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Report to the Chairman, Subcommittee on Income Security and Family 
Support, Committee on Ways and Means, House of Representatives: 

United States Government Accountability Office: 

GAO: 

February 2009: 

Foster Care: 

State Practices for Assessing Health Needs, Facilitating Service 
Delivery, and Monitoring Children's Care: 

Foster Care: 

GAO-09-26: 

GAO Highlights: 

Highlights of GAO-09-26, a report to the Chairman, Subcommittee on 
Income Security and Family Support, Committee on Ways and Means, House 
of Representatives. 

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. 

What GAO Recommends: 

GAO did not make any recommendations in this report. In commenting on 
this report, Health and Human Services provided additional information 
on its technical assistance efforts and technical comments which have 
been incorporated as appropriate. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-26]. For more 
information, contact K. E. Brown, 202-512-3674, brownke@gao.gov or C. 
Bascetta, 202-512-7114, bascettac@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Specific Requirements for Health Assessments--and Using Designated 
Providers to Conduct Them--Are Employed to Identify Children's Health 
Care Needs: 

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: 

Mechanisms for Data Management and Quality Assurance Address Challenges 
to Documenting and Monitoring Children's Health Care: 

ACF Offers States Health-Related Technical Assistance as Part of Its 
Broader Efforts to Improve Delivery of Services: 

Agency Comments and Our Evaluation: 

Appendix I: Selection of States and Practices for GAO Review: 

Appendix II: Comments from the Department of Health and Human Services: 

Appendix III: GAO Contacts and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Findings of ACF Reviews with Respect to Common Challenges 
States Faced in Meeting Children's Health Needs: 

Table 2: Number of EPSDT Screens for Medicaid-Enrolled Children in 
Selected Age Groups, by State: 

Table 3: Examples of States' Approaches to Using Designated Providers 
for Physical Health Assessments: 

Table 4: Centers in ACF's Training and Technical Assistance Network 
That Have Provided Assistance Related to Foster Children's Health Care 
through 2008: 

Table 5: Characteristics of States Contacted for GAO's Review: 

Figures: 

Figure 1: Steps Typically Involved in Addressing Health Needs of 
Children in Foster Care: 

Figure 2: Four Phases of the Initial Round of the CFSR Process: 

Figure 3: State Data Systems Used by One or More State Child Welfare 
Agencies to Develop the Health History of Children in Foster Care: 

Abbreviations: 

AAP: American Academy of Pediatrics: 

ACF: Administration for Children and Families: 

AIDS: Acquired immune deficiency syndrome: 

CBO: Congressional Budget Office: 

CFSR: Child and Family Services Reviews: 

CMS: Centers for Medicare & Medicaid Services: 

EPSDT: Early and Periodic Screening, Diagnosis, and: 

Treatment: 

HHS: Department of Health and Human Services: 

HIV: Human immunodeficiency virus: 

HRSA: Health Resources and Services Administration: 

PIP: Program improvement plan: 

SAMHSA: Substance Abuse and Mental Health Services Administration: 

SCHIP: State Children's Health Insurance Program: 

[End of section] 

United States Government Accountability Office: 

Washington, DC 20548: 

February 6, 2009: 

The Honorable Jim McDermott: 
Chairman: 
Subcommittee on Income Security and Family Support: 
Committee on Ways and Means: 
House of Representatives: 

Dear Mr. Chairman: 

Some of our nation's most vulnerable children are those who have been 
removed from their homes and placed in foster care, often due to abuse 
or neglect. Of the nearly 500,000 children in foster care at the end of 
fiscal year 2007, 80 percent are estimated to have significant health 
care needs, including chronic health conditions, developmental 
concerns, and mental health needs. Treatment for the health care needs 
of children in foster care is generally financed through states' 
Medicaid programs.[Footnote 1] In addition to the extent of foster 
children's health care needs, the disruptions associated with foster 
care--such as having to leave home and experiencing several changes in 
placement--may increase the challenges of ensuring that these children 
receive health care services. However, conditions left untreated can 
impede children's ability to realize their potential or become self- 
sufficient later in life. 

States are responsible for ensuring that children in foster care 
receive necessary health care services. The Administration for Children 
and Families (ACF) within the Department of Health and Human Services 
(HHS) provides funding for state child welfare programs, including 
foster care. In exchange for this funding, states agree to meet basic 
federal requirements.[Footnote 2] However, they also have flexibility 
in how they design and implement their programs. In its past reviews of 
state agencies' performance, ACF determined that children under agency 
supervision, including those in foster care, may not all receive 
appropriate physical or mental health care services. For example, ACF 
found that about 30 percent of children sampled either did not have 
their health needs assessed or did not receive treatment during the 
period reviewed. In these cases, states were required to develop and 
implement improvement plans, and ACF monitored their implementation. 

In October 2008, Congress expanded the federal requirements related to 
foster children by mandating that states explicitly plan for the 
ongoing oversight and coordination of health care services for children 
in foster care.[Footnote 3] The state practices described in this 
report, although in use before the expansion of federal requirements, 
address some of the new requirements and, thus, may be helpful to other 
states as they consider changes in their plans. Specifically, this 
report addresses four objectives. It describes 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, the report describes the technical assistance that 
ACF offers states to help improve their performance in providing for 
the health care needs of these children.[Footnote 4] 

To address these objectives, we selected 10 states for in-depth study 
based on the information they provided and the variations they 
represented in geographic location, foster care caseload, and child 
welfare administrative structures. The 10 states selected were 
California, Delaware, Florida, Illinois, Massachusetts, New York, 
Oklahoma, Texas, Utah, and Washington. (For more information on our 
state selection, see appendix I.) We conducted site visits in three of 
these states to describe state practices in context and gather views of 
multiple stakeholders, such as state child welfare officials, health or 
Medicaid officials, health care providers, foster parents, and in two 
cases (Cook County, Illinois and New York City), the views of child 
welfare personnel in major metropolitan areas. In our interviews with 
officials of the seven remaining states, conducted by telephone, we 
focused primarily on interviewing child welfare and Medicaid officials 
regarding certain practices that state agencies identified.[Footnote 5] 
We cannot generalize the results of our review from the 10 states we 
selected to all states. Although we did not examine the actual 
operation of every practice, we reviewed information about states' 
practices through such means as discussions with researchers, 
advocates, and other parties who had knowledge of these states' foster 
care programs and, where available, we also collected and evaluated 
research, state data, and other information on the effectiveness of the 
practices adopted. In addition, we reviewed relevant federal laws, 
policies, and guidance and research literature on the physical and 
mental health needs and treatment of children in foster care. To obtain 
information on ACF's provision of technical assistance, we reviewed 
documents and interviewed officials at ACF and six centers 
participating in ACF's network of technical assistance providers, 
including the two centers jointly funded by ACF and HHS's Substance 
Abuse and Mental Health Services Administration (SAMHSA). Our work was 
designed to describe specific state and federal practices, not to 
assess compliance with statutory or regulatory requirements. We 
conducted our work from November 2007 to January 2009, in accordance 
with all sections of GAO's Quality Assurance Framework that are 
relevant to our objectives. The framework requires that we plan and 
perform the engagement to obtain sufficient and appropriate evidence to 
meet our stated objectives and to discuss any limitations in our work. 
We believe that the information and data obtained, and the analysis 
conducted, provide a reasonable basis for any findings and conclusions. 

Results in Brief: 

To identify the health needs of children, the states we studied 
generally reported adopting policies that specified the timing and 
scope of children's health assessments and, in some cases, also 
employed designated providers to conduct these assessments. These 
assessment features were intended to increase the likelihood of more 
complete identification and follow-up of children's needs. Although ACF 
had not imposed specific requirements for health assessments, the 10 
states we selected for study required that children have a general 
physical--often referred to as a well-child exam--within 30 days of 
entering foster care, in line with recommendations from professional 
associations. Most of these states also required that children's mental 
health and developmental status be screened after entry, and several of 
the states we selected for study cited screening for substance abuse. 
The 10 states also required preventive health examinations at regular 
intervals thereafter, in line with state Medicaid standards. To conduct 
the assessments, some states used specially selected, trained, or 
dedicated personnel to increase the likelihood that the children 
received appropriate health care services. Limited research associates 
the existence of specific assessment policies or use of specialized 
personnel with higher rates of screening and referral than occur when 
policies are not specific or personnel have no specific training. 
Similarly, some state officials indicated that such assessment 
policies, including the use of designated providers, have allowed them 
to provide follow-up treatment more quickly than before these practices 
were in place. 

To ensure the delivery of appropriate health services, most states we 
studied reported adopting one or more practices to facilitate access to 
services, coordinate health care, and review medications for children 
in foster care. These practices were intended to ensure that children's 
health services were not only delivered in a timely way, but in a 
consistent and complementary way across each step of the health care 
delivery process. In one case, a state used specialized staff to ensure 
that children in foster care were quickly reviewed for Medicaid 
eligibility. Other efforts included increasing payment rates to 
physicians for children in foster care to encourage more physicians to 
provide needed care. With regard to coordination of care, state 
practices included using nurses or other health care managers to help 
ensure that children in foster care received necessary health care 
services. In addition, several of the selected states identified 
practices related to monitoring the use of psychotropic medications-- 
drugs commonly used for the treatment of mental health disorders--owing 
to their effects on thought, behavior, or mood. For example, one state 
requires a review of prescriptions in certain circumstances, such as 
when multiple psychotropic medications are prescribed at the same time. 
Officials in this state reported that after the policy took effect, 
there was a decrease in the number of children in foster care who were 
prescribed multiple psychotropic medications. 

To document and monitor children's health care, some states we studied 
reported having data management practices that included sharing health 
care data across programs, and three states and a major city within 
another state pointed to various quality assurance mechanisms to track 
receipt of services. Data sharing with Medicaid and other data sources 
has helped some states we studied develop and maintain health records. 
In one state, these data sharing efforts include a foster care health 
"passport" that electronically compiles data on a specific child from 
multiple data systems, such as immunization records and data on 
prescription medications. This system allows for continuous updating at 
many points of care and permits access by multiple parties with 
decision-making responsibility for the child's health. Most state child 
welfare agencies we contacted reported using a combination of 
electronic and paper-based data sharing to obtain information other 
state agencies have compiled on children prior to their entry into 
foster care to provide more complete and timely medical histories than 
are otherwise available. However, these states provided more limited 
access to these data, and updates typically relied on the exchange of 
paper reports about medical visits and their results among doctors, 
foster parents, and caseworkers. In addition, the three states we 
visited and one major city reported having quality assurance activities 
that could be used to help monitor the receipt of services for children 
in foster care. For example, officials of some states we studied cited 
specialized case reviews focusing on children's receipt of health care 
services as supports in monitoring performance in meeting the health 
needs of children in their care. 

ACF supports a network of 25 technical assistance centers to help state 
child welfare agencies improve their capacity to meet children's needs, 
including their health care needs. ACF officials explain that they do 
not expect the centers to provide technical assistance regarding 
medical services, but instead to help child welfare agencies carry out 
their broader mission to ensure the safety, wellbeing, and attainment 
of permanent homes for children in their care. With respect to the 
health of children in foster care, ACF officials stated that this may 
involve helping child welfare agencies work collaboratively with other 
agencies that provide health care services, including other federally 
and nonfederally funded public and nonprofit programs. One of ACF's 25 
centers focuses exclusively on children's mental health, and several 
other centers have also assisted in identifying some practices designed 
to improve the health of children in foster care. Included among ACF's 
centers are five new centers that are due to become operational in 2009 
and are expected to provide in-depth, long-term assistance in 
implementing plans to improve agency performance in meeting children's 
needs. 

We provided a draft of this report to HHS for its comment. The agency 
provided some additional information on its technical assistance to 
state foster care agencies, particularly through collaboration between 
ACF and SAMHSA in efforts to assist states to address health issues 
such as mental health and substance abuse that may affect children in 
foster care. HHS's comments are reprinted in appendix II. HHS also 
provided technical comments, which we considered and incorporated as 
appropriate. 

Background: 

Children in foster care tend to exhibit more numerous and serious 
medical conditions than other children, including mental health 
problems. Foster care begins when children are removed from their 
parents or guardians and placed under the responsibility of a state 
child welfare agency. Removal from the home can occur for several 
reasons. For example, parental violence, substance abuse, severe 
depression, or incarceration may have led to the children's removal 
from the home. Other children and youth are referred when their own 
behaviors or conditions are beyond the control of their families or 
pose a threat to themselves or the community. 

The realities of foster care may further contribute to the challenges 
in meeting these children's health care needs. Once children are 
removed from their homes, obtaining information on their health status 
and health history from their parents or guardians may be challenging. 
Also, children often move to several different foster homes or 
treatment facilities during the course of their stay in foster care, 
which may result in having different health care providers. Changes in 
placement pose significant challenges for agencies, foster parents, and 
providers with regard to providing continuity of health care services 
and maintaining uninterrupted information on children's medical needs 
and course of treatment. 

Finally, in addition to specific characteristics or circumstances that 
complicate their care, children in foster care encounter some health 
care challenges in common with other health care users. Child welfare 
agencies generally expect that foster parents or other caregivers will 
recognize when children need medical attention and obtain the needed 
health services, but such services may be in short supply or difficult 
to access because of a lack of providers who serve Medicaid patients-- 
particularly for some specialties or geographic areas. Children 
entering foster care may lack medical care prior to entry, and children 
with prior medical care may have experienced disruptions in care, 
changes in providers, and have missing or incomplete records. 

