An Underutilized Resource

No management system is in place at DCFS to ensure that all medical records are entered into CWS/CMS for CSW monitoring and follow up.

1.1 The number and professional skills of staff and funding allocations to the Hub Clinics vary considerably between facilities, resulting in wide variations in cost-effectiveness, equitable caseloads and productivity.

1 Foster parents and caregivers have expressed to Hub Clinic staff the need for a summary fact sheet listing age specific developmental stages and instructions for the care of children.

1.1 DHS’s oversight of the Hub Clinics has resulted in variations and omissions in key management systems including the absence of a strategic plan, goals and objectives, outcome measures for the Hub Clinic system and budgets for each clinic.

1.1 At least two Hubs currently have comprehensive assessment capacity. In some cases, they are duplicating aspects of the assessments conducted by MAT providers and the Department of Mental Health.

1.1 The new LAC+USC Medical Center has fewer licensed pediatric beds than the old facility had though the number of budgeted beds actually being used is approximately the same.

Case files and medical records for children who have changes in placement and/or CSW are often slow in getting to the corresponding Public Health Nurse to enable their monitoring of the child’s medical information.

Public Health Nurse input on cases depends on CSWs seeking them out for advice and input. As a result of these factors, children in the child welfare system do not always receive consistent medical case management and oversight. The Hub Clinics Have the Capability of Serving as Medical Homes or Medical Overseers for Children at Greatest Risk Medically or of Being Repeat Victims of Abuse There are systemic improvements that could be made at DCFS to improve the existing medical oversight and case management function. Another option to consider to better ensure medical oversight and continuity of care is establishing the Hub Clinics as medical home for at least some DCFS supervised children such as those with the most complex medical conditions and/or victims of sexual abuse. This, in fact, is supposed to 98 2008-2009 Los Angeles County Civil Grand Jury Report be one of the purposes of the Hub Clinics as capacity allows, according to the Memorandum of Understanding between DCFS and the Department of Health Services. Specifically, the Memorandum of Understanding states that, As capacity permits, the Medical Hubs may provide follow-up medical care for children with identified or complex medical needs which would benefit from management by a Medical Hub. This may include serving as a “medical home” for some DCFS involved children.5 “Medical home” characteristics have been defined by the American Academy of Pediatrics as: “…accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. It should be delivered or directed by well-trained physicians who provide primary care and help to manage and facilitate essentially all aspects of pediatric care.”6 Discussions with Hub Clinic administrators confirmed this definition. They indicated that their understanding of “medical home” includes facilitating pediatric care. Many Children in the Child Welfare System Qualify as Having Special Health Care Needs and Need Comprehensive Coordinated Care The American Academy of Pediatrics Policy Statement goes on to quote the U.S. Department of Health and Human Services as stating in its Healthy People 2010 goals and objectives that: “…all children with special health care needs will receive regular ongoing comprehensive care within a medical home.” “Special health care needs” is the term used by the federal Maternal and Child Health Bureau for children “who have or are at increased risk for a chronic physical, developmental or behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” Academic and other studies have found that between 50 and 95 percent of children in foster care have medical conditions requiring attention upon entry into the child welfare system; that approximately 25 percent have three or more conditions; and that moderate to severe mental health and behavioral problems are prevalent, with between 40 and 60 percent having at least one psychiatric disorder. Chronic medical conditions, mental health problems, dental problems and developmental delays are all common7. FY 2008-09 Memorandum of Understanding between DCFS and the Department of Health Services for Countywide Medical Hub Clinics. Policy Statement: The Medical Home, Pediatrics 2002; 110(1):184-186, American Academy of Pediatrics, reaffirmed in Pediatrics 2008; 122(2):450. See: National Survey of Child and Adolescent Well-being # 7: Special Health Care Needs Among Children in Child Welfare, Administration for Children and Families, U.S. Department of Health and Human Services, 2007; and A Guide to Developing Health Care Systems for Children in Foster Care, UCLA Center for Healthier Children, Families and Communities, November 2001. 