Expanding the Role of the Hub Clinics

The nonminor is completing secondary education or a program leading to an equivalent credential.

The nonminor is enrolled in an institution which provides postsecondary or vocational educational education.

The nonminor is participating in a program or activity designed to pro- mote, or remove barriers to employment.

MENTAL HEALTH SERVICES THROUGH DMH Multidisciplinary Assessment Teams (MATs) As part of the County of Los Angeles’ settlement agreement from the Katie A. lawsuit,10 the Department of Children and Family Services (DCFS) has made it a policy that all newly detained youth are required to receive a mental health screening or assessment and appropriate linkage to services in a timely manner. To accomplish this, DCFS and the Department of Mental Health (DMH) have collaborated to expand their Multidiscipli- nary Assessment Team (MAT) Assessment Program to all Service Planning Areas. However, this assessment occurs independent of the DCFS detention process, which includes the Initial Medical Exam and mental health screening at the Hub Clinics. Once detained by DCFS as a result of a court order, a youth is referred by staff for a multidisciplinary assessment, generally conducted by a DMH-contracted community- based organization called a MAT Provider. This assessment is intended to provide a comprehensive understanding of the complicated issues that families face when they first enter the foster care system and to enable DCFS Children’s Social Workers (CSWs) to determine more effectively 1) the appropriate placement for the youth; 2) services needed by the youth and their families; and 3) early diagnosis and intervention of critical medical, dental and mental health issues. The MAT Provider gathers information from various sources in the following key areas with regard to the youth and their family: 1) level of engagement; 2) family’s functioning; 3) family’s strengths and needs; 4) child’s functioning, including interpersonal, physical health, mental health, developmental, educational, and vocational functioning, if appli- cable; 5) child’s strengths and needs; 6) current placement; and 7) alternate place- ments, if applicable. For MAT sessions, interviews are conducted with the youth’s parents and/or caregivers and parent-child interactions are observed. A team is assembled to evaluate the find- ings from the interviews and plan for needed services. This team generally includes a mix of individuals involved with the case including: the caregiver; family members; the child, if appropriate; Children’s Social Worker (CSW); Public Health Nurse (PHN) and others concerned with the case. MAT Assessments and Hub Clinics Linkage between the MAT Assessments and Hub Clinics is very limited. The most direct linkage is through the use of the medical report from the Initial Medical Examinations at the Hub Clinics, but these reports are not always available or used in MAT Assess- 10 In July 2002, the “Katie A., et al. v. Diana Bontá" class-action lawsuit was filed against the State of California and the County of Los Angeles on behalf of five named plaintiff foster children and a class of children and young adults who are in the custody of DCFS, or have been referred to or are subject to being referred to DCFS. In lieu of mone- tary compensation, the Katie A. plaintiffs requested that the State and County improve upon its delivery of mental health services to children and families. http://www.lacdcfs.org/katieA/docs/Settlement%20Agreement.pdf EXPANDING HUB CLINICS – 4. MENTAL HEALTH SERVICES 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 287 ments. For instance, youth referred for a MAT Assessment can obtain a medical report from either a Hub Clinic or a community provider. Although detained youth are mandat- ed by DCFS to obtain an Initial Medical Examination at one of the Hub Clinics, a sepa- rate DCFS policy on MAT Assessments contradicts this requirement by allowing the as- sessments to include medical exams from community providers. Secondly, per DCFS and DMH policy, the MAT Assessment must be completed within 30-45 days after acceptance of a referral. However, according to DMH management, though DCFS requires Initial Medical Examinations to be completed at the Hub Clinics within 30 days of initial placement, the actual timing of the Initial Medical Examinations does not always coincide with the 30-45 day requirement for the completion of the MAT Assessment. As discussed in Section 3 of this report, 22.9 percent of the referrals to the Hub Clinics in FY 2010-11 resulted in missed appointments. Because the findings of the MAT Assessment must be presented to the Court, the medical exam is often provided by a community provider. As previously mentioned, a MAT team