years, Congress has twice amended title IV-B, subpart 1 to add  new state plan requirements related to the health of children served by  child welfare agencies. Congress initially required that state plans describe  the involvement of physicians and other medical professionals in the  assessment and treatment of children in foster care. This requirement  was effective with state plans approved by ACF in 2007. In October 2008,  as we completed our review, Congress further amended title IV-B, subpart  1 to require state agencies to develop plans for the ongoing oversight and  coordination of health care services for children in foster care. This new  requirement expanded on the earlier requirement by mandating that the  agencies include in their plans schedules for initial and follow-up health  screenings that meet reasonable standards of medical practice; steps to  ensure continuity of health care services, which may include the  establishment of a medical home—a primary health care provider or  group—for every child in care; oversight of prescription medications; and  information on how children’s needs identified through screenings will be  monitored and treated and how their medical information will be updated  and appropriately shared—as for example, by using electronic health  records. These requirements apply to all children in foster care, regardless  of whether or not the children meet federal eligibility criteria.
section_title: Federal Oversight and Technical Assistance
paragraphs: Starting in 2001, ACF took a new, results-oriented approach to its  oversight of state child welfare programs, focusing on whether children  and their families served by these programs achieved positive outcomes.  This oversight effort involved four phases of Child and Family Services  Reviews (CFSR), as shown in figure 2. ACF expects to complete the final  phase of the initial round of CFSRs in 2009.
In the second phase of the initial round of the reviews completed in 2004,  ACF identified significant performance challenges, particularly with  respect to meeting children’s mental health needs. ACF assessed state  child welfare agency performance on 45 indicators across a wide range of  areas, such as children’s safety and statewide information systems. On the  two health indicators addressing physical and mental health, ACF  identified 20 states as showing strengths in providing services to meet  children’s physical health needs, and 4 states also showed strengths in  meeting the mental health needs of children in foster care and children  remaining in their homes under agency supervision. Nearly all states  were required to implement program improvement plans because they did  not show strengths in physical health, mental health, or both. ACF is  required by statute to offer technical assistance, to the extent feasible, to  help such states develop and implement plans to improve outcomes for  children, including health outcomes. When ACF determines that a state  has not met the jointly developed goals and action steps identified in these  plans within 2 years of approval of the improvement plan, ACF regulations  specify that it will withhold a portion of the state’s grant funds. In the  course of its oversight, ACF identified several challenges that states faced  in meeting the health needs of children in their care, as summarized in  table 1.
section_title: Medicaid and Health Care Services for Children in Foster Care
paragraphs: Medicaid is the primary health care funding source for most children in  foster care. The Medicaid program is administered at the federal level by  the HHS’s Centers for Medicare & Medicaid Services (CMS) and is jointly  financed by the states and the federal government. All state Medicaid  agencies receive federal funds for the Medicaid program under title XIX of  the Social Security Act. Within broad parameters set by federal statute and  regulation, state Medicaid agencies are responsible for determining  eligibility and establishing the services and payments offered. Although  many coverage, eligibility, and administrative decisions are left to  individual states, the federal government sets certain requirements for  state Medicaid programs, such as coverage of certain screening and  treatment services. Children who meet federal eligibility criteria for IV-E  foster care are required to be covered by state Medicaid programs under  federal law. In addition, states have chosen to extend Medicaid coverage  to other children in foster care. In 2004, Medicaid expenditures for  children in foster care exceeded $5 billion.
Children in foster care who are enrolled in Medicaid may receive services  through one of two distinct service delivery and financing systems— managed care and fee-for-service. Under a capitated managed care model,  states contract with a managed care organization and prospectively pay  the plans a fixed monthly fee per patient to provide or arrange for most  health services. Plans, in turn, pay providers. In the traditional fee-for- service delivery system, the Medicaid program reimburses providers  directly and on a retrospective basis for each service delivered.
States are required to offer certain screening and treatment services to  children enrolled in Medicaid. Termed Early and Periodic Screening,  Diagnostic, and Treatment services (EPSDT), these screenings must  include, but are not limited to, a comprehensive health and developmental  history, a comprehensive unclothed physical exam, appropriate  immunizations, laboratory tests, and health education. The required  services include vision, dental, hearing, and services for other conditions  discovered through screenings, regardless of whether these services are  typically covered by the state’s Medicaid program for other beneficiaries.  The state Medicaid agencies establish standards for the timing and  frequency of these screening and treatment services and set their own  payment rates for fee-for-service providers of these services. Federal  regulations require that EPSDT screening services be provided in  accordance with reasonable standards of medical and dental practice  determined by the state after consultation with recognized medical and  dental organizations involved in child health care.
In addition to EPSDT, states may choose to offer optional Medicaid  benefits, such as rehabilitative services and targeted case management for  children in foster care. States have used the rehabilitative services option  for children in foster care who have mental or developmental problems as  a means of providing a wide range of services designed to help them  achieve their highest level of functioning. States have used targeted case  management in order to provide case management services to a defined  group of Medicaid-eligible individuals, such as children in foster care.  Such case management activities have included assessing a child’s needs,  developing plans to meet those needs, referring a child to services,  monitoring the receipt of such services, and ensuring any necessary  follow-up care.
Federal Medicaid funds are available for a portion of case management  activities, as long as funds are not available from other programs or from  other entities, such as other insurers, that would be legally obligated to  pay for such services. However, concerns exist that Medicaid funds have  been inappropriately used, and CMS has denied payment for services  when funds were available from other programs, such as Title IV-E. In  2007, CMS issued rules—an interim final rule for case management  services and a proposed rule on Medicaid program coverage for  rehabilitative services—that further defined the use of Medicaid funds for  these benefits for children in foster care. However, in 2008, Congress  passed and the President signed into law a moratorium on certain aspects  of the rules that remains in effect until April 1, 2009.
section_title: Other HHS Agencies
paragraphs: In addition to ACF and CMS, other agencies within HHS have roles in  sustaining the health of foster children through supporting research,  providing grants, or offering technical assistance that may assist with  providing necessary health care services to children in foster care, as  shown below:    The Agency for Healthcare Research and Quality is responsible for  supporting research designed to improve the quality of healthcare, reduce  its costs, address patient safety and medical errors, and broaden access to  essential services;  the Health Resources and Services Administration (HRSA) administers  programs related to maternal and child health, as well as services specific  to particular conditions, such as human immunodeficiency virus and  acquired immune deficiency syndrome (HIV and AIDS); and    SAMHSA funds programs and services for individuals—as well as their  families and communities—who suffer from or are at risk for substance  abuse or mental health disorders.
