Children and youth in foster care enter custody with many challenges for child welfare social workers, healthcare providers, and caregivers to understand their overall health and well-being needs. Most children enter foster care due to allegations of neglect and may have been unable to access or attend necessary healthcare, dental, developmental, and/or behavioral health care prior to being placed in foster care. As a result, a complete understanding of their healthcare needs may not have been available during the CPS assessment. A smaller percentage of children and youth enter foster care due to allegations of physical or sexual abuse which may include ongoing medical evaluations and treatment, some of which may not be identified at the time of placement as the medical evaluations are ongoing. A growing percent of children and youth entering custody due to dependency includes children and youth whose caregivers are unable to meet the child/youth’s mental health needs for differing reasons.
Recommended Healthcare Visit Schedule for Children and Youth in Foster Care
Given the complex well-being needs of children and youth in foster care, the American Academy of Pediatrics recognizes them as a population with special healthcare needs. As such, children and youth in foster care are recommended to be seen early, often and comprehensively.
Best practice includes children and youth receiving healthcare in a trauma-informed medical home, a primary care practice that is structured to provide enhanced surveillance to ensure both identification of well-being needs and access to care meeting those needs. Children and youth in foster care follow an enhanced frequency of visits as compared to children and youth not in foster care.
North Carolina DHHS, Child Welfare section recognizes the importance of this structure and has adopted some of the American Academy of Pediatrics requirements into policy. In North Carolina, children and youth newly entering foster care are to be seen at the following frequency:
- An immediate healthcare visit within 7 days of entering care. Best practice is as early as possible and for children with complex and/or chronic healthcare needs, within 24 hours by a provider knowledgeable of the child/youth’s health. The purpose of this visit is to both ensure an assessment of any healthcare needs requiring immediate medical attention as well as an assessment for any infections or other conditions that could be contagious and/or require treatment. Known and existing medications can be refilled and education to the new caregiver regarding the child/youth’s healthcare needs can occur. Updates to the understanding of the child/youth’s healthcare needs for the child welfare permanency placement social worker should occur. Communication regarding any healthcare forms needing completing for placement should occur at this visit. This is critical to ensure the child/youth is placed in a home/facility that can meet their needs. Updates to needed immunizations can occur. To ensure clarity in understanding the child/youth’s healthcare needs, both the permanency placement social worker as well as the current caregiver should attend this visit.
- A comprehensive visit within 30 days. Even if the child has had a recent well-child visit, the 30-day visit should occur. The child is most often going to have a new caregiver who will benefit from education regarding the child’s health and any necessary treatment. The permanency placement social worker may need clarification regarding new concerns for well-being and any recommended treatment. At this visit, the medical provider will follow-up on any referrals, needed immunizations and/or treatment issues identified at the 7-day/initial visit. If this visit occurred in a different location, it is the permanency placement worker’s responsibility to secure those records and provide them to the new medical home. Additionally, the medical home should be informed of the child’s healthcare case manager so that all supports for the child/youth are aware; this individual will assist with identifying in-network supports and reduce barriers to care. A more detailed review of systems will occur at this visit to include a detailed understanding of the child’s current level of functioning. Reviewing behavioral health history to include sleep habits, appetite, interactions with adults and peers as well as toileting will occur. Specific screenings will be tailored to the age of the child, such as understanding developmental and/or educational abilities as well as adolescent health, if appropriate.
Additional enhanced visit types supported by the American Academy of Pediatrics include the following. The caregiver, permanency placement social worker and healthcare provider will also be expected to adhere to any general as well as chronic disease specific guidelines.
- A follow-up health visit 60-90 days after entry to care. This will be to ensure understanding of any new issues because of the adjustment to what may be an unfamiliar environment as well as access to enrollment in school, daycare, or other activities. Any barriers to accessing services will be identified and discussed.
- A healthcare visit with a change in placement. The purpose of this visit is to ensure the new caregiver’s understanding of the child/youth’s healthcare needs and access to essential items for care. Any past medical records should be provided by the permanency placement social worker for the new medical home.
Expected healthcare screenings
Upon entry to foster care, there are standard laboratory and healthcare screenings, similar to other preventive healthcare visits. These include specific developmental, mental health, behavioral health screenings as well as laboratory evaluations.
A caregiver who has recently begun caring for a young child may not have enough time with the child to understand their developmental or behavioral healthcare needs. Ensuring adherence to the recommended frequency of visits greatly assists with improved understanding of any concerns. Pediatric medical providers will use structured and validated screening tools at healthcare visits, to ensure understanding of any needed referrals for ongoing assessment and intervention. For developmental screenings, the pediatric medical provider will be looking for concerns in speech and language, gross and fine motor as well as social concerns and Autism. For school aged children, understanding any specific learning concerns will occur as upwards of 45% of children and adolescents in foster care are reported to have educational challenges resulting in need for support.
Adolescent health screening will follow the same structure for adolescents not in foster care, including honoring adolescent confidentiality rules in North Carolina. It will be expected that the pediatric medical provider will spend time with the adolescent outside the presence of the caregiver.
Who can consent for care for children and youth in foster care?
The discussion for consent is beyond this scope of this review. However, excellent resources are available here: https://www.sog.unc.edu/blogs/civil-side/medical-appointments-consents-and-children-dss-custody. It is important to recognize that foster parents or placement providers cannot consent to medical care.
How do Principles of Partnership impact medical care in foster care?
Shared parenting is a core belief in foster care as out-of-home placements are most often intended to be a short-term solution and reunification most often is the primary goal. To strengthen the understanding of a child/youth’s healthcare needs, the family of origin should be included in updates regarding diagnoses and healthcare needs unless there are restrictions due to safety concerns or court orders. The permanency placement social worker should assist in coordinating the best communication strategy.
Dr. Molly Berkoff is a Professor of Pediatrics at the UNC School of Medicine and the Child Medical Evaluation Program Medical Director
