пятница, 5 октября 2012 г.

Improving Access to Health Care for Foster Children: The Illinois Model - Child Welfare

Children in foster care have lower health status than do their peers and limited access to health care. The Illinois Department of Children and Family Services developed Health Works, a separate primary care preferred provider system for children in foster care. This study compared claims data for children in Health Works with children not enrolled in HealthWorks and with children in Aid to Families with Dependent Children (AFDC) who had never entered foster care. Children enrolled in Health Works were more likely than were other children to receive all of the services except general inpatient hospitalizations. They had greater odds of receiving general exams and physicians' services and were more likely to visit the emergency room than children who were not enrolled. They were more likely to receive all of the measured services when compared with children receiving Medicaid through AFDC.

Children in foster care are one of America's most vulnerable populations, one often overlooked by policymakers. Previous research in several states has shown that children in foster care have a high rate of unmet health care needs and underused health services (Halfon, English, Alien, & DeWoody, 1994; Kass, Weinick, & Monheit, 1999; Schor, 1982; Simms, 1991; Swire & Kavaler, 1977; U.S. General Accounting Office, 1995; Weinstein & LaFleur, 1990; White, Benedict, & Jaffe, 1987).

Not only does this population have a high rate of unmet need, it has higher rates of health care needs in general. Research using health care use as a proxy for need consistently demonstrates that children in foster care have considerably more health care needs than other low-income children. Research in Washington State revealed higher rates of use and health care expenditures among children in foster care when compared with other Medicaid-eligible children, (Takayama, Bergman, & Connell, 1994). In Illinois, Bilaver, Jaudes, Koepke, and Goerge (1999) showed that children in foster care use more health care services than did other lowincome children receiving Medicaid. In addition, research in Illinois demonstrated that children who went on to enter foster care revealed more use of mental health and supportive services than other Medicaid-eligible children in the year prior to their entry into out-of-home care. These children in foster care have far lower health status than did their peers and often have endured documented adverse physical, psychological, and social situations throughout their short lives (Halfon, Mendonca, & Berkowitz, 1995).

In response to the increasing body of knowledge about the health problems of children in foster care, agencies have made concerted efforts to define guidelines for addressing their health care needs. In 1988, the Child Welfare League of America (CWLA) released its Standards for Health Care Services for Children in Outof-Home Care, which called on states to design systems that included four basic components: initial health screening, comprehensive health assessment, developmental and mental health evaluation, and ongoing monitoring of health status. Many states responded by implementing health care policies and programs that addressed their systems' shortcomings and offered innovative approaches to serving the health care needs of children in foster care.

A common model described in the literature is the implementation of a community-based clinic that targets the service of foster children. Simms (1989) described one of the earliest models. In Waterbury, Connecticut, planners established a multiagency, multidisciplinary foster care clinic to identify medical, behavioral, and developmental problems among preschool-age children in foster care. This special clinic assembled a group of key practitioners to identify health care needs, provide appropriate referrals for treatment, and communicate with the children's social workers and primary care providers. Planners established other models designed to identify the needs of children entering foster care in Chicago, Baltimore, and Ramsey County, Minnesota (Chernoff, Combs-Orme, Risley-Curtiss, & Heisle, 1994; Flaherty & Weiss, 1990; Hobbie, Braddock, & Henry, 2000).

Other community-based models not only served as centers for assessment and referral but also delivered primary care. In Onondaga County, New York, children ages 12 and younger were served by a multidisciplinary team of experts that provided assessment and primary care (Blatt et al., 1997). A liaison between the social service agency and the medical staff coordinated the effort. In San Diego County, California, the social service department turned to the state's Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) to ensure the primary care of children in foster care (Ruptier, 1997). By housing social workers and public health nurses in the same location, staff were better able to work together to address the health needs of children in foster care, with an emphasis on preventive service.

Fewer programs designed to serve children in foster care have experimented with fiscal incentives. Schor, Nerf, and LaAsmar (1984) described a very early example in which children in foster care in Baltimore were enrolled in an HMO established to serve foster children. Schor et al. found that the health plan was a successful, workable model to address the needs of foster children.

Although past research has presented data on service model participants, no research has relied on a comparison group to examine the reach and effectiveness of a particular model. This article describes a program involving fiscal incentives that was established in Illinois in July 1995 and provides evidence of its effectiveness. Because of the large number of children already in foster care at the start of the program, the planners enrolled children over the course of four years. The authors took advantage of the staged enrollment practices to compare the health care use of enrolled and nonenrolled children. Unlike previous models described in the literature, this program, known as Health Works, is a statewide program.

