Q: The providers in our practice are often asked to provide exams for children who are in foster care. These kids seem to have a lot of needs. What do clinicians need to know about this population?
A: Nationally over 500,000 children are living in some form of foster care.1 These children experience discontinuity of home, school, health care, and relationships. They are likely to have problems with access to health care. They have an increased prevalence of acute and chronic health conditions, mental health issues, and sporadic care. Approximately 24,000 adolescents age out of foster care each year. They are at greatly increased risk for homelessness (85%), unemployment, illness, incarceration (at a rate triple that of the general population), welfare dependency, and sexual and physical victimization. Eighty percent will have mental health issues.2
Children in foster care cost Medicaid more than three times what non-disabled, Medicaid-eligible children cost due to their complex physical and behavioral health needs.3 Enhancing capacity of Medical Homes to serve this high-need population is the next step.
By definition, all children in foster care are considered CYSHCN (Children and Youth with Special Health Care Needs). In addition to the physical health needs that they are likely to have, many of these children have particular social-emotional challenges that include:
Foster parents themselves have social-emotional challenges. These can include:
Very often foster parents have not had specific training about the social-emotional needs of children in foster care and how to manage them.
The need for standards to ensure coordinated, comprehensive care for foster children, with active involvement of the Medical Home, is a national one. According to the American Academy of Pediatrics standards for the Medical Home and Foster Care,4 the Medical Home helps with obtaining and interpreting the child’s medical history, provides consistency in the child’s life, which may be unstable due to changing environments between homes, and makes recommendations to the child welfare agency and the court about medical (including developmental and behavioral) and safety issues.
In addition, fundamental principles summarized from the Healthy Foster Care America website,4 state that children and adolescents should have an enhanced health care schedule so the PCP can monitor for signs and symptoms of abuse or neglect as well as to monitor a child’s or youth’s adjustment to foster care and visitation. These office visits will also ensure a child or youth has all necessary referrals, medical equipment, and medications, as well as support and education for foster parents, birth parents and kin.
The enhanced health care schedule for children and youth in foster care reflects the principles of the chronic care model. Children and youth in foster care should be seen often upon entry to foster care. These visits occur over the first 2–3 months of care and include a health screening visit within 72 hours of placement; a comprehensive health admission visit within 30 days of placement; and a follow-up health visit within 60 to 90 days of placement. The initial visit is the health screening visit, which is brief and intended to assess for signs and symptoms of child abuse and neglect, for presence of acute and chronic illness, for signs of acute or severe mental health problems, and to ensure that a child or youth has all necessary medical equipment and medications at placement. In order to have time to collect and review pertinent health and school records, the comprehensive health admission visit in the Medical Home should occur at 30 days.
Within 30 days of placement, children and youth in foster care should have the following: a comprehensive mental health evaluation; a developmental health…