Impact of Automated Information Sharing on Health Care Delivery to Youths in Foster Care.

Children in foster care have higher health care costs and poor care coordination, often due to inconsistent information exchanged between health care and child welfare systems. This study implemented secure automated information sharing and detected improvements in time spent gathering information, health care services delivered, and billing practices at participating health care systems.

Enrollment and outcomes of home visiting for mothers with and without a history of out-of-home care.

Women previously in out-of-home care (i.e., foster care) experience poorer health and psychosocial outcomes compared to peers, including higher pregnancy rates and child protective services involvement. Home visiting programs could mitigate risks. Studies examining home visiting enrollment for women with a history of out-of-home care are needed. Women previously in out-of-home care based on child welfare administrative data between 2012 and 2017 (n = 1375) were compared to a demographically matched sample (n = 1375) never in out-of-home care. Vital records data identified live births in the two groups. For those who had given live birth (n = 372), linked administrative data were used to determine and compare rates of referral and enrollment into home visiting, and two indicators of engagement: number of days enrolled, and number of visits received. Women previously in out-of-home care were referred for home visiting more often than their peers. There were no differences in rates of enrollment. Women previously in out-of-home care remained enrolled for shorter durations and completed fewer home visits than peers. Findings suggest barriers to home visiting enrollment and retention in home visiting programs for women previously in out-of-home care. Studies with larger samples and more complete assessments of outcomes are warranted.

Introducción: Las mujeres que previamente han estado bajo cuidado fuera de cada (v.g. hogares de cuidado adoptivo temporal) experimentan una más débil salud y resultados sicosociales en comparación con las compañeras, incluyendo tasas más altas de embarazos y participación en servicios de protección a la niñez. Los programas de visitas a casa pudieran mitigar los riesgos. Se necesitan estudios que examinen la entrada en programas de visitas a casa de mujeres con un historial de cuidado fuera de casa. Métodos: Se comparó la información administrativa entre 2012 y 2017 de mujeres (n = 1375) que previamente estuvieron en cuidados fuera de casa basados en la beneficencia infantil con un grupo muestra demográficamente emparejado (n = 1375) que nunca habían estado bajo cuidado fuera de casa. Los datos vitales registrados identificaron nacimientos vivos en los dos grupos. Para quienes habían tenido un parto y nacimiento vivo (n = 372), se usó la información administrativa conectada para determinar y comparar las tasas de referencia y entrada en programas de visitas a casa, y dos indicadores de participación: el número de días en que estuvieron matriculadas y el número de visitas recibidas. Resultados: A las mujeres previamente bajo cuidado fuera de casa se les refirió a los programas de visita a casa más a menudo que a sus compañeras. No se dieron diferencias en las tasas de matrícula. Las mujeres previamente bajo cuidado fuera de casa permanecieron matriculadas por duraciones más cortas y completaron menos visitas a casa que sus compañeras. Conclusiones: Los resultados identifican barreras a la matrícula y retención en programas de visitas a casa para mujeres previamente bajo cuidado fuera de casa. Se justifican los estudios con grupos muestras más grandes y evaluaciones más completas de los resultados.

Les femmes ayant été placées en famille ou foyer d'accueil font l'expérience d'une plus mauvaise santé et de résultats psychologiques moins bons que les autres femmes, y compris des taux de grossesse plus élevés et l'intervention de services de protection de l'enfance. Les programmes de visite à domicile peuvent mitiger les risques. Les études examinant l'inscription aux visites à domicile pour les femmes ayant un passé de placement en famille ou en foyer sont nécessaires. Méthodes: des femmes ayant vécu un placement en famille ou en foyer selon les données administratives de la protection de l'enfance entre 2012 et 2017 (n = 1375) ont été comparées à un échantillon assorti démographiquement (n = 1375) de femmes n'ayant jamais été placées en famille ou foyer d'accueil. Nous avons identifié des naissances vivantes chez les deux groupes. Pour celles ayant donné naissance (naissance vivante) (n = 372) les données administratives liées ont été utilisées afin de déterminer et de comparer les taux d'orientation et d'inscription aux visites à domicile, et deux indicateurs d'engagement: le nombre de jours inscrites et le nombre de visites reçues. Résultats: les femmes ayant été placées dans des familles ou des foyers d'accueil étaient dirigées vers les visites à domicile plus souvent que leurs pairs. Il n'y avait aucune différence dans les taux d'inscription. Les femmes ayant été en familles ou foyers d'accueil sont restées inscrites pendant des durées plus courtes et ont eu moins de visites à domiciles que leurs pairs. Conclusions: les résultats suggèrent qu'il existe des barrières à l'inscription aux visites à domicile et à la rétention dans les programmes de visites à domicile pour les femmes ayant été placées en famille ou en foyer. Des études avec des échantillons plus grands et des évaluations plus compètes sont justifiées.