Illinois's Health Works Initiative

The Illinois Department of Children and Family Services (DCFS), through contractual relationships with lead agencies statewide (local health departments and community-based agencies), recruited and organized a network of well-qualified health care providers and community agencies to ensure access to comprehensive health care for children in the care of the state. The separate health system for children in foster care is called Health Works.

The model for Health Works is a primary care, preferred provider approach similar to managed care. The system is financed, however, by fee-for-service payments through public-private partnerships with four objectives: develop an accessible network of quality health care providers, coordinate the delivery of comprehensive health care services to children in foster care, ensure continuity in the delivery of care, and improve the health status of children in state custody. These goals are all in accordance with the standards of care produced by the American Academy of Pediatrics Committee on Early Childhood, Adoption and Dependant Care (1994); CWLA (1988); and experts in the field (Simms, Freundlich, Battistelli, & Kaufman, 1999).

The program includes a community-based medical case management component for all children in foster care younger than 6 years of age. Children ages 6 and older receive medical case management by the DCFS caseworker. Participating providers sign an agreement that outlines both the providers' and Health Works' responsibilities and ensures cooperation with the case management component. In addition to an initial screening, participating providers must provide annual or interperiodic screenings that follow the basic EPSDT standards, including unclothed physical exams, behavioral health and developmental screens, maintenance of specially designed medical records, compliance with Advisory Committee on Immunization Practices immunization standards, and hearing and vision screenings. These standard components are provided on the customary EPSDT schedule, annually after 2 years of age or more often as risk assessment dictates.

Health Works has been designed with six interrelated key program features.

1. An Initial Health Screen (IHS). IHS is required for all children and doctors must complete it within 24 hours of a child entering custody and before foster home placement. IHS treats any acute medical illnesses, including any infectious or communicable diseases; documents any signs of maltreatment; and provides the child -welfare caseworker with medical information for making placement decisions. A 24-hour Healthline phone system facilitates IHS, linking children to hospitals and clinics with short waiting times. The children are to be seen within one hour of arrival at the IHS site.

2. A Comprehensive Health Evaluation. In addition to IHS, doctors conduct a comprehensive health evaluation within 21 days of placement in state custody. The comprehensive exam includes a full EPSDT examination and mental health, developmental, alcohol, and substance abuse screenings when appropriate. Doctors make referrals for specialized services as needed.

3. Primary Care Physicians (PCPs). Foster parents select a PCP for their foster child from the Health Works network of participating providers. If they already have a PCP, the lead agency attempts to enroll the provider in the network, assuming they meet the specific enrollment criteria. Criteria for physicians to enroll in Health Works are more stringent than for Medicaid. Participating physicians must complete a residency that includes pediatric training, offer 24-hour availability, and have hospital admitting privileges. Providers receive enhanced Medicaid rates (8% to 10% higher than standard fees) as well as a monthly $5 fee per child for completion of the paperwork and coordination with community-based medical case management agencies. In addition, providers receive a one-time $15 fee per child for initiation of the Health Passport-a portable medical record summary that follows the child regardless of placement location or provider. Participating PCPs receive orientation and training from the lead agency on the use and distribution of DCFS forms and age-appropriate medical records. Providers must sign an agreement with the lead agency that clearly defines the obligations of the lead agency and the provider.

4. Specialty and Subspecialty Care. Specialty and subspecialty care is available through the Health Works program. These referrals include dental care, optometric care, and other pediatric subspecialty care that PCPs arrange.

5. Medical case Management. Children younger than 6 years of age receive medical case management provided by community-based agencies. case managers promote preventive strategies directed at improving access to needed services identified in the care plan individualized for each child. The child welfare worker provides case management for children older than 6 years of age.

6. Standardized Health Forms and Educational Materials. A Health Passport with information about each child's medical problems, past medical and family history, immunization records, and diagnostic studies, recorded in a standardized consistent manner, serves as a portable medical record. The child's Health Passport follows the child from substitute parent to substitute parent and physician to physician. In addition, physicians developed standardized, age-specific medical records. The planners designed educational materials about Health Works and distributed them to caseworkers, foster parents, and physicians.