section_title: Specific Requirements for Health Assessments—and Using Designated Providers to Conduct Them—Are Employed to Identify Children’s Health Care Needs
paragraphs: To help facilitate the timely identification of foster children’s health care  needs, all 10 states we examined had adopted specific policies with regard  to the timing and scope of assessments, and 4 of these states also reported  using designated providers to conduct the assessments. The policies  generally call for assessments shortly after children enter care and take  one of two forms: (1) a two-stage assessment comprised of an initial  screening followed by a comprehensive assessment or (2) a single  comprehensive assessment. Most states we selected for study included a  requirement for screening of children’s mental health and developmental  needs, and most of the states we studied cited substance abuse screenings.  Researchers and state officials have suggested that having designated  providers conduct assessments may improve the quality and utility of  assessment results. State officials report that these assessment practices  have allowed them to make more appropriate and lasting placements of  children in foster care and also to provide follow-up treatment more  quickly than before these practices were in place. Some research also  links specific assessment policies to higher rates of follow-up.
subsections: section_title: Specific Requirements Can Ensure Timely, Appropriate Initial and Comprehensive Assessments
paragraphs: While federal law did not specifically require assessments before fiscal  year 2009, the 10 states we reviewed had made assessments of children’s  physical health mandatory for all children entering care, as recommended  by medical and other professional associations. Because children often  enter foster care with serious health conditions and, at times, without  easily accessible medical histories, it is important to identify their health  needs as quickly as possible. Health or developmental status may be a  critical factor in determining the appropriate placement and level of care  for children, as in the case of children with HIV or significant behavioral  problems. Where there are explicit and comprehensive policies mandating  assessments of all children entering care, greater percentages of children  are likely to be assessed, according to a survey of a nationally  representative sample of child welfare agencies. Further analysis of these  survey data showed that agencies with comprehensive developmental  screening policies were more likely to evaluate children, refer them to  early intervention agencies, and engage in joint planning of health care  services.
Officials from the 10 states we reviewed reported using two general  approaches to conducting assessments, but all required some health  assessment within 30 days of a child’s removal from his or her home.  Florida, Illinois, Massachusetts, and New York generally conduct  screenings or assessments in two stages: (1) an initial screening within 24  hours to 7 days to check for immediate health needs and (2) a later, fuller  assessment within 30 days of entry into foster care. Some state officials  expressed the view that waiting a while for the fuller assessment may give  children the opportunity to adjust to their changed circumstances and for  this reason may offer providers a more accurate picture of the children’s  health. Additionally, they noted that assessments may be lengthy and  require significant time to complete. For example, Florida officials  explained that their comprehensive assessment of mental health,  development, and substance abuse takes 20 hours to complete, double the  amount of time the state previously allotted in order to cover all necessary  aspects of care. A second approach to identifying children’s health care  needs—used by California, Delaware, Oklahoma, Texas, Utah and  Washington—invokes a one-stage assessment process mandating that it be  completed within 14 to 30 days of entry into foster care depending on the  state. Utah officials explained that the state dropped its earlier  requirement for an initial screening followed by another assessment, in  part because the results were duplicative. However, the state expects  caseworkers to be alert to urgent health needs and arrange treatment as  needed. The state has written guidelines advising caseworkers that if there  is any sign of abuse or neglect or if the child is ill, the child should be seen  by a health care provider within 24 hours.
Once a child enters foster care and receives an initial assessment, state  foster care policies in most of the states we selected for study required  that ongoing assessments follow the schedules established by state  Medicaid agencies for children’s screening, which are based on the  children’s age or the time between routine checkups. Six of the 10 states  we selected for our study called for children in foster care to receive at  least annual screening, either under a separate health standard applicable  to foster children or because their EPSDT standard for all Medicaid  enrollees called for at least annual screenings, consistent with the 2008  American Academy of Pediatrics’ recommendation on preventive pediatric  care. See table 2 for a summary of the number of EPSDT screens  incorporated in the Medicaid EPSDT standard for all children in the  Medicaid programs in the 10 states we reviewed.
In addition to policies requiring assessments of children’s physical health,  8 of the 10 states we studied also reported requiring screening or  assessments of children’s mental and developmental health shortly after  entry into foster care. Research indicates that an estimated 30 to 60  percent of children in foster care may have chronic health conditions, and  the proportion estimated to have serious health care needs rises to over 80  percent when behavioral, emotional, and developmental concerns are  included. Guidelines issued by professional associations emphasize the  importance of assessing mental health and other behavioral health issues  for children in foster care. An analysis of the results of ACF reviews  conducted between 2001 and 2004 found no evidence of policies requiring  an assessment of children’s mental health in most states; in one state,  stakeholders noted that children did not get mental health assessments  unless there were problems observed. The ACF reviews have helped  focus attention on the mental health needs of children in foster care,  however, and we found that most of the 10 states we selected for study  had adopted policies to screen or assess the mental health and  development of children entering foster care. Most states we studied had  also adopted policies requiring or recommending screening youth entering  foster care for substance abuse. For example, Delaware officials told us  that—since February 2006—its initial health screening has required the  inclusion of a component alerting staff to any mental health or substance  abuse problems for all children 4 through 17 years of age. Other state  policies varied in whether or not they included specific time frames. For  example, New York has no mandatory time frame for its required mental  health assessment, although it is recommended that this be completed  within 30 days of placement. State guidance also varies on the tools used  for the assessments. In some states, such as Massachusetts, the steps  taken by individual health practitioners as part of either (1) the  comprehensive screening within the first 30 days or (2) in later Medicaid  screenings are considered sufficient to meet the policy requirements. In  other cases, states have adopted or are considering adopting specific  screening tools. For example, Utah reported the state had specified the  tools to be used in assessing the development of children ages 4 months to  5 years. Officials in both California and Oklahoma reported they were  working to identify assessment instruments for the early identification of  children with mental health or developmental needs.
section_title: The Use of Designated Providers Can Increase the Thoroughness of Physical and Mental Health Assessments
paragraphs: Four states we studied reported using designated providers to perform  certain initial and comprehensive assessments, which some evidence  indicates can increase the consistency and thoroughness with which  children’s physical and mental health needs are identified. Illinois, for  example, requires that children’s initial health evaluations be conducted  by a network of hospital emergency rooms and clinics, while subsequent  assessments are generally conducted by a network of community- and  facility-based physicians, with foster parents permitted to use others on  request. We identified two studies that associated use of designated or  specialized health care providers for foster children with higher rates of  preventive and specialty care.
With regard to physical assessments, states that identified the use of  designated providers to perform initial screens and comprehensive  assessments reported that these providers functioned as part of a network  of providers, as primary providers in specific locations, or both and, in  some cases, that the use of such networks had enhanced the numbers  receiving assessments. For example, Florida reported that some of its  counties have focused on developing a network of trained providers, while  Oklahoma and Utah identified specific locations in urban areas—such as  clinics or hospitals—where some children could receive assessments. In  most cases, these initial providers could serve as medical homes for the  children they assessed. (See table 3 for more information on how states  use designated providers.) Some state officials commented that the use of  a specific network of physicians also facilitated quality improvement  efforts. For example, a physician with Cook County’s Healthworks  program noted that the quality of health assessments—once a subject of  complaint from child welfare field staff—had improved when assessments  were channeled to a network of specific providers that could be supported  by targeted training efforts. He noted that the health assessment for a child  entering foster care requires a more thorough, detailed approach and level  of documentation than that involved in a standard EPSDT well-child exam.
