Fostering Health: Coordinating Coverage for Area Foster Children is Moving Forward, Although Challenges Remain

Foster kids in the tri-county area are eligible for healthcare coverage through age 18, and there are ongoing efforts to make sure they are identified, screened, treated and tracked.

On any given day, there are about 8,500 children ages 0-18 in foster care in Oregon. About 2,300 of them are in Portland's tri-county area (Multnomah, Clackamas and Washington counties). They may be removed from their homes because of poverty, substance abuse, domestic violence or other issues and may temporarily stay with relatives or be placed with a foster family.

The average stay in foster care is 21 months, and 59 percent of these kids are eventually reunited with a parent, 21 percent are adopted, and the rest either acquire a guardian, reach age 18, or end up living with other relatives. In 2015, the American Academy of Pediatrics noted that more than 70 percent of children in foster care have a documented history of child abuse and/or neglect, and more than 80 percent have been exposed to significant levels of violence.

As a result, 90 percent of children entering the foster care system have a physical health problem, 55 percent have two or more chronic conditions, and 25 percent have three or more chronic conditions. The most common are skin conditions, asthma, anemia, malnutrition or manifestations of abuse, according to a 2013 report from the Center for Health Care Strategies.

In Oregon, children in foster care are eligible for coverage through the Oregon Health Plan through age 18 and are supposed to be assessed for their physical, mental and dental healthcare needs within 60 days of entering the foster care system.

Health Share of Oregon, a coordinated care organization in the tri-county area, manages Medicaid benefits for an estimated 3,500 foster children, including arranging for initial health assessments.

Last year, Health Share hit the 60-day target for about 57.2 percent of the foster care children on its rolls, according to Bobby Martin, foster care systems manager.

"There is still room to improve," he said, noting that coordinating coverage for this population can be especially complex. "There are three mental health plans, four physical health plans and nine dental health plans we contract with, so, as you can imagine, each kid has some combination of healthcare through these plans.”

Efforts are underway to more consistently reach these children, address their unique needs, and coordinate services so that they can be healthier now and when they reach adulthood.

Barriers to coordinated care

A key player in getting foster children into the healthcare system is the Oregon Department of Human Services, which is responsible for finding foster homes for kids in need and monitoring their progress. Making sure these children have ongoing healthcare is a challenging task.

"When a child is first placed, one of the early steps is to make sure that child has medical coverage, and right now we're looking at how that can be assigned and maybe changed later," said Miriam Green, senior operations manager for child welfare in Multnomah County. "When they move into care, the provider isn't set yet. Plus, the foster parent may say that's the [provider] I'd like to use in my home, or the child may have parents having them seen somewhere. Right now, the system is set up between the parent and the provider about who we should use."

Arranging for consistent coverage is further complicated by incomplete or inaccurate data about which foster children have become eligible. Green indicated that it's a matter of getting large systems to talk to each other, along with other factors such as confidentiality rules, coordination with other agencies, and general confusion about healthcare options. As a result, there's a risk that some children in foster care can fall between the bureaucratic cracks.

"We call them our 'crossover youth' who have some contact with the Oregon Health Authority but also have some contact with dependency with child welfare," said Kellie Barber, a DHS child welfare program manager in Portland. "The other thing … is ensuring that our care providers, whether it's family or other, because of the numerous number of provider and health plans, that they are very knowledgeable about navigating the system."

It's not uncommon for a foster child to move from one city or county to another, or even from one state to another, and this mobility factor can make coordinating healthcare services even tougher. Sen. Sara Gelser (D-Corvallis) has heard about the problem in her capacity as chair of the Senate Human Services and Early Childhood Committee.

"In talking to providers and CCOs last session, there are chronic issues about foster youth moving from one CCO region to another. Sometimes the [insurance] policy doesn't say this, but the experience that providers and kids have reported is a delay in getting services, maybe diabetes meds or mental health meds. It can be a dispute about who's going to pay for that, and there is nothing in the policy allowing that to happen," Gelser said.

