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Dallas, Texas
Health Care Integration for Foster ChildrenThe Rees-Jones Center for Foster Care Excellence
Sara Moore, DNP, APRN, PNP-PC, Sara Pollard, PhD and Kimberly Stone, MD, MPH, FAAPSeptember 24, 2019Child Maltreatment Solutions Network Conference
Rees-Jones Center for Foster Care Excellence
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Dallas, Texas
Disclosures
Dr. Pollard, Dr. Moore and Dr. Stone have nothing to disclose,
except that we love caring for children in foster care
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Rees-Jones Center for Foster Care Excellence
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Dallas, Texas
Thank you to our team!
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Dallas, Texas
Objectives
• Describe the development of the integrated primary care
model at the Rees-Jones Center for Foster Care
Excellence at Children’s Health Dallas
• Outline initiatives for quality improvement, research
priorities and advocacy
• Discuss goals for education, policy and clinical excellence
to improve health outcomes for children in foster care in
North Texas
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Dallas, Texas
Texas Foster Care
– 422,000 children in foster care nationally
– 52,397 children in DFPS conservatorship
(includes PMC, kinship, other substitute
care)
– Region 3: 10,920 children in foster care
– 1,200 children left foster care (or
emancipated)
– Average months in care = 16.4
– Average number of placements = 2.3
– DFPS Data Book:
https://www.dfps.state.tx.us/About_DFPS/Data_Book/Child_Protective_Services
/default.asp
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Dallas, Texas
Permanency Outcomes FY 2018
• 33% Reunified with Parent(s)
• 31% Placed with Relatives
• 28% Parental Rights
Terminated or Adoption
• 7% Age out of Foster Care
or Other
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DFPS Data Book:
https://www.dfps.state.tx.us/About_DFPS/Data_Book/Child_Protective_
Services/default.asp
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Dallas, Texas
Children in Foster Care Have Significant Health
Needs
• 30-80% >1 Medical Problem
• 30% >1 Chronic Health Condition
• 80% Significant Mental/Behavioral Health Needs
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Health Care issues for Children and Adolescents in Foster Care and Kinship
Care. PEDIATRICS Volume 136, number 4, October 2015,
doi:10.1542/peds.2015-2655
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Dallas, Texas
The Development of the Rees-Jones Center for
Foster Care Excellence
• 28+ year history of
foster care clinic
through child abuse
clinic
• Dedicated Foster Care
Clinic established in
late 2000s Rees-
Jones Center for
Foster Care Excellence
in 2014
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Dallas, Texas
The Development of the Rees-Jones Center for
Foster Care Excellence
• What existed already
• Partnership between UT Southwestern & Children’s
Health
• Community Partnerships
• Private Foundations Interested in Foster Care
– Rees-Jones Foundation
– Meadows Foundation
• Child Protective Services Redesign at State Level
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Dallas, Texas
The Development of the Rees-Jones Center for
Foster Care Excellence
• What was lacking
• Communication between stakeholders
– Coordination with community behavior health
services
– Collaboration with DFPS
• Access to evidence-based behavioral health &
trauma treatments
• Trauma-informed primary care
• Mechanism for training professionals in foster care
health care
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Dallas, Texas
The Development of the Rees-Jones Center for
Foster Care Excellence
• What could we do?
• Dream BIG!!! The Kids Deserve IT!!!!
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Dallas, Texas
The Thought
• Medicine
– How can medicine and health care improve the lives of children in foster care?
– Reducing re-traumatization?
– Improving efficiency/reduce redundancy?
