Mr. Chairman, thank you very much for the opportunity to address the committee today about our role in caring for the children in Washington, DC’s foster care system. I am Jacqueline D. Bowens, Vice President of Government and Public Affairs at Children’s Hospital. Joining me today is Dr. Joseph Wright, who is the Medical Director of Advocacy and Community Affairs, as well as the Medical Director of the DC KIDS program.
Background on Children’s Hospital
Children’s Hospital is a 279-bed pediatric inpatient facility located in the District of Columbia. For over 130 years, we have served as the only provider dedicated exclusively to the care of infants, children, and adolescents in this region. It is our mission to be preeminent in providing health care services that enhance the well-being of children regionally, nationally, and internationally.
The Children’s system includes a network of five primary care health centers located throughout the city, and a number of pediatrician practices throughout the region, providing stable medical homes for thousands of children. We also operate numerous regional outpatient specialty centers in Maryland and Virginia, providing access to high quality specialty care right in the communities that we serve. We are proud to be the region’s only Level I pediatric trauma center.
Children’s Hospital serves as the Department of Pediatrics for George Washington University medical school, and runs a highly-respected pediatric residency program, providing education and experience to the next generation of pediatricians, pediatric specialists, and pediatric researchers. We also conduct significant research within Children’s Research Institute, with funds from the National Institutes of Health, the Health Resources Services Administration, the Department of Defense, and countless private funders. Our researchers have received national recognition for recent breakthroughs including identification of the gene associated with matasticizing brain tumors, and discoveries related to muscle development for muscular dystrophy patients.
Recently Children’s Hospital was named as one of the nation’s “Top Ten” pediatric institutions in the country by Child Magazine, based on stringent quality and outcomes measures. Our Hemotology/Oncology program was ranked fourth in the nation. We are the only such facility in the region to receive this honor.
Locally, we also work in collaboration with the District of Columbia Department of Health to operate the District’s School Health program, employing all the school nurses in the public schools, including 21 charter schools. And we are very proud of our affiliation with the District’s Child and Family Services Agency (CFSA), in which we work in conjunction to operate the medical program for children in foster care called DC KIDS. Background on the DC KIDS program
The District of Columbia Kids Integrated Delivery System (DC KIDS), is a collaborative effort between CFSA and Children’s Hospital to provide comprehensive health care services to the children in foster care in the District of Columbia.
The DC KIDS program was first established by CFSA as a medical management model. The initial contract went to the former Public Benefits Corporation and DC General Hospital. Prior to the closure of DC General Hospital and the PBC in early 2001, CFSA approached Children’s to absorb the program on an emergency basis “as is,” with the intent of eventually establishing a more formal long-term relationship—which we did. Children’s assumed the DC KIDS program on May 1, 2001 after a rapid transition. Our current agreement runs through December 31, 2003.
The arrangement allows for this vulnerable population of children to be evaluated and treated in a child friendly, pediatric-specific environment. It provides each child with a continuous and coordinated system of services. DC KIDS supports, informs and navigates the complex systems of care for foster parents and their foster children. There is no paperwork to complete, and no cost to the foster parent or child. All children under 21 years of age and under the care of CFSA, living with a foster family or in a group home, are eligible for enrollment in the program.
The agreement between CFSA and Children’s Hospital provides coordination of ongoing health care services for children in foster care. First, a child is brought to the Children’s DC KIDS assessment center for an initial assessment, before their first foster family placement. This initial screening is done by dedicated staff who complete a medical protocol on each child before certifying that they are healthy enough for placement into a foster home. In addition, each time that a child’s placement is disrupted, they return to the Children’s for a new assessment before being sent to their new placement.
The child is enrolled in DC KIDS at the time of the initial assessment. Within 10 days, the DC KIDS program will arrange for a comprehensive and thorough physical examination and a behavioral/mental health evaluation. Once completed, necessary services for the child and family are identifed, such as:
• early and periodic screening • diagnosis and treatment of illnesses • dental services • immunizations • eye care • hearing services • mental health services • substance abuse services • developmental services • in-home services • inpatient and specialty care • prescription services
From that point forward, DC KIDS assists the foster families in navigating the complex health care system to provide for ongoing treatment for their foster child. The DC KIDS team schedules and confirms appointments, and arranges for families to receive care at the Children’s Health Center and therapists located in close proximity to their neighborhoods. When that is not possible, the staff arranges for transportation—this occurs most often for specialty and follow-up services.. DC KIDS outreach coordinators are available to educate foster parents, social workers and service providers by answering questions about enrollment and eligibility.
Our Successes
Increased Enrollment We at Children’s Hospital feel that we have come a long way since our first days on the job with DC KIDS. We have increased enrollment by over 400 percent. When we first assumed the program, there were less than 1,000 children actively enrolled in the program—we now care for over 4,000. Since May, 2001 we have had 3,053 children come through our assessment center, and 1,870 children have returned for visits due to a disruption in their placement.
Enhanced Technology
We are proud of the new technology we have developed to make the process easier for the social workers. We provide a computer terminal for the social workers on site, with all their required forms on line. This way they can make productive use of their time while waiting for the child’s medical assessment to be completed, and we get the information we need to accurately enroll the children in the program. We have worked very hard to minimize the time that the social worker spends in this process, reaching our goal of 90 percent or more of the cases triaged in less than 2 hours by July, 2002.
Pharmacy Vouchers
Upon our assumption of the program, Children’s also requested the creation of a new system to provide foster families with the prescriptions and other pharmaceutical items they needed in order to care for these children once they left our care. Working with CFSA, we created a new electronic prescription pad that creates a “voucher” that is now accepted at a network of pharmacies throughout the city—allowing our foster families to receive both prescription and over-the-counter products for their new foster child.