The states shown in the table as using designated providers elaborated on  their practices and, in some instances, noted specific strategies that may  contribute to providers’ effectiveness:  Illinois requires that the initial health screening be completed within an  hour of the child’s arrival at the medical facility. Illinois officials reported  that appointments for the screening in Cook County are arranged through  a toll-free telephone service called HealthLine, which is staffed around the  clock by a child welfare contractor who can obtain priority service for  children so they do not experience lengthy waits in hospital emergency  rooms. Hospital emergency rooms are used for many initial screenings  because they are accessible outside of normal business hours, but the  comprehensive health assessments generally take place in physicians’  offices because they require more time. Research on children enrolled in  the Illinois program has shown that these children experienced higher  rates of preventive and necessary specialty care than other children with  similar socio-economic characteristics who were not enrolled in the  program. Although the research did not evaluate the effectiveness of the  program itself, the researchers concluded that the increased attention and  oversight of the health care for the children enrolled in the program  affected their outcomes.
Oklahoma officials noted that their clinic-based assessment process began  with a pediatrician who had experience working with children who had  been removed from their homes and placed into shelters. Concerned about  the continuity of care for children in these situations, this pediatrician set  aside particular times for children in foster care to visit the clinic and see a  familiar provider. A second clinic that was opened in another large city is  also under the medical direction of a pediatrician familiar with the needs  of children in foster care. Officials told us they believe that children’s  health care benefits when they are served by providers with knowledge of  the foster care population.
In addition to using designated providers for physical health screens and  comprehensive assessments, a few states reported using a mental health  specialist who worked with caseworkers to conduct assessments. The use  of specialists to conduct mental health screenings can be an effective  means of identifying children’s mental health needs. One study that  surveyed a nationally representative sample of agencies found that  involving mental health specialists in assessments resulted in a greater  identification of mental health needs, as well as improved follow-up care,  than were received by children whose assessments did not include a  mental health specialist.
The mental health assessments used by states we selected varied. In some  cases, the assessments were comprehensive social assessments that  covered areas such as mental health, emotional health, school, work, and  community involvement. In other cases, the focus was narrower, covering  specific topics such as indicators of mental illness. Washington officials  reported that specialized social workers conducted comprehensive  assessments using standardized tools that assess several aspects of social  and mental health needs, including behavioral, developmental,  educational, family, and social issues. For physical or mental health  concerns identified during the screening that require treatment, state  officials indicated that the social workers refer children to appropriate  health care professionals.
section_title: Practices to Enhance Access to Services, Coordinate Care, and Monitor Use of Medications Are among Efforts to Ensure Delivery of Health Care to Foster Children
paragraphs: To address the challenge of ensuring delivery of appropriate health care  services to children in foster care, several of the states we selected for  review adopted practices designed to facilitate access to care, coordinate  services, and review medications for children in foster care. Practices  relating to access to care included efforts to hasten determination of  Medicaid eligibility, implement financial incentives for providers to serve  children in foster care, and enhance access to medical specialists for  various subgroups of children. Care coordination practices that the  selected states identified employed either nurses or other health care  managers to help ensure that children in foster care received necessary  health care services. Officials of specific states we contacted said that  such care coordination had increased rates of immunization, initial  assessment, and well-child visits. Finally, officials from six of the states we  studied pointed to policies that they had implemented requiring the review  of prescriptions for psychotropic medications commonly used to treat  mental health disorders for children in foster care.
subsections: section_title: Practices to Enhance Access to Care Include Streamlined Medicaid Eligibility, Financial Incentives to Providers, and Strategies to Obtain Specialty Care
paragraphs: Among the states we studied that identified a practice state officials  believed noteworthy in enhancing access to care, some had identified  assigning certain staff—from their Medicaid offices or from their child  welfare offices—to ensure that children in foster care were quickly  reviewed for Medicaid eligibility. Because the removal of a child from  home can change his or her Medicaid eligibility status, some states we  contacted had taken steps to save time in certifying Medicaid eligibility  and facilitate new foster care beneficiaries’ access to providers. For  example, Delaware had assigned two Medicaid staff to foster care cases,  while Florida, Utah, and Illinois used staff members from the child welfare  offices to determine eligibility for Medicaid. Utah has a written agreement  between the state child welfare and Medicaid agencies that specifies that  certain staff in Utah’s Division of Child and Family Services will determine  Medicaid eligibility for children in foster care. The purpose of this  arrangement is to enhance services to children and families, simplify  administration, improve accuracy, conserve state resources by avoiding  duplication, and maximize legitimate Medicaid funding. In Illinois, children  coming into foster care are presumed to be eligible for Medicaid. For  purposes of formal eligibility determination, Illinois officials reported that  using specialized staff members in the state child welfare agency’s central  office to complete the determination had sped up the process. Specifically,  they reported that a process that once took 3 to 4 months could now be  completed within 4 weeks of issuance of the temporary medical card.  Florida officials also reported that their agreement that staff from the child  welfare department determine Medicaid eligibility reduced the amount of  time required to make these determinations from 18 days to within 24  hours.
Illinois and Washington are among the states that offer financial incentives  to providers who treat children in foster care, since providers may be  reluctant to serve children in foster care. In Illinois, physicians serving  children in foster care are paid a one-time $15 fee to initiate a paper health  passport to document the health history and ongoing care of the child.  Additionally, the state uses an enhanced payment rate for initial health  screenings conducted in hospital emergency rooms. Washington officials  reported that the state increased its payments in November 2001 for  medical providers who conducted well-child examinations for children in  foster care. At the time, these rates were about twice the reimbursement  rate paid in other cases. State officials reported that since 2001, other  Medicaid rates—such as payments for EPSDT services—have also  increased, so that rates for foster care children are no longer twice as high.  However, the foster care rates remain equal to or substantially greater  than the standard Medicaid rates. In April 2008, Washington officials told  us that approximately two-thirds of children received well-child  examinations, up from about 17 percent before the state increased the  rates in 2001.
Utah, Illinois, and New York have instituted a variety of programs to  increase access to medical specialists or subspecialists. Under some  circumstances, obtaining specialty care can be difficult for Medicaid- eligible children, and such efforts for children in foster care may be even  more difficult if the children have complex health needs or changing  placements. These states’ efforts typically focused on specific subgroups  of children in foster care, such as those in rural areas, those who need  mental health services, and those who would otherwise require  institutional care.