Figure 1 illustrates the steps that are typically involved in 
addressing health needs of children in foster care.[Footnote 6] 

Figure 1: Steps Typically Involved in Addressing Health Needs of 
Children in Foster Care: 

This figure is a flowchart showing the steps typically involved in 
addressing health needs of children in foster care. 

[Refer to PDF for image] 

Source: GAO analysis; images, Art Explosion (clip art). 

[End of figure] 

State and Federal Funding for Children in Foster Care: 

All state child welfare agencies receive federal funds from ACF for 
children in foster care under two parts of title IV of the Social 
Security Act. The larger source of federal funds, under title IV-E, 
provides open-ended reimbursement for a portion of states' foster care 
expenses for children meeting federal eligibility criteria, who 
represented about 43 percent of children in foster care in 
2006.[Footnote 7] Title IV-E provided $4.8 billion to states in 2007 
for the federal share of the expense of housing and feeding these 
children.[Footnote 8] States cover the remaining costs and 100 percent 
of the costs to house and feed children in foster care who do not meet 
federal eligibility criteria. State child welfare agencies also receive 
funds under title IV-B to provide services to children in foster care 
and to those remaining in their homes for the purpose of preventing 
conditions leading to the need to remove children from their 
homes.[Footnote 9] In 2007, about $700 million was available under 
title IV-B. State child welfare agencies cannot use title IV-E or most 
IV-B funds for the direct provision of health care services. Limited IV-
B funds may be used for some health care services but are intended 
primarily for the support and preservation of families, rather than for 
children in foster care.[Footnote 10] Foster children who meet title IV-
E eligibility criteria, on the other hand, are explicitly identified as 
a group that is eligible for coverage under Medicaid. 

As a condition of receiving federal funds, state child welfare agencies 
must agree to meet certain federal requirements, including requirements 
related to the health of children in foster care. Under both titles IV- 
B and IV-E, states must submit plans to ACF that contain a number of 
statutorily required elements. For title IV-E, state agencies must have 
a written case plan for each child that includes specific health 
information, such as records of immunizations and medications, to be 
shared with foster care providers at the time of placement. The 
agencies must also have standards to ensure that children are provided 
services to protect their safety and health. Because these standards 
have not been further defined in statute or regulation, states have 
some flexibility with respect to their form and content. For safety and 
health standards, some states have cited standards for licensing foster 
care facilities, training foster care parents, or credentialing staff. 

In recent years, Congress has twice amended title IV-B, subpart 1 to 
add new state plan requirements related to the health of children 
served by child welfare agencies. Congress initially required that 
state plans describe the involvement of physicians and other medical 
professionals in the assessment and treatment of children in foster 
care.[Footnote 11] This requirement was effective with state plans 
approved by ACF in 2007. In October 2008, as we completed our review, 
Congress further amended title IV-B, subpart 1 to require state 
agencies to develop plans for the ongoing oversight and coordination of 
health care services for children in foster care.[Footnote 12] This new 
requirement expanded on the earlier requirement by mandating that the 
agencies include in their plans schedules for initial and follow-up 
health screenings that meet reasonable standards of medical practice; 
steps to ensure continuity of health care services, which may include 
the establishment of a medical home--a primary health care provider or 
group--for every child in care; oversight of prescription medications; 
and information on how children's needs identified through screenings 
will be monitored and treated and how their medical information will be 
updated and appropriately shared--as for example, by using electronic 
health records. These requirements apply to all children in foster 
care, regardless of whether or not the children meet federal 
eligibility criteria. 

Federal Oversight and Technical Assistance: 

Starting in 2001, ACF took a new, results-oriented approach to its 
oversight of state child welfare programs, focusing on whether children 
and their families served by these programs achieved positive outcomes. 
This oversight effort involved four phases of Child and Family Services 
Reviews (CFSR), as shown in figure 2. ACF expects to complete the final 
phase of the initial round of CFSRs in 2009. 

Figure 2: Four Phases of the Initial Round of the CFSR Process: 

This figure is a chart showing the following data: 

Phase I: 

State develops a self-assessment. 

1. State and ACF review and correct statewide data profile. 

2. State conducts focus groups and surveys and engages stakeholders and 
staff. 

Result: 

ACF and state use statewide assessment information to select two 
locations for on-site review. (Third location is state's largest 
metropolitan area). 

Phase II (6-7 months later): 
 
ACF conducts its week long on-site review. 

1. ACF draws a sample of cases and state prepares files from up to 65 
cases. 

2. State and ACF select and train review team. 

3. Review team conducts file review and interviews stakeholders.

Result: 

ACF prepares a final report based in part on the findings of the on-
site review and releases this report to the state. 

Phase 3: (within 90 days after report release): 

State develops program improvement plan (PIP). 

1. State and ACF negotiate benchmarks and action steps. 

Result: 

ACF approves PIP, and state submits quarterly reports to ACF for 
monitoring. 

Phase 4: (2 years after PIP approval): 

State completes PIP implementation. 

Result: 

ACF assesses the state's achievements against negotiated benchmarks and 
determines whether or not financial penalties apply.

[Refer to PDF for image] 

Source: GAO analysis. 

[End of figure] 

In the second phase of the initial round of the reviews completed in 
2004, ACF identified significant performance challenges, particularly 
with respect to meeting children's mental health needs.[Footnote 13] 
ACF assessed state child welfare agency performance on 45 indicators 
across a wide range of areas, such as children's safety and statewide 
information systems. On the two health indicators addressing physical 
and mental health, ACF identified 20 states as showing strengths in 
providing services to meet children's physical health needs, and 4 
states also showed strengths in meeting the mental health needs of 
children in foster care and children remaining in their homes under 
agency supervision.[Footnote 14] Nearly all states were required to 
implement program improvement plans because they did not show strengths 
in physical health, mental health, or both. ACF is required by statute 
to offer technical assistance, to the extent feasible, to help such 
states develop and implement plans to improve outcomes for children, 
including health outcomes. When ACF determines that a state has not met 
the jointly developed goals and action steps identified in these plans 
within 2 years of approval of the improvement plan, ACF regulations 
specify that it will withhold a portion of the state's grant 
funds.[Footnote 15] In the course of its oversight, ACF identified 
several challenges that states faced in meeting the health needs of 
children in their care, as summarized in table 1. 

Table 1: Findings of ACF Reviews with Respect to Common Challenges 
States Faced in Meeting Children's Health Needs: 

Physical health: Number of physicians and dentists in the state willing 
to accept Medicaid is not sufficient to meet the need.[A]; 
Mental health: * There is a lack of mental health services for children 
in the state. 

Physical health: The state agency is not consistent in conducting 
adequate, timely health assessments; 
Mental health: * The state agency is not consistent in conducting 
mental health assessments. 

Physical health: The state agency is not consistent in providing 
children with preventive health or dental services; 
Mental health: [Empty]. 

Source: ACF, Summary of the Results of the 2001 - 2004 Child and Family 
Services Reviews, p.10, [hyperlink, 
http://www.acf.hhs.gov/programs/cb/cwmonitoring/results/index.htm] 
(accessed on Nov. 21, 2008). 

[A] See GAO, Medicaid: Extent of Dental Disease in Children Has Not 
Decreased and Millions Are Estimated to Have Untreated Tooth Decay, 
[hyperlink, http://www.gao.gov/products/GAO-08-1121 (Washington, D.C.: 
Sept. 23, 2008)]. 

[End of table] 

Medicaid and Health Care Services for Children in Foster Care: 

Medicaid is the primary health care funding source for most children in 
foster care.[Footnote 16] The Medicaid program is administered at the 
federal level by the HHS's Centers for Medicare & Medicaid Services 
(CMS) and is jointly financed by the states and the federal government. 
All state Medicaid agencies receive federal funds for the Medicaid 
program under title XIX of the Social Security Act. Within broad 
parameters set by federal statute and regulation, state Medicaid 
agencies are responsible for determining eligibility and establishing 
the services and payments offered. Although many coverage, eligibility, 
and administrative decisions are left to individual states, the federal 
government sets certain requirements for state Medicaid programs, such 
as coverage of certain screening and treatment services. Children who 
meet federal eligibility criteria for IV-E foster care are required to 
be covered by state Medicaid programs under federal law.[Footnote 17] 
In addition, states have chosen to extend Medicaid coverage to other 
children in foster care.[Footnote 18] In 2004, Medicaid expenditures 
for children in foster care exceeded $5 billion.[Footnote 19] 

Children in foster care who are enrolled in Medicaid may receive 
services through one of two distinct service delivery and financing 
systems--managed care and fee-for-service. Under a capitated managed 
care model, states contract with a managed care organization and 
prospectively pay the plans a fixed monthly fee per patient to provide 
or arrange for most health services. Plans, in turn, pay providers. In 
the traditional fee-for-service delivery system, the Medicaid program 
reimburses providers directly and on a retrospective basis for each 
service delivered.[Footnote 20] 

States are required to offer certain screening and treatment services 
to children enrolled in Medicaid.[Footnote 21] Termed Early and 
Periodic Screening, Diagnostic, and Treatment services (EPSDT), these 
screenings must include, but are not limited to, a comprehensive health 
and developmental history, a comprehensive unclothed physical exam, 
appropriate immunizations, laboratory tests, and health education. The 
required services include vision, dental, hearing, and services for 
other conditions discovered through screenings, regardless of whether 
these services are typically covered by the state's Medicaid program 
for other beneficiaries. The state Medicaid agencies establish 
standards for the timing and frequency of these screening and treatment 
services and set their own payment rates for fee-for-service providers 
of these services. Federal regulations require that EPSDT screening 
services be provided in accordance with reasonable standards of medical 
and dental practice determined by the state after consultation with 
recognized medical and dental organizations involved in child health 
care.[Footnote 22] 

In addition to EPSDT, states may choose to offer optional Medicaid 
benefits, such as rehabilitative services and targeted case management 
for children in foster care. States have used the rehabilitative 
services option for children in foster care who have mental or 
developmental problems as a means of providing a wide range of services 
designed to help them achieve their highest level of functioning. 
States have used targeted case management in order to provide case 
management services to a defined group of Medicaid-eligible 
individuals, such as children in foster care.[Footnote 23] Such case 
management activities have included assessing a child's needs, 
developing plans to meet those needs, referring a child to services, 
monitoring the receipt of such services, and ensuring any necessary 
follow-up care. 

Federal Medicaid funds are available for a portion of case management 
activities, as long as funds are not available from other programs or 
from other entities, such as other insurers, that would be legally 
obligated to pay for such services.[Footnote 24] However, concerns 
exist that Medicaid funds have been inappropriately used,[Footnote 25] 
and CMS has denied payment for services when funds were available from 
other programs, such as Title IV-E.[Footnote 26] In 2007, CMS issued 
rules--an interim final rule for case management services and a 
proposed rule on Medicaid program coverage for rehabilitative services-
-that further defined the use of Medicaid funds for these benefits for 
children in foster care.[Footnote 27] However, in 2008, Congress passed 
and the President signed into law a moratorium on certain aspects of 
the rules that remains in effect until April 1, 2009.[Footnote 28] 

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. The policies generally call for assessments shortly after 
children enter care and take one of two forms: (1) a two-stage 
assessment comprised of an initial screening followed by a 
comprehensive assessment or (2) a single comprehensive assessment. Most 
states we selected for study included a requirement for screening of 
children's mental health and developmental needs, and most of the 
states we studied cited substance abuse screenings. Researchers and 
state officials have suggested that having designated providers conduct 
assessments may improve the quality and utility of assessment results. 
State officials report that these assessment practices have allowed 
them to make more appropriate and lasting placements of children in 
foster care and also to provide follow-up treatment more quickly than 
before these practices were in place. Some research also links specific 
assessment policies to higher rates of follow-up. 

Specific Requirements Can Ensure Timely, Appropriate Initial and 
Comprehensive Assessments: 

While federal law did not specifically require assessments before 
fiscal year 2009, the 10 states we reviewed had made assessments of 
children's physical health mandatory for all children entering care, as 
recommended by medical and other professional associations.[Footnote 
29] Because children often enter foster care with serious health 
conditions and, at times, without easily accessible medical histories, 
it is important to identify their health needs as quickly as possible. 
Health or developmental status may be a critical factor in determining 
the appropriate placement and level of care for children, as in the 
case of children with HIV or significant behavioral problems. Where 
there are explicit and comprehensive policies mandating assessments of 
all children entering care, greater percentages of children are likely 
to be assessed, according to a survey of a nationally representative 
sample of child welfare agencies.[Footnote 30] Further analysis of 
these survey data showed that agencies with comprehensive developmental 
screening policies were more likely to evaluate children, refer them to 
early intervention agencies, and engage in joint planning of health 
care services.[Footnote 31] 

Officials from the 10 states we reviewed reported using two general 
approaches to conducting assessments, but all required some health 
assessment within 30 days of a child's removal from his or her home. 
Florida, Illinois, Massachusetts, and New York generally conduct 
screenings or assessments in two stages: (1) an initial screening 
within 24 hours to 7 days to check for immediate health needs and (2) a 
later, fuller assessment within 30 days of entry into foster 
care.[Footnote 32] Some state officials expressed the view that waiting 
a while for the fuller assessment may give children the opportunity to 
adjust to their changed circumstances and for this reason may offer 
providers a more accurate picture of the children's health. 
Additionally, they noted that assessments may be lengthy and require 
significant time to complete. For example, Florida officials explained 
that their comprehensive assessment of mental health, development, and 
substance abuse takes 20 hours to complete, double the amount of time 
the state previously allotted in order to cover all necessary aspects 
of care. A second approach to identifying children's health care needs-
-used by California, Delaware, Oklahoma, Texas, Utah and Washington-- 
invokes a one-stage assessment process mandating that it be completed 
within 14 to 30 days of entry into foster care depending on the 
state.[Footnote 33] Utah officials explained that the state dropped its 
earlier requirement for an initial screening followed by another 
assessment, in part because the results were duplicative. However, the 
state expects caseworkers to be alert to urgent health needs and 
arrange treatment as needed. The state has written guidelines advising 
caseworkers that if there is any sign of abuse or neglect or if the 
child is ill, the child should be seen by a health care provider within 
24 hours. 