consisting of various stakeholders and service providers is assembled to evaluate the detained youth’s condition and service needs. According to the Memorandum of Understanding between DCFS and DHS, one of the goals of the Hub Clinics is to “improve coordination and child health care outcomes.” Though their input could be valuable, particularly for youth with Special Health Care Needs,11 except for rare occasions, Hub Clinic staff do not participate in the MAT team meetings. Without the participation of medical Hub Clinic staff and PHNs in MAT team meetings, an opportunity is lost to improve coordination and integration of medical and other care in service plans. PHNs could serve as the critical link between the Hub Clinics and the MAT Assess- ments because of their understanding of medical issues and their responsibility to coun- sel CSWs on medical issues related to their cases. With the approval of additional Title IV-E Waiver funds for hiring PHNs to be co-located at the Hub Clinics, DCFS and DHS should include attending MAT Assessments as one of the prioritized responsibilities of these PHNs. Mental Health Screenings and Ongoing Mental Health Services An additional shared goal of the MAT Assessments conducted by MAT Providers and the Initial Medical Exams conducted at the Hub Clinics is to perform mental health screenings, identify mental health needs, and ensure linkage to additional services. Though there are shared goals in identifying mental health needs, the MAT Providers and the Hub Clinics were provided different mental health screening tools by DMH. In particular, the MAT Providers use a more in-depth screening tool. According to DMH management, the use of different mental health screening tools at the Hub Clinics is dic- 11 Special Health Care Needs is defined by DCFS Procedural Guide 0600-505.10 as: 1) a condition that can rapidly deteriorate resulting in permanent injury or death, or 2) a medical condition that requires specialized in-home health care. EXPANDING HUB CLINICS – 4. MENTAL HEALTH SERVICES 288 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT tated by the varying levels of expertise of the screeners at the Hubs. Inconsistent train- ing and the use of a different screening tool could potentially lead to: 1) inability to iden- tify mental health services that are needed or 2) referrals for mental health services that are not needed. Although DMH-contracted MAT Providers are able to provide MAT Assessments as well as ongoing mental health services, there is limited linkage between the MAT Providers and Hub Clinics for ongoing mental health services. There are 50 organizations in the County that contract with DMH to be MAT Providers and provide MAT Assessments and ongoing mental health services. In contrast, there are seven Hub Clinic locations and only two are affiliated with organizations that have contracts with DMH to be MAT Providers and ongoing mental health service providers: LAC+USC and Children’s Hos- pital. The East San Gabriel Valley Satellite Hub Clinic has access to mental health ser- vice providers through its affiliation with LAC+USC. Data on mental health screenings at the Hub Clinics in FY 2010-11 illustrates that as high as 80 percent of youth screened at the clinics have a positive result, indicating a need for additional mental health services. Without strong linkages to the DMH system, these youth are in danger of not receiving needed mental health services, violating the intent of the Katie A. Settlement. Table 4-1 below shows the number of mental health screenings and results across all Hub Clinics in FY 2010-11. Table 4-1. Number of Mental Health Screenings and Results (FY 2010-11) ESGV H-UCLA LAC+USC MLK OV-UCLA HD CHLA TOTAL # Screenings 1,184 1,713 6,244 1,537 1,051 1,238 466 13,433 # Positive Results 482 859 3,253 322 844 802 369 6,931 % Positive 41% 50% 52% 21% 80% 65% 79% 52% Source: DHS records System of Integration LAC+USC and Children’s Hospital are the only Hub Clinics that are able to provide mental health services simultaneously or immediately after an Initial Medical Examina- tion because they are both affiliated with larger organizations that contain separate mental health service divisions that are also DMH contractors. (The Violence Interven- tion Project is the parent non-profit organization for the LAC+USC Hub Clinic and the Children’s Hospital Hub Clinic is part of Children’s Hospital LA.) The East San Gabriel Valley Satellite has access to mental health providers through LAC+USC. The new Children’s Medical Village at LAC+USC, which is slated to begin operations in 2012, will also provide mental health services to its patients as part of its comprehensive, multi- disciplinary approach. Two other Hub Clinics are poised to provide