Children in Rural Areas: Utah and Illinois have efforts focused on  children living in rural areas where it may be harder to find a pediatric  health specialist or subspecialist. For example, Utah has eight clinics to  which multidisciplinary teams travel in order to provide specialty services  for children with special health care needs across rural Utah. State  officials told us that in some cases, children are seen more quickly in these  locations than in Salt Lake City. Illinois officials reported transportation is  available and sometimes is used to get rural foster children to providers,  including oral dental surgeons, orthodontists, and child psychiatrists.  Despite these efforts, state child welfare officials cited a continuing  challenge in obtaining mental health and substance abuse services, and  especially child psychiatry for children in Medicaid and other publicly- funded medical care, not just those in foster care. As a result, Illinois has  also begun to look at the use of telepsychiatry in one of its downstate  regions.
Children Needing Mental Health Services: To address children who are  experiencing mental health crises, Illinois developed a psychiatric crisis  intervention program with a single, statewide 24-hour, 7-day-a-week crisis  hotline. When a person calls the crisis line, a mental health provider is  expected to reach the child in crisis within 90 minutes of the call to  conduct a screening and determine if the child requires psychiatric  hospitalization. Following this decision, the mental health provider is to  continue to provide treatment and other service interventions for a  minimum of 90 days. State officials reported that this program serves  about 18,000 children per year, including all children who receive  Medicaid or other public funding for medical care (not just those in foster  care). Medicaid covers all the services provided by this program, which  began in 2004, on a fee-for-service basis.
Children Who Might Otherwise Require Institutional Care: With respect  to difficulty in accessing specialty services, New York launched a program  in early 2008 for children in foster care who have developmental  disabilities, serious emotional disturbances, and medical problems that are  so severe they would otherwise likely be in restrictive and high-cost  institutions. By making community-based services available to a fixed  number of these children, the state hopes to help them function in family  and community settings instead. New York officials reported that when  the program is fully implemented after 2011, it will serve approximately  3,000 children in foster care.
section_title: Public Health Nurses and Other Health Care Managers Coordinate Care to Help Ensure Health Services Are Delivered Appropriately
paragraphs: Several states we studied discussed their development of the role of health  care managers with the goal of improving health care and health outcomes  for children in foster care. While all children in foster care have  caseworkers, they focus on issues related to the child’s safety and  permanency and do not necessarily have medical expertise. Typically,  health care managers are nurses who are colocated with the child welfare  agency and work with the child’s foster care caseworker. Officials in  California told us that the nurses are colocated in the child welfare offices  so they can easily talk directly to caseworkers. These nurses may be able  to more quickly spot gaps in care than foster care caseworkers because  they are trained to understand children’s health and developmental needs,  they are able to communicate clearly with health care providers, and they  can provide medical guidance to both foster care caseworkers and foster  and biological parents. In some states—such as California and Utah—each  child is assigned a nurse, while in other states—such as Illinois and  Massachusetts—only those children with specific or medically complex  needs are individually assigned to a nurse. In some states, public health  nurses provided the care coordination services for children in foster care,  whereas in Illinois, the state child welfare agency or a local contracting  agency served as health care manager. Some positive results in achieving  health-related goals for children in foster care had been documented for a  health care management effort in New York.
The specific services provided by health care managers varied in the states  we contacted, but usually included the development and maintenance of  the child’s health history, medical case planning—that is, identifying the  child’s medical needs and arranging for receipt of medical services—and  identification of medical professionals available to provide services to  children in foster care. For example, state officials in Utah told us that the  state has 29 Maternal and Child Health agency nurses serving about 90  children each. The nurses may provide medical, mental health, and dental  consultation; identify the child’s primary care provider; place the child in  the appropriate health plan; gather, evaluate, and document the health  history of each child; track ongoing health care; and maintain an up-to- date medical history on each child within an electronic database.  Officials in Utah reported that use of public health nurses has reduced  errors in transcribing information about medical history and ongoing care  into the state’s electronic database. Utah officials also reported that they  find that biological parents are more comfortable talking openly with the  nurse, who they said biological parents tend to view as an advocate rather  than an adversary. According to data provided by state officials, another  result of the program is that more children are getting their comprehensive  assessments completed than before, and more quickly than required.  Specifically, Utah officials reported that about 76 percent of children  received these assessments in a timely fashion in 2008, compared to 58  percent in 1998, before the program was implemented. They further noted  that these assessments are being conducted in 18 days, on average, rather  than taking the full 30 days allowed by state requirements.
Health care managers may also provide other services. Caseworkers in  Illinois told us that in medically complex situations, families can be  assigned to a regional nurse who can provide recommendations and assist  a caseworker in communicating with the family on medical needs.  Similarly, in Massachusetts, staff told us that nurses in regional offices  provide consultation to staff regarding the medical needs of all children  and work with children who have difficult or complex medical needs. In  Illinois, officials at one of the privately-run case management programs in  Chicago became concerned about immunization and well-child exam  completion rates. As a result, they implemented a paper-based reminder- recall system that gives foster parents, providers, and caseworkers  information about when and what medical services are needed. Prior to  the implementation of the reminder-recall system, officials in one agency  that had adopted it told us that 77 percent of children had up-to-date  immunizations and 44 percent had received appropriate well-child visits.  These officials reported that in 2007, after implementation of this  reminder-recall system, 96 percent received appropriate immunizations  and 90 percent had received well-child care. We were told that the five  community-based medical care management agencies in Cook County  used the reminder-recall system. In addition, some counties outside of  Cook County have instituted a similar system.
New York conducted a formal evaluation of its health care management  project and found that such care coordination had a significant, positive  impact on many aspects of care, including the receipt of both initial  physical and dental assessments, access to nonpreventative care, and  health-related contacts between agency workers and foster parents.  However, funding was not available for the state to continue this program  when the initial pilot project was completed and the project did not meet  nonhealth and well-being related child welfare goals, such as reducing the  number of days spent in foster care and increasing the likelihood of  leaving foster care for a permanent placement.
section_title: Policies Governing the Review of Psychotropic Medications Implemented to Help Ensure Children in Foster Care Receive Appropriate Health Care
paragraphs: Officials in six of the states we selected for interview identified specific  policies they had adopted to govern the review of psychotropic  medications intended for the treatment of mental health disorders. An  Illinois official noted that the use of psychotropic medications is uniquely  challenging for children in foster care, given that foster children who  change placements often do not have a consistent person to plan  treatment, offer consent, and provide oversight. Most of the policies states  identified require an extra level of review beyond the person prescribing  the medication, either by state officials or local experts. Concerns have  been expressed that psychotropic medications have frequently not been  tested for their safety and efficacy with children, and one study of children  in foster care found that the most frequently prescribed medication was an  antipsychotic drug that had not been tested for use by children and  adolescents. Some research has also found that use of psychotropic  drugs by children in foster care is three to four times greater than by other  low-income children insured by Medicaid. Greater prevalence of use is  not, by itself, evidence of inappropriate use; children in foster care may be  more likely to have conditions for which the drugs are indicated. However,  administrative data from one state associated the introduction of its policy  with modest decreases in prescribing psychotropic drugs and declines in  specific patterns of prescribing, such as prescribing multiple drugs.