Once a child enters foster care and receives an initial assessment, 
state foster care policies in most of the states we selected for study 
required that ongoing assessments follow the schedules established by 
state Medicaid agencies for children's screening, which are based on 
the children's age or the time between routine checkups.[Footnote 34] 
Six of the 10 states we selected for our study called for children in 
foster care to receive at least annual screening, either under a 
separate health standard applicable to foster children or because their 
EPSDT standard for all Medicaid enrollees called for at least annual 
screenings, consistent with the 2008 American Academy of Pediatrics' 
recommendation on preventive pediatric care. See table 2 for a summary 
of the number of EPSDT screens incorporated in the Medicaid EPSDT 
standard for all children in the Medicaid programs in the 10 states we 
reviewed. 

Table 2: Number of EPSDT Screens for Medicaid-Enrolled Children in 
Selected Age Groups, by StateA: 

State: California[B]; 
Age group: Less than 1: 6; 
Age group: 1-5: 6; 
Age group: 6-14: 3; 
Age group: 15-20: 1; 
Age group: Total: 15. 

State: Delaware; 
Age group: Less than 1: 7; 
Age group: 1-5: 8; 
Age group: 6-14: 9; 
Age group: 15-20: 6; 
Age group: Total: 30. 

State: Florida[C]; 
Age group: Less than 1: 7; 
Age group: 1-5: 7; 
Age group: 6-14: 7[D]; 
Age group: 15-20: 15-20: 6; 
Age group: Total: 27. 

State: Illinois[D]; 
Age group: Less than 1: 7; 
Age group: 1-5: 7; 
Age group: 6-14: 5; 
Age group: 15-20: 3; 
Age group: Total: 22. 

State: Massachusetts; 
Age group: Less than 1: 6; 
Age group: 1-5: 7; 
Age group: 6-14: 9; 
Age group: 15-20: 6; 
Age group: Total: 28. 

State: New York; 
Age group: Less than 1: 7; 
Age group: 1-5: 8; 
Age group: 6-14: 9; 
Age group: 15-20: 15-20: 6; 
Age group: Total: 30. 

State: Oklahoma; 
Age group: Less than 1: 5; 
Age group: 1-5: 7; 
Age group: 6-14: 4; 
Age group: 4; 
Age group: Total: 20. 

State: Texas; 
Age group: Less than 1: 5; 
Age group: 1-5: 7; 
Age group: 6-14: 7; 
Age group: 15-20: 6; 
Age group: Total: 25. 

State: Utah; 
Age group: Less than 1: 6; 
Age group: 1-5: 7; 
Age group: 6-14: 7; 
Age group: 15-20: 6; 
Age group: Total: 26. 

State: Washington[E]; 
Age group: Less than 1: 5; 
Age group: 1-5: 6; 
Age group: 6-14: 5; 
Age group: 15-20: 3; 
Age group: Total: 19. 

Source: GAO analysis of states' EPSDT screening requirements. 

[A] Because some states used age categories in describing their 
policies that did not align with those shown here, the distribution of 
screens across age groups is an approximation, with no screen counted 
more than once. 

[B] California adopted a screening schedule based on an earlier 
American Academy of Pediatrics screening schedule. According to state 
officials, California is in the process of updating the state's 
screening schedule to conform to the most recent American Academy of 
Pediatrics screening schedule. 

[C] Florida follows the 1999 American Academy of Pediatrics schedule, 
which recommended a total of 27 screens. Florida Medicaid also 
recommends check-ups at 7 and 9 years of age for "children at risk." 

[D] Illinois recommends that health screening be provided to children 
on a periodicity schedule based on acceptable medical practice 
standards, such as the schedule recommended by the American Academy of 
Pediatrics. The schedule above was provided by the Illinois Department 
of Public Aid, now known as the Illinois Department of Healthcare and 
Family Services, as a minimum guideline for children in the Medicaid 
program. The Illinois Department of Children and Family Services 
requires that children in foster care receive at minimum annual health 
screenings between the ages of 6 and 21. 

[E] The Washington EPSDT standard specifies annual screening for 
children in foster care between the ages of 2 and 20. 

[End of table] 

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. Research indicates that an estimated 30 
to 60 percent of children in foster care may have chronic health 
conditions, and the proportion estimated to have serious health care 
needs rises to over 80 percent when behavioral, emotional, and 
developmental concerns are included.[Footnote 35] Guidelines issued by 
professional associations emphasize the importance of assessing mental 
health and other behavioral health issues for children in foster care. 
An analysis of the results of ACF reviews conducted between 2001 and 
2004 found no evidence of policies requiring an assessment of 
children's mental health in most states; in one state, stakeholders 
noted that children did not get mental health assessments unless there 
were problems observed.[Footnote 36] 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. Most states we studied 
had also adopted policies requiring or recommending screening youth 
entering foster care for substance abuse. For example, Delaware 
officials told us that--since February 2006--its initial health 
screening has required the inclusion of a component alerting staff to 
any mental health or substance abuse problems for all children 4 
through 17 years of age. Other state policies varied in whether or not 
they included specific time frames. For example, New York has no 
mandatory time frame for its required mental health assessment, 
although it is recommended that this be completed within 30 days of 
placement. State guidance also varies on the tools used for the 
assessments. In some states, such as Massachusetts, the steps taken by 
individual health practitioners as part of either (1) the comprehensive 
screening within the first 30 days or (2) in later Medicaid screenings 
are considered sufficient to meet the policy requirements. In other 
cases, states have adopted or are considering adopting specific 
screening tools. For example, Utah reported the state had specified the 
tools to be used in assessing the development of children ages 4 months 
to 5 years. Officials in both California and Oklahoma reported they 
were working to identify assessment instruments for the early 
identification of children with mental health or developmental needs. 

The Use of Designated Providers Can Increase the Thoroughness of 
Physical and Mental Health Assessments: 

Four states we studied reported using designated providers to perform 
certain initial and comprehensive assessments, which some evidence 
indicates can increase the consistency and thoroughness with which 
children's physical and mental health needs are identified. Illinois, 
for example, requires that children's initial health evaluations be 
conducted by a network of hospital emergency rooms and clinics, while 
subsequent assessments are generally conducted by a network of 
community-and facility-based physicians, with foster parents permitted 
to use others on request. We identified two studies that associated use 
of designated or specialized health care providers for foster children 
with higher rates of preventive and specialty care.[Footnote 37] 

With regard to physical assessments, states that identified the use of 
designated providers to perform initial screens and comprehensive 
assessments reported that these providers functioned as part of a 
network of providers, as primary providers in specific locations, or 
both and, in some cases, that the use of such networks had enhanced the 
numbers receiving assessments. For example, Florida reported that some 
of its counties have focused on developing a network of trained 
providers, while Oklahoma and Utah identified specific locations in 
urban areas--such as clinics or hospitals--where some children could 
receive assessments. In most cases, these initial providers could serve 
as medical homes for the children they assessed. (See table 3 for more 
information on how states use designated providers.) Some state 
officials commented that the use of a specific network of physicians 
also facilitated quality improvement efforts. For example, a physician 
with Cook County's Healthworks program noted that the quality of health 
assessments--once a subject of complaint from child welfare field 
staff--had improved when assessments were channeled to a network of 
specific providers that could be supported by targeted training 
efforts. He noted that the health assessment for a child entering 
foster care requires a more thorough, detailed approach and level of 
documentation than that involved in a standard EPSDT well-child exam. 

Table 3: Examples of States' Approaches to Using Designated Providers 
for Physical Health Assessments: 

State: Florida; 
Description of approach: * Some counties within Florida use a network 
of physicians to conduct initial screenings for children in foster 
care; 
* Such networks may serve as a medical home for children throughout and 
beyond their stay in foster care. 

State: Illinois; 
Description of approach: * Illinois has a network of providers who 
conduct initial health screenings, comprehensive health evaluations, 
and ongoing primary care for all children in foster care, and some 
comprehensive evaluation providers may serve as sources of continuing 
care; 
* Providers may be located in hospitals or clinics, with hospital 
emergency rooms or clinics serving as the initial screening location 
for children. 

State: Oklahoma; 
Description of approach: * Oklahoma uses primary care providers in 
clinics in Oklahoma City and Tulsa to screen children for physical, 
mental health, and dental needs, as well as any social needs; 
* The clinic location can serve as a medical home for the child after 
assessment. 

State: Utah; 
Description of approach: * Children entering custody with a medical 
home are to be sent to their original provider for the comprehensive 
health assessment; 
* For children in foster care who do not have an identified medical 
home, Utah uses providers located in a public health clinic in Salt 
Lake City to provide initial screening and comprehensive health 
assessments to local children in foster care; 
* The clinic can serve as a medical home for the child after 
assessment. 

Source: GAO analysis of state interview responses, as of August 2008. 

[End of table] 

The states shown in the table as using designated providers elaborated 
on their practices and, in some instances, noted specific strategies 
that may contribute to providers' effectiveness: 

* Illinois requires that the initial health screening be completed 
within an hour of the child's arrival at the medical facility. Illinois 
officials reported that appointments for the screening in Cook County 
are arranged through a toll-free telephone service called HealthLine, 
which is staffed around the clock by a child welfare contractor who can 
obtain priority service for children so they do not experience lengthy 
waits in hospital emergency rooms. Hospital emergency rooms are used 
for many initial screenings because they are accessible outside of 
normal business hours, but the comprehensive health assessments 
generally take place in physicians' offices because they require more 
time. Research on children enrolled in the Illinois program has shown 
that these children experienced higher rates of preventive and 
necessary specialty care than other children with similar socio- 
economic characteristics who were not enrolled in the program. Although 
the research did not evaluate the effectiveness of the program itself, 
the researchers concluded that the increased attention and oversight of 
the health care for the children enrolled in the program affected their 
outcomes.[Footnote 38] 

* Oklahoma officials noted that their clinic-based assessment process 
began with a pediatrician who had experience working with children who 
had been removed from their homes and placed into shelters. Concerned 
about the continuity of care for children in these situations, this 
pediatrician set aside particular times for children in foster care to 
visit the clinic and see a familiar provider. A second clinic that was 
opened in another large city is also under the medical direction of a 
pediatrician familiar with the needs of children in foster care. 
Officials told us they believe that children's health care benefits 
when they are served by providers with knowledge of the foster care 
population. 

In addition to using designated providers for physical health screens 
and comprehensive assessments, a few states reported using a mental 
health specialist who worked with caseworkers to conduct assessments. 
The use of specialists to conduct mental health screenings can be an 
effective means of identifying children's mental health needs. One 
study that surveyed a nationally representative sample of agencies 
found that involving mental health specialists in assessments resulted 
in a greater identification of mental health needs, as well as improved 
follow-up care, than were received by children whose assessments did 
not include a mental health specialist.[Footnote 39] 

The mental health assessments used by states we selected varied. In 
some cases, the assessments were comprehensive social assessments that 
covered areas such as mental health, emotional health, school, work, 
and community involvement. In other cases, the focus was narrower, 
covering specific topics such as indicators of mental illness. 
Washington officials reported that specialized social workers conducted 
comprehensive assessments using standardized tools that assess several 
aspects of social and mental health needs, including behavioral, 
developmental, educational, family, and social issues.[Footnote 40] For 
physical or mental health concerns identified during the screening that 
require treatment, state officials indicated that the social workers 
refer children to appropriate health care professionals. 

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. Practices relating to access to care included efforts to 
hasten determination of Medicaid eligibility, implement financial 
incentives for providers to serve children in foster care, and enhance 
access to medical specialists for various subgroups of children. 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. 
Officials of specific states we contacted said that such care 
coordination had increased rates of immunization, initial assessment, 
and well-child visits. Finally, officials from six of the states we 
studied pointed to policies that they had implemented requiring the 
review of prescriptions for psychotropic medications commonly used to 
treat mental health disorders for children in foster care. 

Practices to Enhance Access to Care Include Streamlined Medicaid 
Eligibility, Financial Incentives to Providers, and Strategies to 
Obtain Specialty Care: 

Among the states we studied that identified a practice state officials 
believed noteworthy in enhancing access to care, some had identified 
assigning certain staff--from their Medicaid offices or from their 
child welfare offices--to ensure that children in foster care were 
quickly reviewed for Medicaid eligibility. Because the removal of a 
child from home can change his or her Medicaid eligibility status, some 
states we contacted had taken steps to save time in certifying Medicaid 
eligibility and facilitate new foster care beneficiaries' access to 
providers. For example, Delaware had assigned two Medicaid staff to 
foster care cases, while Florida, Utah, and Illinois used staff members 
from the child welfare offices to determine eligibility for Medicaid. 
Utah has a written agreement between the state child welfare and 
Medicaid agencies that specifies that certain staff in Utah's Division 
of Child and Family Services will determine Medicaid eligibility for 
children in foster care. The purpose of this arrangement is to enhance 
services to children and families, simplify administration, improve 
accuracy, conserve state resources by avoiding duplication, and 
maximize legitimate Medicaid funding. In Illinois, children coming into 
foster care are presumed to be eligible for Medicaid. For purposes of 
formal eligibility determination, Illinois officials reported that 
using specialized staff members in the state child welfare agency's 
central office to complete the determination had sped up the process. 
Specifically, they reported that a process that once took 3 to 4 months 
could now be completed within 4 weeks of issuance of the temporary 
medical card. Florida officials also reported that their agreement that 
staff from the child welfare department determine Medicaid eligibility 
reduced the amount of time required to make these determinations from 
18 days to within 24 hours. 