more direct linkages to mental health ser- vices. Though they are not officially affiliated, the Martin Luther King, Jr. Hub Clinic is located in the same building as SHIELDS, a DMH contractor and MAT Provider, while the Harbor-UCLA Hub Clinic is located a few bungalows away from Children’s Institute, EXPANDING HUB CLINICS – 4. MENTAL HEALTH SERVICES 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 289 also a DMH contractor and MAT Provider. To help the Hub Clinics ensure that linkage to ongoing mental health services occurs for their patients, DHS and DCFS should re- quire that each Hub Clinic establish contractual relationships with DMH contractors/MAT Providers to enable integrated mental health services at the clinics and documented as- surances that Hub Clinic patients are receiving needed mental health services from those contractors. The remaining two Hub Clinics, Olive View-UCLA and High Desert, do not have strong linkages to mental health providers at this time and currently do not have Clinical Psy- chologists on their staff. Olive View-UCLA Hub Clinic staff reported that they have lim- ited access to Clinical Psychologists staffed by the hospital for emergency cases only (i.e. suicidal youth) and are rarely able to follow up on youth referred for mental health services outside of the hospital. The youth screened at Olive View-UCLA and High De- sert could be receiving mental health assessments and services through other MAT Providers, but a stronger system should be established to coordinate the mental health screenings and services at the Hub Clinics to: 1) ensure that youth are receiving mental health services; and, 2) reduce any duplication of efforts. Development of a more integrated system and structure for the MAT Assessment, Initial Medical Examinations, and ongoing mental health services would require the collabora- tion of the directors of DCFS, DHS, and DMH, along with MAT Providers and Hub Clinic staff. While DMH management generally agrees with the concept of better integrating the Initial Medical Examination and MAT Assessment processes as well as ongoing treatment, Department representatives raised a concern about ensuring an even distri- bution of workload among MAT Providers. For example, a MAT Provider located in close proximity to a Hub Clinic, could end up with a higher volume of referrals for ser- vices as compared to other MAT Providers. DMH management noted that there is already an uneven distribution of workload among the MAT Providers because the distribution of funding to these contractors is based on where youth are detained, not where they are placed. For instance, a youth may begin the MAT Assessment Process in one service area, but must continue the Assessment or ongoing mental health services in another area because that is where he/she is placed. Even though DMH has a better understanding of the distribution of workload among the MAT Providers, DCFS is responsible for making referrals and MAT Providers respond to DCFS referrals on a first come, first served basis,. Therefore, in developing a more integrated system, DCFS, DHS, and DMH should con- sider developing agreements between the Hub Clinics and multiple MAT Providers in the same service area for one or more MAT Providers to provide office hours for mental health screenings/MAT Assessments and/or ongoing services at the Hub Clinics. This would allow multiple MAT Providers to each have a role in the provision of mental health services at the Hub Clinics as well as at other locations closer to the youth’s home or placement location. Further, DMH should consider alternative contracting options to bet- ter align services needed by DCFS youth and services actually provided by MAT Pro- viders, given that youth are placed in different areas throughout the County. Finally, EXPANDING HUB CLINICS – 4. MENTAL HEALTH SERVICES 290 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT DMH and DCFS should have better oversight of the distribution of referrals and provi- sion of ongoing mental health services among MAT Providers. Mental Health Services for Youth Ages 0-5 and their Families Youth ages 0-5 are the most vulnerable population in the child welfare system. Accord- ing to DMH management, one desirable skill for MAT Providers, which could help en- sure the provision of mental health services to this target population, is the ability to identify the medical necessity of such services among the youth ages 0-5 and their par- ent(s). Identification of medical necessity is critical for ongoing treatment for mental health issues and is required for Medi-Cal reimbursement through State Early Periodic Screening, Diagnosis and Treatment (EPSDT) funds. Most of the child deaths among DCFS involved youth occur when they