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The Foster Child Health Program

State: MT Type: Promising Practice Year: 2019

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Missoula City-County Health Department
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The Foster Child Health Program

Description of LHD: Missoula City-County Health Department (MCCHD) serves Missoula County in SW Montana. 2,600 sq. miles are home to 117,400 residents. The City of Missoula is a regional economic and medical hub. Almost 40% of county residents live in rural areas where population density averages 18 people/mi2. Driving between southwest and northeast county borders takes over 2 hours.

The Foster Child Health Program (FCHP) is a multi-agency collaboration of MCCHD, Montana DPHHS-Child & Family Services Division (CFSD), and Providence Grant Creek Family  Medicine—Foster Child Clinic (FCC).

Public health issue: FCHP addresses health disparities for the high-risk population of foster children. At the time of out-of-home placement, 80% of foster children have chronic physical and behavioral conditions, often preceded by maltreatment. They face significant health care barriers such as lack of medical and dental homes, incomplete or missing medical histories, multiple conditions requiring primary and specialized care providers, and disjointed or uncoordinated treatment. Limited local medical resources further challenge rural foster families. 

FCHP Goal 1/Objectives: To address health inequities experienced by foster children in Missoula County.

  • To establish medical/dental homes within 1 month of referral to FCHP with appropriate referrals made and needed appointments set.
  • To compile medical and other health records for review by CFSD caseworker, primary care provider, and foster parents. Records will follow child to future placements.
  • To develop and monitor care plan jointly with CFSD and foster health care providers, referring community resources (WIC, CDC) as needed.
  • To provide in-home health education to foster parents, anticipating child's health and behavioral needs.

FCHP Goal 2/Objectives: To coordinate, serve, and maintain multi-agency partnership

  • To communicate with CFSD caseworkers regularly
  • To coordinate monthly case review meetings of FCHP team
  • To facilitate program evaluation (data collection, analysis, case studies, interviews, focus groups, summary of findings)

FCHP Goal 3/Objectives: To support FCHP replication in other Montana counties, including rural regions

  • To provide model data-sharing agreements, scope of practice, priority areas, and guiding protocol
  • To provide medical definition dictionary of acute, chronic, and common health conditions and treatments as guideline for data collection 
  • To suggest clinical and community partners and coordination strategies

Activities and implementation: When a child is removed from their home, FCHP team members begin work immediately:

  1. CFSD refers child to FCC and MCCHD 
  2. FCC provides exam within 72 hours of referral, coordinates forensic exam if needed, outlines medical needs.
  3. Public health nurse (PHN) compiles health history, reviews FCC recommendations, develops care plan, establishes medical/dental homes, updates immunizations, arranges specialized care as needed. 
  4. PHN initiates ongoing visits to foster home, administers developmental screenings, monitors child's health progress, provides child-specific health education to foster parents, and refers community and medical services as needed.
  5. Child's progress is reviewed at monthly team meetings. 

Results/outcomes: A 2016 evaluation at entry and exit data for 415 foster children in FCHP between 2011 and 2016 showed approximately 1/3 had no primary care provider; 3/4 reported at least one physical health problem; 33% were not up-to-date on immunizations; 35% reported dental problems; and 58% had no dental home.

By exit, children's health conditions had improved measurably. The number of physical and mental health conditions decreased (including eye/vision problems, skin conditions, feeding concerns, obesity, frequent colds, ear infections, asthma, heart conditions, mental health treatment, depression, ADHD). Use of medications also decreased. 

Objectives met: Since 2011, FCHP has provided all CFSD-referred children with EPSDT assessments, established medical/dental homes, secured timely treatment for acute and chronic conditions; all referred foster parents received in-home health education and support.

Specific factors leading to success: FCHP partners including foster parents identified these critical elements of success: consistent communication, formal data sharing agreements, trusting long-term relations, stable participation. 

Public health impact: All FCHP partners recognize the benefits of PHN home visiting: anticipatory guidance teaches foster parents about impending developmental milestones, health needs, and potential challenges. It helps them confidently navigate complex care systems. Caseworkers say this support stabilizes foster placements. When changes occur, health records, immunizations, medical home, and services follow the child.

In 2017, Governor Bullock included FCHP in his Protect Montana Kids Initiative: Improvement to Systems Serving Children and Families.” Montana DPHHS recognizes FCHP as a potential model and will support one or more replication pilots in 2021. In 2016, the American Psychological Association named FCHP a Promising Practice”.