The health care information system captures computerized service delivery data, including IHS, comprehensive health evaluation, initiation of the Health Passport, PCP selection, and assignment of a medical case management agency. Workers send all other documents to the lead agency. They copy and distribute these records to foster care providers, caseworkers, and PCPs as appropriate. The lead agency maintains the original records in a central file. Planning is under way for the implementation of an electronic Health Passport.

Health Works Implementation

More than 70% of the children in foster care in Illinois are placed in Cook County. The complexities of the health care delivery system in Cook County made this an excellent proving ground for the design and initial implementation of Health Works. Implementation began in Chicago with the formal development of networks of IHS sites, PCPs, and community-based medical case management agencies. At this time, Health Works has been fully implemented in Cook County and most other Illinois counties.

In FY1995, only 43% of children in foster care in Cook County were enrolled in Health Works. By FY 1997, 61% were. More recently, enrollment in Cook County has reached levels greater than 90%. At the same time enrollment was increasing, the network of PCPs expanded. In FY 1995, two years after program implementation, 51 clinics, 13 hospitals, and 257 PCPs participated in the Health Works initiative. In 1999, Health Works had grown to include 94 clinics, more than 100 hospitals, and more than 3,400 PCPs statewide.

The study used no controlled process to enroll children in Health Works. Ideally, random assignment would be the preferred selection method used to make decisions about which children were enrolled. The lack of such a controlled process makes it difficult to draw conclusions about any differences in outcomes between children enrolled in the program and children not enrolled. This study instead takes advantage of the administrative data available on the entire population of children in foster care in Cook County during the study period. With the population data, the authors could determine rates of health service use that are adjusted for differences in demographic and case characteristics between children enrolled in Health Works and children not enrolled. In this way, they could control for differences in the two populations that may have an effect on health care use.

The authors also compared the levels of service use for children in foster care with children receiving Aid to Families with Dependent Children (AFDC) whose health care service is also funded through Medicaid. Although past research on use rates shows that children in foster care have a higher level of need than children receiving AFDC, approximately 70% of children in foster care came from families that received AFDC (U.S. Department of Health and Human Services, 2000). This comparison will provide a measure of Health Works' effect in relation to a socioeconomically similar population.

The authors chose to focus on health service use (outpatient and inpatient services) as the outcome measure because each of the Health Works program components was designed to improve access to health care, which would lead to higher rates of appropriate health care use. Appropriate refers to higher rates of preventive health care services; higher rates of needed specialized services, including mental health; and lower rates of nonemergency emergency room (ER) visits. Key to this distinction, however, is the ability to recognize services as being appropriate. Unfortunately, the administrative data on health service use do not permit a measure of the need for services. To the extent that children in Health Works have greater health care needs than children who were not enrolled, one must use caution in interpreting the results. We believe, however, that no systematic enrollment of children with greater health needs in the program existed.*

To assess the effect of Health Works on health services use, the authors analyzed Medicaid-paid claims for the population of children who had been in foster care or AFDC for at least one day during FY 1997. In Illinois, all children become eligible for Medicaid on entry to the system. The authors performed a cross-sectional analysis to measure the effect of Health Works on the entire population of children in foster care rather than only on children new to the system.

The authors defined three study populations for comparison: (1) children in foster care from Cook County enrolled in Health Works during the fiscal year (n = 28,844), (2) children in foster care from Cook County not enrolled in Health Works during the fiscal year (n = 18,187), and (3) children from Cook County eligible for Medicaid through the AFDC program during the fiscal year (n = 601,772). Because computerized data on Health Works were only available for children in Cook County cases at the time of the study, this analysis does not represent an assessment of the program for the entire Illinois foster care population; however, Cook County does include Chicago and 71% of the foster care caseload in Illinois.

Data

The researchers identified the study populations from the Integrated Database on Children's Services (IDB) in Illinois. IDB is a relational database that combines administrative data collected by the state public welfare agencies for administrative purposes (Goerge, Van Voorhis, & Lee, 1994). IDB comprises data from child welfare, juvenile justice, AFDC and Temporary Aid for Needy Families, Medicaid, special education, mental health, and disability systems. Information in the database includes individual demographic information, such as age, race or ethnicity, and family composition, and information on case histories both in foster care and public assistance.

Part of the foster care case history are data on Health Works participation in Cook County. Data on health care use stem from extracts of Medicaid claims from the Illinois Department of Public Aid. The Medicaid claims data maintained in IDB include all paid claims for individuals younger than age 21 in Illinois excluding prescription claims. Key variables in the claims data include category of service, primary International Classification of Diseases, Clinical Modification diagnosis code, primary procedure code, and dates of service.