Texas has developed a policy that notes the importance of conducting a  health history, psychosocial assessment, mental status exam, and physical  exam before prescribing psychotropic medications. The policy suggests  that alternative interventions should generally be considered before  beginning the use of psychotropic medications and outlines specific  circumstances under which a case may require further review. Data  examining the percentage of children prescribed a psychotropic  medication for at least 60 days, the percentage prescribed two or more  medications concurrently from the same drug class, and the percentage  prescribed five or more medications concurrently showed decreases from  fiscal year 2004, before the new policies were implemented, through fiscal  year 2007.
Because of concerns raised about the appropriate use of psychotropic  medications, California requires judicial approval for their administration  to a foster child. The prescribing physician must make the case to a  juvenile court judge that the particular medication is appropriate for the  given child and that alternatives have been considered. The Judicial  Council of California has adopted rules of court to implement this legal  requirement. Specifically, these rules require that an application be made  to a juvenile court judge requesting the use of psychotropic medication  and that the application include the signature of the physician to request  the medication’s use; the child’s diagnosis, the specific medication, and  dosage recommended for use; the anticipated benefits and possible side  effects of the medication; a list of other medications the child is taking,  along with a description of possible drug interactions; a description of  other treatment plans; and a statement that the child has been informed of  the recommended course of treatment with their responses. The court  may grant the application or may delegate that authority to the parent if it  is found that the parent poses no danger to the child and that the parent  has the capacity to understand the request. In an emergency, the rules  allow the administration of psychotropic medications without court  approval in accordance with existing law, but court approval must be  obtained within 2 days.
Other states have worked with universities and local experts to help with  the oversight of psychotropic medication use by children in foster care.  For example, Illinois has contracted with a university to provide an  independent review of each psychotropic medication request to ensure  safe and appropriate usage with children in foster care. The request is  forwarded to a board-certified child and adolescent psychiatrist who  reviews the information and determines whether to approve, deny, or  adjust the request. According to state officials, Florida has also worked  with a local university to develop a process whereby caregivers of children  in foster care receive a consultation with a physician before psychotropic  medications are prescribed. The state also has a mandatory preconsent  consultation for all children age 5 and under in foster care. The state then  tracks information about the medication, such as the prescribing  physician, medication, dosage, number of refills, and its purpose. As a  result, the state is able to determine the number of children receiving  certain types of medication and can then identify areas where there might  be concerns about inappropriate use. Oklahoma and New York also work  with experts to review and provide training related to the use of  psychotropic medications by children in foster care.
section_title: Mechanisms for Data Management and Quality Assurance Address Challenges to Documenting and Monitoring Children’s Health Care
paragraphs: To address the challenges of documenting and monitoring children’s  health care, some states we studied shared health care data across various  state systems to acquire more complete medical histories and used quality  assurance mechanisms, such as medical audits or specialized case  reviews, to track receipt of services. Efforts to share health care data  generally focused on enhancing access to existing health information  among parties responsible for the health of children in foster care while  meeting requirements for data security and privacy protection. For  example, through data sharing with Medicaid and other data sources,  Texas has developed an electronic health record—known as the Foster  Care Health Passport—that can be viewed by authorized individuals  involved in the child’s care through a secure Web site. More commonly,  states we studied identified initiatives that also combined data from  different sources but did not offer electronic access or provide for any  updating at the point of care, relying on paper-based transfers of medical  histories and providers’ updates via the foster parents. Quality assurance  activities have also made use of electronic systems as a means of  monitoring the receipt of services for children in foster care. These efforts  can be important to ensuring that individual children receive the  appropriate level of services, avoiding duplication of services such as  immunizations, and ensuring the receipt of needed services.
subsections: section_title: Data Sharing with Medicaid and Other Systems May Yield More Complete Medical Information
paragraphs: Some states share data with Medicaid and other state systems, such as  immunization registries, in order to obtain more complete medical  information than might otherwise be available as a child enters foster care.  Basic health information should be included in a written case plan and  provided to foster parents before children are placed with them. Obtaining  information that is important to a child’s health records can be a complex  task, which may involve four or more separate systems (see fig. 3).  Additionally, information collected from parents and caregivers may also  be of assistance in understanding the needs of a child.
States that pointed to records management systems as a means of  developing health history cited the use of an electronic health record— sometimes termed an electronic passport—or other efforts to combine  sources of information. Combining these sources of information is  important because few children enter foster care with records that  accurately identify their health providers, health conditions, or receipt of  services. Without these records, their health care may be delayed until  records are available, or their care may be compromised. For example,  officials in two states told us of cases in which health providers had  refused to provide specific treatments to children in foster care because  they did not know their histories or did not have medical records available  to prevent improper treatment. Similarly, children may miss  immunizations, receive duplicate immunizations, or forego necessary  medications.
subsections: section_title: Web-Based Electronic Passport Can Allow Access to Comprehensive Health Information on Individual Children in Foster Care
paragraphs: In April 2008, Texas began implementing an electronic passport to track  health data for 29,000 children in foster care. This passport can be  updated regularly and is accessed through a secure Web site by foster  parents, caseworkers, and health care providers who are responsible for  making health decisions on behalf of children. The Foster Care Health  Passport is operated by a managed care organization that is under contract  with the state Medicaid agency. Texas developed and implemented the  Health Passport using funds from the state and CMS. Officials told us that  total funding data were not readily available.
When a child enters the Texas foster care system, his or her electronic  health record is created by obtaining information from a variety of  sources. The Health Passport is initially populated with Medicaid and State  Children’s Health Insurance Program (SCHIP) claims, including pharmacy  claims data from the past 2 years for children previously enrolled in  Medicaid or SCHIP. Officials told us that generally, data from these  sources are available for a majority, but not all, children who enter foster  care. Immunization records are entered through a data sharing  arrangement with the state’s immunization registry. Once the electronic  health record is created, it can be electronically updated with information  on any health care services that were delivered by any foster care health  provider in the managed care organization’s network. Claims data are  added when the claim is processed, which state officials indicated could  take a few weeks or months, noting that providers have 90 days after a  medical visit to submit a claim. Services provided outside of the  contractor’s network must be added manually through an online form  mailed or faxed to the managed care organization. Officials told us that the  passport also records behavioral health, dental, and vision services.  Finally, officials stated that information in the Health Passport remains  accessible statewide, even when the child’s placement changes and the  child moves to new foster parents, localities, or health providers. When  children leave foster care, the electronic health record is printed out for  the child or his caregiver.
While the Health Passport has not been operational long enough to  determine its effectiveness, state officials told us that they are working on  baseline measures for several variables, such as well-child outcomes, and  have developed measures to assess the contractor’s performance.