Illinois and Washington are among the states that offer financial 
incentives to providers who treat children in foster care, since 
providers may be reluctant to serve children in foster care. In 
Illinois, physicians serving children in foster care are paid a one- 
time $15 fee to initiate a paper health passport to document the health 
history and ongoing care of the child. Additionally, the state uses an 
enhanced payment rate for initial health screenings conducted in 
hospital emergency rooms.[Footnote 41] Washington officials reported 
that the state increased its payments in November 2001 for medical 
providers who conducted well-child examinations for children in foster 
care. At the time, these rates were about twice the reimbursement rate 
paid in other cases. State officials reported that since 2001, other 
Medicaid rates--such as payments for EPSDT services--have also 
increased, so that rates for foster care children are no longer twice 
as high. However, the foster care rates remain equal to or 
substantially greater than the standard Medicaid rates. In April 2008, 
Washington officials told us that approximately two-thirds of children 
received well-child examinations, up from about 17 percent before the 
state increased the rates in 2001. 

Utah, Illinois, and New York have instituted a variety of programs to 
increase access to medical specialists or subspecialists. Under some 
circumstances, obtaining specialty care can be difficult for Medicaid- 
eligible children, and such efforts for children in foster care may be 
even more difficult if the children have complex health needs or 
changing placements. These states' efforts typically focused on 
specific subgroups of children in foster care, such as those in rural 
areas, those who need mental health services, and those who would 
otherwise require institutional care. 

* Children in Rural Areas: Utah and Illinois have efforts focused on 
children living in rural areas where it may be harder to find a 
pediatric health specialist or subspecialist. For example, Utah has 
eight clinics to which multidisciplinary teams travel in order to 
provide specialty services for children with special health care needs 
across rural Utah. State officials told us that in some cases, children 
are seen more quickly in these locations than in Salt Lake City. 
Illinois officials reported transportation is available and sometimes 
is used to get rural foster children to providers, including oral 
dental surgeons, orthodontists, and child psychiatrists. Despite these 
efforts, state child welfare officials cited a continuing challenge in 
obtaining mental health and substance abuse services, and especially 
child psychiatry for children in Medicaid and other publicly-funded 
medical care, not just those in foster care. As a result, Illinois has 
also begun to look at the use of telepsychiatry in one of its downstate 
regions.[Footnote 42] 

* Children Needing Mental Health Services: To address children who are 
experiencing mental health crises, Illinois developed a psychiatric 
crisis intervention program with a single, statewide 24-hour, 7-day-a- 
week crisis hotline. When a person calls the crisis line, a mental 
health provider is expected to reach the child in crisis within 90 
minutes of the call to conduct a screening and determine if the child 
requires psychiatric hospitalization. Following this decision, the 
mental health provider is to continue to provide treatment and other 
service interventions for a minimum of 90 days. State officials 
reported that this program serves about 18,000 children per year, 
including all children who receive Medicaid or other public funding for 
medical care (not just those in foster care). Medicaid covers all the 
services provided by this program, which began in 2004, on a fee-for- 
service basis. 

* Children Who Might Otherwise Require Institutional Care: With respect 
to difficulty in accessing specialty services, New York launched a 
program in early 2008 for children in foster care who have 
developmental disabilities, serious emotional disturbances, and medical 
problems that are so severe they would otherwise likely be in 
restrictive and high-cost institutions. By making community-based 
services available to a fixed number of these children, the state hopes 
to help them function in family and community settings instead. New 
York officials reported that when the program is fully implemented 
after 2011, it will serve approximately 3,000 children in foster care. 

Public Health Nurses and Other Health Care Managers Coordinate Care to 
Help Ensure Health Services Are Delivered Appropriately: 

Several states we studied discussed their development of the role of 
health care managers with the goal of improving health care and health 
outcomes for children in foster care. While all children in foster care 
have caseworkers, they focus on issues related to the child's safety 
and permanency and do not necessarily have medical expertise. 
Typically, health care managers are nurses who are colocated with the 
child welfare agency and work with the child's foster care caseworker. 
Officials in California told us that the nurses are colocated in the 
child welfare offices so they can easily talk directly to caseworkers. 
These nurses may be able to more quickly spot gaps in care than foster 
care caseworkers because they are trained to understand children's 
health and developmental needs, they are able to communicate clearly 
with health care providers, and they can provide medical guidance to 
both foster care caseworkers and foster and biological parents. In some 
states--such as California and Utah--each child is assigned a nurse, 
while in other states--such as Illinois and Massachusetts--only those 
children with specific or medically complex needs are individually 
assigned to a nurse. In some states, public health nurses provided the 
care coordination services for children in foster care, whereas in 
Illinois, the state child welfare agency or a local contracting agency 
served as health care manager. Some positive results in achieving 
health-related goals for children in foster care had been documented 
for a health care management effort in New York.[Footnote 43] 

The specific services provided by health care managers varied in the 
states we contacted, but usually included the development and 
maintenance of the child's health history, medical case planning--that 
is, identifying the child's medical needs and arranging for receipt of 
medical services--and identification of medical professionals available 
to provide services to children in foster care. For example, state 
officials in Utah told us that the state has 29 Maternal and Child 
Health agency nurses serving about 90 children each. The nurses may 
provide medical, mental health, and dental consultation; identify the 
child's primary care provider; place the child in the appropriate 
health plan; gather, evaluate, and document the health history of each 
child; track ongoing health care; and maintain an up-to-date medical 
history on each child within an electronic database.[Footnote 44] 
Officials in Utah reported that use of public health nurses has reduced 
errors in transcribing information about medical history and ongoing 
care into the state's electronic database. Utah officials also reported 
that they find that biological parents are more comfortable talking 
openly with the nurse, who they said biological parents tend to view as 
an advocate rather than an adversary. According to data provided by 
state officials, another result of the program is that more children 
are getting their comprehensive assessments completed than before, and 
more quickly than required. Specifically, Utah officials reported that 
about 76 percent of children received these assessments in a timely 
fashion in 2008, compared to 58 percent in 1998, before the program was 
implemented. They further noted that these assessments are being 
conducted in 18 days, on average, rather than taking the full 30 days 
allowed by state requirements. 

Health care managers may also provide other services. Caseworkers in 
Illinois told us that in medically complex situations, families can be 
assigned to a regional nurse who can provide recommendations and assist 
a caseworker in communicating with the family on medical needs. 
Similarly, in Massachusetts, staff told us that nurses in regional 
offices provide consultation to staff regarding the medical needs of 
all children and work with children who have difficult or complex 
medical needs. In Illinois, officials at one of the privately-run case 
management programs in Chicago became concerned about immunization and 
well-child exam completion rates. As a result, they implemented a paper-
based reminder-recall system that gives foster parents, providers, and 
caseworkers information about when and what medical services are 
needed. Prior to the implementation of the reminder-recall system, 
officials in one agency that had adopted it told us that 77 percent of 
children had up-to-date immunizations and 44 percent had received 
appropriate well-child visits. These officials reported that in 2007, 
after implementation of this reminder-recall system, 96 percent 
received appropriate immunizations and 90 percent had received well-
child care. We were told that the five community-based medical care 
management agencies in Cook County used the reminder-recall 
system.[Footnote 45] In addition, some counties outside of Cook County 
have instituted a similar system. 

New York conducted a formal evaluation of its health care management 
project and found that such care coordination had a significant, 
positive impact on many aspects of care, including the receipt of both 
initial physical and dental assessments, access to nonpreventative 
care, and health-related contacts between agency workers and foster 
parents.[Footnote 46] However, funding was not available for the state 
to continue this program when the initial pilot project was completed 
and the project did not meet nonhealth and well-being related child 
welfare goals, such as reducing the number of days spent in foster care 
and increasing the likelihood of leaving foster care for a permanent 
placement. 

Policies Governing the Review of Psychotropic Medications Implemented 
to Help Ensure Children in Foster Care Receive Appropriate Health Care: 

Officials in six of the states we selected for interview identified 
specific policies they had adopted to govern the review of psychotropic 
medications intended for the treatment of mental health 
disorders.[Footnote 47] An Illinois official noted that the use of 
psychotropic medications is uniquely challenging for children in foster 
care, given that foster children who change placements often do not 
have a consistent person to plan treatment, offer consent, and provide 
oversight. Most of the policies states identified require an extra 
level of review beyond the person prescribing the medication, either by 
state officials or local experts. Concerns have been expressed that 
psychotropic medications have frequently not been tested for their 
safety and efficacy with children, and one study of children in foster 
care found that the most frequently prescribed medication was an 
antipsychotic drug that had not been tested for use by children and 
adolescents.[Footnote 48] Some research has also found that use of 
psychotropic drugs by children in foster care is three to four times 
greater than by other low-income children insured by Medicaid.[Footnote 
49] Greater prevalence of use is not, by itself, evidence of 
inappropriate use; children in foster care may be more likely to have 
conditions for which the drugs are indicated. However, administrative 
data from one state associated the introduction of its policy with 
modest decreases in prescribing psychotropic drugs and declines in 
specific patterns of prescribing, such as prescribing multiple drugs. 

Texas has developed a policy that notes the importance of conducting a 
health history, psychosocial assessment, mental status exam, and 
physical exam before prescribing psychotropic medications. The policy 
suggests that alternative interventions should generally be considered 
before beginning the use of psychotropic medications and outlines 
specific circumstances under which a case may require further 
review.[Footnote 50] Data examining the percentage of children 
prescribed a psychotropic medication for at least 60 days, the 
percentage prescribed two or more medications concurrently from the 
same drug class, and the percentage prescribed five or more medications 
concurrently showed decreases from fiscal year 2004, before the new 
policies were implemented, through fiscal year 2007.[Footnote 51] 

Because of concerns raised about the appropriate use of psychotropic 
medications, California requires judicial approval for their 
administration to a foster child. The prescribing physician must make 
the case to a juvenile court judge that the particular medication is 
appropriate for the given child and that alternatives have been 
considered. The Judicial Council of California has adopted rules of 
court to implement this legal requirement. Specifically, these rules 
require that an application be made to a juvenile court judge 
requesting the use of psychotropic medication and that the application 
include the signature of the physician to request the medication's use; 
the child's diagnosis, the specific medication, and dosage recommended 
for use; the anticipated benefits and possible side effects of the 
medication; a list of other medications the child is taking, along with 
a description of possible drug interactions; a description of other 
treatment plans; and a statement that the child has been informed of 
the recommended course of treatment with their responses. The court may 
grant the application or may delegate that authority to the parent if 
it is found that the parent poses no danger to the child and that the 
parent has the capacity to understand the request. In an emergency, the 
rules allow the administration of psychotropic medications without 
court approval in accordance with existing law, but court approval must 
be obtained within 2 days. 

Other states have worked with universities and local experts to help 
with the oversight of psychotropic medication use by children in foster 
care. For example, Illinois has contracted with a university to provide 
an independent review of each psychotropic medication request to ensure 
safe and appropriate usage with children in foster care. The request is 
forwarded to a board-certified child and adolescent psychiatrist who 
reviews the information and determines whether to approve, deny, or 
adjust the request. According to state officials, Florida has also 
worked with a local university to develop a process whereby caregivers 
of children in foster care receive a consultation with a physician 
before psychotropic medications are prescribed. The state also has a 
mandatory preconsent consultation for all children age 5 and under in 
foster care. The state then tracks information about the medication, 
such as the prescribing physician, medication, dosage, number of 
refills, and its purpose. As a result, the state is able to determine 
the number of children receiving certain types of medication and can 
then identify areas where there might be concerns about inappropriate 
use. Oklahoma and New York also work with experts to review and provide 
training related to the use of psychotropic medications by children in 
foster care. 

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. Efforts to 
share health care data generally focused on enhancing access to 
existing health information among parties responsible for the health of 
children in foster care while meeting requirements for data security 
and privacy protection. 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. More commonly, states we studied identified initiatives that 
also combined data from different sources but did not offer electronic 
access or provide for any updating at the point of care, relying on 
paper-based transfers of medical histories and providers' updates via 
the foster parents. Quality assurance activities have also made use of 
electronic systems as a means of monitoring the receipt of services for 
children in foster care. These efforts can be important to ensuring 
that individual children receive the appropriate level of services, 
avoiding duplication of services such as immunizations, and ensuring 
the receipt of needed services. 

Data Sharing with Medicaid and Other Systems May Yield More Complete 
Medical Information: 

Some states share data with Medicaid and other state systems, such as 
immunization registries, in order to obtain more complete medical 
information than might otherwise be available as a child enters foster 
care. Basic health information should be included in a written case 
plan and provided to foster parents before children are placed with 
them. Obtaining information that is important to a child's health 
records can be a complex task, which may involve four or more separate 
systems (see fig. 3). Additionally, information collected from parents 
and caregivers may also be of assistance in understanding the needs of 
a child. 