Because IDB includes data from multiple human service agencies, much of the data is not linked by a common identification number. To identify the Medicaid-paid claims of children in foster care, the authors linked records using a technique called probabilistic record-matching. Used widely in epidemiology and demography (Newcombe, 1993; Roos & Wajda, 1991; Roos, Wajda, Nicol, & Roberts, 1992), probabilistic record-matching assumes that no comparison between fields common to the source databases will link an individual's records with complete confidence. Instead, the method calculates the likelihood that two records belong to the same person by matching as many pieces of identifying information as possible from each database. This study used first and last name, birth date, gender, race or ethnicity, Social Security number, and county of residence to link the foster care data to the Medicaid claims.

Data Analysis

The authors analyzed the rates of service use of 10 different categories of health services paid by Medicaid: EPSDT exams, physicians' services, psychiatric clinic services, services of mental health providers, hearing exams, eye exams, lead screenings, ER visits, general inpatient hospitalizations, and psychiatric hospitalizations. Mental health services comprise the diagnosis and treatment of mental health problems provided to clients of agencies, including DCFS and the Department of Mental Health and Developmental Disabilities. For each of these service categories, the authors assessed whether children enrolled in Health Works reported different rates of service use than a comparison group.

The authors used logistic regression models to estimate the odds of service receipt while controlling for differences among the three groups of children. They used two types of models in each fiscal year. The first model included children in Cook County foster care cases; the second included children participating in the Health Works program and children receiving AFDC. They estimated a separate model for each of the 10 service categories. In each model, an indicator of whether a child received the particular service during the fiscal years served as the dependent variable. One disadvantage of the cross-sectional design is that it did not allow the researchers to precisely model the time of Health Works enrollment during the year.*

The authors examined the following independent variables for inclusion in the model depending on fit to the data: race/ethnicity (white, black, Hispanic, and other), continuous age at the beginning of the fiscal year, categorical age at the beginning of the fiscal year (infant or ages 1-3, 4-6, 7-9, 10-12, 13-15, and older than 15), continuous proportion of the year in foster care or AFDC, categorical time in foster care or AFDC (less than 3 months, 3-6 months, 6-9 months, and 9-12 months), an indicator of the child's first entry to foster care or AFDC (1 = new to the system, O = not new), gender, and group membership (enrolled in Health Works, not enrolled in Health Works, or in AFDC). From each model, the adjusted odds ratio (OR) of service receipt for those enrolled in Health Works describes the odds that children enrolled in Health Works will receive services compared with either children not enrolled or children participating in AFDC, while controlling for differences between the three groups.

The authors used goodness-of-fit measures to evaluate the model fit for each service and each fiscal year. They evaluated both the Hosmer and Lemeshow goodness-of-fit tests for all of the models and the deviance chi-square statistic for models not including the continuous form of age and time in foster care or AFDC. In many cases, the authors could not specify models that had insignificant deviance chi-square statistics with the available covariates. In nearly all cases, the Hosmer and Lemeshow tests indicated adequate fit for at least one model for each service type. If at least one of the models that they tested indicated adequate fit (p = .05), the authors selected the model with the greatest fit based on this test. If the authors could not achieve adequate fit, they estimated the fullest model. This method provided controls for the greatest number of covariates for each service as deemed necessary by the goodness-of-fit measures.

Results

Demographics of Children

In FY 1997, 61% of children ever served in Cook County foster care were enrolled in HealthWorks. The authors found several substantial differences in the characteristics of the study groups that they believed could affect health care service use. They were concerned about differences in the racial and ethnic composition, given that national estimates show that African American children have poorer access to health care than children of other races and ethnicities (Kass et al, 1999). Only 59% of the AFDC child population served in FY 1997 were African American compared with 85% to 87% of the Cook County foster care population (see Table 1). Differences also existed in the length of time that children were served in either foster care or AFDC during the study period. The duration of services during the fiscal year would have a direct effect on the opportunity that children had to receive health care services. In FY 1997, 80% of children enrolled in Health Works had been in foster care for the entire fiscal year compared with 73%; of children not enrolled in Health Works, and children receiving AFDC during FY 1997 were served for the entire year.