• Community Engagement
– Improve interaction/communication/engagement among stake holders
• Education
– Teach/educate/lobby regarding the plight of children in foster care
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Dallas, Texas
The Dream
• Medical
– Integrated Multispecialty Healthcare
– Professionals working together in one setting who have
one goal
• Limit re-traumatization
• Prevent unnecessary transitions
– Maximizing visits by coordinating care and services in
one Space at one time
– Consultation Service
– Active involvement (in real time) with Child Protective
Services
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Dallas, Texas
The Dream
• Community Engagement
• Child Protective Service Engagement
• Stake Holders Engagement
– Care Conferences
– Transition services
• Family Advisory Council
• Community participation (Individual, Local,
Regional, State)
• Trauma Education and Support
• Bio Parent Support Services
• Safe Babies
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Dallas, Texas
The Dream
• Education
– Multispecialty Education
• Community Lectures
• Trauma Focused
• Research
• Engaging learners at a local/regional/state/national
level
• Poster and publications
• Onsite learners
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Dallas, Texas
Definitions and Models of Integrated Care
Integrated care
• The coordination of physical and behavioral health
care (Johns Hopkins)
• Level of integration may vary (SAMHSA)
• Minimal Collaboration
• Basic Collaboration at a Distance
• Basic Collaboration Onsite
• Close Collaboration in a Partly Integrated System
• Close Collaboration in a Fully Integrated System
https://www.integration.samhsa.gov/integrated-care-models/a_standard_framework_for_levels_of_integrated_healthcare.pdf
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Dallas, Texas
Definitions and Models of Integrated Care
Models of Integrated Care (Kolko & Perrin, 2014)
• Coordination With an External Provider
• Consultation With the Primary Care Provider
• Training the Primary Care Provider in Mental Health Skills
• Onsite Intervention
• Onsite Collaborative Care
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Dallas, Texas
Definitions of Integrated Care
“The care a patient experiences as a result of a team of
primary care and behavioral health clinicians, working
together with patients and families, using a systematic
and cost-effective approach to provide patient-centered
care for a defined population.”
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https://integrationacademy.ahrq.gov/products/ibhc-measures-atlas/what-
integrated-behavioral-health-care-ibhc
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Dallas, Texas
Trauma-informed Care
• An organizational structure and treatment framework that involves:
– understanding, recognizing, and responding to the effects of all types of trauma
– seeking to employ practices that do not traumatize or re-traumatize.
• Emphasizes
– physical, psychological, and emotional safety
– trustworthiness and transparency
– collaboration and mutuality; empowerment
– cultural sensitivity and responsiveness.
(Adapted from Johns Hopkins and SAMHSA)
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Dallas, Texas
Trauma-informed CareSAMHSA (2016)
• Realizes the widespread impact of trauma and understands
potential paths for recovery
• Recognizes the signs and symptoms of trauma in clients,
families, staff, and others involved with the system
• Responds by fully integrating knowledge about trauma into
policies, procedures, and practices
• Seeks to actively resist re-traumatization
• Can be implemented in any service setting or organization
• Distinct from trauma-specific treatments designed specifically to
address the consequences of trauma and facilitate healing
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Dallas, Texas
Rationale for Integrated Care for Foster Care
• Common health problems related to trauma or drug exposure:
– Infections and injuries
– Inflammatory response and cardiovascular changes
– Sleep, eating, toileting
– Developmental or learning delays
– Depression, anxiety, PTSD, grief reactions
– Substance use and other risky and disruptive behaviors
– Poor emotional and behavioral self-regulation
• Behavioral and physical health concerns are expressed in visits with either discipline
• Caregivers need support to develop a trauma lens for symptoms
• Frequent changes in health providers
• Lack of communication, fragmented systems of care
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Dallas, Texas
Putting it all together:
Need for Trauma-Informed Integrated Care
• A systematic approach to the health care of this highly
mobile, medically high-risk, complex population (AAP)
• Educational and mental health care services must be an
integral part of the overall care of children in foster care.
• Care coordination across multiple disciplines is
fundamental to ensuring continuity of care for children and
adolescents in foster care.
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Dallas, Texas
Putting it all together:
Hopes for Trauma-Informed Integrated Care
• Enhanced access to services
• Improved quality of care
• Lower overall healthcare costs
• Improvements in mental and physical health
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Dallas, Texas
Rees-Jones Center for Foster Care Excellence
• Video:
https://www.childrens.com/specialties-services/specialty-
centers-and-programs/foster-care
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Dallas, Texas
Rees-Jones Center for Foster Care Excellence
• System-wide partnership between Children’s & UTSW
• 3 Branches
– Clinical
• Medical
• Mental health
• Developmental
– Academic/Research
• Trainees
• Research projects
– Community
• Policy
• Family Advisory Council
• Community relationships and trainings
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Dallas, Texas
Center Overview
• 7,000+ patient visits annually
(1,800 unique patients 2018)
• Medical home serving children
upon entry into foster care through
permanency
• Modeled after the American
Academy of Pediatrics – Healthy
Foster Care America guidelines
• Typically referred by Child Placing
Agencies (CPA), Child Protective
Services (CPS) or word-of-mouth
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Dallas, Texas
• Research Coordinator
Director of Policy,
Advocacy, and Research
• Pediatricians
• Nurse PractitionersMedical Director
• Psychologist, Clinical Therapists
• Early Childhood Specialist
Lead Psychologist
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Staff and Trainees
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Dallas, Texas
Psychiatrist
• Nurses and MAs
• Schedulers/Front Desk staff
• Nurse Coordinators Community Manager
• Administrative Support
• Practice Administrators CPS Liaison
Program Administrator
• Medical Students/Medical Residents
• Psychology Pre-doc Intern/Post-doc Fellow
• Social Justice Scholar
• Early Childhood Intern
• Public Health Students
• Psychiatry Fellow
Trainees
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Staff and Trainees
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Dallas, Texas
Integrated Primary Care
• On-site collaborative model
– Shared EHR
– Weekly huddle
– PCP and behavioral
health provider assess
child and family
together.
• Designation as PCP &
integrated visits for all +
standard primary care
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Dallas, Texas
Our Model for Integrated Visits
• Interdisciplinary Team
– Primary Care Provider
• Pediatricians
• Nurse Practitioners
– Behavioral Health Provider
• Psychologists/Clinical Therapists (3+)
• Early Childhood Specialists (0-3)
– Developmental screening and education
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Dallas, Texas
Our Model for Integrated Visits
• CPS History into “Child in Foster Care” problem in EHR
• Nurses and CPS Liaison gather records
• Vitals and screeners
– Pediatric Symptom Checklist, PHQ-9, GAD-7, ASQ-3
• Shared interview with PCP and Behavioral Health
– Placement/case status
– Sleep, eating, toileting
– Medical and behavior concerns
• PCP does physical exam while BH further interviews/supports caregiver
– Identifies strengths
– Trauma-informed caregiving
• Behavioral health provider assesses child
• Providers consult and provide integrated treatment plan with written instructions
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Dallas, Texas
Our Model
• Follow-up Visits
– 6 weeks to 3 months
• Between Visits
– Behavioral health provider may consult with community therapist, case worker, or psychiatrist
– Transition letters
– Transition visits
– Review of EHR
• Problem list
• Involving Others
– Care conferences
– Case reviews
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Dallas, Texas
Standard Primary Care Services
• 3-day examination
– DFPS requirement
• Sick visits
• Well Child Checks
– Integrated
– Longer
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Dallas, Texas
Behavioral Health Services
• Child & Adolescent Needs and Strengths (CANS)
• Psychological and Developmental Assessment
• Individual Therapy
– Trauma-focused Cognitive Behavioral Therapy
– Parent-Child Interaction Therapy
– Cognitive Behavioral Therapy
– Play Therapy
• Parent Education
– Triple P Primary Care
– Developmental
– Behavioral
• Groups
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Dallas, Texas
How we do what we do…
• Grants
– Rees-Jones Foundation
– Meadows Foundation
• Insurance
– Medicaid/STAR Health (MCO)
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Dallas, Texas
Benefits of Our Integrated Model
• Service Coordination
– Nurse Coordinator/CPS Liaison
• Family tells story one time
• More time with families
• Trauma informed providers & space
• Address core factors undermining well-being
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Dallas, Texas
Benefits of Our Integrated Model
• Early identification of stressors, symptoms, and placement moves
• Expedited access to needed services and improved engagement
• Joint treatment planning
• Unified message to families
• More tailored and nuanced behavioral health recommendations,
made in context of understanding medical concerns
• Close monitoring of needs and services
• Knowledge of transcultural caregiving and foster care resources
and policies
• Rich inter-professional training and consultation opportunities
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Dallas, Texas
Challenges
• Mindset shift for providers and families
• Systems issues
– Integration of multiple systems
– Time/quality vs. access/productivity
– Family size, sibling sets, learners
– How to systemize who/when to integrate
• Preference for in-home services and agency preferences
– Who owns treatment plan?
– Role definition and boundaries for BH
• Different ethical guidelines and information sharing
• Reimbursement and sustainability
• Measuring outcomes
• Training
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Dallas, Texas
Rees-Jones Center for Foster Care Excellence
• Our Mission
• To be the trusted health resource making
life better for children in foster care
• Our Vision
• To achieve hope, health, and healing for all
children in foster care
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Dallas, Texas
Strategic Plan
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Clinical Research
Education
Advocacy
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Dallas, Texas
Integrated Care Goal
Contribute to knowledge base on integrated care for children in Foster Care
Learn• Systematic Review of Literature on Integrated Care• Seek input from integrated care experts• Participate in Pediatric Integrated Care Collaborative
Evaluate• Conduct rigorous, evidence-supported evaluation of our
integrated care model
Implement• Make changes based on our assessment• Disseminate in literature, policy briefs and education
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Dallas, Texas
Clinical Goals
Optimize Service Delivery
• Leverage Technology
• Community Stakeholder Needs Assessment
• Expand Services to High Need Populations
• Maximize existing clinic resources
Sustainability
• Reimbursement
• Advocate for Billing that Supports Integrated Care
Reduce Staff Burnout
• Wellness Promotion
• Training on Trauma-Informed Care
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Dallas, Texas
Research Goals
Describe Patient Population
• Chronic Medical Conditions
• Children with Medical Complexity
• Laboratory Values
• Medications
• Traumatic stressors/ACES and mental health
Caregiver Stress
Resiliency
Outcomes research on integrated care model
Long-Acting Reversible Contraception
Healthcare Utilization Comparison
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Dallas, Texas
Advocacy Issues
Restructure Foster Care Consortium
• Planned Consultant
• Survey of members – needs assessment
Statewide Collaborative on Trauma-Informed Care
Child abuse reporting
• Advocate for Reporting Laws
Extending insurance plan post-adoption
• Continue managed care for high needs, complex kids
Child Protection Roundtable
Texas Coalition for Healthy Minds
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Dallas, Texas
Educational Goals
Formalize Center Training Program• Trauma informed care curriculum
• Evaluate the training of learners from medical, public health and behavioral health disciplines.
Community and Stakeholder Education• Caseworkers
• Biological Parents
• Child Placing Agencies
• District Attorney/Judges
Healthcare Provider Education• Community Primary Care Providers
• Medical Students
• Residents
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Center Goals
• Expand and formalize center training program
• Increase awareness of needs of children in foster care by
strategic marketing
• Increase input of caregivers, both biologic and foster, and
through expansion of the Family Advisory Council
• Increase Partnership Internally in Children’s Health System and
Externally with Community Stakeholders
• Increase National Collaboration
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Dallas, Texas
Challenges
• Difficult to conduct research with children in foster care
• Advocacy efforts may be successful, but may be limited or modified
• Improved relationship with managed care organization, but referral
approval and reimbursement issues continue
• Foster family and caseworker level of interest in integrated care
variable
• No-show rates still high
• Continuity still difficult
• Many factors beyond our control limit children’s placement stability,
access to services
• While improved, collaboration and communication issues still exist
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Rees-Jones Center for Foster Care Excellence
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Dallas, Texas
Special thanks to our team members who
contributed to this presentation
• Hilda Loria, MD
• Heidi Roman, MD
• Laura Losinger, MBA
• Annie Flores, LMSW
• Latreaca Ivey, MPH
• Jill McLeigh, PhD
• Laura Lamminen, PhD
• Chasity Holcomb, MA, LPC
• Kathryn Dumond, MEd, LPC-S
• Anu Partap, MD
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Dallas, Texas
Our Partners
Rees-Jones Center Family Advisory Council
Region 3 Foster Care Consortium
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Resources
• TED Talk—Nadine Burke Harris. https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime
• Healthy Foster Care America, https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/default.aspx
• AAP-Trauma Toolbox, https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Pages/Trauma-Guide.aspx#trauma
• National Child Traumatic Stress Network. (2018). Trauma Informed Integrated Care for Children and Families in Healthcare Settings. Retrieved from: https://www.nctsn.org/resources/trauma-informed-integrated-care-children-and-families-healthcare-settings
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Resources
• AAP Healthy Foster Care America Models of Care.
https://www.aap.org/en-us/advocacy-and-policy/aap-
health-initiatives/healthy-foster-care-
america/Pages/ModelSearch.aspx, accessed 8-21-19.
• SAMSHA Integrated Care,
https://www.integration.samhsa.gov/integrated-care-
models/children-and-youth
• http://integratedcareforkids.org/
• https://www.integration.samhsa.gov/integrated-care-
models/a_standard_framework_for_levels_of_integrated_healt
hcare.pdf
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References-Foster Care
1. Steenbakkers, A et al. The Needs of Foster Children and How to
Satisfy Them: A Sytematic Review of the Literature. Clin Child Fam
Psychol Rev (2018) 21:1–12, https://doi.org/10.1007/s10567-017-
0246-1
2. Szilagyi, MA et al. Health Care Issues for Children and Adolescents
in Foster Care and Kinship Care Technical Report. Pediatrics (2015)
136:e1142, http://pediatrics.aappublications.org/content/136/4/e1142
3. Health Care Issues fro Children and Adolescents in Foster Care and
Kinship Care, Policy Statement, Pediatrics (2015) 136; e1131,
http://pediatrics.aappublications.org/content/136/4/e1131
4. Sege, R et al. Clinical Considerations Related to the Behavioral
Manifestations of Child Maltreatment, Pediatrics (2017);139;
http://pediatrics.aappublications.org/content/139/4/e20170100
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References-Integrated Care
1. Ader, J, and Perrin, JM et al. The Medical Home and Integrated Behavior Health: Advancing the Policy Agenda. Pediatrics. 2015: 135(5); www.pediatrics.org/cgi/doi/10.1542/peds.2014-3941.
2. Zlotnik, S, and Noonan, K et al. Mandates for Collaboration: HealthCare and Child Welfare Policy and Practice Reforms Create the Platform for Improved Health for Children in Foster Care. CurrProb in Pediatr Health Care. 2015;45:316-322.
3. Godoy, L and Beers, L. et al. Behavior Health Integration in Health Care Settings: Lesson Learned from a Pediatric Hospital Primary Care System. J Clin Psychol Med Settings (2017) 24:245–258.
4. Kolko, D. J., & Perrin, E. (2014). The Integration of Behavioral Health Interventions in Children's Health Care: Services, Science, and Suggestions, Journal of Clinical Child & Adolescent Psychology, 43:2, 216-228, DOI: 10.1080/15374416.2013.862804
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Questions?
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Contact Information
• Rees Jones Center for Foster Care Excellence
– https://www.childrens.com/specialties-services/specialty-
centers-and-programs/foster-care
• Kim Stone [email protected]
• Sara Pollard [email protected]
• Sara Moore [email protected]
• Jill Mcleigh [email protected]
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