Website: https://www.missoulacounty.us/government/health/health-department

Public health issue: Foster children are a high-risk population subject to severe health inequity; 80% have chronic physical and behavioral conditions often preceded by maltreatment (Scribano, P.V. et al. 2015. Foster care and health in the U.S: Current Problems in Pediatric & Adolescent Health Care, 45(10): 281). At the profound moment of out-of-home placement, foster children demonstrate higher rates of chronic health and mental health conditions. 

When children are removed from biological parents and placed in the custody of CFSD, they face persistent barriers to health care. Social Security Act, Title IV-B, subpart 1 Section 422(b)(15) guarantees coordinated, responsive health care for foster children. However, several systemic barriers hinder the timing and quality of care provided:

  • Foster children experience long wait times to see a specialist, especially if they live in rural areas distant from medical service hubs.
  • Foster parents can be overwhelmed or might not fully understand the health needs of a newly placed child; it can be challenging to coordinate multiple treatment providers. 
  • Foster children often have incomplete or missing health and/or immunization records. Many don't have medical or dental homes. 
  • Health care providers can lack understanding of the foster care system and may not be trained in the trauma-informed EPSDT assessment recommended by AAP (Syilagyi, M.A., Rosen D.S., Rubin D., Zlotnik, S. 2015. Health care issues for children and adolescents in foster care and kinship care. American Academy of Pediatrics, 136(4): 1142-1166). 
  • Providers might be unfamiliar with the cultural traditions of Native American foster care and implications of the Indian Child Welfare Act of 1978.  

Less than half of child protection agencies have policies specifically addressing the physical, mental, and developmental health care needs of children in foster care (Leslie et al. 2003. Comprehensive assessments for children entering foster care: A national perspective. National Institute of Health Public Access,1-17). This includes Montana DPHHS.

FCHP tackles system-level barriers and service gaps. We identify critical community partners with parallel aims and responsibilities, convening them in case management and care coordination. Public health nurse, medical provider(s), and CFSD caseworker(s) collaborate to ensure medical histories, medical/dental homes, case management and case conferencing. We then provide ongoing PHN home visiting specific to the needs of child and foster caregivers.

Foster caregivers as stakeholders: Foster children may be placed in 3 different categories of care (family foster home, group home, kinship placement). A grandparent may not be familiar with current recommendations for infant sleep safety or feeding; group home staff may not understand a child's complicated health history or schedule of medications. PHNs work with caregivers through onsite visits and training. PHNs observe child and caregiver needs, adapt health education and anticipatory guidance to meet placement capacities, and make referrals to appropriate services. PHN on-site visiting supports children's health care and environmental safety by working with directly with caregivers.

Target population: 3,900 children are currently in Montana foster care placement, an increase of 35% since 2015. In 2015, over half of thechildren in foster care experienced 2 or more placements despite known adverse effects of multiple placements. Native American children are 36% of Montana foster care placements (vs. 10% of Montana child population). FCHP's target population is children in Missoula County foster placements in the following groups:

  • Newborn through their 5th birthday
  • Entering foster care or in placement transition (any age)
  • Youth ages 16-18 aging out of foster care

Target population size: DPHHS estimates there are currently 350 children in active Region V foster placements. Since November 2011, MCCHD has worked with 698 foster children. In FY17, 120 children were referred; in FY18, 107 children were referred. 

Percentage reached: MCCHD works with 100% of foster children referred by CFSD; this population accounts for ~40% of all foster children in Region V. MCCHD is unable to serve foster children who are placed in neighboring Ravalli and Mineral Counties, those who work with CFSD caseworkers in other regions of the state, and children in temporary legal custody (removed from home but not yet legal wards of the state).

Past efforts: Unlike other pediatric clients, foster children are in state custody under non-parental care and often manifest profound health problems subsequent to trauma. Before 2004, MCCHD's model of including foster children in general home visiting, clinic, and health education services did not address this trauma, nor the deep health care inequities faced by foster children. Current FCHP services recognize the needs of foster children as a cohort and convene partnering systems to coordinate case management and care plans.

