Many children in foster care have experienced significant trauma and have complex physical and behavioral health care needs. Quality foster parenting is a therapeutic intervention that promotes children’s health and well-being. A core aspect of this role is being an effective partner in ensuring children receive the health services they need. Meeting those needs, however, can be frustrating for foster parents because of systemic barriers in the areas of medical consent, information sharing, access and coordination of services, and training. Policy should, to the extent possible, eliminate those barriers so that children receive the care they need.
What the Research Says
Research has consistently identified that children in foster care have high levels of physical and mental health needs. Foster parents report that addressing those needs is often a challenge and even a reason for discontinuing to foster. Further, the inability of foster parents to manage the physical and mental health needs of the children in their care has been linked to placement disruption. Studies also show that when foster parents receive appropriate supports, including access to children’s physical and mental health services, their retention improves. A research summary is available here.
Recommended Policy Approaches
Authorize foster parents to consent to routine medical care
Requiring birth parent or agency consent for all medical treatment, even routine care, can delay treatment for minor conditions such as head lice or scabies, which can keep children out of school and away from activities such as team sports.
Facilitate sharing of health information through electronic information exchange
Providing foster parents with paper copies of health records is burdensome and inefficient. The information in such records is likely to be out-of-date and incomplete. Electronic exchange can ensure that information is current. It can also allow for tiered access to maintain appropriate privacy protections while promoting coordination.
Develop and implement federally-required Health Oversight and Coordination Plans (HCOPs) that provide for medical homes and trauma-informed care
The Fostering Connections to Success and Increasing Adoptions Act, as amended, requires state child welfare and Medicaid agencies to develop HCOPs in consultation with pediatricians and other healthcare and child welfare experts. These plans must ensure a coordinated strategy to identify and respond to the health care needs of children in foster care, including mental and dental health needs. Development and implementation of these plans is an opportunity to improve care coordination and quality.
Establish a mobile crisis response program:
Mobile crisis response provides immediate help to families, including resource families, with children who are experiencing escalating emotional symptoms and behaviors. These services promote placement stability by preventing the need for higher intensity interventions, such as residential treatment.
Ensure that foster parents are prepared to understand and manage children’s physical and behavioral health needs
Foster parents should receive training and support that addresses the effects of trauma, developmental delays, prenatal substance exposure and care for medically fragile children. Foster parents need baseline knowledge and a sense of self-efficacy regarding management of children’s complex needs.
Require child welfare agencies to have medical
When feasible, agency leadership should include pediatricians and/or child psychologists to bring a medical perspective to agency decision-making and policy formulation.
Examples of Existing Policies and Programs
California Medical Consent Statute
Ventura County, CA Foster Health Link
This public/private initiative, launched in 2015, provides caregivers secure electronic access to up-to-date health information about the children in their care. Prior to 2015, caseworkers were required to deliver to foster parents paper copies of health records that were often out of date and fragmentary. Foster Health Link is a website and mobile application that pulls current health and education data from the state’s Child Welfare Services Case Management System (CWS/CMS) and the county health care agency regarding children’s immunizations, allergies, medical conditions, medications, well child physical and dental exams, Medi-Cal enrollment, as well as educational records. Ventura County developed the system in collaboration with the Children’s Partnership and several private foundations and technology companies.
Minnesota Statute on Mental Health and FASD Training
Massachusetts DCF Healthcare Reforms
In 2014, the state Department of Children and Families (DCF) convened a Task Force on Medical Services for children in foster care. As a result of the task force’s recommendations, DCF hired a medical director and medical social workers for each of the 29 DCF area offices. The medical social workers ensure that children receive a screening medical exam and comprehensive medical visit within one month of entering foster care, verify that visits are documented in the DCF database, provide care coordination, arrange medical follow-up, address insurance issues and provide support to foster caregivers. As a result, compliance with medical visit policy increased from 22 percent to 85 percent. In addition to medical social workers, each of the five DCF regions employs a full-time nurse who provides consultation on individual cases, is a liaison to healthcare providers and leads training for caseworkers and managers.
New Jersey Mobile Response and Stabilization Services (MRSS)
Under the MRSS intervention, administered by the New Jersey Department of Children and Families (DCF) as part of the Children’s System of Care, a behavioral health worker is available to any family in the state at any time, 24 hours a day, seven days a week, 365 days a year. Services offered include crisis de-escalation, in-home counseling, behavioral assistance, caregiver therapeutic support, intensive community-based services, skill-building and medication management. The services are available to all families–birth, kinship, foster, guardianship and adoption. In April 2017, DCF adopted a policy that assigns an MRSS worker to every child newly placed in out-of-home care within 72 hours after removal. The worker meets with the child individually and also with the caregiver to discuss how the worker can support the family and strategies the caregiver can use to respond to difficult behaviors.3 The MRSS program has achieved impressive results. During the period from 2014 to 2018, between 95 and 98 percent of children served have remained in their current living situations.4 Other jurisdictions that have adopted mobile response as part of their children’s system of care include Connecticut; Delaware; Milwaukee, Wisconsin; Nevada and Oklahoma.
Health Oversight and Coordination Plans
Several states have used their HOCP process to develop innovative approaches to managing and improving access to care for children in foster care. Missouri, Ohio, and Washington are key examples of collaboration and demonstrated ability to overcome challenges in care delivery. A key feature of all three states is partnership with their state chapter of the American Academy of Pediatrics. Engaging AAP chapters in the HOCP development process offers agencies health expertise and the perspective of professionals currently caring for children in foster care. Missouri’s HOCP emphasizes trauma-informed care, data collection and sharing, and ongoing quality improvement. Ohio’s HOCP also adopts a trauma-informed approach and incorporates responses to parental opioid use and FASD. The Ohio HOCP outlines partnering with school health systems, medical homes, Medicaid managed care plans, and the Fostering Connections Program at Nationwide Children’s Hospital. The Washington state HOCP reflects strengths in data and information sharing, upcoming integration of physical and behavioral health systems, and formal psychotropic medication utilization review.
Texas 3 in 30
Texas requires that all children entering foster care receive three critical health assessments within 30 days. Known as 3 in 30, this new initiative requires that all children entering foster care receive timely assessments related to their medical, behavioral, and developmental health. Within three days of entering care, children must receive an initial medical exam, to assess for injuries and illness and receive any related treatment.4 Within 30 days, children must also receive a Child and Adolescent Needs and Strengths (CANS) assessment, a tool that can help professionals determine the level of trauma a child has experienced, the services that may help them, and the strengths they currently have to build upon.5 Also required within 30 days is a complete check-up with lab work in accordance with the state’s Early and Periodic Screening, Diagnosis and Treatment program, known as Texas Health Steps. This is critical for identifying health needs, assessing whether a child is experiencing any developmental delay, and ensuring a child’s caregivers know how to support their growth and development.
Fond Du Lac Tribe Child Care Guidance
A tribal ordinance provides guidance on daily activities that promote optimal physical, social, mental and emotional health and development of children in care, including activities that enhance children’s appreciation of their cultural heritage. For example, the ordinance requires that infants have ample opportunities for freedom of movement every day in order to promote large-muscle development. For toddlers, the ordinance requires that each child be provided with limits consistent with age and understanding in order to protect the child’s and others’ safety. Similar requirements exist for preschool, school-age and adolescent children. The ordinance also includes a daily food guide, including food groups, average serving sizes and recommended number of servings for children in each age group.
Maryland and Virginia Legislation Requiring Medical Directors
In 2018, the Maryland General Assembly enacted HB 1582, which established the position of Medical Director for Children Receiving Child Welfare Services within the state Department of Human Services (DHS). The legislation was passed in response to an audit of DHS and a report by the Citizen’s Review Board for Children that found significant deficiencies in tracking and monitoring the health of children in the department’s custody. DHS filled the position of medical director in February 2019. The legislation tasks the medical director with data collection on provision of health services; tracking of health outcomes; assessing the competency of health care providers; assessing supply and diversity of health care services for children in foster care; identifying systemic problems affecting health care for children in out-of-home care; and ensuring best-practice medical review and evaluation of cases of suspected child abuse or neglect. The legislation also requires the medical director to develop a centralized comprehensive health care monitoring program. The bill’s preamble cites the health care monitoring program in Baltimore called Making All the Children Healthy (MATCH), in which a non-profit organization works closely with the Baltimore City Department of Social Services to ensure that children in foster care and kinship care receive medical assistance coverage, health care coordination, individualized health care plans, and case management or care coordination services. Finally, the bill expresses the General Assembly’s intent that DHS establish a centralized data portal to provide the department with integrated health information on children in out-of-home placement and create an electronic health passport for such children.
The Virginia General Assembly enacted SB 1339 in 2019 that, among other things, requires the state Department of Social Services (VDSS) to establish the office of Director of Foster Care Health and Safety. The director’s duties include, among others, identifying local boards of social services that fail to ensure the health, safety and well-being of children in foster care; ensuring that local boards remedy such failures, including those related to physical, mental and behavioral health screenings and services; and tracking health outcomes of children in foster care. The legislation also requires that VDSS regional offices be equipped with sufficient staff to provide oversight of foster care and adoption services, including reviewing the medical necessity of placement of children in residential facilities and monitoring children’s health issues such as medication management, frequency of visits with health care providers, and use of psychotropic medications. Amendments to the state’s biennial budget included funding for 18 new positions to monitor the health and well-being of children in foster care, including the Director of Foster Care Health and Safety.
The need for stable, quality foster parenting has never been more urgent. A compelling body of research has emerged about the importance of quality parenting to the well-being of children, especially for children who have suffered the trauma of abuse, neglect and abandonment. Unfortunately, far too many foster parents give up because they lack needed support, services, information and recognition as key partners in promoting children’s safety and well-being. Some states, localities and tribes are beginning to put into place a wide variety of policies and programs to meet the need for quality foster parenting. A few of these policies and programs are highlighted in this Policy Playbook. CHAMPS will continue documenting examples and disseminating best practice information as the campaign progresses. Accordingly, we invite all who are interested in this critical issue to get involved with CHAMPS and share their ideas, knowledge and experience. Please visit our website, www.fosteringchamps.org, for ways to get in touch.
1Cal. Health and Safety Code, §1530.6
2Minn. Stat. §245A.175
3New Jersey Department of Children and Families Policy Manual, Child Protection and Permanency, Vol. IV, Chapter B, Subchapter 8, Child Protection and Permanency Access to MRSS Process for Placements and Replacements in Resource Care and Kinship Homes
4Casey Family Programs, Strategy Brief: What is New Jersey’s Mobile Response and Stabilization Services Intervention?, May 2018.
5Texas S.B. 11 (2017), codified at Tex. Fam. Code § 264.1076
6Texas S.B. 125 (2015), codified at Tex. Fam. Code § 266.012