Other HHS Agencies

In addition to ACF and CMS, other agencies within HHS have roles in  sustaining the health of foster children through supporting research,  providing grants, or offering technical assistance that may assist with  providing necessary health care services to children in foster care, as  shown below:    The Agency for Healthcare Research and Quality is responsible for  supporting research designed to improve the quality of healthcare, reduce  its costs, address patient safety and medical errors, and broaden access to  essential services;  the Health Resources and Services Administration (HRSA) administers  programs related to maternal and child health, as well as services specific  to particular conditions, such as human immunodeficiency virus and  acquired immune deficiency syndrome (HIV and AIDS); and    SAMHSA funds programs and services for individuals—as well as their  families and communities—who suffer from or are at risk for substance  abuse or mental health disorders. Specific Requirements for Health Assessments—and Using Designated Providers to Conduct Them—Are Employed to Identify Children’s Health Care Needs

To help facilitate the timely identification of foster children’s health care  needs, all 10 states we examined had adopted specific policies with regard  to the timing and scope of assessments, and 4 of these states also reported  using designated providers to conduct the assessments. In addition to policies requiring assessments of children’s physical health,  8 of the 10 states we studied also reported requiring screening or  assessments of children’s mental and developmental health shortly after  entry into foster care. The ACF reviews have helped  focus attention on the mental health needs of children in foster care,  however, and we found that most of the 10 states we selected for study  had adopted policies to screen or assess the mental health and  development of children entering foster care. Some state officials commented that the use of  a specific network of physicians also facilitated quality improvement  efforts. Practices to Enhance Access to Services, Coordinate Care, and Monitor Use of Medications Are among Efforts to Ensure Delivery of Health Care to Foster Children

To address the challenge of ensuring delivery of appropriate health care  services to children in foster care, several of the states we selected for  review adopted practices designed to facilitate access to care, coordinate  services, and review medications for children in foster care. Care coordination practices that the  selected states identified employed either nurses or other health care  managers to help ensure that children in foster care received necessary  health care services. Mechanisms for Data Management and Quality Assurance Address Challenges to Documenting and Monitoring Children’s Health Care

To address the challenges of documenting and monitoring children’s  health care, some states we studied shared health care data across various  state systems to acquire more complete medical histories and used quality  assurance mechanisms, such as medical audits or specialized case  reviews, to track receipt of services. For  example, through data sharing with Medicaid and other data sources,  Texas has developed an electronic health record—known as the Foster  Care Health Passport—that can be viewed by authorized individuals  involved in the child’s care through a secure Web site. ACF Offers States Health-Related Technical Assistance as Part of Its Broader Efforts to Improve Delivery of Services

Although states are ultimately responsible for meeting the health needs of  children in foster care, HHS is required by law to provide technical  assistance to the extent feasible to help states develop and implement  plans to improve their performance. ACF officials told us that their  emphasis is on providing technical assistance that will increase the  capacity of state child welfare agencies over the long term to serve the  needs of children in their care. These and other agencies are listed among possible stakeholders in ACF’s  reviews of state child welfare agencies. The center’s focus is on children who have or are at risk  of having emotional disorders, including children in foster care. These included describing practices that  selected states have adopted to address the challenges of (1) identifying  health care needs, (2) ensuring delivery of appropriate health services, and  (3) documenting and monitoring the health care of children in foster care. In addition, we describe technical assistance the Department of Health  and Human Services’ Administration for Children and Families (ACF)  provides to states to help improve their performance in providing for the  health care needs of these children.
Why GAO Did This Study

Providing health care services for foster children, who often have significant health care needs, can be challenging. The Administration for Children and Families (ACF) oversees foster care, but state child welfare agencies are responsible for ensuring that these children receive health care services, which are often financed by Medicaid. In light of concerns about the health care needs of foster children, GAO was asked to study states' efforts to improve foster children's receipt of health services. This report has four objectives. It describes specific actions that some states have taken to (1) identify health care needs, (2) ensure delivery of appropriate health services, and (3) document and monitor the health care of children in foster care. It also describes the related technical assistance ACF offers to states. To address these objectives, GAO selected 10 states and interviewed state officials and reviewed related documentation regarding the nature and results of the states' practices. To describe ACF's technical assistance, GAO interviewed officials and reviewed documents from ACF, states, and relevant technical assistance centers.

What GAO Found

To identify the health needs of children entering foster care, all 10 states we studied have adopted policies that specify the timing and scope of children's health assessments, and some states use designated providers to conduct the assessments. All of the states we selected for study required physical examinations, most states we studied required mental health and developmental screens, and several of them required or recommended substance abuse screens for youth shortly after entry into foster care. Preventive health examinations for foster children were required at regular intervals thereafter, in line with states' Medicaid standards. Limited research has suggested that having assessment policies and using designated providers who have greater experience in the health needs of foster children may permit fuller identification and follow-up of children's health care needs. To help ensure the delivery of appropriate health care services, states have adopted practices to facilitate access, coordinate care, and review medications for children in foster care. Some states used specialized staff to quickly determine Medicaid eligibility; others issued temporary Medicaid cards to prevent delays in obtaining treatment. In addition, certain states had increased payments to physicians serving children in foster care to encourage more physicians to provide needed care. Nurses or other health care managers were given roles in coordinating care to help ensure that children received necessary health care services. Six states we studied also reported monitoring the use of various medications, including psychotropic medications intended for the treatment of mental health disorders. To document and monitor children's health care, several states we studied had shared data across state programs and employed quality assurance measures, such as medical audits, to track receipt of services. One state has developed a foster care health "passport" that electronically compiles data from multiple sources, including the state's immunization registry, and this passport can be accessed and updated by responsible parties through a secure Web site. Other states used electronic databases to obtain more complete and timely medical histories than otherwise available but provided more limited access to these and continued to update them through use of paper records. ACF's network of 25 technical assistance centers is intended to improve state performance in meeting children's needs, including their health care needs, by increasing the capacity of state agencies to ensure safety, wellbeing, and availability of permanent homes for children in their care. According to ACF officials, the centers are not intended to provide medical expertise, but to help state child welfare agencies collaborate with others involved with health programs. One center in ACF's network focuses exclusively on children's mental health and several others have also assisted in identifying some practices to improve the health of children in foster care. Five of the centers are newly funded and are expected to provide long-term help in implementing plans to improve agency performance in meeting children's needs.