are placed in-home with their parents. A mental health service that could address the needs of youth ages 0-5 is collateral treatment, or mental health services provided to both the parent(s) and child. To ensure that this population receives the mental health services it needs, DMH should continue training MAT Providers so they are all able to adequately screen, assess, and provide treatment to youth ages 0-5, including: 1) sufficiently identifying medical neces- sity, and 2) appropriately providing collateral treatment for the parent(s) and child. In addition to training staff, DMH should provide more support for the trained staff to help prevent staff burnout, while dealing with the traumatic experiences of vulnerable youth ages 0-5. SUMMARY The Department of Children and Family Services (DCFS) has mandated that youth in the child welfare system receive mental health screening or assessment and appropri- ate linkage to mental health services in a timely manner, as part of the County’s Katie A. lawsuit settlement. However, DCFS has created two separate systems by which a de- tained youth can receive such services, the Multidisciplinary Assessment Team (MAT) Assessment Program through its collaboration with the Department of Mental Health (DMH) and the Initial Medical Examinations at the Hub Clinics through its Memorandum of Understanding with the Department of Health Services (DHS). The MAT Assessment process and the Initial Medical Examinations at the Hub Clinics may utilize separate sources of medical information for the assessment of a youth, sometimes have disjointed timelines, generally use different mental health screening tools, and have access to different providers for ongoing mental health services. Great- er linkage between the two processes is needed for Hub Clinics to: 1) ensure that youth are receiving mental health services and 2) reduce duplication of efforts. Such integra- tion should be developed by DCFS, DHS, and DMH, with input from MAT Providers and Hub Clinic staff. Additionally, a system or structure that provides greater integration should also take into consideration the distribution of referrals, assessments, and ongo- ing services among existing MAT Providers to allow for multiple providers to have op- portunities to provide services in coordination with the Hub Clinics. EXPANDING HUB CLINICS – 4. MENTAL HEALTH SERVICES 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 291 According to DMH management, two skills among staff of MAT Providers that could help further address the mental health needs of youth ages 0-5 are the abilities to: 1) identify medical necessity for ongoing mental health services among youth ages 0-5, and 2) provide collateral treatment, i.e., treatment of both the parent(s) and child. DMH has conducted training in these areas for MAT Providers in the past. FINDINGS 4.1. Linkage between the Multidisciplinary Assessment Team (MAT) Assessments and Initial Medical Examinations at Hub Clinics is very limited, though both are required by DCFS for newly detained youth. For example, medical reports from the Hub Clinics are not always completed or sent in time to be included in the MAT As- sessments and Hub Clinic staff and Public Health Nurses do not participate in the MAT team meetings. 4.2. MAT Providers, i.e., community-based organizations contracted by DMH, and the Hub Clinics that are not MAT Providers, use different mental health screening tools, though the goal for both processes is to identify a youth’s mental health needs. 4.3. There is limited linkage between the DMH-contracted MAT Providers and Hub Clin- ics for providing ongoing mental health services to clinic patients. Divisions of the LAC+USC and Children’s Hospital Hub Clinics’ affiliated organizations contract with DMH as MAT Providers and provide such services; the Martin Luther King, Jr. and Harbor-UCLA Hub Clinics are in close proximity to MAT Providers, but their linkage to these providers is limited; and Olive View-UCLA and High Desert’s linkage to MAT Providers is not as strong as in the other Hub Clinics. 4.4. The Olive View-UCLA and High Desert Hub Clinics do not have any budgeted clin- ical psychologists on-site. 4.5. The distribution of referrals for MAT Assessments and ongoing mental health ser- vices from DCFS to DMH contract MAT Providers is uneven and is a concern by DMH management regarding the development of a more integrated system be- tween the MAT Assessments, Initial Medical Examinations, and ongoing mental health services. 4.6. Youth ages 0-5 and their parents and families could benefit from ongoing mental health services when medical necessity is appropriately identified and when they participate in collateral treatment, or therapy that includes the parent and child.