Officials in several other states we contacted expressed an interest in  pursuing the development of an electronic health passport. For example,  Illinois uses several data systems to manage Medicaid, foster care, and  community health and preventive care for children, but the state is  working toward integrating data electronically from the many systems in  use, with the ultimate goal being the construction of an electronic  passport. Some obstacles to data sharing have included concerns about  privacy and security. As states look to sharing individuals’ health data to  better serve and treat them, they are also implementing standards  governing the transmission of data, policies to ensure that only authorized  users have access to records, and provisions to protect individuals’  privacy. CMS has taken steps to provide assistance to states on issues of  security and privacy. Several of the states included in this study cited  practices they used to create medical histories and agreements they have  to address data security and privacy issues.
section_title: Other Forms of Data Sharing Can Improve Access to Timely Health Information
paragraphs: Other forms of data sharing use and combine existing record-keeping  systems, usually through a combination of electronic matches and paper  exchange of data among doctors, foster parents, and the Medicaid or the  foster care agency, as shown in the examples below.
Oklahoma officials noted that the state’s efforts to obtain medical  information for children entering foster care centered on using Medicaid  claims data, which it has been doing on a statewide basis since 2007. State  officials reported that the project has been particularly successful because  over 90 percent of children entering foster care had some prior Medicaid  history and over 80 percent were already on Medicaid when they entered  the state’s care. Officials noted that the Medicaid claims data can provide  information on developmental assessments, immunizations, as well as the  receipt of both physical and mental health services.
In Utah and Illinois, nurses enter children’s health information into the  state child welfare agency’s database. In Utah, public health nurses who  work in collaboration with child welfare workers provide medical care  coordination and record visits, diagnoses, and prescriptions for children in  foster care. The child welfare agency in Illinois has a memorandum of  agreement with its Medicaid agency to share pharmacy claims data for  purposes of identifying doctors prescribing psychotropic medications  without consent, and it also electronically obtains immunization data on  children in foster care from an immunization registry. Both Utah and  Illinois state officials told us that they were in the process of creating an  integrated system that will store more complete electronic health records  for children in foster care. For example, Illinois child welfare officials  reported they were working with other state agencies to be able to pull  data from Medicaid claims and other sources.
Massachusetts uses a combination of paper and electronic records. They  exchange medical information with foster parents and health care  providers on paper, which they then enter into an electronic database.
An official with HHS’s Agency for Healthcare Research and Quality told us  that health information exchanges in Colorado and Indiana are being  developed with federal demonstration grants that will include foster  children along with other patients. The HHS Inspector General reported in  August 2007 that at least 27 states are developing at least partially  electronic health records for Medicaid with funds from CMS. These efforts  may extend to children in foster care but are not focused on them.
section_title: Quality Assurance Activities Can Help Monitor the Receipt of Services
paragraphs: New York, Utah, Delaware, and Illinois specifically pointed to quality  assurance activities relevant to monitoring foster children’s receipt of  health care services. Such activities can be used to help track the receipt  of services by individual children in foster care, including ensuring that  individual children are assessed as required and treated appropriately.  Monitoring procedures that aggregate information across foster children  can help managers ensure that health policies are consistently  implemented and having the intended results.
The four states that discussed their quality assurance activities cited  practices that included the use of technology and electronic records to  collect, analyze, and aggregate health care data, perform medical audits,  and conduct evaluations or other checks to ensure the quality of health  care services provided to children in foster care. ACF’s reviews found that  states with identifiable quality assurance systems that conformed to  specific criteria had a higher percentage of cases rated as having met the  health needs of children in the states’ custody. Further, ACF’s analysis  suggested that states with well-functioning quality assurance systems were  more likely to succeed on measures of enhancing a family’s capacity to  provide for the needs of their children and ensuring that the children’s  physical and mental health needs were being met.
The states that identified relevant quality assurance activities to us  provided examples of two approaches: (1) requiring managed care  organizations to track and report individual or aggregate data on foster  children in their care and (2) conducting medical audits of health records  for children in foster care.
With regard to requiring managed care organizations to track and report  certain data, officials in Delaware described a new requirement in its  contracts with managed care organizations aimed at ensuring that initial  health screenings occur and result in the receipt of necessary services. In  2008, Delaware required that contracts with managed care organizations  track and report on services rendered following initial health screenings.  According to Delaware Medicaid officials, the reports are intended to  provide aggregate data on health screenings provided. The officials told us  that no specific concern triggered the 2008 quality check on initial health  screenings, but officials noted that the state would like to be able to  provide aggregate data on the percentage of children in their foster care  program who received an initial health assessment within a set number of  days. Utah uses a statewide case management system that can generate  detailed data on individual children, as well as aggregate reports. Utah  officials explained that these aggregate reports had been used to contact  medical providers when the state received alerts from the U.S. Food and  Drug Administration on the adverse effects of certain drugs. In this  instance, the state sent letters to medical providers urging them to  examine specific patients on these medications. Utah officials believed  that having a majority of records in electronic form facilitated this effort.
Finally, one city and two states reported the use of medical audits to  ensure the receipt and quality of health care provided to children in foster  care. For example, New York City uses medical care audits to examine the  quality of services provided to the 17,000 children in the city’s foster care  program. The city reported conducting two types of medical care  audits—a routine medical audit conducted every 2 years and a special  medical audit for children with HIV, conducted at least annually. These  reviews apply an audit tool that is based on local foster care standards for  physical and mental health to assess documentation in medical records of  the child’s medical history, consent for treatments, comprehensive  physical examinations, diagnostic screenings, immunization history and  status, developmental and behavioral health screenings, and the use of  psychotropic medications. Reviewers provide their results to foster care  agencies, noting findings that must be addressed immediately, as well as a  corrective action plan. The audit score is incorporated into a cumulative  score on the agency’s performance. Officials in Illinois and Utah also  reported the use of medical audits to ensure the delivery of appropriate  care.
section_title: ACF Offers States Health-Related Technical Assistance as Part of Its Broader Efforts to Improve Delivery of Services
paragraphs: Although states are ultimately responsible for meeting the health needs of  children in foster care, HHS is required by law to provide technical  assistance to the extent feasible to help states develop and implement  plans to improve their performance. ACF officials told us that their  emphasis is on providing technical assistance that will increase the  capacity of state child welfare agencies over the long term to serve the  needs of children in their care. ACF officials point out that they do not  expect to provide expertise in the area of health care, but instead to help  child welfare agencies carry out their mission within the flexibility that  states have.
ACF’s 25 technical assistance centers—including one center that  specializes in children’s mental health—offer states a range of assistance,  from on-site consultation to Web-based information on promising  practices. In some cases, the centers help state child welfare agencies  develop strategies to obtain needed services and coordinate their efforts  with others involved in health care, such as the agencies responsible for  Medicaid, public health, mental health, and substance abuse treatment.  These and other agencies are listed among possible stakeholders in ACF’s  reviews of state child welfare agencies. ACF and center staff also referred  to the assistance that is available from nonfederal sources, such as  universities and private foundations.
