State Practices for Assessing Health Needs, Facilitating Service Delivery, and Monitoring Children's Care
GAO-09-26: Published: Feb 6, 2009. Publicly Released: Feb 6, 2009.
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.
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.