Closing the Gap: Foster Parents' Lived Experiences and Recommendations for Interdisciplinary Health-Care Providers.

Purpose: This study explored barriers and facilitators to utilizing health-care services for foster youth, from the perspective of foster parents. Background: There are nearly 437,283 youths in the United States foster care system. Youths living in locations that are different from their familial home situations have a significantly higher occurrence of physical and mental health illnesses than children who remain in their familial homes, increasing risk for homelessness, substance use and abuse, chronic long-term illnesses, and incarceration, thus placing additional burden on the health-care system. Design and Methods: This study utilized a qualitative descriptive design with purposive sampling, with video focus groups to explore 15 foster parents' experiences in accessing health-care services for foster youth. Results: Barriers and facilitators to accessing health care and care coordination were identified, including logistics, transportation, electronic health record access, location of health care, and the impact of the social worker. Practice Implications: Nurses are well-positioned to aid in closing gaps in care for foster youth. Conclusions: These experiences provide important insights and implications for health-care providers and for future research and policy development.

What Do Child Abuse and Neglect Medical Evaluation Consultation Notes Tell Researchers and Clinicians?

Child abuse and neglect (CAN) medical experts provide specialized multidisciplinary care to children when there is concern for maltreatment. Their clinical notes contain valuable information on child- and family-level factors, clinical concerns, and service placements that may inform the needed supports for the family. We created and implemented a coding system for data abstraction from these notes. Participants were 1,397 children ages 0-17 years referred for a consultation with a CAN medical provider at an urban teaching and research hospital between March 2013 and December 2017. Coding themes were developed using an interdisciplinary team-based approach to qualitative analysis, and descriptive results are presented using a developmental-contextual framework. This study demonstrates the potential value of developing a coding system to assess characteristics and patterns from CAN medical provider notes, which could be helpful in improving quality of care and prevention and detection of child abuse.

Child Sexual Abuse Documentation in Primary Care Settings.

Primary care providers (PCPs) can play an important role in the continuity of care for children who experience sexual abuse (SA). We performed a retrospective, chart-based study of children 3 to 17 years old with SA history. Primary care medical records were reviewed for 2 years after a subspecialty SA evaluation. Descriptive statistics and logistic regression were used to assess factors associated with documentation of SA history and mental health management by the PCP. Of 131 included patients, 43% had PCP documentation of their SA history, which was associated with care from resident providers (P < .01). There was greater mental health management and mental health referrals by PCPs for the group with documentation compared with the group without documentation (52% vs 23%, P < .001). Overall, child SA history was poorly documented in primary care settings. Identifying mechanisms to improve communication about a child's SA history with PCPs is important for the child's ongoing care.

Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?

BACKGROUND: Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic. OBJECTIVE: To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three. PARTICIPANTS AND SETTING: Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231). METHODS: We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed. RESULTS: Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95 % confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95 % CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95 % CI: 0.7, 1.3). CONCLUSION: This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.

Electronic Health Record Tools to Identify Child Maltreatment: Scoping Literature Review and Key Informant Interviews.

OBJECTIVE: To prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to 1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and 2) examine clinical perspectives regarding the use of such tools and factors that affect uptake. METHODS: We searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0 to 18-year olds. We performed semistructured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics. RESULTS: Our search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14 to 1.00, specificity from 0.865 to 1.00, positive predictive value from 0.03 to 1.00 and negative predictive value from 0.55 to 1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation. CONCLUSIONS: Interviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.

Kinship Care and Foster Care: A Comparison of Out-of-Home Placement From the Perspective of Child Abuse Experts in North Carolina.

BACKGROUND Children may be placed in either kinship or foster care, forms of out-of-home placement (OHP), if maltreatment is suspected. The American Academy of Pediatrics has identified them as children with special health needs requiring elevated care. While North Carolina has increased support for foster care, it is unclear whether similar support exists for kinship care. Child abuse medical providers (CAMPs) were interviewed regarding their understanding and assessment of the state of the kinship care system in North Carolina, and how it can be improved.METHODS CAMPs were individually interviewed using a semi-structured, open-ended question guide to assess their perspectives on kinship versus foster care in North Carolina. Data were coded, and the analysis was conducted in an inductive manner, allowing themes and then recommendations to emerge from interviews.RESULTS The following three themes were identified: 1) providers have a foundational understanding of the kinship care system, marked by knowledge gaps; 2) children in kinship care and foster care have equivalent, elevated health needs, but children in kinship care do not receive the same level of care; 3) individual and structural changes have to be made to the interprofessional teams working within the OHP system.LIMITATIONS The study sample was small, including eight CAMPs who had relatively homogenous demographic characteristics. CAMPs typically see the worst cases of maltreatment, which may bias responses. Additionally, the majority of children in kinship care are unknown to CAMPs and may not be fully represented in responses.CONCLUSION CAMPs' responses were summarized into a set of recommendations targeting four different components of the OHP team: the general interprofessional team, policymakers and state leaders, medical providers, and social workers.

Improving Timeliness of Medical Evaluations for Children Entering Foster Care.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics (AAP) recommends children in foster care (FC) have an initial medical evaluation within 3 days of custody initiation; however, this vulnerable population often suffers from disjointed care. Our aim was to improve the mean time to initial foster care evaluation (TIE) from 32 to <7 days within 12 months for children in FC in Durham County, North Carolina. METHODS: This study was a time series, quality improvement project used to target interventions within an academic clinic and a community agency. Interventions were tested through multiple plan-do-study-act cycles. Control charts of the primary outcome, the TIE, were constructed. Charts were annotated with the dates of interventions, including workshops, performance feedback, integration of state forms, identification of appointments, development of an urgent appointment pathway, and empowerment of the scheduler. RESULTS: The mean TIE improved from 32 to 9 days within 12 months. Significant improvement in the following 2 process measures contributed to this: the time from custody initiation to the referral date improved from an average of 10 to 3 days, and the time from referral date to the initial evaluation improved from an average of 22 to 6 days. CONCLUSIONS: Improvement interventions and increased collaboration between medical and child welfare agencies can result in significant improvement of the TIE. However, despite improvement efforts, challenges remain in meeting the AAP 3-day TIE recommendation. We recommend further assessment of the AAP guideline as it relates to implementation feasibility and health outcomes of children in FC.