Figure 3: State Data Systems Used by One or More State Child Welfare 
Agencies to Develop the Health History of Children in Foster Care: 

This figure is an image of a child's health care record, which should 
contain the following: medicaid claims, immunization registry, health 
provider's records, and pharmacy claims. 

[Refer to PDF for image] 

Source: GAO analysis; images, Art Explosion (clip art). 

[End of figure] 

States that pointed to records management systems as a means of 
developing health history cited the use of an electronic health record-
-sometimes termed an electronic passport--or other efforts to combine 
sources of information. Combining these sources of information is 
important because few children enter foster care with records that 
accurately identify their health providers, health conditions, or 
receipt of services. Without these records, their health care may be 
delayed until records are available, or their care may be compromised. 
For example, officials in two states told us of cases in which health 
providers had refused to provide specific treatments to children in 
foster care because they did not know their histories or did not have 
medical records available to prevent improper treatment. Similarly, 
children may miss immunizations, receive duplicate immunizations, or 
forego necessary medications. 

Web-Based Electronic Passport Can Allow Access to Comprehensive Health 
Information on Individual Children in Foster Care: 

In April 2008, Texas began implementing an electronic passport to track 
health data for 29,000 children in foster care.[Footnote 52] This 
passport can be updated regularly and is accessed through a secure Web 
site by foster parents, caseworkers, and health care providers who are 
responsible for making health decisions on behalf of children.[Footnote 
53] The Foster Care Health Passport is operated by a managed care 
organization that is under contract with the state Medicaid agency. 
Texas developed and implemented the Health Passport using funds from 
the state and CMS. Officials told us that total funding data were not 
readily available. 

When a child enters the Texas foster care system, his or her electronic 
health record is created by obtaining information from a variety of 
sources. The Health Passport is initially populated with Medicaid and 
State Children's Health Insurance Program (SCHIP) claims, including 
pharmacy claims data from the past 2 years for children previously 
enrolled in Medicaid or SCHIP. Officials told us that generally, data 
from these sources are available for a majority, but not all, children 
who enter foster care. Immunization records are entered through a data 
sharing arrangement with the state's immunization registry. Once the 
electronic health record is created, it can be electronically updated 
with information on any health care services that were delivered by any 
foster care health provider in the managed care organization's network. 
Claims data are added when the claim is processed, which state 
officials indicated could take a few weeks or months, noting that 
providers have 90 days after a medical visit to submit a claim. 
Services provided outside of the contractor's network must be added 
manually through an online form mailed or faxed to the managed care 
organization. Officials told us that the passport also records 
behavioral health, dental, and vision services. Finally, officials 
stated that information in the Health Passport remains accessible 
statewide, even when the child's placement changes and the child moves 
to new foster parents, localities, or health providers. When children 
leave foster care, the electronic health record is printed out for the 
child or his caregiver. 

While the Health Passport has not been operational long enough to 
determine its effectiveness, state officials told us that they are 
working on baseline measures for several variables, such as well-child 
outcomes, and have developed measures to assess the contractor's 
performance.[Footnote 54] 

Officials in several other states we contacted expressed an interest in 
pursuing the development of an electronic health passport. For example, 
Illinois uses several data systems to manage Medicaid, foster care, and 
community health and preventive care for children, but the state is 
working toward integrating data electronically from the many systems in 
use, with the ultimate goal being the construction of an electronic 
passport. Some obstacles to data sharing have included concerns about 
privacy and security. As states look to sharing individuals' health 
data to better serve and treat them, they are also implementing 
standards governing the transmission of data, policies to ensure that 
only authorized users have access to records, and provisions to protect 
individuals' privacy. CMS has taken steps to provide assistance to 
states on issues of security and privacy. Several of the states 
included in this study cited practices they used to create medical 
histories and agreements they have to address data security and privacy 
issues. 

Other Forms of Data Sharing Can Improve Access to Timely Health 
Information: 

Other forms of data sharing use and combine existing record-keeping 
systems, usually through a combination of electronic matches and paper 
exchange of data among doctors, foster parents, and the Medicaid or the 
foster care agency, as shown in the examples below. 

* Oklahoma officials noted that the state's efforts to obtain medical 
information for children entering foster care centered on using 
Medicaid claims data, which it has been doing on a statewide basis 
since 2007. State officials reported that the project has been 
particularly successful because over 90 percent of children entering 
foster care had some prior Medicaid history and over 80 percent were 
already on Medicaid when they entered the state's care. Officials noted 
that the Medicaid claims data can provide information on developmental 
assessments, immunizations, as well as the receipt of both physical and 
mental health services. 

* In Utah and Illinois, nurses enter children's health information into 
the state child welfare agency's database. In Utah, public health 
nurses who work in collaboration with child welfare workers provide 
medical care coordination and record visits, diagnoses, and 
prescriptions for children in foster care. The child welfare agency in 
Illinois has a memorandum of agreement with its Medicaid agency to 
share pharmacy claims data for purposes of identifying doctors 
prescribing psychotropic medications without consent, and it also 
electronically obtains immunization data on children in foster care 
from an immunization registry. Both Utah and Illinois state officials 
told us that they were in the process of creating an integrated system 
that will store more complete electronic health records for children in 
foster care. For example, Illinois child welfare officials reported 
they were working with other state agencies to be able to pull data 
from Medicaid claims and other sources. 

* Massachusetts uses a combination of paper and electronic records. 
They exchange medical information with foster parents and health care 
providers on paper, which they then enter into an electronic database. 

* An official with HHS's Agency for Healthcare Research and Quality 
told us that health information exchanges in Colorado and Indiana are 
being developed with federal demonstration grants that will include 
foster children along with other patients. The HHS Inspector General 
reported in August 2007 that at least 27 states are developing at least 
partially electronic health records for Medicaid with funds from CMS. 
These efforts may extend to children in foster care but are not focused 
on them.[Footnote 55] 

Quality Assurance Activities Can Help Monitor the Receipt of Services: 

New York, Utah, Delaware, and Illinois specifically pointed to quality 
assurance activities relevant to monitoring foster children's receipt 
of health care services. Such activities can be used to help track the 
receipt of services by individual children in foster care, including 
ensuring that individual children are assessed as required and treated 
appropriately. Monitoring procedures that aggregate information across 
foster children can help managers ensure that health policies are 
consistently implemented and having the intended results. 

The four states that discussed their quality assurance activities cited 
practices that included the use of technology and electronic records to 
collect, analyze, and aggregate health care data, perform medical 
audits, and conduct evaluations or other checks to ensure the quality 
of health care services provided to children in foster care. ACF's 
reviews found that states with identifiable quality assurance systems 
that conformed to specific criteria had a higher percentage of cases 
rated as having met the health needs of children in the states' 
custody. Further, ACF's analysis suggested that states with well- 
functioning quality assurance systems were more likely to succeed on 
measures of enhancing a family's capacity to provide for the needs of 
their children and ensuring that the children's physical and mental 
health needs were being met.[Footnote 56] 

The states that identified relevant quality assurance activities to us 
provided examples of two approaches: (1) requiring managed care 
organizations to track and report individual or aggregate data on 
foster children in their care and (2) conducting medical audits of 
health records for children in foster care. 

With regard to requiring managed care organizations to track and report 
certain data, officials in Delaware described a new requirement in its 
contracts with managed care organizations aimed at ensuring that 
initial health screenings occur and result in the receipt of necessary 
services. In 2008, Delaware required that contracts with managed care 
organizations track and report on services rendered following initial 
health screenings. According to Delaware Medicaid officials, the 
reports are intended to provide aggregate data on health screenings 
provided. The officials told us that no specific concern triggered the 
2008 quality check on initial health screenings, but officials noted 
that the state would like to be able to provide aggregate data on the 
percentage of children in their foster care program who received an 
initial health assessment within a set number of days. Utah uses a 
statewide case management system that can generate detailed data on 
individual children, as well as aggregate reports. Utah officials 
explained that these aggregate reports had been used to contact medical 
providers when the state received alerts from the U.S. Food and Drug 
Administration on the adverse effects of certain drugs. In this 
instance, the state sent letters to medical providers urging them to 
examine specific patients on these medications. Utah officials believed 
that having a majority of records in electronic form facilitated this 
effort. 

Finally, one city and two states reported the use of medical audits to 
ensure the receipt and quality of health care provided to children in 
foster care. For example, New York City uses medical care audits to 
examine the quality of services provided to the 17,000 children in the 
city's foster care program.[Footnote 57] The city reported conducting 
two types of medical care audits--a routine medical audit conducted 
every 2 years and a special medical audit for children with HIV, 
conducted at least annually. These reviews apply an audit tool that is 
based on local foster care standards for physical and mental health to 
assess documentation in medical records of the child's medical history, 
consent for treatments, comprehensive physical examinations, diagnostic 
screenings, immunization history and status, developmental and 
behavioral health screenings, and the use of psychotropic medications. 
Reviewers provide their results to foster care agencies, noting 
findings that must be addressed immediately, as well as a corrective 
action plan. The audit score is incorporated into a cumulative score on 
the agency's performance. Officials in Illinois and Utah also reported 
the use of medical audits to ensure the delivery of appropriate care. 

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. ACF officials point out that they 
do not expect to provide expertise in the area of health care, but 
instead to help child welfare agencies carry out their mission within 
the flexibility that states have. 

ACF's 25 technical assistance centers--including one center that 
specializes in children's mental health--offer states a range of 
assistance, from on-site consultation to Web-based information on 
promising practices. In some cases, the centers help state child 
welfare agencies develop strategies to obtain needed services and 
coordinate their efforts with others involved in health care, such as 
the agencies responsible for Medicaid, public health, mental health, 
and substance abuse treatment.[Footnote 58] These and other agencies 
are listed among possible stakeholders in ACF's reviews of state child 
welfare agencies. ACF and center staff also referred to the assistance 
that is available from nonfederal sources, such as universities and 
private foundations.[Footnote 59] 

Technical assistance in the form of on-site consultation is provided at 
state request, and few states have requested on-site consultation 
specifically to address health care services for children. On-site 
consultation generally is requested from ACF regions, coordinated 
through the National Child Welfare Resource Center for Organizational 
Improvement, and tracked by ACF through a dedicated data system. The 
centers we contacted generally report that they have not been asked to 
provide consultants on site, but have provided other forms of 
assistance related to the health care needs of children in foster 
care.[Footnote 60] 

Table 4 provides summary information on the centers in ACF's network 
that either specialize in an aspect of health care or have reported 
providing some assistance on health care practices through 2008, 
including one center with funding from HHS's SAMHSA that focuses on 
children's mental health.[Footnote 61] Examples of some of the work 
these centers perform in relation to health care are discussed below. 

Table 4: Centers in ACF's Training and Technical Assistance Network 
That Have Provided Assistance Related to Foster Children's Health Care 
through 2008: 

Name of center: Center specializing in aspects of health care: National 
Technical Assistance Center for Children's Mental Health; Web site 
address: [hyperlink, http://gucchd.georgetown.edu/]; 
ACF funds in 2008: Center specializing in aspects of health care: $ 
350,000[A]; 
SAMHSA funds in 2008: Center specializing in aspects of health care: 
$3,050,000. 

Name of center: Centers with other responsibilities that report having 
assisted with health care practices: National Resource Center for 
Family-Centered Practice and Permanency Planning; 
Web site address: Center specializing in aspects of health care: 
[hyperlink, http://www.nrcfcppp.org]; 
ACF funds in 2008: Center specializing in aspects of health care: 
1,270,000; 
SAMHSA funds in 2008: Center specializing in aspects of health care: 
None. 

Name of center: Centers with other responsibilities that report having 
assisted with health care practices: National Child Welfare Resource 
Center for Organizational Improvement; 
Web site address: Center specializing in aspects of health care: 
[hyperlink, http://www.nrcoi.org]; 
ACF funds in 2008: Center specializing in aspects of health care: 
1,750,000; 
SAMHSA funds in 2008: Center specializing in aspects of health care: 
None. 

Name of center: Centers with other responsibilities that report having 
assisted with health care practices: National Child Welfare Resource 
Center for Youth Development; 
Web site address: Center specializing in aspects of health care: 
[hyperlink, http://www.nrcys.ou.edu/yd]; 
ACF funds in 2008: Center specializing in aspects of health care: 
1,250,000; 
SAMHSA funds in 2008: Center specializing in aspects of health care: 
None. 

Name of center: Centers with other responsibilities that report having 
assisted with health care practices: Child Welfare Information Gateway; 
Web site address: Center specializing in aspects of health care: 
[hyperlink, http://www.childwelfare.gov]; 
ACF funds in 2008: Center specializing in aspects of health care: 
7,982,000; 
SAMHSA funds in 2008: Center specializing in aspects of health care: 
None. 

Source: GAO analysis of ACF information. 

[A] $200,000 is for assistance to recipients of a discretionary grant 
to implement systems of care, only some of which are state agencies. 