MCCHD began providing PHN expertise to foster families in 2004 and entered a formal data-sharing agreement with CFSD in 2011. In 2010 Providence Grant Creek Family Medicine trained Foster Care Clinic providers in the trauma-informed Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) assessment. This specialized training prepared primary care providers to provide the thorough 80-minute exam (despite no more reimbursement than the shorter well-child exam). Later, FCC doctors participated in cultural sensitivity training in order to work more effectively with Native American families. 

In 2012, MCCHD secured a Missoula County Community-Based Organization (CBO) grant to help fund personnel costs of a PHN assigned to work with CFSD; Professional Service Agreement was signed to clarify roles, responsibilities, and scope of services. In 2013, an amendment to the Agreement allowed DPHHS to compensate MCCHD based on monthly caseload. This funding was terminated by state budget constraints in 2017 and reinstated in 2018.The CBO grant and MCCHD/CFSD agreement have been renewed every year since 2012.

Innovation of current practice: The public health practice we have adapted to innovative service for foster children is public health nurse home visiting. 

       Providing services in the foster home (vs. a clinic setting) allows more accurate assessment of family resources and a more accurate assessment of how the child is doing in activities of daily living, and both contribute to a more realistic plan of care for meeting health needs. Sometimes, more importantly, the home visit provides a natural setting to offer support to the foster parent and encouragement to continue providing hope and love to a traumatized child. -- Judith Birr, R.N., B.C.

Historically, home visiting programs provide on-site service delivery, help children by helping parents, and emphasize a population of high-risk children. Public health departments have used this strategy to improve health outcomes for children for well over 60 years. Multiple studies demonstrate the potential effectiveness of this intervention (Sweet, M.A. & Applebaum, M.I. 2004. Is Home Visiting an Effective Strategy? A Meta-Analytic Review of Home Visiting Programs for Families with Young Children. Child Development, 75(5): 1435-1456). 

Factors related to improved health outcomes include nurses with advanced education, frequent visits over a long period of time, focus on building relationships with parents, and coaching in child development are effective interventions that improve health outcomes (Kearney, M.H., York, R., Deatrick, J.A. 2004. Effects of Home Visits to Vulnerable Young Families. Journal of Nursing Scholarship, 32(4): 369-76). Recently several maternal child home visiting programs were shown to be effective at reducing child maltreatment and improving health outcomes for high-risk families (Sama-Miller, E. et al. 2018. Home Visiting Evidence of Effectiveness Review. Office of Planning, Research and Evaluation, DHHS Administration for Children & Families).

Content and delivery of our onsite visits are tailored to meet transitional needs of foster children and caregivers. PHN visiting provides ongoing monitoring, health education, anticipatory guidance, referrals, expertise and support. PHNs cover use of medications, management of disease and chronic conditions, behavioral and emotional problems, nutrition, sleep safety, and environmental safety. They guide foster parents on appropriate use of crisis or emergency care and provide follow-through when social service referrals are needed, routinely reaching out to schools and community services on behalf of foster families 

In our 2016 evaluation, team members felt that PHN services to foster caregivers created greater permanency for foster children by stabilizing placements and allowing health care to remain consistent and uninterrupted. In 2017, FCHP was recognized as a Promising Practice” by the American Psychological Association (Klika, J.B., Schelbe, L., Pecora, P. 2017. Health of children in out-of-home care: The Missoula Foster Child Health Program. Child Maltreatment Insider, 22(3): 4-6).

Using strategies learned from our evidence-based, federally funded nurse home visiting programs, we adapted the demonstrated public health practice of home visiting to meet the needs and risks of the foster child population. When combined with system-level case coordination between child protective services, medical providers, and public health nurses, onsite visits bring health care management directly into the foster home, making FCHP unique among foster care community partnerships. 

Benefits of practice: By viewing foster children as a cohort rather than individual cases, we created local change at a system level, safeguarding vulnerable children's health at the critical moment of out-of-home placement. Much progress has resulted from FCHP's work over the last six years. In 2017 FCHP received recognition from Governor Bullock and was included in his Protect Montana Kids Initiative: Improvement to Systems Serving Children and Families.” Other Montana counties reached out to us for technical support and guidance; Montana DPHHS recognizes FCHP as a potential model for replication. 

Benefits for rural areas: PHN home visiting to foster families in sparsely populated areas breaks family isolation and improves coordination with distant health services. The FCHP model is a potentially replicable strategy for rural health departments. We will work with DPHHS and Montana partners to develop rural-ready partnership strategies in 2019-2020 with a pilot in 2021.