The nonminor is incapable of doing any of the activities described in sub- paragraphs (1) to (4), inclusive, due to a medical condition, and that inca- pability is supported by regularly updated information in the case plan of the nonminor. Based on data provided by DCFS, the total population in Los Angeles County eligible for extended foster care services due to AB 12 is estimated to be between 3,800 (16 and 17 year olds as of Nov. 30, 2011) to 5,483 (including those 18 and older as of Nov. 30, 2011). However, this estimate does not include Transition Age and eligible youth that may enter or exit the child welfare system up until 2014, the expected sunset date for AB 12 unless it is extended by the State legislature. Medical and mental health services for youth aged 18 years or older and under the ju- risdiction of DCFS have been limited. However, there are services offered by DMH that youth can continue to receive after they turn 18, independent of their status with DCFS. With the implementation of extended foster care services under AB 12, DCFS, DHS, and DMH should improve or create systems to address the specialized needs of youth aged 18 years or older. Medical Services for 18 Year Olds and Older Prior to the implementation of AB 12, DCFS provided youth aging out of the system with referral information on medical and mental health services and requirements for receiv- ing Medi-Cal under the Former Foster Care Children Program (FFCC) which allowed coverage until the age of 21. However, the former foster care youth would have to re- new their enrollment in Medi-Cal themselves, and DCFS management reported that not all of them were doing so. California Welfare and Institutions Code §11403(a) 18 California Welfare and Institutions Code §11403(b) EXPANDING HUB CLINICS – 5. TRANSITION AGE YOUTH 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 295 Since most Transition Age Youth are eligible for Medi-Cal coverage, they can obtain medical services from any Medi-Cal provider. There is no mandate or requirement for this population to go to a Hub Clinic. As a result, a majority of the Hub Clinics report serving very few youth aged 18 years or older. Medically Fragile/Vulnerable Youth who are medically fragile/vulnerable are those with special needs due to a mental health diagnosis, developmental delay or a physical or medical condition that requires specific care.19 As of November 30, 2011, there were 2,163 youth under the jurisdiction of DCFS identified as medically fragile/vulnerable, of which 198 were 18 years old or older. Within the medically fragile/vulnerable group, there is a subgroup of youth receiving DCFS services from the Medical Case Management Services (MCMS) Unit. These youth have special health care needs defined as: 1) a condition that can rapidly deterio- rate, resulting in permanent injury or death, or 2) a medical condition that requires spe- cialized in-home health care such as an enteral feeding tube, ventilator, intravenous therapy, or other medical or surgical procedures or special medication regiments.20 Youth under the supervision of the MCMS Unit require the most medical care and atten- tion of all the medically fragile/vulnerable youth under the jurisdiction of DCFS. The MCMS Unit works with families, caretakers, and the youth to ensure that the youth ob- tain the medical services they need. As of February 2012, there was a total of 580 youth under the MCMS Unit, of which 52 are 18 years old or older. The medical services for youth under the supervision of the MCMS Unit are funded through 1) Medi-Cal’s fee-for-service or managed care, depending on their enrollment; 2) California Children’s Services for special equipment such as wheelchairs and beds; and 3) Regional Centers21 for services such as occupational, physical and behavioral therapy. When youth under the supervision of the MCMS Unit turn 18, they may either remain under the supervision of the MCMS Unit because they are still in high school or the Courts have not terminated their DCFS cases due to severe health conditions. Medical- ly fragile/vulnerable youth over the age of 18 who are eligible for long-term Regional Center services are transitioned to service coordination by their local Regional Centers. If a youth does not fall under any of these categories, he/she could be emancipated and transitioned out of DCFS or any other supervision and oversight. DCFS Procedural Guide 0900-522.10 (Specialized Care Increment – D – Rate), DCFS Procedural Guide 0900- 522.11 (Specialized Care Increment – F – Rate). DCFS Procedural Guide 0600-505.10 (Assessments of and Services for Children with Special Health Care Needs) 21 Regional Centers are non-profit agencies under contract with the California Department of Developmental Services that help coordinate services needed because of a developmental disability. Depending on eligibility, most services offered at Regional Centers are free regardless