[End of table] 

The center that specializes in aspects of children's health care is the 
National Technical Assistance Center for Children's Mental Health, 
based at Georgetown University, which helps states and other entities 
build systems to improve access and outcomes for all children with 
mental health concerns. The center's focus is on children who have or 
are at risk of having emotional disorders, including children in foster 
care. This focus has been extended to include youth facing mental 
health problems who have also become involved with substance abuse. The 
center's services range from the development and dissemination of 
various publications to consultation on how to increase a state's 
capacity to meet children's mental health needs.[Footnote 62] 
Specifically, at state request, center staff and consultants may work 
for a year or more with mental health leaders in individual states, 
often along with child welfare directors, to help these states identify 
and implement strategies to improve services for children. One staff 
position at the center has been reserved for a consultant with child 
welfare expertise. According to center staff, the center provides this 
type of consultation to an average of 8 to10 states each year and has 
served 22 states through 2008.[Footnote 63] To reach more agency 
personnel, the center holds a training institute every other year for 
approximately 2,000 to 2,500 attendees that in 2008 offered a series of 
sessions on partnerships between mental health and child welfare 
agencies for assessment, early intervention and treatment, support 
services, and care coordination, among other topics. In carrying out 
their work, center officials reported coordinating closely with other 
federally funded centers and organizations, state professional 
associations, private foundations, and research groups.[Footnote 64] 
While currently focused primarily on mental health, the center is also 
concerned with the integration of primary care and mental health, and 
prior to implementation of the ACF reviews, received funds from the 
Maternal and Child Health Bureau of HHS's HRSA to examine promising 
approaches to providing the full range of health care services for 
children in foster care. A series of reports were published detailing 
these approaches that continue to be available through this and other 
technical centers for use by child welfare agencies in improving their 
service delivery.[Footnote 65] 

In several other centers, staff described information that they have 
provided on health care practices, including the following examples: 

* Seven audio conferences on topics, such as the use of psychotropic 
medications, assessing and treating children up through age 3, and 
other issues concerning the mental health of children in foster care 
were developed by the National Resource Center for Family-Centered 
Practice and Permanency Planning at New York's Hunter College School of 
Social Work. Among many sample areas of technical assistance, the 
center lists health and mental health issues for children and youth in 
foster care, and to that end, hosts a Webpage devoted to health care 
with multiple links to other relevant sites. 

* Sessions regarding the role of clinics dedicated to assessing and 
treating children in foster care and the options for financing mental 
health care were featured at the 2007 annual conference for child 
welfare agency staff arranged by the National Child Welfare Resource 
Center for Organizational Improvement at the University of Maine. 

* The sharing of information on the steps states are taking to extend 
Medicaid coverage to older youth when they leave foster care is a key 
area of focus for the National Child Welfare Resource Center for Youth 
Development in Oklahoma. The center connects states that have been 
successful in this area with states asking for assistance and maintains 
a list serve for state child welfare agency officials who are 
responsible for helping youth prepare for independence. 

ACF regional and central office staff may also share promising 
practices that they observe during reviews of state programs. These 
practices are posted to an ACF Web site and include several related to 
child and family wellbeing.[Footnote 66] ACF's Web site notes that the 
Children's Bureau does not make any representations pertaining to the 
effectiveness of the posted approaches, and ACF officials stated they 
had taken no further steps to share them and that they had not 
evaluated specific state practices. Other practices have been shared 
among states at regional meetings, as in ACF Region VII, where Kansas 
shared information on its medical passport. Regional staff may also 
share information on various practices adopted by states within the 
regions. For example, ACF reported that regional staff members have 
shared strategies for meeting children's dental needs, such as using 
hygienists in Kansas and using a traveling dental van in Missouri. 
Florida officials reported that they received assistance from ACF on 
referrals to early intervention programs. New York and Utah officials 
also acknowledged the help that they received from regional ACF 
staff.[Footnote 67] 

To assist in states' efforts to implement improvement strategies, ACF 
newly funded five centers in fall 2008 that are expected to provide in- 
depth, long-term consultation and support to states to improve the 
quality and effectiveness of their child welfare services starting in 
July 2009. ACF expects the assistance to help build partnerships to 
deliver a broad array of integrated services that can be individually 
tailored to meet the diverse needs of children and families served by 
child welfare agencies, including their physical, mental, and 
developmental needs as appropriate. As with the older centers, states' 
identification of needs and potential strategies will determine the 
assistance provided. Some assistance with aspects of health care may be 
available from these centers if states request it, according to ACF 
officials. 

Agency Comments and Our Evaluation: 

We provided a draft of this report to the Department of Health and 
Human Services for comment and received a written response, which is 
included in this report as appendix II. HHS provided some additional 
information on its technical assistance to state foster care agencies, 
particularly through collaboration between ACF and SAMHSA, to assist 
states in addressing mental health and substance abuse issues among 
foster children. The agency also provided technical comments, which we 
have incorporated as appropriate. 

We are sending copies of this report to the Secretary of Health and 
Human Services, state child welfare agencies, and other interested 
parties. We will provide copies to others on request. In addition, this 
report is available at no charge on the GAO Web site at [hyperlink, 
http://www.gao.gov]. 

If you or your staff have questions about this report, please contact 
Kay E. Brown at (202) 512-3674 or brownke@gao.gov or Cynthia A. 
Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this report. GAO staff members who made key 
contributions to this report are also listed in appendix III. 

Sincerely yours, 

Signed by: 

Kay Brown: 

Director Education, Workforce and Income Security Issues: 

Cynthia A. Bascetta: 

Director Health Care Issues: 

[End of section] 

Appendix I: Selection of States and Practices for GAO Review: 

Our study had four objectives. 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. 

To gain an initial understanding of the types of practices states have 
adopted, we reviewed relevant reports and interviewed various experts 
and researchers. We reviewed information on promising practices listed 
on ACF's Web site that were identified during ACF's reviews of state 
performance and a list of state practices that ACF provided to us. We 
also interviewed several prominent child welfare experts and 
researchers, including individuals affiliated with the American Academy 
of Pediatrics, the Center for Health Care Strategies, the Chapin Hall 
Center for Children, the Georgetown University Child Development 
Center, and the National Academy for State Health Policy to obtain 
additional information on practices to improve the delivery of health 
care to children in foster care. 

To update information on practices described in available publications 
and to obtain additional examples that may not have been reported in 
publications, we e-mailed requests for information on current practices 
they believed were noteworthy efforts to address children's health care 
needs to representatives of child welfare agencies in 50 states and the 
District of Columbia. To minimize the burden on state representatives, 
we suggested that they could limit the number of practices they 
described. We sent our e-mail requests in October 2007, and 
representatives for 42 of the 51 child welfare agencies provided 
responses. 

To gather more detailed examples of these practices, we selected 10 
state child welfare agencies for further review--conducting visits to 3 
states and telephone interviews with 7. In selecting states and their 
practices for further review, we considered descriptions of each 
state's practices obtained from the states and other research. For 
practical reasons, in order to collect sufficient examples from each 
category while limiting the number of distinct states we would contact, 
we also considered whether a state had more than one practice it 
considered noteworthy and whether it encompassed practices in at least 
two of our five broad categories. We also gave some weight to the level 
of context and information the state had provided about its practices 
and generally limited our consideration of practices to those that 
states indicated they had begun to implement. In addition, we made 
efforts to include states that had achieved a strong rating on the ACF 
reviews for children's physical and mental health indicators and to 
achieve some distribution in geographic location and administrative 
structure. 

For 3 of the 10 states selected--Illinois, New York, and Utah--we 
conducted site visits and interviewed officials of state child welfare 
agencies and state Medicaid Offices, and when possible, health care 
providers, interest groups, and foster care parents. For seven states-
-California, Delaware, Florida, Massachusetts, Oklahoma, Texas, and 
Washington--we conducted interviews by telephone with officials of each 
state's child welfare agency and, in some instances, officials of state 
Medicaid Offices. 

Key characteristics of the selected states are shown in table 5. 
Collectively, the states we contacted account for 53 percent of federal 
IV-E funds distributed in fiscal year 2007. 

Table 5: Characteristics of States Contacted for GAO's Review: 

States GAO selected: Sites visited: Ill; 
Foster care caseload Sept. 30, 2007: 16,000; 
Federal foster care funds 2007 (IV-E): $199,758,813; 
State match required for IV E and XIX: 50.00; 
Federal child welfare services funds 2007 (IV-B1): $11,343,733; 
Type of child welfare administration: State; 
Medicaid included in same State agency as child welfare: No; 
Public, maternal & child health in same agency as child welfare: No; 
Strength in physical health Per ACF review: No; 
Strength in mental health per ACF review: No. 

States GAO selected: Sites visited: NY; 
Foster care caseload Sept. 30, 2007: 30,548; 
Federal foster care funds 2007 (IV-E): 370,648,137; 
State match required for IV E and XIX: 50.00; 
Federal child welfare services funds 2007 (IV-B1): 14,424,182; 
Type of child welfare administration: County; 
Medicaid included in same State agency as child welfare: No; 
Public, maternal & child health in same agency as child welfare: No; 
Strength in physical health Per ACF review: Yes; 
Strength in mental health per ACF review: No. 

States GAO selected: Sites visited: Utah; 
Foster care caseload Sept. 30, 2007: 2,600; 
Federal foster care funds 2007 (IV-E): 19,232,449; 
State match required for IV E and XIX: 29.86; 
Federal child welfare services funds 2007 (IV- B1): 3,368,524; 
Type of child welfare administration: State; 
Medicaid included in same State agency as child welfare: No; 
Public, maternal & child health in same agency as child welfare: No; 
Strength in physical health Per ACF review: Yes; 
Strength in mental health per ACF review: Yes. 

States GAO selected: Sites contacted by teleconference: Calif; 
Foster care caseload Sept. 30, 2007: 78,282; 
Federal foster care funds 2007 (IV-E): 1,302,357,112; 
State match required for IV E and XIX: 50.00; 
Federal child welfare services funds 2007 (IV-B1): 33,565,519; 
Type of child welfare administration: County; 
Medicaid included in same State agency as child welfare: Yes; 
Public, maternal & child health in same agency as child welfare: Yes; 
Strength in physical health Per ACF review: Yes; 
Strength in mental health per ACF review: No. 

States GAO selected: Sites contacted by teleconference: Del; 
Foster care caseload Sept. 30, 2007: 970; 
Federal foster care funds 2007 (IV-E): $5,737,528; 
State match required for IV E and XIX: 50.00; 
Federal child welfare services funds 2007 (IV- B1): 783,771; 
Type of child welfare administration: State; 
Medicaid included in same State agency as child welfare: No; 
Public, maternal & child health in same agency as child welfare: Yes; 
Strength in physical health Per ACF review: Yes; 
Strength in mental health per ACF review: Yes. 

States GAO selected: Sites contacted by teleconference: Fla; 
Foster care caseload Sept. 30, 2007: 26,124; 
Federal foster care funds 2007 (IV-E): 152,407,545; 
State match required for IV E and XIX: 41.24; 
Federal child welfare services funds 2007 (IV-B1): 15,930,592; 
Type of child welfare administration: County; 
Medicaid included in same State agency as child welfare: No; 
Public, maternal & child health in same agency as child welfare: No; 
Strength in physical health Per ACF review: No; 
Strength in mental health per ACF review: No. 

States GAO selected: Sites contacted by teleconference: Mass; 
Foster care caseload Sept. 30, 2007: 10,000; 
Federal foster care funds 2007 (IV-E): 64,838,028; 
State match required for IV E and XIX: 50.00; 
Federal child welfare services funds 2007 (IV-B1): 4,094,353; 
Type of child welfare administration: State; 
Medicaid included in same State agency as child welfare: Yes; 
Public, maternal & child health in same agency as child welfare: No; 
Strength in physical health Per ACF review: No; 
Strength in mental health per ACF review: No. 

States GAO selected: Sites contacted by teleconference: Okla; 
Foster care caseload Sept. 30, 2007: 12,200; 
Federal foster care funds 2007 (IV-E): 42,892,775; 
State match required for IV E and XIX: 31.26; 
Federal child welfare services funds 2007 (IV-B1): 1,891,061; 
Type of child welfare administration: State; 
Medicaid included in same State agency as child welfare: No; 
Public, maternal & child health in same agency as child welfare: No; 
Strength in physical health Per ACF review: No; 
Strength in mental health per ACF review: No. 

States GAO selected: Sites contacted by teleconference: Tex; 
Foster care caseload Sept. 30, 2007: 18,000; 
Federal foster care funds 2007 (IV-E): 216,799,611; 
State match required for IV E and XIX: 39.22; 
Federal child welfare services funds 2007 (IV-B1): 25,115,256; 
Type of child welfare administration: State; 
Medicaid included in same State agency as child welfare: Yes; 
Public, maternal & child health in same agency as child welfare: Yes; 
Strength in physical health Per ACF review: No; 
Strength in mental health per ACF review: No. 

States GAO selected: Sites contacted by teleconference: Wash; 
Foster care caseload Sept. 30, 2007: 11,015; 
Federal foster care funds 2007 (IV-E): 84,681,985; 
State match required for IV E and XIX: 49.88; 
Federal child welfare services funds 2007 (IV-B1): 5,313,865; 
Type of child welfare administration: State; 
Medicaid included in same State agency as child welfare: Yes; 
Public, maternal & child health in same agency as child welfare: Yes; 
Strength in physical health Per ACF review: No; 
Strength in mental health per ACF review: No. 

States GAO selected: Total; 
Federal foster care funds 2007 (IV-E): $4,669,165,598. 

Source: GAO analysis of federal and state child welfare data. 

[End of table] 

For our visits and telephone interviews, we developed semistructured 
interview guides for state and local child welfare agencies, including 
caseworkers, state Medicaid offices, interest groups, and foster 
parents. In addition, we obtained from officials of state child welfare 
agencies detailed information on their identified practices, including 
the dates of operation; numbers of children served; size of 
jurisdiction covered; variety of services offered; funding mechanisms 
used; outcomes, if any, reported; and whether any evaluative studies 
had been conducted or other documents prepared that discussed the 
effectiveness of the practice. 