Developmental Service Referrals and Utilization Among Young Children in Protective Custody.

Children in foster care are at high risk for developmental delay. In this retrospective cohort study of young children presenting to a foster care clinic, 77% were not receiving developmental services and 75% failed developmental screening. Of those potentially eligible, 60% were not referred for developmental services.

Developing a Health Care System for Children in Foster Care.

In 2012, the Comprehensive Health Evaluations for Cincinnati's Kids (CHECK) Center was launched at Cincinnati Children's Hospital Medical Center to provide health care for over 1,000 children placed into foster care each year in the Cincinnati community. This consultation model clinical program was developed because children in foster care have been difficult to manage in the traditional health care setting due to unmet health needs, missing medical records, cumbersome state mandates, and transient and impoverished social settings. This case study describes the history and creation of the CHECK Center, demonstrating the development of a successful foster care health delivery system that is inclusive of all community partners, tailored for the needs and resources of the community, and able to adapt and respond to new information and changing systems.

Children in nonparental care: health and social risks.

Approximately 2.3 million children in the United States live separately from both parents; 70-90% of those children live with a relative. Compared with children living with one or both parents, children in nonparental care are in poorer health, are at heightened risk for experiencing disruptions and instability in caregiving, and are vulnerable to other social antecedents of child health (e.g., neglect, poverty, maltreatment). Given the significant impact of adversity in childhood on health across the lifespan, which is increased among children in nonparental care, it is informative to consider the health risks of children living in nonparental care specifically. Research examining the contributions of poverty, instability, child maltreatment, and living in nonparental care, including meta-analyses of existing studies, are warranted. Longitudinal studies describing pathways into and out of nonparental care and the course of health throughout those experiences are also needed. Despite these identified gaps, there is sufficient evidence to indicate that attention to household structure is not only relevant but also essential for the clinical care of children and may aid in identifying youth at risk for developing poor health across the lifespan.

Utility of head computed tomography in children with a single extremity fracture.

OBJECTIVES: To determine the clinical and forensic utility of head computed tomography (CT) in children younger than 2 years of age with an acute isolated extremity fracture and an otherwise-negative skeletal survey. STUDY DESIGN: Retrospective chart review of children younger than 2 years of age who obtained a skeletal survey in the Cincinnati Children's Hospital Medical Center Emergency Department during the 159-month study period. Clinically important head injury was determined based on previously defined Pediatric Emergency Care Applied Research Network criteria. Forensically significant head injury was defined as that which increased the concern for inflicted injury. The rate of head CT relative to patient age and location of fracture (proximal vs distal extremity, upper vs. lower extremity) was determined via χ2 tests. RESULTS: Of the 320 children evaluated, 37% received neuroimaging, 95.7% of which had no signs of skull fracture or intracranial trauma. Five children (4.3%) with head imaging had traumatic findings but no children in the study had clinically significant head injury. Three of these children had previous concerns for nonaccidental trauma and findings on head CT that were forensically significant. There was a greater rate of head imaging in children in the younger age groups and those with proximal extremity fractures (P < .05). CONCLUSIONS: In young children who present with an isolated extremity fracture, clinicians should consider obtaining head CT in those who are younger than 12 months of age, have proximal extremity fractures, or who have previous evaluations for nonaccidental trauma. Evaluation with head CT in children without these risk factors may be low yield.

Young people in foster care and substance use.

Adolescents are at high risk for using substances and for young people in foster care, substance use rates are estimated to be as high as 49 %. Adolescence is an important period for preventing substance use and SUD. Universal screening, brief interventions, and substance use treatment can be used to decrease substance use and substance use disorders among adolescents. Brief interventions often used with adolescents include motivational interviewing and contingency management. Of the many types of outpatient therapies utilized to treat adolescents with substance use disorder, some of the most established include cognitive behavioral therapy, family-based therapy, and a combination of different types of interventions. Medication treatment is less frequently offered to adolescents due to buprenorphine being the only drug FDA approved for youth under the age of 18. Residential treatment is also an option if lower levels of care are not adequate to safely support youth. Lastly, limited research has looked at the effectiveness of continuing care options to support youth in maintaining treatment results.

Dedicated retinal examination in children evaluated for physical abuse without radiographically identified traumatic brain injury.

OBJECTIVE: To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging. STUDY DESIGN: This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI. RESULTS: The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification. CONCLUSIONS: Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination.