Children enrolled in Health Works tended to be younger than children not enrolled. This was especially true of children between ages 1 and 6. Of children in Health Works, 45% were ages 1 to 6, compared with just 22% of children not enrolled in Health Works. The age distribution of children served in AFDC was similar to children enrolled in Health Works.

Service Use

Levels of service use varied considerably across the comparison groups. More than 70% of children in Health Works received a general exam or physician service during the fiscal year compared with approximately 50% of children not enrolled and 40% of children in the AFDC program (see Table 2). Other primary care services such as hearing and eye exams and lead screenings were used 2 to 2.5 times as often by children in foster care than by children in AFDC. A much larger percentage of children in foster care used psychiatric and mental health services, compared with children in AFDC. The percentage of children using ER services and requiring general inpatient hospitalization was similar across the three groups. Between 16% and 23% of children in foster care and AFDC in Cook County visited the ER, and nearly 8% required hospitalization.

Even after controlling for differences across the comparison groups, children in Health Works were significantly more likely to receive 9 of the 10 services measured compared with children not enrolled in Health Works. In terms of primary care, children in Health Works had approximately two times the odds of receiving general exams and physicians' services after controlling for race and ethnicity, age, gender, time in care, and whether the case was new (see Table 3). Hearing and eye exams were approximately 20% more likely for children in Health Works than for children not in Health Works (ORs = 1.22 and 1.27, respectively). Children in Health Works also had 49% greater odds of being screened for elevated lead levels. In terms of mental health services, the authors found that children enrolled in Health Works were more likely to use psychiatric clinic services (OR = 1.49), use outpatient mental health services (OR = 1.28), and experience inpatient psychiatric hospitalizations (OR = 1.26) than children not enrolled. Despite the assignment of PCPs, children enrolled in Health Works had 12% greater odds of using ER services than children not enrolled. General inpatient hospitalization, however, was just as likely among children enrolled and not enrolled in Health Works. An appendix -with the full set of parameter estimates for the best fitting model can be requested from the authors.

Children in Health Works had even greater odds of service receipt in all 10 of the services measured than children in the AFDC program (see Table 3). Children in Health Works were more than five times more likely to receive general exams or physician service during the fiscal year than children in AFDC were (OR = 5.15, OR = 5.46). The authors observed even more dramatic differences in the adjusted odds of mental health service receipt. Children in Health Works had 22 times the odds of receiving a mental health service and more than 9 times the odds of receiving a psychiatric clinic service, compared with children in the AFDC program. The authors observed the smallest differences in ER services and general inpatient hospitalization. Although still more likely to receive service, children in Health Works were 55% more likely to use the ER during the fiscal year and 2.32 times as likely to experience a general inpatient hospitalization than children in AFDC were.

Discussion

Children in foster care are not just like other children. To appreciate the significance of the Health Works program, one must understand two factors: First, children in foster care are among the unhealthiest in the United States, and second, children in foster care have been underserved for years both by the physical and mental health care fields. Therefore, increased use of health care services for this population is desirable.

Children in Health Works used more health care services than both children in foster care not enrolled in Health Works and children in AFDC. This is significant because it offers some evidence that the increased oversight and attention given to health care use through the Health Works program has affected outcomes for children in care. Of course, this research does not address how the Health Works model affects outcomes. Future research, as called for by Simms, Dubowitz, and Szilagyi (2000), should take these initial findings a step further by comparing various models of health care delivery.

Although the increase in use of mental health services by children in Health Works is encouraging, the levels fall far below the level of need reported for this population. Between 30% and 70% of children in foster care have behavioral or mental health problems (Dubowitz, Feigelman, Zuravin, & Tepper, 1992; Gruber, 1973; Hochstadt, Jaudes, Zimo, & Schachter, 1987; Horwitz, Simms, & Farrington, 1994; Mclntyre & Keesler, 1986; Schor, 1982; Simms, 1989; Takayama et al., 1994; White & Benedict, 1986). Some would say all children in foster care require some mental health intervention. In Illinois, as in most states, no mental health system is designed to meet these needs; Health Works is currently designed only to meet the physical health requirements of these children. A future challenge is to take a disjointed approach to children in foster care with emotional problems and coordinate a comprehensive behavioral and mental health system to include these services for all children in foster care.