We conducted our work from November 2007 to January 2009 in accordance 
with all sections of GAO's Quality Assurance Framework that are 
relevant to our objectives. The framework requires that we plan and 
perform the engagement to obtain sufficient and appropriate evidence to 
meet our stated objectives and to discuss any limitations in our work. 
We believe that the information and data obtained, and the analysis 
conducted, provide a reasonable basis for any findings and conclusions. 

[End of section] 

Appendix I: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 

Assistant Secretary for: 
Washington, DC 20201: 

Kay E. Brown, Director: 
Education, Workforce, and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street NW: 
Washington, DC 20548: 

Dear Ms. Brown:

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled: "Foster Care: 
State Practices for Assessing Health Needs, Facilitating Service 
Delivery, and Monitoring Children's Care (GAO-09-26). The Department 
appreciates the opportunity to review and comment on this report before 
its publication.

Sincerely,

Signed by: 

Craig Burton: 
Acting Assistant Secretary for Legislation: 

Attachment: 

Department Of Health & Human Services: 
Administration For Children And Families: 
Office of the Assistant Secretary, Suite 600: 
370 L'Enfant Promenade, S.W.: 
Washington, DC— 20447: 

January 9, 2009: 

To: Vincent J. Ventimiglia, Jr.: 
Assistant Secretary for Legislation: 

From: Daniel C. Schneider: 
Acting Assistant Secretary for Children and Families: 

Subject: Government Accountability Office (GAO) Draft Report Titled, 
"Foster Care: State Practices for Assessing Health Needs, Facilitating 
Service Delivery, and Monitoring Children's Care" (GAO-09-26) 

Attached are comments of the Administration for Children and Families 
and the Substance Abuse and Mental Health Services Administration on 
the above-referenced report. 

Should you have questions or need additional information, please 
contact Christine Calpin, Associate Commissioner, Children's Bureau, 
Administration on Children, Youth and Families, at 202-205-8618. 

Attachment: 

Comments Of The Administration For Children And Families And The 
Substance Abuse And Mental Health Services Administration On The 
Government Accountability Office Draft Report Titled, "Foster Care: 
State Practices For Assessing Health Needs, Facilitating Service 
Delivery, And Monitoring Children's Care" (GAO-09-26): 

The Administration for Children and Families (ACF) and the Substance 
Abuse and Mental Health Services Administration (SAMHSA) appreciate the 
opportunity to comment on the Government Accountability Office (GAO) 
draft report. 

GAO Recommendations: 

GAO did not make any recommendations in this report. 

In describing the National Technical Assistance Center for Children's 
Mental Health (Georgetown), GAO did not mention that part of the 
funding for this center (i.e., $150,000) comes from an Interagency 
Agreement with ACF. The report states, "One staff position at the 
center has been reserved for a consultant with child welfare 
expertise." This is accomplished through the Interagency Agreement 
between SAMHSA and ACF. This should be stated. 

There is no mention that the SAMHSA-funded Technical Assistance 
Partnership also has a staff position for a child welfare consultant 
that provides assistance to SAMHSA-funded system of care communities 
that are part of the Comprehensive Community Mental Health for Children 
and Their Families Program. This staff position is similarly funded 
through an Interagency Agreement with ACF in the amount of $200,000, 
which makes the total Interagency Agreement $350,000. This position and 
the relationship established with ACF has allowed SAMHSA to prioritize 
services and consultation related to child welfare issues. 

As a result of the collaboration between SAMHSA and ACF, and the 
significant mental health needs of foster children, SAMHSA has made the 
child welfare population a priority in the Request for Application 
(RFA) used to solicit proposals for the Comprehensive Community Mental 
Health for Children and Their Families Program. Specifically, page 2 of 
the RFA states that applicants are encouraged to address children and 
youth involved with the child welfare system. Creating priority status 
for children and youth in the child welfare system has resulted in a 
number of grantees that specifically focus on foster children, which 
has helped create collaborations and partnerships between mental health 
and child welfare systems in States and communities across the nation. 
Of the 59 currently funded system of care grantees, 7 have a primary 
focus on foster children. 

While SAMHSA manages this Center, ACF is a significant fund provider of 
the Center's activities. Similar to the other technical assistance 
centers funded by ACF, NCSACW does not provide direct medical services, 
but provides assistance to agencies supporting positive child welfare 
outcomes. 

NCSACW completed a review of the Round 1 Child and Family Services 
Reviews (CFSRs) and Program Improvement Plans, managed by ACF, and 
found that 13 of the States specifically mentioned that services were 
inadequate to meet the substance abuse treatment needs of adolescents 
in their caseloads. Although not specifically mentioned in reports-from 
other States, this is likely to be a much more widely experienced 
problem. 

[End of section] 

Appendix II: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Kay E. Brown, (202) 512-3674 or brownke@gao.gov Cynthia A. Bascetta, 
(202) 512-7114 or bascettac@gao.gov: 

Staff Acknowledgments: 

In addition to the contacts named above, Betty Ward-Zukerman and 
Carolyn L. Yocom (Assistant Directors), Patricia Elston, Carolyn Feis 
Korman, Jacqueline Harpp, Darryl Joyce, Jasleen Modi, Alexandra 
Edwards, Alison Goetsch, Kevin Milne, Mimi Nguyen, James Rebbe, Jay 
Smale, and Charlie Willson made key contributions to this report. 

[End of section] 

Related GAO Products: 

Medicare Physician Payment: Care Coordination Programs Used in 
Demonstration Show Progress, but Wider Use of Payment Approach May Be 
Limited. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-65]. 
Washington, D.C.: February 15, 2008. 

Department of Health and Human Services, Centers for Medicare and 
Medicaid Services: Medicaid Program; Elimination of Reimbursement Under 
Medicaid for School Administration Expenditures and Costs Related to 
Transportation of School-Age Children Between Home and School. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-394R]. Washington, 
D.C.: January 11, 2008. 

Child Welfare: Additional Federal Action Could Help States Address 
Challenges in Providing Services to Children and Families. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-850T]. Washington, D.C.: May 
15, 2007. 

Medicaid: Concerns Remain about Sufficiency of Data for Oversight of 
Children's Dental Services. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-826T]. Washington, D.C.: May 2, 2007. 

Pediatric Drug Research: Studies Conducted Under Best Pharmaceuticals 
for Children Act. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-
557]. Washington, D.C.: March 22, 2007. 

Children's Health Insurance: States' SCHIP Enrollment and Spending and 
Considerations for Reauthorization. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-558T]. Washington, D.C.: March 1, 2007. 

Child Welfare: Improving Social Service Program, Training, and 
Technical Assistance Information Would Help Address Long-standing 
Service-Level and Workforce Challenges. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-07-75]. Washington, D.C.: October 
6, 2006. 

Foster Care and Adoption Assistance: Federal Oversight Needed to 
Safeguard Funds and Ensure Consistent Support for States' 
Administrative Costs. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
06-649]. Washington, D.C.: June 15, 2006. 

Administrative Expenditures and Federal Matching Rates of Selected 
Support Programs. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-
839R]. Washington, D.C.: June 30, 2005. 

Medicaid Financing: States' Use of Contingency-Fee Consultants to 
Maximize Federal Reimbursements Highlights Need for Improved Federal 
Oversight. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-748]. 
Washington, D.C.: June 28, 2005. 

Medicaid: States' Efforts to Maximize Federal Reimbursements Highlight 
Need for Improved Federal Oversight. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-05-836T]. Washington, D.C.: June 28, 2005. 

Child And Family Services Reviews: States and HHS Face Challenges in 
Assessing and Improving State Performance. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-04-781T]. Washington, D.C.: May 
13, 2004. 

Child And Family Services Reviews: Better Use of Data and Improved 
Guidance Could Enhance HHS's Oversight of State Performance. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-333]. Washington, 
D.C.: April 20, 2004. 

Medicaid and SCHIP: States' Premium and Cost Sharing Requirements for 
Beneficiaries. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
491]. Washington, D.C.: March 30, 2004. 

SCHIP: HHS Continues to Approve Waivers That Are Inconsistent with 
Program Goals. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
166R]. Washington, D.C.: January 5, 2004. 

Child Welfare: States Face Challenges in Developing Information Systems 
and Reporting Reliable Child Welfare Data. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-04-267T]. Washington, D.C.: 
November 19, 2003. 

Child Welfare: Most States Are Developing Statewide Information 
Systems, but the Reliability of Child Welfare Data Could Be Improved. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-809]. Washington, 
D.C.: July 31, 2003. 

Child Welfare and Juvenile Justice: Federal Agencies Could Play a 
Stronger Role in Helping States Reduce the Number of Children Placed 
Solely to Obtain Mental Health Services. [hyperlink, 
http://www.gao.gov/cgi-bin/getrpt?GAO-03-397]. Washington, D.C.: April 
21, 2003. 

Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's 
Access to Care. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-
222]. Washington, D.C.: January 14, 2003. 

Mental Health Services: Effectiveness of Insurance Coverage and Federal 
Programs for Children Who Have Experienced Trauma Largely Unknown. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-02-813]. Washington, 
D.C.: August 22, 2002. 

Medicaid and SCHIP: States' Enrollment and Payment Policies Can Affect 
Children's Access to Care. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-01-883]. Washington, D.C.: September 10, 2001. 

Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health 
Screening Services. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
01-749]. Washington, D.C.: July 13, 2001. 

Foster Care: Health Needs of Many Young Children Are Unknown And Unmet. 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-95-114]. 
Washington, D.C.: May 26, 1995. 

[End of section] 

Footnotes:  

[1] Medicaid is a federal-state health financing program established in 
1965 to provide health care coverage to certain categories of low- 
income adults and children. 

[2] For example, federal law requires that states have standards to 
ensure children in foster care are provided quality services to protect 
their safety and health. In addition, states must maintain case plans 
for children that include health records, including the most recent 
information available regarding their immunizations, known medical 
problems, medications, and their health providers' names and addresses. 

[3] Pub. L. No. 110-351 (2008). 

[4] Throughout the report, we use the term "health" to refer to both 
physical and mental health. Physical health includes dental health. 
Other health areas included are those dealing with children's 
development and with substance abuse. 

[5] As part of our process to select states, we asked all state child 
welfare agencies to identify some practices that they had adopted and 
considered noteworthy to screen and assess needs, facilitate and 
coordinate access to care, or manage data and information. We received 
42 responses. While most of the 10 states reported having multiple 
practices, we did not cover all of these practices adopted by each 
state. 

[6] While states have primary responsibility for the welfare of 
children in their care, this responsibility has been delegated to 
county agencies in about one-fifth of the states, including many of the 
nation's most populous states such as California, Florida, and New 
York. 

[7] Data for federal fiscal year 2006 were the most recent available. 
The proportion of children who meet federal eligibility criteria has 
decreased over the past decade since the income criteria are set at the 
1996 income levels under the former Aid to Families with Dependent 
Children program. See GAO, Foster Care and Adoption Assistance: Federal 
Oversight Needed to Safeguard Funds and Ensure Consistent Support for 
States' Administrative Costs, [hyperlink, 
http://www.gao.gov/products/GAO-06-649] (Washington, D.C.: June 15, 
2006). 

[8] Included are IV-E funds available to states to reimburse up to 50 
percent of their IV-E administrative costs for child placement, 
information systems, and other purposes and up to 75 percent of their 
IV-E training costs. (45 C.F.R. § 1356.60(b) and (c)) 

[9] States may also use other federal funds, such as the title XX 
Social Services Block Grant or Temporary Assistance to Needy Families, 
to provide some child welfare services. 

[10] Title IV-B includes two different programs: subpart 1 for general 
child welfare services and subpart 2 for family preservation, family 
support, time-limited family reunification, and adoption promotion and 
support services. Some of the funds available under subpart 2 may be 
used for health care services, such as counseling, mental health, and 
substance abuse treatment for foster children or their families, during 
the 15 months following the children's entry into foster care in order 
to facilitate the timely, safe reunification of these foster children 
with their families. 

[11] Child and Family Services Improvement Act of 2006, Pub. L. No. 
109- 288 (2006). 

[12] Fostering Connections to Success and Increasing Adoptions Act of 
2008, Pub. L. No. 110-351 (2008). ACF alerted states to this new 
requirement but did not issue further instructions in 2008. 

[13] ACF's reviews examined a sample of the case records of children 
served by state agencies; children in foster care, the focus of GAO's 
work, were a subset of this sample. 

[14] In the initial round of CFSRs, ACF designated a state as showing 
strength when 85 percent of the up to 65 case records examined in that 
state indicated that the state had assessed needs and provided 
treatment as appropriate. Depending on the state, the results varied 
widely, with the percentage of sampled children who were not assessed 
or treated ranging from 8 percent to 49 percent. In the next round of 
reviews, occurring from 2007 through 2010, states will have to assess 
and treat 90 percent of cases examined in order to show strengths and 
95 percent of cases in order to be deemed in substantial conformity. 

[15] In November 2008, ACF reported that 39 states had achieved their 
planned goals and action steps, including those for children's health; 
that 7 states had missed their planned goals and action steps and were 
subject to withholding of federal grant funds; and that the actions of 
6 states were still being evaluated. ACF withheld grant funds from one 
state that did not complete the action steps for improving children's 
health. See 45 C.F.R. § 1355.36 for regulations governing the 
withholding of grant funds. 

[16] In addition to Medicaid, federal funds are available to states for 
health-related services for a population that may include children in 
foster care under title V of the Social Security Act for maternal and 
child health, under title XIX of the Public Health Service Act for 
community mental health centers, and under the Individuals with 
Disabilities Education Act. 

[17] See 42 U.S.C. § 1396a(a)(10)(A)(i)(I). 