Is the current practice evidence-based? We are building FCHP towards evidence-based standards by following AAP guidelines for foster health care (early assessment, timely treatment of acute and chronic health conditions, designation of medical and dental home, continuity of care, EPSDT) and CDC guidelines for preventive health care (immunization, feeding, sleep safety). An independent evaluation completed in 2016 measured changes in children's health outcomes from admit to exit over a 5-year period. We have committed to a second evaluation in 2019-2020 to further define program impacts using data from a comparison county designated by DPHHS. 

We adapted a tool developed by the Denver County, CO Developing Integrated Behavioral Health Services (DIBS) project, Elements for High Quality Healthcare for Colorado Children in Foster Care System, to reflect guiding principles of FCHP. This tool can be adapted by other counties or regional projects to fit their local services and partnerships. 

Guided by the NACCHO tool, "Implementing Local Public Health Practices to Reduce Social Inequities In Health,” and using NACCHO's "Public Health Structure and Systems: Community Health Assessment (CHA) and Community Health Improvement Plans (CHIP) Process Models," we progressively framed three CHAs in which foster child health was prioritized, planned for, and implemented. Missoula's original Foster Child Health Program was a focus in each of three cycles of CHA, CHIP, and Strategic Plans from 2013 to the present. 

In summary, FCHP's collaboration model, plus innovative use of PHN home visiting to foster children's out-of-home placements, brings health care from the clinician's office into the foster care home. 

     The FCH home visiting nurse plays a critical role in helping foster parents understand the relationship between abuse trauma and possible lifelong health effects. Restoring "Health"—physical, emotional and developmental wellbeing—is the first step in building resiliency in the child. -- Judith Birr, R.N., B.C.


Steps to achieve goals and objectives:

  1. CFSD refers child to FCC and MCCHD 
  2. FCC completes EPSDT within 72 hours, coordinates forensic exam if needed, outlines medical needs
  3. PHN compiles health history, reviews FCC recommendations, develops care plan, establishes medical/dental homes, arranges specialized care as needed 
  4. PHN initiates visits to foster home, monitors child's health progress, provides child-specific health education to foster parents, administers developmental screenings and refers community and medical services as needed
  5. Progress reviewed at monthly team meetings  

Steps to implement program: FCHP growth reflects NACCHO's Five Promising Strategies for Local Health Department HiAP Initiatives (Jan 2018):

  1. Started small with informal person-to-person contact between partners
  2. Organizational champions at DPHHS and FCC recognized value of coordinated case/care management
  3. Meetings from 2010 built relationships and outlined measurable objectives (referrals, EPSTD, data-sharing) 
  4. 2004 pilot funded by federal grant; 2011 PHN staffing funded by County; staffing flexed to meet unexpected fluctuations
  5. 2012 agreements incorporated duties into job descriptions, dedicated staff, formalized protocol

Criteria for participation:

  • State agency agrees to refer foster children to local health department (LHD) and medical provider(s) 
  • Provider(s) train in EPSDT, forensic referrals, and cultural sensitivity
  • LHD adapts maternal-child home visiting programs for foster parents
  • Partners enter data-sharing agreements allowing access to state, clinical electronic records
  • Partners dedicate staff

Timeframe for stakeholder involvement: 

  • Originally foster children were served through Providence St. Patrick Hospital First Step
  • 2004-PHN begins foster home visits and care coordination 
  • 2010-Providence Grant Creek Family Medicine launches Foster Child Clinic (EPSDT, primary care) 
  • 2011-MCCHD signs data-sharing agreement with CFSD
  • 2012-Full coordination 
  • 2018-Partnering organizations state commitment to maintain services and coordination

Stakeholder role in planning and implementation: All partners contributed to program design, data-sharing agreements, referral protocol, scope of services, and activity schedules. Concerns voiced by foster parents guided planning. School and community input was collected through Missoula Partnership for Children & Youth. 

Collaborative relationships and program goals: The Foster Care Committee” met for the first time in December 2010 and has met every 1-3 months since, leading to strong working relationships. FCHP mutually advances stakeholder goals and improves efficiency. 