Mental Health Diagnoses, Health Care Utilization, and Placement Stability on Antipsychotic Prescribing Among Foster Care Youth.

OBJECTIVE: This study sought to examine how mental health diagnoses, health care utilization and foster care placement instability affect antipsychotic prescribing and how these factors may contribute to disproportionate antipsychotic prescribing among youth in foster care. METHODS: This retrospective cohort study utilized EHR data that were linked to administrative child welfare data. Two outcome variables were analyzed: 1) any antipsychotic prescription documented and 2) number of antipsychotic prescriptions documented. Predictor variables included foster care status, number of unique mental health diagnoses, counts of health care encounters over the study period, and counts of foster care placements. Covariates included gender, persons of color, and age in years. Models were estimated using logistic regression for the dichotomous outcome and Poisson regression for the count outcome. RESULTS: Increased antipsychotic prescribing among children in foster care persists even after accounting for mental health diagnoses and health care utilization. However, the number of placements modified the effect of foster care involvement on antipsychotic prescribing such that after 2 placement changes, the odds of being prescribed an antipsychotic surpassed the effect of foster care involvement. More mental health diagnoses, more inpatient and emergency health care encounters, and more foster care placements were associated with an increased odds of being prescribed an antipsychotic and an increased count of antipsychotic prescriptions. Decreased primary care encounters were associated with increased odds of antipsychotic prescriptions, and decreased specialty encounters were associated with higher counts of antipsychotic prescriptions. CONCLUSIONS: Placement instability is associated with disproportionate antipsychotic prescribing among youth in foster care.

Patterns of substance use among adolescents in and out of foster care: An analysis of linked health and child welfare administrative data.

BACKGROUND: Young adults with a history of foster care have higher risk for substance use disorders. Social systems can deliver substance use prevention to youth; however, the timing of intervention delivery and how needs differ for youth in foster care are unclear. OBJECTIVE: To compare initiation and rates of substance use among adolescents in foster care to demographically similar adolescents never in foster care as identified by the healthcare system, and identify factors associated with increased substance use. PARTICIPANTS AND SETTING: Youth in foster care (n = 2787, ages 10-20, inclusive) and demographically matched youth never in foster care (n = 2787) were identified using linked child welfare and electronic health records from a single pediatric children's hospital and county over a five-year period (2012-2017). METHODS: All healthcare encounters were reviewed and coded for substance use by type (alcohol, tobacco, cannabis, other). Age of first reported or documented substance use was also captured. Demographic and child welfare information was extracted from administrative records. Survival and logistic regression models were estimated. RESULTS: In adjusted models, youth in foster care initiated substance use at earlier ages (HR = 2.50, p < .01) and had higher odds of engaging in use (AOR = 1.54; p < .01) than youth never in care. By age 12, substance use initiation was more likely while youth were in foster care than when they were not in foster care (HR = 1.42, p < .01). Placement stability and family care settings reduced odds of lifetime substance use. CONCLUSIONS: Foster care placement is associated with substance use. Screening may be important for prevention.

Early clinical indicators of developmental outcome in abusive head trauma.

PURPOSE: The purpose of the study was to determine the developmental prognostic significance of early clinical indicators in abusive head trauma. METHODS: Seventy-one children were diagnosed with abusive head trauma and followed in a post-injury growth and development clinic. A retrospective chart review was completed to gather clinical features at the time of injury, including presence or absence of early post-traumatic seizures, presence or absence of intubation, and presence or absence of pediatric intensive care unit admission. Children then underwent developmental testing with use of the Capute Scales of the Cognitive Adaptive Test (CAT) and the Clinical Linguistic and Auditory Milestone Scale (CLAMS) during follow-up clinic visits. Clinical features at initial injury were compared to developmental outcome. RESULTS: Thirty-four of 71 patients with seizures during their admission hospitalization scored significantly lower on follow-up developmental testing than patients who did not have seizures. Twenty-one of 71 patients who required intubation scored lower on developmental testing than patients who did not require intubation. Thirty-five of 71 patients who required pediatric intensive care unit admission scored lower on developmental testing than patients who did not require pediatric intensive care unit admission. CONCLUSIONS: This study demonstrates that clinical factors at the time of injury, such as early post-traumatic seizures and intubation requirement, are associated with poorer developmental outcome. This study also suggests that close developmental follow-up should be obtained for all children with abusive head trauma, regardless of whether or not the child was admitted to the PICU.

Understanding the impact of COVID-19 on stress and Access to Services for Licensed and Kinship Caregivers and Youth in Foster Care.