Technical assistance in the form of on-site consultation is provided at state  request, and few states have requested on-site consultation specifically to  address health care services for children. On-site consultation generally is  requested from ACF regions, coordinated through the National Child  Welfare Resource Center for Organizational Improvement, and tracked by  ACF through a dedicated data system. The centers we contacted generally  report that they have not been asked to provide consultants on site, but  have provided other forms of assistance related to the health care needs of  children in foster care.
Table 4 provides summary information on the centers in ACF’s network  that either specialize in an aspect of health care or have reported  providing some assistance on health care practices through 2008,  including one center with funding from HHS’s SAMHSA that focuses on  children’s mental health. Examples of some of the work these centers  perform in relation to health care are discussed below.
The center that specializes in aspects of children’s health care is the  National Technical Assistance Center for Children’s Mental Health, based  at Georgetown University, which helps states and other entities build  systems to improve access and outcomes for all children with mental  health concerns. The center’s focus is on children who have or are at risk  of having emotional disorders, including children in foster care. This focus  has been extended to include youth facing mental health problems who  have also become involved with substance abuse. The center’s services  range from the development and dissemination of various publications to  consultation on how to increase a state’s capacity to meet children’s  mental health needs. Specifically, at state request, center staff and  consultants may work for a year or more with mental health leaders in  individual states, often along with child welfare directors, to help these  states identify and implement strategies to improve services for children.  One staff position at the center has been reserved for a consultant with  child welfare expertise. According to center staff, the center provides this  type of consultation to an average of 8 to10 states each year and has  served 22 states through 2008. To reach more agency personnel, the  center holds a training institute every other year for approximately 2,000  to 2,500 attendees that in 2008 offered a series of sessions on partnerships  between mental health and child welfare agencies for assessment, early  intervention and treatment, support services, and care coordination,  among other topics. In carrying out their work, center officials reported  coordinating closely with other federally funded centers and  organizations, state professional associations, private foundations, and  research groups. While currently focused primarily on mental health, the  center is also concerned with the integration of primary care and mental  health, and prior to implementation of the ACF reviews, received funds  from the Maternal and Child Health Bureau of HHS’s HRSA to examine  promising approaches to providing the full range of health care services  for children in foster care. A series of reports were published detailing  these approaches that continue to be available through this and other  technical centers for use by child welfare agencies in improving their  service delivery.
In several other centers, staff described information that they have  provided on health care practices, including the following examples:    Seven audio conferences on topics, such as the use of psychotropic  medications, assessing and treating children up through age 3, and other  issues concerning the mental health of children in foster care were  developed by the National Resource Center for Family-Centered Practice  and Permanency Planning at New York’s Hunter College School of Social  Work. Among many sample areas of technical assistance, the center lists  health and mental health issues for children and youth in foster care, and  to that end, hosts a Webpage devoted to health care with multiple links to  other relevant sites.
Sessions regarding the role of clinics dedicated to assessing and treating  children in foster care and the options for financing mental health care  were featured at the 2007 annual conference for child welfare agency staff  arranged by the National Child Welfare Resource Center for  Organizational Improvement at the University of Maine.
The sharing of information on the steps states are taking to extend  Medicaid coverage to older youth when they leave foster care is a key area  of focus for the National Child Welfare Resource Center for Youth  Development in Oklahoma. The center connects states that have been  successful in this area with states asking for assistance and maintains a list  serve for state child welfare agency officials who are responsible for  helping youth prepare for independence.
ACF regional and central office staff may also share promising practices  that they observe during reviews of state programs. These practices are  posted to an ACF Web site and include several related to child and family  wellbeing. ACF’s Web site notes that the Children’s Bureau does not  make any representations pertaining to the effectiveness of the posted  approaches, and ACF officials stated they had taken no further steps to  share them and that they had not evaluated specific state practices. Other  practices have been shared among states at regional meetings, as in ACF  Region VII, where Kansas shared information on its medical passport.  Regional staff may also share information on various practices adopted by  states within the regions. For example, ACF reported that regional staff  members have shared strategies for meeting children’s dental needs, such  as using hygienists in Kansas and using a traveling dental van in Missouri.  Florida officials reported that they received assistance from ACF on  referrals to early intervention programs. New York and Utah officials also  acknowledged the help that they received from regional ACF staff.
To assist in states’ efforts to implement improvement strategies, ACF  newly funded five centers in fall 2008 that are expected to provide in- depth, long-term consultation and support to states to improve the quality  and effectiveness of their child welfare services starting in July 2009. ACF  expects the assistance to help build partnerships to deliver a broad array  of integrated services that can be individually tailored to meet the diverse  needs of children and families served by child welfare agencies, including  their physical, mental, and developmental needs as appropriate. As with  the older centers, states’ identification of needs and potential strategies  will determine the assistance provided. Some assistance with aspects of  health care may be available from these centers if states request it,  according to ACF officials.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Department of Health and Human  Services for comment and received a written response, which is included  in this report as appendix II. HHS provided some additional information  on its technical assistance to state foster care agencies, particularly  through collaboration between ACF and SAMHSA, to assist states in  addressing mental health and substance abuse issues among foster  children. The agency also provided technical comments, which we have  incorporated as appropriate.
We are sending copies of this report to the Secretary of Health and Human  Services, state child welfare agencies, and other interested parties. We will  provide copies to others on request. In addition, this report is available at  no charge on the GAO Web site at http://www.gao.gov.
If you or your staff have questions about this report, please contact Kay E.  Brown at (202) 512-3674 or brownke@gao.gov or Cynthia A. Bascetta at  (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff members who made key contributions to this  report are also listed in appendix III.
section_title: Appendix I: Selection of States and Practices for GAO Review
paragraphs: Our study had four objectives. These included describing practices that  selected states have adopted to address the challenges of (1) identifying  health care needs, (2) ensuring delivery of appropriate health services, and  (3) documenting and monitoring the health care of children in foster care.  In addition, we describe technical assistance the Department of Health  and Human Services’ Administration for Children and Families (ACF)  provides to states to help improve their performance in providing for the  health care needs of these children.
To gain an initial understanding of the types of practices states have  adopted, we reviewed relevant reports and interviewed various experts  and researchers. We reviewed information on promising practices listed  on ACF’s Web site that were identified during ACF’s reviews of state  performance and a list of state practices that ACF provided to us. We also  interviewed several prominent child welfare experts and researchers,  including individuals affiliated with the American Academy of Pediatrics,  the Center for Health Care Strategies, the Chapin Hall Center for Children,  the Georgetown University Child Development Center, and the National  Academy for State Health Policy to obtain additional information on  practices to improve the delivery of health care to children in foster care.
To update information on practices described in available publications and  to obtain additional examples that may not have been reported in  publications, we e-mailed requests for information on current practices  they believed were noteworthy efforts to address children’s health care  needs to representatives of child welfare agencies in 50 states and the  District of Columbia. To minimize the burden on state representatives, we  suggested that they could limit the number of practices they described. We  sent our e-mail requests in October 2007, and representatives for 42 of the  51 child welfare agencies provided responses.