of age or income. EXPANDING HUB CLINICS – 5. TRANSITION AGE YOUTH 296 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT Medically fragile/vulnerable youth aged 18 and older who do not remain with DCFS or who are not eligible for Regional Center services are at risk of abuse, isolation, home- lessness, neglect, or self-neglect. However, these youth are eligible for referrals to Adult Protective Services (APS) so that they may continue to have contact with social workers and access to needed services. It is unclear if all medically fragile/vulnerable youth ag- ing out of DCFS services are referred and transitioned to APS, when they are not eligi- ble for Regional Center services, but DCFS should strive to make such referrals when- ever possible. According to DCFS management, the medically fragile/vulnerable youth under the su- pervision of the MCMS Unit only access or interact with Hub Clinic staff when they are newly detained and require an Initial Medical Examination. These exams provide the medical history for the newly detained youth. However, continued medical services are obtained at specialized clinics across public and private hospitals throughout the Coun- ty. Although Hub Clinics may not offer the specialized services and clinics needed by the medically fragile/vulnerable youth under the MCMS Unit, the Hub Clinics can still play a role as the medical home for youth with multiple medical providers and specialists within the hospital system affiliated with each Hub Clinic. The Hub Clinics can also serve as the medical coordinators for the medically fragile/vulnerable Transition Age Youth who are 18 and older and have not transitioned to Regional Center services, such as an 18 year old who is diabetic and is in constant need of insulin shots. To serve as the medi- cal home, Hub Clinics would have to obtain and maintain all medical records for the pa- tient from multiple service providers within the hospital system affiliated with each Hub Clinic. Currently, DCFS staff coordinates services across multiple providers in different hospital systems for these youth, and should continue doing so for youth with medical providers across both County and private hospital systems. However, the specialized medical knowledge of Hub Clinic staff could facilitate the transfer of medical information more easily for medically fragile/vulnerable youth with specialists in the same hospital system. Ideally, youth aging out of DCFS would be transitioned to a program where they still have access to social workers and coordinated medical and mental health services ei- ther through a Regional Center, if developmentally disabled, or Adult Protective Ser- vices. For youth transitioned to Adult Protective Services, the Hub Clinics could com- plement the social services provided by coordinating the youth’s medical services. Mental Health Services for TAYs According to data provided by DMH, 3,904 DCFS youths with open DMH cases were aged 16 or older, representing 16.2 percent of the a total of 24,116 DCFS youths with open DMH cases. This also represents 71.2 percent of the 5,483 youth under the juris- diction of DCFS who were 16 years old or older as of November 30, 2011. These youths could have received DMH services through any number of DMH programs pro- EXPANDING HUB CLINICS – 5. TRANSITION AGE YOUTH 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 297 vided throughout the County including: 1) services provided through the Multidisciplinary Assessment Team (MAT) Assessment Program,22 2) Full Service Partnership Program (FSP),23 3) Assertive Community Treatment (ACT),24 and 4) Specialized Foster Care In- tensive In-Home Mental Health Services (IIHMHS),25 etc. Only two of the seven Hub Clinics, LAC+USC and Children’s Hospital, have contracts with DMH and have multiple mental health service professionals onsite. The East San Gabriel Valley Satellite Hub Clinic has access to mental health service providers through its affiliation with LAC+USC. Children’s Hospital is the only Hub Clinic that has services directed specifically toward Transition Age Youth. These are provided by the Children Hospital’s Division of Ado- lescent Medicine and located in a clinic separate from the CHLA Hub Clinic for younger children. Services for 12 to 21 year olds include specialized services for adolescents dealing with anger management, depression, substance abuse, homelessness, HIV and transgender issues. These services are provided to all adolescents, not just those re- ferred to the Hub Clinic by DCFS. Furthermore, LAC+USC hopes to obtain additional funding and resources to expand its Children’s Medical Village to include service for adults. This would require staffing the Medical Village with providers who are trained in both pediatrics and adult medicine, similar to the staff at the Children’s Hospital Division of Adolescent Medicine. Further, LAC+USC hopes to include Adult Protective Services