Children in foster care in the United States face unique challenges related to access to health and education services. With the COVID-19 pandemic, many of those services were temporarily disrupted, adding burden to an already strained system. This observational study describes the experiences of licensed and kinship caregivers (N = 186) during the peak of COVID-19 stay-at-home orders and as restrictions to services were lifted, to understand the overall impact of COVID-19 on this already vulnerable population. Purposive sampling methods were used, where caregivers known to have received placement of children prior to, during, and following COVID-19 stay-at-home orders were identified and recruited to complete a 45-minute phone-administered survey assessing stress, risks for contracting COVID-19, strain resulting from COVID-19, and access to services for children in foster care in their care across five domains: healthcare, mental health, education, child welfare, and family visitation. Differences by caregiver type (licensed, kinship) and timing in the pandemic were examined. Licensed and kinship caregivers reported similar social and economic impacts of COVID-19, including similar rates of distress for themselves and the youth placed with them. Almost half of caregivers experienced challenges accessing mental health services, with access to services more disrupted during COVID-19 stay-at-home orders. Caregiver reports regarding the social and economic impacts of COVID-19 were similar across the study, suggesting that lessened restrictions have not alleviated strain for this population.

Modeling changes in adolescent health risk behaviors approaching and just after the time of emancipation from foster care.

BACKGROUND: Emancipated foster youth frequently engage in behaviors that contribute to poor health. Whether health risk behaviors increase following emancipation or are established while in foster care remains unclear. OBJECTIVE: This secondary data analysis examined substance use and attitudes toward sexual risk behaviors to understand continuity in risk behaviors among foster youth before emancipation and following emancipation. PARTICIPANTS AND SETTING: Youth ages 16-20 (N = 151) who had been in foster care for at least 12 months and were expected to emancipate were recruited. The urban county where the study was conducted allowed youth to remain in foster care until 21 years of age. METHODS: Participants completed surveys assessing substance use and attitudes toward sexual risk behaviors at baseline, 6 and 12 months. Multilevel models estimated trajectories of health behaviors and attitudes, with emancipation timing as the primary predictor. Individual and child welfare characteristics were included as covariates. RESULTS: Substance use did not change with emancipation (Bs = 0.01, p = 0.81) and positive attitudes about risky sexual behavior significantly decreased as youth approached emancipation (Bs = 1.67, p < 0.01). Placement instability and adversity were not associated with either outcome (ps > 0.08). Females reported more positive attitudes about higher-risk sexual behavior than males (B = 3.09, p < 0.01) and less substance use (B = -1.15, p = 0.03). CONCLUSIONS: Substance use and attitudes about sexual risk behaviors are established before emancipation; interventions prior to emancipation are necessary to improve health outcomes.

Patterns of healthcare utilization with placement changes for youth in foster care.

BACKGROUND: Children in foster care experience poor health and high healthcare use. Child welfare agencies frequently require healthcare visits when children enter foster care; subsequent placement changes also disrupt healthcare. Studies of healthcare use have not accounted for placement changes. OBJECTIVE: To understand patterns of healthcare use throughout the time a child enters foster care and with placement changes, accounting for mandated visits when children enter foster care or experience a placement change. PARTICIPANTS AND SETTING: Children 4 and older in foster care between 2012 and 2017 (N = 2787) with linked child welfare administrative data from one county child welfare agency and one Midwest pediatric healthcare system. METHODS: Negative binomial models predicted healthcare days per month that were planned (e.g., scheduled primary/specialty care), unplanned (e.g., emergency care), or missed. RESULTS: Planned healthcare days increased as a function of placement changes (Incident Rate Ratio [IRR] =1.69, p < .05) and decreased with placement stability (IRR = 0.92, p < .01). Mandated visits that occurred later in a placement were associated with fewer planned (IRR = 0.81, p < .01) and unplanned (IRR = 0.82, p < .01) healthcare days during that placement. CONCLUSIONS: Patterns of planned healthcare over the time children are in one placement and move between placements suggest more can be done to ensure youth remain connected to primary and specialty care throughout placements and placement transitions, s that children are seen as clinically appropriate rather than a function of placement disruption. Findings regarding the timing of mandated visits suggest that delays in mandated care may also reflect lower healthcare use overall.

Effects of Child Protective Custody Status and Health Risk Behaviors on Health Care Use Among Adolescents.