     It's great to have a CASA assigned for support, but my Foster Child Health nurse understands the medical needs of my child, and that is what our CFSD caseworker needs to decide on proper placement.”—Foster Parent

Estimated start-up costs and budget:  In Missoula, providing in-kind support for infrastructure, MCCHD estimates start-up costs of ~ $112,500/year:

  • Annual personnel costs (1 FTE PHN, 0.33 FTE administrative support, 0.03 FTE supervisor) ~$110,000
  • Annual operation costs (mileage, training, materials, printing, supplies, etc.) ~$2,500

Goal 1/Objectives: To address health inequities experienced by foster children in Missoula County

  • To establish medical/dental homes, make referrals, set appointments 
  • To compile health records, update immunizations
  • To develop and monitor care plan
  • To provide health education to foster parents through home visiting

Goal 2/Objectives: To coordinate, serve, and maintain multi-agency partnership

  • To report to CFSD quarterly
  • To coordinate monthly case review meetings 
  • To facilitate program evaluation 

Goal 3/Objectives: To support FCHP replication in Montana counties, including rural regions

  • To provide model data-sharing agreements, scope of practice, priority areas, protocol
  • To provide medical definition dictionary for data collection 
  • To suggest key partners and coordinating activities

Description of evaluation, primary and secondary data sources, data collectors: Dr. J. Bart Klika of University of Montana School of Social Work led a 2016 evaluation of FCHP. Funding was provided by DPHHS with technical assistance from Casey Family Programs. 

The period under review was November 2011 to June 2016.  Final sample included 415 children who were involved with FCHP (70 additional cases were dropped from the study due to incomplete medical histories at the time of entry into the program). Dr. Klika worked with a team of graduate-level research assistants to gather health outcome data and conduct interviews with partners and foster parents. 

Secondary data was secured from the MCCHD electronic medical record system and from the state child protection database. 

Performance measures, process and outcome measures used: 

Outcome measures indicated by using quantitative data responded to these questions:

  1. What are key demographics and health characteristics of foster children in FCHP? 
  2. Are there key health differences based on gender, age, or placement type for FCHP participants? 
  3. Do foster children experience improved health from FCHP admission to exit? 
  4. What factors lead to improved health of children in FCHP? 

Process measures indicated by qualitative data responded to these questions:

  1. What are essential team, care, and system-level elements of FCHP? 
  2. How does essential elements of FCHP contribute to child health and placement permanency? 

How results were analyzed: Descriptive analyses were run for demographic and health characteristics of the entire sample. Chi-squared tests of independence were used to examine healthcare utilization and health conditions by gender at entry to FCHP. Analysis of Variance tests were used to examine differences in mean levels of health conditions, mental health conditions, and medications by age category at admit and discharge. Linear regression analysis was used to predict changes in the number of physical and mental health conditions and medication from admit to discharge, using the variables of age, gender, number of days in FCHP, number of placements, and whether a child had an identified primary care physician at admit. 

Essential team, care, and system-level elements were explored in semi-structured interviews with FCHP partners; FCHP contributions to child health and placement permanence were also discussed.

Overall findings: Children entering FCHP demonstrated physical, emotional, behavioral and dental problems, yet improvements in these conditions occurred over time. 

  1. 1/3 of children had no primary care provider identified and nearly 3/4 of children reported at least one physical health problem at admit 
  2. 1/3 of children were not up-to-date on immunizations at admit 
  3. 58% of children had no dental home while 35% reported a dental problem at admit 
  4. Decrease in the number of physical health conditions, mental health conditions, and medications from admit to discharge 
  5. Decrease in eye/vision problems, skin conditions, feeding concerns, obesity, frequent colds, ear infections, asthma, heart conditions, mental health treatment, depression, ADHD, vitamins, fluoride, formula, other medications from admit to discharge

Key Group Differences at Admit and Exit: Differences in physical health, mental health, and medications across gender, age, and placement were identified.

Gender 

  • At admit: Boys reported higher rates of ADHD than girls
  • At exit: Boys reported higher rates of asthma and other medication use than girls 

Age (conditions correlated with age groups)

  • At admit: Number of children with frequent colds, ear infections, eye/vision problems, feeding, obesity, mental health treatment, depression, ADHD, tantrums varied with age
  • At admit: Number of mental health conditions and medications were highest at 12-18 yrs.