staff in its proposed expanded Medical Village to provide easy access to social work services while remaining the med- ical home and coordinator of medical and mental health services for medically frag- ile/vulnerable Transition Age Youth aged 18 and older. Targeted Medical and Mental Health Services for Transition Age Youth As discussed in Section 1 of this report, “The Model Medical Hub Clinic”, model Hub Clinics should serve as the medical home and provide onsite mental health services for youth under the jurisdiction of DCFS. With the implementation of AB 12, youth aged 18 years old and older will continue to be eligible for medical and mental health services at Hub Clinics. At this time, Children’s Hospital is the only Hub Clinic that is able to pro- vide both medical and mental health services that are targeted toward the issues and 22 The Multidisciplinary Assessment Team (MAT) Assessment Program provides comprehensive assessments to evaluate a foster youth’s needs and strengths in various areas including medical, dental, developmental, hear- ing/language, education, mental health, vocational, and family/caregiver issues. The Transition Age Youth Full Service Partnership Program offers intensive services with 24/7 staff availability to help 16 to 25 year olds address emotional, housing, physical health, transportation, and other needs to help them function independently in the community. Assertive Community Treatment is a team-based approach to the provision of treatment, rehabilitation, and support services. A variety of services are offered under the Specialized Foster Care Intensive In-Home Mental Health Services (IIHMHS) program, including 24/7 intensive case management, Trauma Focused Cognitive Behavioral Therapy, Functional Family Therapy, as well as programs to assist caregivers with behavioral and emotional problems in young children. EXPANDING HUB CLINICS – 5. TRANSITION AGE YOUTH 298 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT concerns of youth 18 years old and older. Therefore, DCFS should encourage youth 18 years old and older with complex medical and/or mental health needs to go to the Chil- dren’s Hospital services. According to Children’s Hospital staff, should referrals to the adolescent clinic from DCFS increase, the clinic would then consider applying for Federally Qualified Health Center (FQHC) status, which would allow the clinic to receive greater reimbursement for costs than they currently receive through Medi-Cal. However, until the adolescent clinic officially receives such a status, the clinic will need grant funding to absorb the addition- al referrals. Children’s Hospital is not conveniently located for all Transition Age Youth located throughout the County, particularly for the medically fragile/vulnerable youth aged 18 and older. DCFS, DHS, and DMH should work together to identify funding for additional transportation services to and from CHLA. Currently, Children’s Hospital is able to pro- vide transportation passes to youth participating in its Full Service Partnership Program, funded through a DMH contract. Similar funding should be identified or expanded for the additional DCFS referrals of youth to the Children’s Hospital. For youth who are not lo- cated near public transportation, DCFS, DHS, and DMH should explore funding for van services. This type of service is already provided to youth living in the Lancas- ter/Palmdale area for services at the High Desert Hub Clinic. Children’s Hospital currently has the greatest capacity to serve the special needs of Transition Age Youth aged 18 and older. Additionally, resources could be designated or reassigned to LAC+USC to expand its Children’s Medical Village to include medical services for adults and access to Adult Protective Services social workers to meet the medical and mental health needs of Transition Age Youth aged 18 and older. SUMMARY Prior to January 1, 2012, most youth under the jurisdiction of DCFS were emancipated and their DCFS cases were terminated after they turned 18 years old. Though there were exceptions for some 18 year olds to remain under foster care and receive inten- sive case management services, a majority of the youth 18 years old or older received additional DCFS services on a voluntary basis but did not access medical and mental health services at the Hub Clinics. Though most of these youth were eligible for Medi- Cal after they turned 18, which could reimburse the Hub Clinics if used by the youth, their choice of medical provider was left up to them. None of the County-affiliated Hub Clinics made special efforts to encourage these youth to obtain medical care from them. With the passage of extended foster care services through AB 12, as of January 1, 2012, youth under the jurisdiction of DCFS can remain in the child welfare system until the age of 21, as long as they meet certain criteria. Therefore, Transition Age Youth aged 18 to 21 