Can recent change to Texas' child welfare system help make a broken system better?
Thirty days. That’s how long it used to take for a child who enters foster care to see a physician in Texas. That 30-day limit, a state-mandated deadline, might not sound like a long time. But Tyler pediatrician Valerie Borum Smith, MD, has seen firsthand the problems it has caused.
“I saw [a patient] 27 days into [foster] care, and she had actually attempted suicide the night before — thankfully unsuccessfully and thankfully she was medically stable,” Dr. Smith said. “If I had been able to see her earlier and do a mental health assessment and identify those suicidal ideations she was having, I could have gotten her into either inpatient or outpatient medical services without the trauma of that suicide attempt and with a lot more stability for her.”
The drawbacks to the 30-day deadline have been so pervasive that the 2017 Texas Legislature sped up the timetable by which children in foster care receive their initial medical exam. Senate Bill 11, authored by Sen. Charles Schwertner, MD (R-Georgetown), and passed into law, launched a series of major reforms of Texas’ troubled foster care system. (See “The Impact of SB 11” below.)
Among other things, it requires that foster kids be seen by a physician within three business days of coming into the care of Child Protective Services (CPS).
“Of the 30,000 children in the CPS system, there is a high number — a growing number — who have very complex medical needs and psychological needs,” Senator Schwertner told Texas Medicine. “We need to do a better job of identifying those children quickly so they’re able to receive the kind of care that they need. Until SB 11, that was not really not being done.”
Texas’ move to a three-day deadline brings the state up to the standard recommended by the American Academy of Pediatrics (AAP).
The three-day exam is not designed to be as extensive as the 30-day exam — which will still take place along with other checkups.
Anu Partap, MD, director of the Center for Child Abuse Prevention at Cook Children’s Medical Center in Fort Worth (left), says there are three types of medical homes for children in foster care: a small number of foster care clinics across the state; practices that happen to serve a large number of children in foster care through local relationships; and practices that serve a few children in foster care as part of a larger routine pediatric practice.
“My hunch is that last group [will be] the largest group of providers serving children in foster care,” said Dr. Partap, who is also a consultant for the Texas Health and Human Services Commission on foster care policies. “When you think about the number of children entering care and the size of our state, children are likely to be seen in a variety of practice settings.”
Kids under stress
When serious physical or sexual abuse is suspected, children often see a medical professional before they enter a foster or kinship home, Dr. Partap says. But the overwhelming number of children who enter foster care do so because of neglect, not abuse. These neglected children often suffer from overlooked medical problems tied to hunger, poor hygiene, and lack of medical care.
In many cases, they also have been abused, but the abuse hasn’t been detected yet.
“We know these stressors affect children’s health in every way,” Dr. Partap said. “It’s no surprise that the AAP states up to 80 percent of children in foster care have at least one medical condition.”
Having a 30-day deadline for a first medical evaluation was bad enough, says James Lukefahr, MD, a pediatrician who works at the Division of Child Abuse at UT Health San Antonio (left), but to make things worse, the 30-day deadline often was not enforced because CPS workers carried such heavy caseloads.
“The 30-day requirement was actually only being met about half the time,” Dr. Lukefahr said. “In other words, the initial medical evaluation was later than 30 days. From our point of view, it really was a big problem.”
However, the Department of Family and Protective Services (DFPS), CPS’ parent agency, says its data show that most foster care children actually do see physicians within the 30-day limit.
“We are working to address the discrepancies between what the compliance data show and what we know is actually happening around the state,” Patrick Crimmins, media relations manager for DFPS, said in an email.
The three-day deadline is expected to be more rigidly enforced in part because of the reforms created by SB 11 and because staffing and pay for workers at CPS has improved, Dr. Lukefahr says.
“The initial exam isn’t going to be a comprehensive physical,” he said. “It’s going to be more of a screening exam to make sure they don’t have any significant needs. We’re looking for previously unrecognized injuries and anything that needs to be treated and — especially for older kids — we’re looking at mental health screenings.”
The three-day visit also is important for new foster parents or relatives who serve as caregivers, says Dr. Smith, the Tyler pediatrician. Many of them have not been trained to recognize or deal with trauma in children.
“The variety of training that foster parents receive is extremely variable depending on the child placement agency and those sorts of things,” Dr. Smith said. “So we want to be able to help families with these transitions as they’re welcoming children into their homes.”
San Antonio pediatrician Ryan Van Ramshorst, MD, who is a member of TMA’s Committee on Child and Adolescent Health, says a key provision in SB 11 requires CPS to notify a physician when a child changes placement. In the past, children who changed caregivers frequently just disappeared from a physician’s practice with no explanation.
This reform allows for a “warm handoff” between physicians, Dr. Van Ramshorst said.
“Now I can call the new pediatrician or the new family physician and let him or her know what’s been going on with the care of that child to make that transition a little bit more seamless,” he said.
What doctors can do
Because foster children in Texas are covered under a Medicaid program called STAR Health, only pediatricians and family physicians who accept Medicaid are likely to see children in foster care. According to TMA’s 2016 Physician Survey, just 41 percent of Texas doctors accept all new Medicaid patients, while 21 percent accept some on a limited basis. So, access for children in foster care can be limited in some areas, such as rural counties where there are already physician shortages.
Dr. Partap says it’s not clear if the new rule will cause an uptick in the number of patients Texas physicians see. That also will depend on the number of placements that occur at any given time in their region. But it is important for physicians to coordinate with local CPS officials ahead of time to ensure that care can be provided as needed.
“I think the more that STAR Health contracted medical professionals can come together and work with their county CPS to create pathways for immediate access, the better this experience will be for a scared child,” Dr. Partap said.
Physicians who have little experience with children in foster care can obtain guidance from the AAP.
These physicians often are surprised by the need to take a different approach, Dr. Partap says.
“My medical exam now as a foster care pediatrician is completely different from what I did prior to foster care,” she said.
The move to a three-day deadline has been successfully piloted in Dallas and Lubbock, and the transition for the entire state will happen in stages. The entire state should be in compliance by Jan. 1, 2019.
Dr. Smith, the Tyler pediatrician, says that because each region has different child placement agencies and because of the other structural reforms in SB 11, the program will play out differently across the state. Also, Texas is a diverse state, so “there is no one-size-fits-all approach to implementation,” she said.
But the pilot programs showed important progress. For instance, in Lubbock, all children were seen within the three-day window by primary care providers, and none were sent to an emergency department, Dr. Smith says. Building on that success will require a lot of cooperation among physicians and DFPS.
“It’s really rewarding to do something that makes you feel like you’re going to have an impact on [health care] systems,” she said. “I think at the end of the day what we all want for children in foster care is for them to be safe, for them to be healthy, and for them to have the best outcomes possible.”
The impact of SB 11
Before the 2017 session of the Texas Legislature, lawmakers were under pressure to reform the state’s child welfare system. Between 2010 and 2014, 144 Texas children died while Child Protective Services (CPS) was investigating claims of abuse in their cases, and many children in state custody had to sleep in CPS offices for lack of suitable homes. Meanwhile, problems such as low pay and high turnover among CPS workers created instability. In 2015, U.S. District Judge Janis Jack declared the child welfare system “broken.”
Gov. Greg Abbott made reforming the child welfare system an emergency item for the 2017 legislature. Senate Bill 11, one of four reform bills that passed, was an omnibus measure designed to address the foster system’s most pressing issues.
SB 11’s most important provision creates a transition to “community-based” foster care, also called privatized foster care. That means the state will transfer foster care case management to nonprofit agencies or local government entities, like counties or municipalities.
Some critics opposed privatization, saying similar approaches have been tried in Florida and Kansas with mixed results. But the bill’s author, Sen. Charles Schwertner, MD (R-Georgetown), said Texas needed to take drastic steps to improve the child welfare system, and SB 11 allows that change to take place. Among other things, SB 11 also creates standardized child abuse and neglect investigations and covers the cost of day care services for foster children.
“I think this is a significant step toward improving the lives of children in our foster care system,” he said.
Despite these changes, Ms. Jack ruled in January that special masters would continue to monitor the state’s progress.
“Years later, the system remains broken and [the Department of Family and Protective Services] has demonstrated an unwillingness to take tangible steps to fix the broken system,” Ms. Jack wrote.
When seeing foster children in care
According to Anu Partap, MD, physicians should remember:
- Children in foster care and their caregivers are new to each other. “Pediatricians especially are accustomed to working with well-informed parents, and that has to shift. [The pediatrician needs] to help this caregiver know this child. … The caregiver doesn’t have the background information that I normally rely on.”
- Trauma has almost always happened. “My actual physical exam is much more slow-paced and child-centered and trauma-informed, realizing this is a child who probably doesn’t know anyone in this exam room. I need to be very sensitive to how scared the child is.”
- To speak privately with both the caregiver and the child. Caregivers often have concerns about the child that should not necessarily be shared with the child. Also, children often don’t want to say anything about their experiences with their birth families in front of their foster parents. “You don’t want to ask them a lot of sensitive questions in front of their caregivers that [the caregivers] don’t know yet.”
- To be careful about how you address people. “This sounds kind of silly, but it’s normally safe to say ‘mom’ or ‘dad’ to whatever adult is in the room, and I don’t know how well that would go across with [these kids].”
Tex Med. 2018;114(3):32-35