Placement Type (conditions correlated with placement in foster home, group home or kinship) 

  • At admit: Number of children with skin problems, feeding concerns, mental health treatment, depression, ADHD varied with placement type 
  • At admit: Number of children with physical health conditions and mental health conditions varied with placement type
  • At exit: Number of children with frequent colds, feeding concerns, vitamins, formula, other medication varied with placement type

Factors Leading to Improved Health:

  • Age predicted improvement in total number of physical and mental health conditions, and in number of medications used, from admit to exit
  • Age predicted whether a child would experience improved mental health from admit to exit 
  • Number of placements predicted whether a child would experience improved physical health from admit to exit, with fewer placements resulting in more positive outcomes

Key Program Factors: Strong trust and communication gives value to FCHP's practice. Partnering relationships are key to replication by other LHDs.

  • FCHP team has strong communication among members, occurring on a consistent basis and made possible through formal legal agreements for information sharing 
  • Collaboration is essential for FCHP success. Partners have built trusting relationship over time. Assessment of collaboration using the Partnership Self-Assessment Tool showed that the team excels in leadership and team synergy 
  • Key medical providers in Missoula are committed to the goals of FCHP and provide specialized care when needed
  • FCHP improves the health of children by providing coordinated, continuous care
  • FCHP supports child permanency by supporting foster families, helping to ensure proper fit” between child and placement 

Modifications to practice as result of data findings:  In response to recommendations made by Dr. Klika, we made the following modifications.

  • Clarified and expanded definitions for child medical, dental and behavioral health conditions in our Health Practice Screening and Medical Definition Dictionary 
  • Expanded tracking of children's medications from 3 to 15 categories, to show changes in health conditions and use of drugs over time
  • Commissioned a second evaluation to compare FCHP child health outcomes with those of another county to be designated by DPHHS. Dr. Trish Miller of University of Montana will implement the independent evaluation in 2019-2020

The following elements are needed in order to replicate FCHP in other communities: 

  • State agency support for child protection caseworkers to consider medical provider and PHN input when managing a foster child's case 
  • Access to medical providers trained in population-specific health needs of foster children, and willing to coordinate with child protection caseworker and PHN 
  • Local health department support for PHN to coordinate health care services and offer onsite child-specific health education/support to foster parents and group caregivers 

Our 2016 evaluation verified the value of FCHP to Missoula foster children, foster caregivers and our tri-agency partners. The model has inherent flexibility and can be adapted to fit diverse communities or regions. Features of a rural partnership such as geographic boundaries, location of medical services, and key community partners might differ from urban communities. Our evaluation showed that FCHP methods benefitted partners by facilitating ongoing communication, legal data-sharing, and clearly stated protocol.

Lessons learned from FCHP practice: We initially provided general pediatric health services to individual foster children. However, when we recognized the health care disparities and barriers experienced by foster children, we began to serve them as a cohort. By creating system-level coordination between CFSD case managers, medical providers, PHNs and foster parents, FCHP remove barriers (lost health records, needed immunization, lack of medical/dental home, access to specialized care), coordinates children's care plans, and improves timeliness and continuity of care. 

  • We recognized that clients” included foster caregivers (parents in foster homes, staff in group homes, family members in kinship placements) as well as medical providers and CFSD caseworkers. Without coordination between these stakeholders, children experience disjointed and incomplete health care, and greater risk of foster placement instability. 
  • Our 2016 evaluation documented the value of ongoing contact between partners; face-to-face meetings are key to successful coordination with CFSD caseworkers who can experience high turnover. 
  • Formal data-sharing agreements advanced the effectiveness and ease of case coordination. 
  • Our 2016 program evaluation clarified challenges in data collection, as each partner maintains its own system. MCCHD worked within our own data system to implement standardized definitions of acute, chronic, and common health conditions and treatments in order to facilitate consistent internal data collection.
  • Long tenure has earned FCHP community and state credibility. For over a decade, we have strategically moved towards more stable funding sources. When we experienced funding setbacks, we learned how to prioritize and scale the model to match resources while still providing essential services. 

Cost/benefit analysis: It stands to reason that early assessment, a preventive care plan, and guidance to foster caregivers leads to earlier identification of health needs, more timely provision of services, and more thorough adherence to treatment thereby saving healthcare dollars.