could continue to use Hub Clinics for medical and mental health needs. Their medical care would continue to be reimbursed under the Medi-Cal fee-for-service arrangement, which provides a better cost recovery for the clinics than Medi-Cal man- aged care rates. EXPANDING HUB CLINICS – 5. TRANSITION AGE YOUTH 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 299 A majority of the Hub Clinics currently do not provide medical services to youth under the jurisdiction of DCFS that are 18 years old or older. Youth that are medically frag- ile/vulnerable currently receive medical services from specialized medical providers and clinics throughout the County. Further, only two of the Hub Clinics have Department of Mental Health contracts and multiple mental health providers at their Hub Clinics to pro- vide mental health services to DCFS youth. Only Children’s Hospital LA offers an ado- lescent clinic that provides medical and mental health services targeted toward youth aged 12 to 21. However, LAC+USC has plans to expand its Children’s Medical Village with medical services for adults, particularly Transition Age Youth aged 18 and older, including access to Adult Protective Services social workers. The Hub Clinics could serve as medical homes for medically fragile/vulnerable TAYs by coordinating services among the various specialized medical and mental health provid- ers, as long as they are within the same hospital system. Such coordination would re- quire additional training for the medical providers to be aware of the various issues spe- cific to TAYs. Finally, DCFS and DHS could refer other medically fragile/vulnerable TAYs to Children’s Hospital to benefit from their specialized Adolescent Clinic and initi- ate a plan to establish similar specialty clinics for TAYs at some or all of the County Hub Clinics. The Hub Clinic with the greatest capacity for expansion of services for Transi- tion Age Youth is currently LAC+USC because it is building a Children’s Medical Village with an aim to provide access to subspecialty medical services beginning in the summer of 2012. FINDINGS 5.1. According to national statistics, youth transitioning out of foster care are at risk and have higher rates of homelessness, as well as mental health, physical, and devel- opmental problems. For example, 27 percent of the nation’s homeless population have been in foster care, while youth emancipating out of foster care have a one in six chance of being homeless within one year. 5.2. As of November 30, 2011, there were 1,672 youth under the jurisdiction of DCFS that were 18 or older. Prior to January 1, 2012, most of these youth were emanci- pated and their DCFS cases were terminated after they turned 18 years old. Most of these youth were only able to receive additional DCFS services on a voluntary basis and, though not precluded from doing so, most did not access medical and mental health services at the Hub Clinics which are generally geared toward chil- dren, and have not made efforts to encourage Transition Age Youth emancipating from the child welfare system to use their services. 5.3. With the passage of extended foster care services through AB 12, youth under the jurisdiction of DCFS may now remain in the child welfare system until the age of 21, as long as they meet certain criteria. Based on DCFS data on youth 16 years old and older and under DCFS jurisdiction as of November, 30, 2011, the estimat- ed total number of Transition Age Youth that could remain in DCFS through 2014 ranges from 3,800 to 5,483 youth. EXPANDING HUB CLINICS – 5. TRANSITION AGE YOUTH 300 2011–2012 LOS ANGELES COUNTY CIVIL GRAND JURY FINAL REPORT 5.4. The number of medically fragile/vulnerable youth with special needs due to a men- tal health diagnosis, developmental delay or a physical or medical condition that requires specific care under the jurisdiction of DCFS was 2,163 as of November 30, 2011, of which 198 were 18 years old or older. Though Hub Clinics may not of- fer the specialized services and clinics needed by the medically fragile/vulnerable youth, the Hub Clinics can still play a role as the medical homes for youth who need to see multiple medical providers and specialists within the hospital system affiliated with each Hub Clinic. 5.5. The majority of the Hub Clinics currently do not provide medical services to youth aged 18 years old or older. Further, only two of the Hub Clinics have Department of Health contracts and multiple mental health providers onsite at their Hub Clinics to provide mental health services to DCFS youth. Only Children’s Hospital LA current- ly offers an adolescent clinic that provides medical and mental health services tar- geted toward youth age 12 to 21 years old. However, LAC+USC has plans to ex- pand its Children’s Medical Village, which will provide access to several medical subspecialty services, to include adult medical services for Transition Age Youth aged 18 or older.