Health Works provides primary care and encourages foster parents and children to use it, thus ensuring that they will have access to health care services. Increased use is positive, and the program is beginning to meet these children's health care needs. Increased access over time would also provide for better health care by providing preventive medicine. The real test of the system is to measure health outcomes to assess if children in foster care are truly healthier after they enter custody than before. The authors are establishing systems to monitor and track health status indicators and perform a cost-benefit analysis of this model.

Children in Health Works used hospital services, including ER visits and inpatient medical and psychiatric hospitalization, slightly more frequently than children in the AFDC population. Considering their increased access to health care, it was surprising that a more substantial increase in hospital services did not exist, because these children are truly unhealthy.

The goal of this study was to assess if children in foster care enrolled in a noncapitated managed care system received more health care services than children in foster care who were not yet enrolled in the health care system and children in AFDC. Some assumptions must be noted. Many children in AFDC probably did not have easy access to health care. This could account for some proportion of children in AFDC receiving less than the study group; however, the socioeconomic characteristics of children in foster care in Illinois suggest that a clear majority were AFDC eligible or enrolled prior to being in state custody.

In addition, only Medicaid claims that were submitted and paid were available for analysis. This would lead to an underestimation of service use. The study did not measure compliance for IHSs, comprehensive evaluations, or care provided specifically by the Health Works PCP. The Illinois Medicaid system does have a case management component, but it is limited in the scope of service and by the age of participant and is much less intense than the HealthWorks' model. Medicaid managed care is not compulsory, and enrollment is on a steady decline. No children in foster care are enrolled in the state's Medicaid managed care programs.

Conclusion

Providing health care to this high-risk population of children has been attempted by very few groups, predominately on a community level (Blatt et al., 1997; Chernoff et al, 1994; Horwitz et al, 1994; Ruptier, 1997; Schor et al., 1984; Simms, 1989). Studies have shown that children in foster care are not provided the health care services they need (Dubowitz, Feigelman, Tepper, Sawyer, & Davidson, 1990; Frank, 1980; Gruber, 1978; Kavaler & Swire, 1983; Moffatt, Peddie, Stulginskas, Pless, & Steinmeitz, 1985; Risley-Curtiss, Combs-Orme, Chernoff, & Heisler, 1996; Schor, 1982). Most child welfare agencies depend on their state's public aid system to provide health care for children in foster care. Typically, states issue a Medicaid card for the children and leave the foster parents to manage the complex issues associated with finding qualified providers. Having a Medicaid card alone, however, is not sufficient to obtain health care because many health care providers will not take the Medicaid card. In general, Medicaid is ill prepared or unable to meet the unique needs of this growing population.

Due to a federal waiver, children in foster care are not subject to compulsory managed care enrollment, so capitated rates are not yet available for this population. Unlike any other city, county, or state, Illinois developed a separate health system through public-private partnerships to ensure access to comprehensive, quality care for children in state custody. This study clearly demonstrates a model of care that has addressed these issues of access and use outside of compulsory managed care enrollment.

As a separate health care system, Health Works has adapted the primary care case management model of service delivery. States will find it relatively easy to replicate Health Works because children who enter foster care are immediately eligible for Medicaid. This translates to a form of health insurance that ensures payment for all medical services that are in the state health care plan or identified through an EPSDT screening and case management that is eligible for federal matching funds. Although Health Works was designed in the context of a large, urban foster care system, most child welfare systems could benefit from a focus on primary care and case management. Even in rural areas where the provider network is not as vast as in Illinois, child welfare systems can benefit by establishing formal agreements and incentives with PCPs to care for children in foster care. This model identifies medical professionals assigned to provide health care, thereby giving caseworkers and foster parents much needed direction as to appropriate access to health care.

Each component of the Health Works model provides support to child welfare practitioners and foster parents, many of whom serve an ever-changing caseload of children. By developing a network of PCPs, agencies have greater incentives to promote continuity of care among children who may experience a lack of continuity in their family lives. Even if a child changes placements while in foster care, the child's caseworker can rely on the assigned PCP to continue providing health care. Primary care in conjunction with medical case management should reduce the likelihood that foster parents visit ERs for primary or nonurgent care. Based on the increases in service delivery identified in the Illinois' Health Works model, child welfare practitioners and the children and families they serve should expect to experience improved access to care. Although access alone does not necessarily translate to improved health status, it represents a major hurdle that can be mitigated through this model.

