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

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

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

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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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• 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

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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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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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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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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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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Standard Primary Care Services

• 3-day examination

– DFPS requirement

• Sick visits

• Well Child Checks

– Integrated

– Longer

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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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How we do what we do…

• Grants

– Rees-Jones Foundation

– Meadows Foundation

• Insurance

– Medicaid/STAR Health (MCO)

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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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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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Strategic Plan

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Clinical Research

Education

Advocacy

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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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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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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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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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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

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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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 Kimberly.Stone@utsouthwestern.edu

• Sara Pollard Sara.Pollard@childrens.com

• Sara Moore Sara.Moore@childrens.com

• Jill Mcleigh Jill.McLeigh@childrens.com

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