OBJECTIVE: To determine whether current protective custody status (ie, youth currently in the temporary or permanent custody of child protective services, eg, foster and kinship care) contributes to increased health care utilization compared to youth never in protective custody. Health characteristics (eg, mental health diagnoses) and behaviors (eg, substance use) were expected to account for differences in health care use among the two groups. METHODS: Retrospective child welfare administrative data and linked electronic health records data were collected from a county's child welfare system and affiliated freestanding children's hospital between 2012 and 2017. Youth currently in protective custody (n = 2787) were identified and demographically matched to peers never in custody (n = 2787) who received health care from the same children's hospital. Health care use, health risk behaviors, and social, demographic, and diagnostic data were extracted and compared for both cohorts. RESULTS: In baseline models, health care use was higher for youth in protective custody compared to peers. In adjusted models that included health risk behaviors and patient characteristics, protective custody status was associated with decreased primary and missed care, and no longer a significant predictor of other types of health care use. CONCLUSIONS: Youth had significantly higher utilization while in protective custody than their demographically similar peers; however, health risk behaviors appear to account for most group differences. Identification of current custody status in pediatric settings and addressing health risk behaviors in this population may be important for health care systems interested in altering health care use and/or cost for this population.

Careful: An administrative child welfare and electronic health records linked dataset.

Between 2012 and 2017, N = 2814 youth between the ages of 4 and 20 were in child protective services (CPS) custody in Hamilton County, Ohio, and placed in out-of-home care. Child welfare administrative records were extracted and linked to electronic health records for all encounters at Cincinnati Children's Hospital Medical Center, with n = 2787 (99.1%) of records successfully linked prior to de-identifying the data for research purposes. Child welfare administrative data fields in the dataset include demographics, dates of entry into and exit from protective custody and out-of-home care, reasons for entry into custody, dates of placement changes, reasons for placement changes, and types of placement (e.g., foster home, kinship home, group home, residential treatment, independent living). Electronic health records (EHR) data fields include demographics, all inpatient and outpatient encounters with medications, diagnoses, screening results, laboratory test results, flowsheet data, and problem list entries. Data have been coded to capture broader categories of health needs and encounter details, medications, and other health concerns. Due to the high representation of children in CPS custody and out-of-home care who are also represented in the EHR data, this dataset provides a comprehensive view of the medical needs and health concerns for school-aged children in CPS custody in an entire county. As a result, these data can be useful for understanding the emergence of global and specific health concerns, frequency of healthcare use, and placement stability for all youth in CPS custody in this community, accounting for variation due to other health and child welfare factors. These data are likely generalizable to other mid-sized urban communities where academic medical centers provide healthcare for children in CPS custody. De-identified data may be made available to other researchers with approved data transfer agreements between academic institutions in place.

The Impact of Health Care Education on Utilization Among Adolescents Preparing for Emancipation From Foster Care.

PURPOSE: As teens in foster care prepare for emancipation, health care navigation is often overlooked, as caseworkers address other social needs. This study examined the impact of health care education materials designed for foster youth, called ICare2CHECK. It was hypothesized that ICare2CHECK would increase nonurgent ambulatory health care use and decrease emergency/urgent care use. METHODS: Adolescents (N = 151; aged 16-22 years) were enrolled in ICare2CHECK and received health education materials at their baseline study visit. Surveys were repeated every 3 months to assess health care utilization. After 12 months of enrollment, health care data for all eligible youth and matched comparison youth (N = 151) over the previous 24 months were extracted from the electronic health record (N = 302). Electronic health record data were coded as counts of completed nonurgent ambulatory care encounters (i.e., primary and preventative care and specialty care), completed urgent or emergency encounters (i.e., urgent and emergency department visits and hospitalizations), completed foster care clinic visits, and total completed visits. RESULTS: Health care use significantly decreased over time for both enrolled and comparison youth. Females, youth engaging in health risk behaviors, and those with a mental health or chronic condition diagnosis used significantly more health care. Receipt of educational materials was associated with a smaller decline in health care use and nonurgent ambulatory care use, controlling for covariates. Self-reported use of educational materials was associated with increased utilization in the enrolled condition. CONCLUSIONS: Results suggest that ICare2CHECK is associated with increased engagement in health care generally and nonurgent ambulatory care specifically (e.g., outpatient primary and specialty care).

Socioeconomic Characteristics of Neighborhoods where Youth in Out-of-Home Care Reside.

In the U.S., little is known about the neighborhoods where youth in out-of-home care live prior to emancipation. This study describes the socioeconomic characteristics of such neighborhoods. Addresses for 229 youth aged 16-20 years and residing in out-of-home care in a single Midwest county were used. Addresses were geocoded and linked to U.S. Census' data at the census tract level. Neighborhoods, or tracts, with youth in out-of-home care were significantly more disadvantaged across five area-based socioeconomic indicators. Findings suggest that youth in out-of-home care live in neighborhoods with disproportionately high rates of socioeconomic disadvantage.