With relatively few additional dollars, states can leverage their medical insurance funds to develop a cadre of qualified providers, offer incentives for timely access to preventive services, and use a customized set of child-oriented medical records (including a Health Passport) for systemwide tracking of service delivery and health status indicators. Although the process may take several years to develop and implement, a separate primary care-managed health care system, with Medicaid funds at its core, offers public child welfare agencies substantially improved control over access to and quality of the health care of children in foster care.

* Based on an indicator of disability found in the child welfare records, 62% of children without a disability who were in care at the beginning of FY 1997 were enrolled in Health Works, compared with 58% of children who had a disability (p < .001). Among children who entered during FY 1997, 55% of those with no disability and 58% of those with a disability were enrolled in the program (p < .13).

* The authors tested other modeling techniques including proportional hazard regression models incorporating entry to Health Works as a time-varying covariate. Results were similar to the logistic regression results presented here.

[Reference]

References

American Academy of Pediatrics, Committee on Early Childhood, Adoption and Dependent Care. (1994). Health care of children in foster care. Pediatrics, 93, 335-338.

Bilaver, L. A., Jaudes, P. K., Koepke, D., & Goerge, R. M. (1999). The health of children in foster care. Social Service Revieio, 73, 301-417.

Blatt, S. D., Saletsky, R. D., Meguid, V., Church, C. C, O'Hara, M. T., Anderson, J. M., et al. (1997). A comprehensive multidisciplinary approach to providing health care for children in out-of-home care. Child Welfare, 76, 331-347.

Chernoff, R., Combs-Orme, T., Risley-Curtiss, C., & Heisle, A. (1994). Assessing the health status of children entering foster care. Pediatrics, 93, 594-601.

Child Welfare League of America. (1988). Standards for health care services for children in out-of-home care. Washington, DC: Author.

Dubowitz, H., Feigelman, S., Tepper, V, Sawyer, R., & Davidson, N. (1990). The physical and mental health and education status of children placed with relatives. Final report. Baltimore: Maryland Department of Human Resources and Baltimore City Department of Social Services.

Dubowitz, H., Feigelman, S., Zuravin, S., & Tepper, V. (1992). The physical health of children in kinship care. American Journal of Disease of Children, 146, 603-610.

Flaherty, E. G., & Weiss, H. (1990). Medical evaluation of abused and neglected children. American Journal of Disease of Children, 144, 330-334.

Frank, G. (1980). Treatment needs of children in foster care. American Journal ofOrthopsychiatry, 50, 256-263.

Goerge, R., Van Voorhis, J., & Lee, B. J. (1994). Illinois's longitudinal and relational child and family research database. Social Science Computer Review, 12, 351-365.

Gruber, A. R. (1973). Foster home care in Massachusetts: A study of foster children-Their biologicnl and foster parents. Boston: Governor's Commission on Adoption and Foster Care.

Gruber, A. R. (1978). Children infester care: Destitute, neglected,...betrayed. New York: Human Sciences Press.

Halfon, N., English, A., Alien, M., & DeWoody, M. (1994). National health care reform, Medicaid, and children in foster care. Child Welfare, 73, 99-115.

Halfon, N., Mendonca, A., & Berkowitz, G. (1995). Health status of children in foster care: The experience of the Center for the Vulnerable Child. Archives of Pediatrie & Adolescent Medicine, 149, 386-392.

Hobbie, C., Braddock, M., & Henry, J. (2000). Medical assessment of children going into emergency out-of-home placement. Journal of Pediatrie Health Care, 24(4), 172-179.

Hochstadt, N. J., Jaudes, P. K., Zimo, D. A., & Schachter, J. (1987). The medical and psychosocial needs of children entering foster care. Child Abuse & Neglect, 11, 53-62.

Horwitz, S. M., Simms, M. D., & Farrington, R. (1994). Impact of developmental problem on young children's exits from foster care. Journal of Developmental and Behavioral Pediatrics, 15(2), 105-110.

Kass, B. L., Weinick, R. M., & Monheit, A. C. (1999). Racial and ethnic differences in health, 1996 (MEPS Chartbook No. 2, AHCPR Pub. No. 99-0001). Rockville, MD: Agency for Health Care Policy and Research.

Kavaler, F., & Swirc, M. R. (1983). Foster-child health care. Lexington, MA: DC Health.

McIntyre, A., & Keesler, T. Y. (] 986). Psychological disorders among foster children. Journal of Clinical Child Psychology, 15(4), 297-303.