Greater healthcare needs

Children in foster care usually have greater healthcare needs than other children. Because of trauma and limited access to consistent care, they suffer from a higher incidence of chronic problems such as depression, PTSD, ADD and asthma, and generally have more physical, mental and dental problems.

The Pediatrics Academy has classified children in foster care as a population with special healthcare needs, and recommends that all children entering foster care have a full mental health evaluation, including a trauma assessment, and notes there aren't enough therapists with appropriate training nor is there sufficient funding to make sure that kids who need such help will get it. One provider reaching out to this population is Randall Children's Clinic at Legacy Emanuel Medical Center. It coordinates care with provider partners and has dedicated staff to handle its foster care program for about 200 children.

"We hear of kids in foster care from many ways," explained Christian Huber, R.N., manager of ambulatory services. "One is we're in a collaboration right now with CareOregon, who insures these kids. So there's a kind of code that's put on their insurance, so as soon as CareOregon is aware of that, we are informed. We also get direct referrals from [Oregon Department of Human Services] caseworkers, and we also work directly with foster parents who will contact us when they have a child who needs services."

The clinic initially started to see positive outcomes from coordinating care for foster kids through a 2009 Portland Children's Levy grant, Huber said, with hospital admissions and emergency room visits trending down and immunization levels and completed referrals going up.

These days, clinic staff try to get as much information as possible on each child in foster care before they come in for an appointment, said Holly Hermes, a pediatric social worker and care coordinator at the clinic.

"They see pediatricians for an initial physical exam and from there we basically coordinate their ongoing care," she said. "If there are referrals to be made, myself or the provider will coordinate that care, see if there are barriers to them getting ongoing care, [get them] up to date on well child, immunizations, referrals for mental health assessments, help them to establish a dental home if they don't already have one, just really follow the child so that all of their developmental needs are met."

Besides the potential cost savings now, coordinated healthcare intervention early on can pay social dividends later. In a presentation to Health Share's community advisory council, Health Share’s Martin cited 2013 statistics showing that children who transition out of foster care without a solid support network are more likely to experience these longer-term negative outcomes:

  • More than one in five will become homeless after age 18.
  • Only 58 percent will graduate from high school by age 19 (compared to 87 percent of all 19-year-olds).
  • 71 percent of young women are pregnant by age 21.
  • At the age of 24, only half are employed.
  • Fewer than 3 percent will earn a college degree by age 25 (compared to 28 percent of all 25-year-olds).
  • One in four will be involved in the justice system within two years of leaving the foster care system.

Martin told The Lund Report that Health Share is partnering with seven large clinics in the Portland area on a year-long initiative focused on about 1,500 children in foster care.

"Before this, this population didn't get the attention it deserves," he said.

"There was little or no medical history with them and a diffused authority setup for children in foster care, and the system responsible for their health and well-being didn't really have policies to address issues related to primary care. The delivery system hasn't been set up to understand the population and deliver care."

Trauma and healthcare

It's an ongoing struggle for many foster children who start out in a chaotic family of origin and carry that burden into a foster family situation. Healthcare providers are cognizant of trauma's role in the overall health of foster children and are increasingly coming up with ways to address the issue.

"We don't do well with talking about abuse and trauma and the impact on their lives," Martin noted. "What we want to do is create a system of care where that's standard."

Randall Children's Clinic offers a free trauma workshop twice each year with curriculum from the National Childhood Traumatic Stress Network. In the first year, 10-15 parents participated.

"We saw that as an opportunity to stabilize children in those foster homes," Hermes said. "We've found it to be helpful for our foster parents. It helps them to understand what is trauma and how does it affect children, and it gives them some tips to help kids succeed in their home."

Children currently in foster care and adults who have transitioned out are sometimes acutely aware of how inadequate healthcare has negatively affected their lives, said Lisa McMahon, program director for Oregon Foster Youth Connection. She noted that these youth can use their experiences both to heal themselves and to help younger children still in foster care.