2008-2009 Los Angeles County Civil Grand Jury Report 99 The Hub Clinics, in conjunction with the Public Health Nurses, could serve as medical homes for at least those children with special health care needs and those victims of sexual abuse who do not otherwise have a medical home through their current medical providers. The Hub Clinics and Public Health Nurses could together provide compre- hensive, continuous care, coordination of services and ongoing oversight. Discussions with Hub Clinic administrators confirmed that they have the expertise to be effective medical homes for foster children and youth. In addition, DCFS Social Workers, Public Health Nurses, and their supervisors and administrators, as well as Hub Clinic staff and administrators all repeatedly identified the clinics as the most qualified medical settings for foster children and youth. A secondary benefit of the Hub Clinics serving as medical homes is that clinic staff are trained and highly skilled at detecting signs of child abuse and neglect. This same level of expertise cannot be assumed for community providers. Hub Clinics Not Needed for All Children at Medical Risk but Should Be Used for Highest Medical Risk Children Who Lack Medical Homes While some children in the child welfare system undoubtedly have “medical homes” with community providers with whom they have ongoing relationships, many children do not, particularly those who end up changing placements while they are in the system. If these children also have special health care needs, they are even more at risk. Hub Clinic administrators interviewed for this investigation indicated that they would be open to the concept of serving as medical home for children in the DCFS system. A key concern expressed by some administrators was whether they had the capacity to serve all of these children on an ongoing basis. While all children in the child welfare system would benefit from having a medical home, not all children in the child welfare system, even those with special health care needs, need to have the Hub Clinics and their highly specialized teams serve as their medical homes. Some may be relatively healthy and well-served by community providers. Others may not be able to access Hub Clinics easily because of transportation issues and/or the nearest Hub Clinic being a long distance from their homes. Still others may have a relationship with a community medical provider whom they trust. Also, not all children in the DCFS system are under court supervision. Children in the DCFS system include those under Voluntary Family Maintenance, which means they get services through DCFS on a voluntary basis. These families have the freedom to choose any provider they wish as the court does not order them to see a particular provider. While there appears to be some excess capacity at certain Hub Clinics, as discussed in Section 2 of this report, expansion of staff and/or facilities might be needed at other Hubs if they were to accommodate all children needing medical homes. This consideration points to the need for a tiered approach to creating medical homes so that children needing close medical attention receive more intensive, ongoing care by the Hub Clinics as their medical home while other children receive less intensive direct service but some oversight through periodic Hub Clinic visits and reassessments. Combined with some system changes at DCFS to ensure more consistent oversight and coordination of medical services by Public Health Nurses and CSWs, more children in the system would realize the benefits of a medical home. 100 2008-2009 Los Angeles County Civil Grand Jury Report DCFS statistics from the past three years show that there has been a yearly average of 635 cases classified as having special health care needs and 679 sexual abuse cases per year for an average of 1,306 cases, some of which might benefit from having the Hub Clinics serve as their medical home. While some number of these children may be ongoing patients at the Hub Clinics, it is assumed that most are being seen by community providers. Depending on the number of children who transfer to the Hub Clinics as their medical home and the frequency with which they schedule appointments, this could represent a sharp increase in activity at some of the clinics. However, these children now are primarily seen by private community providers and, as stated above, may have established medical homes through them. For children with special health care needs or who are victims of sexual abuse and don’t have a medical home, the Hub Clinics should be advocated for ongoing treatment. DCFS would need to develop risk criteria to identify such cases. Besides having special health care needs or being the victims of sexual abuse, other factors to consider could include frequent changes in placement, no established medical provider and other characteristics. The CSW, in collaboration with the assigned PHN for these cases, could assess the situation and make recommendations to the court so that children who meet these criteria will be required to obtain their medical services at a Hub Clinic. As this transition takes place and the number of new patients and patient visits for the Hub Clinics are determined, it may require staffing additions at some of the facilities. Presently, most direct costs of the Hub Clinics are recovered from Medi-Cal billings such that new positions added to see more patients should also recover the majority of their costs. However, some costs may be incurred as positions may need to be added to accommodate increases in caseload before the number of patients is sufficient to ensure full cost recovery through Medi-Cal. One-time costs may be incurred for space reconfigurations or expansions. Stronger Systems and Controls Needed at DCFS to Ensure Consistent Medical Case Management and Oversight In addition to directing children who meet certain criteria to the Hub Clinics for their medical home, recommended systemic changes at DCFS to improve medical case management and coordination for other children in the system include the following: