Children in state protective service programs face any number of challenges, not the least of which is getting good health care. Indeed, according to the Center for Health Care Strategies (CHCS), between 2007 and 2009, "not a single child welfare agency in the nation achieved substantial conformity with the federal Child and Family Services Review, which assesses the extent to which child welfare agencies meet standards [regarding a child's health and well-being]."
Those years happen to be the time period CHCS worked with nine managed care organizations (MCOs) nationwide to identify and pilot ways to improve the process and outcomes of health care for children and youth in the child welfare system. These collaborations, funded by the Annie E. Casey Foundation, were compiled in a publication called Improving Outcomes for Children in Child Welfare: A Medicaid Managed Care Toolkit. CHCS calls it a resource "for state policymakers, MCOs, and others considering effective quality improvement approaches for a small but significantly high-need subset of the Medicaid child population."
That population includes about half a million kids -- "only about 3 percent of the overall Medicaid child population, but their expenditures are huge and extremely disproportionate," says Kamala Allen, director of child health quality and vice president for program operations at CHCS, and the toolkit's lead author.
Almost all of the kids entering child welfare have physical health problems, and more than half of them have two or more chronic conditions. About half of them also have significant emotional and behavioral health conditions as well. With the constant disruptions and fluctuations in their living situations and caregivers, the coordination and consistency needed to deliver effective health care for these kids is severely challenged.
Allen's group selected nine health plans and grouped them into three areas targeted for improvement: access to care, coordination of care and appropriate use of psychotropic prescriptions. "We supplied the overarching goal -- improve QI [quality] -- and their charge was to look at their data and pick and refine their specific goals," Allen says. Over the three-year period, CHCS provided technical assistance, regular phone calls and held quarterly meetings to help the plans customize their approaches to suit their membership's needs.
Here's what each plan accomplished -- or didn't:
• Connecticut Behavioral Health Partnership focused on access and reducing wait times for appointments. "Their assessment approach was particularly inefficient, with lots of variation among centers throughout the state," Allen says. Through enhanced training and outreach and a closer partnership with the child welfare agency, the MCO increased the number of kids who received services within 60 days by 60 percent, and decreased average wait time for an appointment from 22.5 days to 6.5, a 71 percent improvement.
• Magellan Behavioral Health of Florida sought to improve "kinship care" (whereby foster children are placed with family members) for kids with behavioral needs. They employed a national model called Kinship Navigators to pair families new to the foster care program with experienced families to mentor and help them navigate the system. The plan was able to maintain 100 percent retention for kinship placements with the model.
• Massachusetts Behavioral Health Partnership worked on improving prescribing patterns for kids on multiple drugs, and reduced the number of children on three or more medications by 84 percent. That saved $422 per child on average.
• Mid Rogue Health Plan in Oregon was able to create a medical home (coordination with a primary care provider along with physical and mental health assessments) for 88 percent of all new foster children, more than double the pre-program level, by improving coordination among the various players and identifying gaps in care. "It was so successful they are replicating the entire project in another county," Allen says.
• Volunteer State Health Plan in Tennessee wanted to increase the use of electronic health records (EHRs) to improve continuity of care. With hands-on training among providers, the plan increased the rate at which providers reviewed the EHR from 27 percent to 52 percent of children.
• UPMC For You in Pittsburgh worked to establish the use of EHRs and increase access to care. Establishing a liaison to negotiate gaps in care and improve communication, they increased well child visits from 53 percent to 79 percent and dental visits from 60 percent to 75 percent.
• Wraparound Milwaukee's goal was to improve coordination of care with medications. They wanted 100 percent of kids to have a primary care provider and have all kids on multiple psychotropics seen by a provider every year, Allen says. The results: Overall primary-care visits jumped from 60 percent to 94 percent, and those on multiple drugs who visited their physicians went from 65 percent to 81 percent. That in turn lowered the number of kids on three or more meds from 87 percent to 39 percent, resulting in substantial savings.
• Priority Partners in Baltimore County, Md., wanted to improve access to care. The MCO didn't hit its goal of getting a health screening for 75 percent of newly-enrolled kids, but was close -- 64 percent received a screening. "There was less there there," Allen says, meaning many children simply didn't have a clear place to turn for health care. So the county created a new health unit within the child welfare agency. Now any child without health care goes directly into Priority Partners care.
"One of [the] themes in all our research was that success came from the ability to establish partnerships and trust between the health plan and welfare agency," Allen reports. Indeed, two plans that didn't "get traction," CareOregon and Health Net of California (not featured in the report), couldn't get buy-in from stakeholders.
There are two important takeaways, Allen says. First, health care for kids in foster care can be improved significantly, especially when effective partnerships between child welfare agencies are established and nurtured. Also, change takes time. "This research took three years," she says.