[18] The Urban Institute reports that all states have extended Medicaid 
coverage to children in foster care. See Rob Geen, Anna Sommers, and 
Mindy Cohen, The Urban Institute, Medicaid Spending on Foster Children 
(Washington, D.C., 2005). However, some children are excluded, such as 
noncitizens, those with private health insurance, and children who 
leave foster care while they are on trial visits to their homes. 

[19] This represents federal and state dollars combined for the most 
recent year available. Expenditures for children in foster care are 
likely to be underestimated and may exclude expenditures for some 
children participating in foster care. 

[20] Fee-for-service arrangements may also include primary care case 
management, where primary care providers are paid a monthly, per capita 
case management fee, usually around $3, to coordinate care for 
beneficiaries, in addition to fee-for-service reimbursement for any 
health care services they provide. Coordination may involve referrals 
to specialists and other providers. 

[21] See 42 U.S.C. §§ 1396a(a)(43), 1396d(a)(4)(B). 

[22] See 42 C.F.R. § 441.50 et seq. 

[23] For example, The Urban Institute reported that 38 states funded 
targeted case management under Medicaid for children in foster care. 
See Rob Geen, Anna Sommers, and Mindy Cohen, The Urban Institute, 
Medicaid Spending on Foster Children, (Washington, D.C., 2005). 

[24] See 42 U.S.C. §§ 1396(a)(25), 1396n(g)(4). 

[25] We reported that most states have used contingency-fee consultants 
to help implement a wide range of projects, including rehabilitative 
and targeted case management services, to maximize federal Medicaid 
reimbursements. In particular, we found that during fiscal years 1999 
through 2003, combined state and federal spending for one category of 
Medicaid services--targeted case management--increased by 76 percent, 
from $1.7 billion to $3 billion, across all states. See GAO, Medicaid 
Financing: States' Use of Contingency-Fee Consultants to Maximize 
Federal Reimbursements Highlight Need for Improved Federal Oversight, 
[hyperlink, http://www.gao.gov/products/GAO-05-748] (Washington, D.C.: 
June 28, 2005). 

[26] The Deficit Reduction Act of 2005 amended the Social Security Act 
provisions concerning Medicaid coverage for case management and 
targeted case management services effective January 1, 2006. See Pub. 
L. No. 109-171, §6052, 120 Stat. 4, 93-95. 

[27] See Medicaid Program; Optional State Plan Case Managed Services 
(72 Fed. Reg. 68077, December 4, 2007); and Medicaid Program; Coverage 
for Rehabilitative Services (72 Fed. Reg. 45201, August 13, 2007). 

[28] Supplemental Appropriations Act, 2008, Pub. L. No. 110-252, 
§7001(a), 122 Stat. 2323, 2387-88. 

[29] Organizations such as the American Academy of Pediatrics, the 
American Academy of Child and Adolescent Psychiatry, and the Child 
Welfare League of America recommend assessments for children shortly 
after children enter foster care. However, to avoid undue burden on 
children and providers, both Delaware and New York consider that 
assessments made prior to entry into foster care may suffice. 

[30] Laurel K. Leslie, Michael S. Hurlburt, John Landsverk et al., 
"Comprehensive Assessments for Children Entering Foster Care: A 
National Perspective," Pediatrics, 112 (1) (2003), pp. 134-142. 
(Accessible via [hyperlink, 
http://www.pediatrics.org/cgi/content/full/112/1/134].) Also see N. 
Halfon, A. Zepeda, and M. Inkelas (2002), Mental Health Services for 
Children in Foster Care (Policy Brief Number 4). Los Angeles: UCLA 
Center for Healthier Children, Families and Communities. 

[31] A.C. Stahmer, L.K. Leslie, J. A. Landsverk et al., "Developmental 
Services for Young Children in Foster Care: Assessment and Service 
Delivery," Journal of Social Service Research, 33 (2) (2006), pp. 27- 
38. 

[32] Florida requires the initial screening within 72 hours; New York 
recommends but does not require that its counties and agencies provide 
an initial screening. 

[33] California has no policy on initial screenings, but some of its 
counties conduct examinations that are similar. Texas's contract with 
its health providers requires that children newborn to age 3 receive an 
exam within 14 days of enrollment in the health plan and that older 
children receive an exam within 21 days. A dental exam must be provided 
within 60 days for children age 1 or older. Providers may be penalized 
financially if they do not meet these timelines for certain percentages 
of children. Washington's assessment process must be completed within 
30 days of entry into foster care for children who are expected to 
remain in out-of-home placement longer than 30 days. 

[34] Such a policy may involve separate child welfare and Medicaid 
requirements. For example, Massachusetts officials indicated that the 
state child welfare agency has a policy specifying that foster parents 
schedule and support subsequent health care screenings of the foster 
children in their care. The Massachusetts Medicaid agency requires that 
Medicaid providers perform ongoing screenings which follow the 
standards set by the state Medicaid agency for EPSDT screens. 

[35] See Administration for Children and Families, Office of Planning, 
Research, and Evaluation, National Survey of Child and Adolescent Well-
Being Research Brief No. 7: Special Health Care Needs among Children in 
Child Welfare, Research Brief, Findings from the NSCAW Study (2008).

[36] See Jan McCarthy and others, National Technical Assistance Center 
for Children's Mental Health and Technical Assistance Partnership for 
Child, and Family Mental Health, Child and Family Services Reviews 2001-
2004--A Mental Health Analysis (Washington, D.C., August 2007), p. 14. 

[37] See P. K. Jaudes, L. A. Bilaver, R. M. George and others, 
"Improving Access to Health Care for Foster Children: The Illinois 
Model," Child Welfare, 83 (3) (2004), 215-238; and S. M. Horowitz, P. 
Owens, and M. D. Simms, "Specialized Assessments for Children in Foster 
Care," Pediatrics, 106 (2000), 59-66 (available at [hyperlink, 
http://www.pediatrics.org/cgi/content/full/106/1/59], accessed on 
November 18, 2008). 

[38] P.K. Jaudes and others "Improving Access to Health Care for Foster 
Children: The Illinois Model," Child Welfare, 83 (3) (2004), 215-238. 

[39] See L. K. Leslie and others "Comprehensive Assessments for 
Children Entering Foster Care: A National Perspective", Pediatrics, 112 
(1)(2003), pp. 134-142. (Accessible via [hyperlink, 
http://www.pediatrics.org/cgi/content/full/112/1/134].), or S. M. 
Horowitz, P. Owens, and M.D. Simms, "Specialized Assessments for 
Children in Foster Care," Pediatrics, 106 (2000), 59-66 (available at 
[hyperlink, http://www.pediatrics.org/cgi/content/full/106/1/59], 
accessed on November 18, 2008). 

[40] State officials reported that in 2008, the agency funded 45 full- 
time equivalent social worker positions to assess children, with at 
least one social worker in each of the state's 44 child welfare 
offices. Each social worker was responsible for assessing approximately 
12 to 14 children each month and entering the results into the state's 
child welfare case management system. 

[41] For all children covered by Medicaid, not just those in foster 
care, state officials told us that Illinois also has a performance 
payment of $30 per child per year if a required number of visits is 
met, as well as an expedited payment process that returns payment 
within 30 days. Additionally, the state was implementing a pay-for- 
performance bonus for serving a certain number of children. 

[42] Telepsychiatry is a form of video conferencing that can facilitate 
provision of psychiatric services to patients living in remote 
locations or otherwise underserved areas. 

[43] Rebecca Colman and others, The New York State Care Coordination 
Pilot Project: Process and Impact Evaluation Study Findings, a report 
for the New York State Office of Children and Family Services, March 
2007. 

[44] State officials told us the 2008 budget for the nursing program is 
approximately $3.1 million. The majority of costs are personnel costs, 
with about 46 percent paid for by federal Medicaid funds, 18 percent by 
state health department funds, and 36 percent by state child welfare 
department funds. These funds are used to provide services for up to 
2,600 children enrolled in foster care on any given day. 

[45] The two medical care management agencies in Cook County that do 
not use the reminder-recall system are local health departments. 

[46] Colman et. al., The New York State Care Coordination Pilot 
Project: Process and Impact Evaluation Study Findings, a report for the 
New York State Office of Children and Family Services, March 2007. 

[47] Psychotropic medications may have more than one purpose and may be 
used to treat other medical conditions. For example, the same drug may 
be used to control seizures for someone with epilepsy and to reduce 
mood swings in someone with bipolar disorder. 

[48] Diane L. Green, Wesley Hawkins, and Michelle Hawkins, "Medication 
of Children and Youth in Foster Care," Disability Issues for Social 
Workers and Human Services Professionals in the Twenty-First Century, 
(New York: Haworth Press, 2005). Also see GAO, Pediatric Drug Research: 
Studies Conducted under Best Pharmaceuticals for Children Act, 
[hyperlink, http://www.gao.gov/products/GAO-07-557] (Washington, D.C.: 
Mar. 22, 2007). 

[49] Julie M. Zito and others, "Psychotropic Medication Patterns Among 
Youth in Foster Care," Pediatrics, vol. 121, no. 1 (2008): e157-e163. 

[50] The types of circumstances cited include the absence of a clinical 
diagnosis, the concurrent use of five or more psychotropic medications, 
multiple medications being used before trying just one, exceeding the 
usually recommended dose, and prescribing psychotropic medications for 
children less than 4 years of age. 

[51] See [hyperlink, 
http://www.hhsc.state.tx.us/medicaid/occ/Psychoactive_Medications.html] 
(accessed on Sept. 2, 2008). 

[52] The passport covers children in foster care placements, children 
placed with relatives by the state, children formerly in the foster 
care program who have returned home but remain in the state's custody, 
and children who voluntarily entered into the state's care. 

[53] See the following Web site for further information: [hyperlink, 
https://www.fostercaretx.com/portal/public/fc/fostercare/health_passport
/health_passport_online_training_tools.com]. 

[54] The Congressional Budget Office recently noted that electronic 
health records in general might help with the sharing of health 
information, which in turn might improve the quality of care. See 
Congressional Budget Office, Evidence on the Costs and Benefits of 
Health Information Technology (May 2008). 

[55] Department of Health and Human Services, Office of Inspector 
General, State Medicaid Agencies' Initiatives on Health Information 
Technology and Health Information Exchange, OEI-02-06-00270 
(Washington, D.C., August 2007). 

[56] See the Department of Health and Human Services, Administration 
for Children and Families Web site, Summary of the Results of the 2001-
2004 Child and Family Services Reviews, General Findings from The 
Federal Child and Family Services Review, p. 17 of 39. This is 
available at [hyperlink, 
http://www.acf.hhs.gov/programs/cb/cwmonitoring/results/index.htm] 
(accessed on Aug. 28, 2008). 

[57] According to New York officials, as of February 2008, New York 
City's foster care population represented more than 80 percent of all 
children in the foster care system in the state. 

[58] In commenting on a draft of this report, HHS officials noted that 
ACF uses an interagency agreement with the Substance Abuse and Mental 
Health Services Administration to contribute to an additional technical 
assistance center called the "National Center on Substance Abuse and 
Child Welfare." While GAO's research identified this additional center, 
the mission of the center focused on substance use in intact families 
and did not specifically address foster children; therefore, this 
center was not included in the scope of the GAO study. 

[59] Several of the centers include links to the websites of these 
other organizations. For example, the National Resource Center for 
Family- Centered Practice and Permanency Planning Center provides a 
link to The Commonwealth Fund for information on developmental 
screening. 

[60] The centers submit regular reports to ACF on their activities, but 
they do not have to identify the particular assistance provided 
individual states. On-site consultation to individual states, however, 
must be reported by eight centers through the Technical Assistance 
Tracking Internet System. As GAO has previously reported, ACF has not 
independently evaluated the centers' effectiveness. 

[61] The National Center on Substance Abuse and Child Welfare, operated 
by the Center for Children and Family Futures, is charged with 
assisting states and others to improve outcomes for families with 
substance use disorders who are involved in the child welfare and 
family court systems. 

[62] An example of the center's recent publications is: Child and 
Family Services Reviews 2001-2004 - A Mental Health Analysis, 2007, 
which reports on mental health service delivery challenges and 
management trends noted in ACF reviews and state improvement plans. 

[63] The 22 states are Alaska, Arizona, Arkansas, Florida, Georgia, 
Illinois, Indiana, Kentucky, Maryland, Minnesota, Mississippi, 
Missouri, Nebraska, Nevada, New Hampshire, New Mexico, Oklahoma, 
Pennsylvania, South Carolina, Tennessee, Utah, and Vermont. 

[64] The center has worked closely with the Technical Assistance 
Partnership for Child and Family Mental Health operated by the American 
Institutes for Research with SAMHSA funding, the National Association 
of State Mental Health Program Directors, The Annie E. Casey 
Foundation, and the University of South Florida. 

[65] See Meeting the Health Care Needs of Children in the Foster Care 
System, 2002, an HRSA-sponsored publication that reported on a 3-year 
study of promising approaches to meeting the physical, mental, 
emotional, developmental, and dental health needs of foster children. 

[66] See [hyperlink, 
http://www.acf.hhs.gov/programs/cb/cwmonitoring/promise/index.htm] 
(accessed on Nov. 21, 2008). 

[67] For more information on ACF's technical assistance and states' 
reactions, see GAO, Child and Family Services Reviews: Better Use of 
Data Could Enhance HHS's Oversight of State Performance, [hyperlink, 
http://www.gao.gov/products/GAO-04-333] (Washington, D.C.: Apr. 20, 
2004). 

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