FCHP incorporates many elements of evidence-based nurse home visiting programs with demonstrated cost benefits. A 2005 study by the RAND Corporation evaluated the cost-effectiveness of two evidence-based home visiting programs for which cost/benefit data were available. The study found a range of savings per dollar invested (Karoly, L.A., Kilburn, M.R., Cannon, J.S. 2005. Early Childhood interventions: proven results, future promise. Santa Monica, CA: RAND). 

A recent review of evidence-based programs estimated that every dollar invested can yield up to $5.70 in savings in the long run. (Zaveri, H., Burwick, A., Maher, E. 2014. The Potential for Cost Savings from Home Visiting Due to Reductions in Child Maltreatment”, Casey Family Programs).

Stakeholder commitment: FCHP makes each partner's work on behalf of foster child health easier and more effective. For this reason, caseworkers, health care providers, and foster caregivers are committed to FCHP's continued success.

  • DPHHS has stated its intent to continue to refer foster children to FCHP and coordinate with partners.  In 2019, DPHHS will designate a comparison county whose foster child health outcomes will be compared to Missoula County, providing program evaluator access to state data.
  • Providence Grant Creek Family Medicine—Foster Care Clinic has stated its intent to continue to see children within 48-72 hours of referral, train providers to provide EPSDT exams, address acute and chronic conditions with referrals, provide medical home as needed, maintain medical records and coordinate with FCHP.
  • MCCHD has stated intent to continue home visiting to foster caregivers, and to participate in FCHP and other community partnerships that address the needs of the foster child population. Moreover, we are committed to further evaluation of FCHP, hoping to move it closer to an evidence-based practice.

MCCHD continues to participate in other innovative Missoula partnerships related to foster child well-being. For example, FQHC Partnership Health Center's new K.E.L.P. project seeks system-level coordination to address legal, mental health, and addictions issues that act as barriers to reunification of biological families. 

As we offer support to other counties interested in the FCHP model, we understand that not all communities have identical resources, and local stakeholders may be limited. Significant geographical distance can separate PHNs, child protection caseworkers, medical providers and foster families in rural areas. Rural FCHPs might collaborate at a regional level to accommodate distantly located stakeholders across county boundaries.

In any community, FCHP's success relies on public support for health departments to address foster child health issues, and state agency support for child protection caseworkers to collaborate. If health departments currently serve foster children through locally funded home visiting programs, this model can focus resources on foster child health outcomes. One medical provider willing to be trained and/or act as a champion for foster child health can promote future services. Foster parents will provide the most credible testimony to the value of coordinated case management and health education. 

     For our family, the Foster Child Health Nurse was always a welcome visitor and a valuable resource and support.” –Foster  Parent

Sustainability plans: Each partner covers the costs of their own tasks related to foster child health (CFSD's case work; medical exams and office visits; PHN home visiting). 

MCCHD funds the cost of PHN coordinating duties of scheduling meetings and overseeing care plans. Foster child health care is a Missoula County Board of Commissioners priority, as stated in the Community Health Assessments and Community Health Plans since 2016. 

We envision MCCHD and other health departments working with state government to access a blend of resources adequate to support implementation and replication.

Potential funding sources for local health departments include:

  • State allocation of federal funds to local health departments on a caseload basis (demonstrated in Missoula County for 5 years) 
  • Dedication of county levy or related tax fund (used in Missoula County since 2012) 
  • Medicaid Targeted Case Management for Children with Special Health Care Needs reimbursement (children must meet eligibility criteria)
  • Children's Special Health Services reimbursement (DPHHS program separate from Medicaid, maximum $2000/year/child, requires qualifying client permission) 
  • Local, state or national grant funding 
  • 2018's federal Family First Prevention Services Act will fund programs that prevent children from entering foster care and/or improve the wellbeing of children already in foster care

Potential funding sources for medical partners include:

  • Contracted services reimbursement to federal qualified health or rural health center (allows medical providers to bill for services)
  • Contracted services reimbursement to Comprehensive Primary Care+ medical provider (federal program allows medical providers to bill for services)
  • Private insurers, fee-for-service private pay (billing options available to medical providers and clinics)

FCHP has the potential to create new health partnerships and generate strategies for secure timely and thorough health care for foster children.  Through continued program evaluation, funding development and NACCHO's peer response, we are preparing a viable replication model for diverse local health departments.    

NACCHO Website