Moffatt, M. E. K., Peddie, M., Stulginskas, J., Pless, I. B., & Steinmeitz, N. (1985). Health care delivery to foster care children: A study. Health and Social Work, 10,129-137.

Newcombe, H. B. (1993). Distinguishing individual linkages of personal records from family linkages. Methods of Information in Medicine, 32, 358-364.

Risley-Curtiss, C., Combs-Orme, T., Chernoff, R., & Heisler, A. (1996). Health care utilization by children entering foster care. Research on Social Work Practice, 6, 442-461.

Roos, L. L., & Wajda, A. (1991). Record linkage strategies. Methods of Information in Medicine, 30(2), 117-123.

Roos, L. L, Wajda, A., Nicol, J. P., & Roberts, J. (1992). Record linkage: An overview. In H. A. Schwartz & M. L. Grady (Eds.), Medical effectiveness research data methods (pp. 119-135). Rockville, MD: U.S. Department of Health and Human Services.

Ruptier, N. M. (1997). Ensuring health care for foster children through Medicaid's EPSDT program. American Journal of Public Health, 87, 290-291.

Schor, E. L. (1982). The foster care system and health status of foster children. Pediatrics, 69, 521-528.

Schor, E. L., Nerf, J. M., & LaAsmar, J. L. (1984). The Chesapeake health plan: An HMO model for foster children. Child Welfare, 63, 431-440.

Simms, M. D. (1989). The foster care clinic: A community program to identify treatment needs of children in foster care. Journal of Developmental and Behavioral Pediatrics, 20(3), 121-128.

Simms, M. D. (1991). Foster children and the foster care system, Part II: Impact on the child. Current Problems in Pediatrics, 22(8), 345-369.

Simms, M. D., Dubowitz, H., & Szilagyi, M. A. (2000). Health care needs of children in the foster care system. Pediatrics, 106, 909-918.

Simms, M. D., Freundlich, M., Battistelli, E. S., & Kaufman, M. D. (1999). Delivering health and mental health care services to children in family foster care after welfare and health care reform. Child Welfare, 78, 166-183.

Swire, M. R., & Kavaler, F. (1977). The health status of foster children. Child Welfare, 56(10), 635-653.

Takayama, J. L., Bergman, A. B., & Connell, F. A. (1994). Children in foster care in the state of Washington: Health care utilization and expenditures, journal of the American Medical Association, 271, 1850-1855.

U.S. Department of Health and Human Services/Office of the Assistant secretary for Planning and Evaluation. (2000, March 31). Dynamics of children's movement among the AFDC, Medicaid, and foster care programs: (1995-1996). Available from http://aspe.hhs.gov/hsp/movementOO/.

U.S. General Accounting Office. (1995). Foster care: Health needs of many young children are unknown and unmet. Report to the ranking minority member, Subcommittee on Human Resources, Committee on Ways and Means, House of Representatives (GAO-HEHS-95-114). Washington, DC: Author.

Weinstein, J., & LaFleur, J. (1990). Caring for our children: An examination of Healthcare services for foster children. California Western Law Review, 26, 319-349.

White, R., & Benedict, M. (1986). Health status and utilization of patterns of children in foster care: Executive summary (Grant #90-PD-86509). Washington, DC: U.S. Department of Health and Human Services Administration for Children, Youth and Families.

White, R. B., Benedict, M. I., & Jaffe, S. M. (1987). Foster child health care supervision policy. Child Welfare, 66, 387-398.

[Author Affiliation]

Paula Kienberger Jaudes, MD, is Medical Director of the Illinois Department of Family Service, Professor of Pediatrics, Department of Pediatrics at the University of Chicago, and President and CEO of La Rabida's Children's Hospital, Chicago, IL. Lucy A. Bilaver, MA, is Senior Research Associate at the Chapin Hall Center for Children at the University of Chicago. Robert M. Goerge, PhD, is Research Fellow at the Chapin Hall Center for Children at the University of Chicago and Faculty Associate at the Northwestern University/University of Chicago Joint Center for Poverty Research, Chicago. James W. Masterson, MPH, former First Deputy Commissioner of the Chicago Department of Health, and Charles R. Catania, MA, former Bureau Chief of Community Health Services at the Chicago Department of Health, are currently Senior Partners at Hamilton Bell Associates, Chicago.

[Author Affiliation]

(Address requests for a reprint to Paula Kienbcrger Jaudes, University of Chicago, E. 65th St. at Lake Michigan, Chicago, IL 60649.)