"I've had more than one young person tell me that they've had a crappy past, all these things that happened to them, and they say, 'I'm not happy that it happened to me, but I'm happy that I can use the knowledge and expertise to impact the system,'" McMahon said. "They now own their story and tell it from a place of expertise and not from a place of being a victim. … They are super empowered by it."

(She noted that Trauma Informed Oregon, a collaboration between the Oregon Health Authority and Portland State University, is holding a free day-long event on April 21 in Portland to discuss and share how trauma affects individuals and families.)

Foster care controversies

Foster care in Oregon recently attracted negative headlines after a Portland-area provider was accused of abusing foster children and misspending funds. As a result, DHS management was slammed for insufficient oversight and failure to adequately investigate reports of abuse and neglect spanning several years.

A rural Yamhill County couple was arrested in March 2015 and charged with physically, mentally and emotionally abusing two foster children placed in their care. DHS is being sued for $60 million in connection with that case.

Top agency managers have recently been replaced, and Gov. Kate Brown has ordered an investigation of DHS. The Portland-area foster home provider is out of business and being sued by the state, while the Yamhill County couple, if convicted, could face up to 20 years in prison.

As a longtime DHS employee, Green said there's no way not to feel saddened, horrified and dismayed when confronted with such cases. At the same time, she noted the "pretty impossible task" of meeting the public trust of keeping children safe.

"The criticism is warranted, but there's a lot of good work that should be noted as well, and I don't think that it's getting near the iota of attention that should be paid to it," Green added. DHS caseworkers have large caseloads, and the agency has about 600 new family assessments every month.

Huber called the DHS employees the clinic works with "incredibly dedicated" to the cause of Oregon's foster children and foster families, especially those who lack resources.

Since the state can't provide everything that foster children need, private groups have stepped up to fill some perceived gaps. Embrace Oregon/Project Leadership Foundation is a case in point. Volunteers bring snacks for foster kids to DHS offices on a monthly basis and have helped fix up the agency's lobbies in Oregon City and Tigard.

Green emphasized that there’s always a need for foster parents in the tri-county area, and those interested are encouraged to call the recruitment number at 800-331-0503. The state compensates foster parents with monthly clothing and food payments ranging from $575-741, depending on the age of the foster child. More information is available here.

Cooperating to find solutions

Acknowledging problems in Oregon's foster care system can lead to solutions, and it's clear there are creative and dedicated people rising to the challenge. Healthcare is just one piece of the puzzle.

While the Affordable Care Act is supposed to cover young people up to age 26, McMahon said there's "this little loophole" some can slip through if they move away from the state where they were in foster care.

"The feds meant for states [to cover these youth], but they didn't make it mandatory, so there will be legislative action forthcoming on this," she said. "This is one of the things OFYC has pushed for. It's not good for Oregon."
Another ongoing issue for youth in foster care is that certain services such as braces and contacts aren't typically covered, a situation McMahon said makes them feel like second-class citizens.

"If your tooth is falling out, you can get that taken care of, but if your teeth are crooked, that's not included. And you can't have contacts, you have to have glasses because contacts cost more," McMahon said, relating some perspectives kids in foster care have shared with her. "They are pushing for equity. Foster youth want to go to the prom and have braces like everybody else."

Gelser is aware of these coverage disparities, and called youth in foster care "kind of a hidden category" of young people who are missing out on some common life experiences that others take for granted.

She expects the Senate to confirm newly appointed DHS Director Clyde Saiki when it meets next month, and is hopeful the state's foster care system will make sure that the welfare of kids is at the top of the agency's priority list.

"Safety is more than the absence of abuse," Gelser said. "Safety and well-being are about having enough food, a foster family treating them like they belong there, being supported in schools, having access to quality healthcare. It means a lot of things. Clyde [Saiki} and [Deputy DHS Director Reginald] Dr. Richardson, I think, are pretty serious about making those changes pretty quickly at the department."

You can reach Cathy at cmossback@gmail.com

This story has been corrected.

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