To gather more detailed examples of these practices, we selected 10 state  child welfare agencies for further review—conducting visits to 3 states and  telephone interviews with 7. In selecting states and their practices for  further review, we considered descriptions of each state’s practices  obtained from the states and other research. For practical reasons, in  order to collect sufficient examples from each category while limiting the  number of distinct states we would contact, we also considered whether a  state had more than one practice it considered noteworthy and whether it  encompassed practices in at least two of our five broad categories. We  also gave some weight to the level of context and information the state  had provided about its practices and generally limited our consideration of  practices to those that states indicated they had begun to implement. In  addition, we made efforts to include states that had achieved a strong  rating on the ACF reviews for children’s physical and mental health  indicators and to achieve some distribution in geographic location and  administrative structure.
For 3 of the 10 states selected—Illinois, New York, and Utah—we conducted  site visits and interviewed officials of state child welfare agencies and state  Medicaid Offices, and when possible, health care providers, interest groups,  and foster care parents. For seven states—California, Delaware, Florida,  Massachusetts, Oklahoma, Texas, and Washington—we conducted interviews  by telephone with officials of each state’s child welfare agency and, in some  instances, officials of state Medicaid Offices.
Key characteristics of the selected states are shown in table 5.  Collectively, the states we contacted account for 53 percent of federal IV-E  funds distributed in fiscal year 2007.
For our visits and telephone interviews, we developed semistructured  interview guides for state and local child welfare agencies, including  caseworkers, state Medicaid offices, interest groups, and foster parents. In  addition, we obtained from officials of state child welfare agencies  detailed information on their identified practices, including the dates of  operation; numbers of children served; size of jurisdiction covered; variety  of services offered; funding mechanisms used; outcomes, if any, reported;  and whether any evaluative studies had been conducted or other  documents prepared that discussed the effectiveness of the practice.
We conducted our work from November 2007 to January 2009 in  accordance with all sections of GAO’s Quality Assurance Framework that  are relevant to our objectives. The framework requires that we plan and  perform the engagement to obtain sufficient and appropriate evidence to  meet our stated objectives and to discuss any limitations in our work. We  believe that the information and data obtained, and the analysis  conducted, provide a reasonable basis for any findings and conclusions.
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: In addition to the contacts named above, Betty Ward-Zukerman and  Carolyn L. Yocom (Assistant Directors), Patricia Elston, Carolyn Feis  Korman, Jacqueline Harpp, Darryl Joyce, Jasleen Modi, Alexandra  Edwards, Alison Goetsch, Kevin Milne, Mimi Nguyen, James Rebbe, Jay  Smale, and Charlie Willson made key contributions to this report.
section_title: Related GAO Products
paragraphs: Medicare Physician Payment: Care Coordination Programs Used in  Demonstration Show Progress, but Wider Use of Payment Approach May  Be Limited. GAO-08-65. Washington, D.C.: February 15, 2008.
Department of Health and Human Services, Centers for Medicare and  Medicaid Services: Medicaid Program; Elimination of Reimbursement  Under Medicaid for School Administration Expenditures and Costs  Related to Transportation of School-Age Children Between Home and  School. GAO-08-394R. Washington, D.C.: January 11, 2008.
Child Welfare: Additional Federal Action Could Help States Address  Challenges in Providing Services to Children and Families.  GAO-07-850T. Washington, D.C.: May 15, 2007.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of  Children’s Dental Services. GAO-07-826T. Washington, D.C.: May 2, 2007.
Pediatric Drug Research: Studies Conducted Under Best  Pharmaceuticals for Children Act. GAO-07-557. Washington, D.C.:   March 22, 2007.
Children’s Health Insurance: States’ SCHIP Enrollment and Spending  and Considerations for Reauthorization. GAO-07-558T. Washington, D.C.:  March 1, 2007.
Child Welfare: Improving Social Service Program, Training, and  Technical Assistance Information Would Help Address Long-standing  Service-Level and Workforce Challenges. GAO-07-75. Washington, D.C.:  October 6, 2006.
Foster Care and Adoption Assistance: Federal Oversight Needed to  Safeguard Funds and Ensure Consistent Support for States’  Administrative Costs. GAO-06-649. Washington, D.C.: June 15, 2006.
Administrative Expenditures and Federal Matching Rates of Selected  Support Programs. GAO-05-839R. Washington, D.C.: June 30, 2005.
Medicaid Financing: States’ Use of Contingency-Fee Consultants to  Maximize Federal Reimbursements Highlights Need for Improved  Federal Oversight. GAO-05-748. Washington, D.C.: June 28, 2005.
Medicaid: States’ Efforts to Maximize Federal Reimbursements  Highlight Need for Improved Federal Oversight. GAO-05-836T.  Washington, D.C.: June 28, 2005.
Child And Family Services Reviews: States and HHS Face Challenges in  Assessing and Improving State Performance. GAO-04-781T. Washington,  D.C.: May 13, 2004.
Child And Family Services Reviews: Better Use of Data and Improved  Guidance Could Enhance HHS’s Oversight of State Performance.  GAO-04-333. Washington, D.C.: April 20, 2004.
Medicaid and SCHIP: States’ Premium and Cost Sharing Requirements  for Beneficiaries. GAO-04-491. Washington, D.C.: March 30, 2004.
SCHIP: HHS Continues to Approve Waivers That Are Inconsistent with  Program Goals. GAO-04-166R. Washington, D.C.: January 5, 2004.
Child Welfare: States Face Challenges in Developing Information  Systems and Reporting Reliable Child Welfare Data. GAO-04-267T.  Washington, D.C.: November 19, 2003.
Child Welfare: Most States Are Developing Statewide Information  Systems, but the Reliability of Child Welfare Data Could Be Improved.  GAO-03-809. Washington, D.C.: July 31, 2003.
Child Welfare and Juvenile Justice: Federal Agencies Could Play a  Stronger Role in Helping States Reduce the Number of Children Placed  Solely to Obtain Mental Health Services. GAO-03-397. Washington, D.C.:  April 21, 2003.
Medicaid and SCHIP: States Use Varying Approaches to Monitor  Children’s Access to Care. GAO-03-222. Washington, D.C.:   January 14, 2003.
Mental Health Services: Effectiveness of Insurance Coverage and Federal  Programs for Children Who Have Experienced Trauma Largely  Unknown. GAO-02-813. Washington, D.C.: August 22, 2002.
Medicaid and SCHIP: States’ Enrollment and Payment Policies Can  Affect Children’s Access to Care. GAO-01-883. Washington, D.C.:  September 10, 2001.
Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health  Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Foster Care: Health Needs of Many Young Children Are Unknown And  Unmet. GAO/HEHS-95-114. Washington, D.C.: May 26, 1995.