DC KIDS Challenges
While we are very proud of these achievements, we acknowledge that there is so much more that needs to be done to overcome the challenges that Children’s, CFSA, and the entire system faces.
Mental Health
One challenge that is a struggle city-wide is the lack of capacity for mental health services. There simply are not enough providers, beds, services and programs to adequately serve the children of this region—not just children enrolled in DC KIDS, but for all children.
The DC KIDS population is a very vulnerable one. More than 50 percent of these children require some type of mental or behavioral health service, most on an ongoing basis. Children’s Hospital has a 12 bed inpatient psychiatric unit, which cannot absorb all of the needs of this population. Children’s Hospital does not have the facilities such as quiet rooms and restraints that are needed to treat the severely mentally ill; patients needing that type of care must be treated elsewhere. As a result, we have tried to establish partnerships and collaborations with other community providers to refer our DC KIDS population when we are unable. We serve as the coordination point, because we simply cannot provide all of the services needed. More of this collaboration needs to be done.
Dental Services
The same situation exists with dental services. There is a nation-wide shortage of pediatric dentists, and we feel that shortage in the District as well. Many of the DC KIDS that need specialized dental care are “special needs” children, and must be seen by a dentist that is appropriately trained. In order to address this problem, Children’s has purchased half the time of two pediatric dentists who work at two of the District’s special needs schools. These dentists are dedicated to provide dental services to our DC KIDS population. While this arrangement has helped, it is insufficient.
One recent strategy has developed with the award of $450,000 in funding from the Department of HHS, through a State Innovations Grant to the District of Columbia. The District was one of five states to receive this grant, which is intended to spur states into finding new and innovative ways to improve access to health care. Children’s partnered with the DC Department of Health to create a program with two state-of-the-art dental clinics in schools for children with special health care needs. The centers will use telemedicine tools to link patients with pediatric dentists and hygienists. This will allow us to focus on the provision of dental services to the most vulnerable children, a population which includes many foster children. It is one step towards a comprehensive ongoing strategy in this area.
Focus on Young Children
Another challenge that Children’s faces with this population is the orientation of our facility primarily on younger children, as the only acute care facility solely dedicated to pediatrics in this region. Although we are licensed to treat patients up to age 21, and do so, we have met challenges in providing for the unique needs of the older DC KIDS population. As with mental health, to meet this challenge, we have had to build partnerships and collaborations with outside community providers, serving as the coordinator of those services instead of the primary provider.
Court-ordered Medical Treatment
Children’s works hand-in-hand with the judges and the Family Court to assure appropriate health care services are provided to this vulnerable population. There are no better advocates for these children than the judges. Their sensitivities to these children’s needs demand their strict attention, which they provide. But a growing concern for our institution and the DC KIDS program is the amount and nature of court-ordered medical treatment. As these cases get adjudicated, often times a specific medical treatment or therapy will be ordered without any physician consultation. As the medical provider for these children, we are forced to comply with a court order, even if it is medically inappropriate for the child. Our physicians have great difficulty in treating a child in a manner they feel in unnecessary, regardless of whether the court has ordered it or not. For example:
• It is common to receive an order to admit child for an inpatient psychiatric stay for a specified number of days. The child may not need to be admitted for that period of time—they may be appropriately released in half the time. But because of the order, the child may be required to remain in the inpatient psychiatric unit for the full number of days prescribed in the court order. These types of social admissions are not always in the best interest of the child.
• Another example is a court order for occupational therapy within 14 days. But an occupational therapist cannot treat a child without a physician’s order. So DC KIDS must first arrange a visit with a physician for an evaluation before an appropriate occupational therapist can be scheduled. It is usually extremely difficult to accomplish this within the short time frame usually ordered by the courts.
Unfortunately, such court-ordered referrals are continuing to grow. From October, 2002 to April, 2003, the number of court-ordered outpatient referrals grew from about 10 percent of our load to nearly 20 percent. We have begun to educate the judges about the difficulty of these very specific orders for medical care, but we have a long way to go.
We want to make it very clear—the judges are passionate advocates for these children. They demand the very best of service and care, with the children as their number one priority. Our task is to educate CFSA, the judges and the Family Court, social workers and families about the best ways to work together.
Transportation Problems
Another internal challenge we have with this population is the high rate of “no-shows” we encounter. We make every effort to expedite and facilitate appropriate medical care for these very vulnerable and needy children—but it is to no avail if the foster family does not bring them to their appointments. Even though we coordinate transportation services for them, it often does not help. The result is a negative domino effect: children, who are not getting necessary medical care; frustrated pysicians, who block out entire days or afternoons to treat this population, only to have none of their appointments show up; and other needy children in the community who may be waiting several weeks for an appointment. We’ve got to find a better way.
Our Vision for the Future
At Children’s Hospital we continually strive to make things better. We have ideas and solutions for which we are searching for ways to implement.
Information Integration
We envision an assessment program that could be a model for the rest of the country. This assessment process would build on the foundation we have created. The first step would be complete integration with the CFSA computer system.
Right now, when we enroll the children at the time of their initial assessment, often this is before CFSA has confirmed their family placement. This requires a DC KIDS staff member to contact the social worker or CFSA to locate the child in order to make their follow-up appointments and comply with the 10-day window to complete the physical and mental health assessment. Waiting for address and contact information creates a major bottleneck in the system. If we were fully integrated with the CFSA system, we could simply log into the child’s file and see the placement immediately after it is entered into the system by the social worker. It would save immeasurable time.
In addition, integration would eliminate duplication of effort. Right now, we keep the medical records and CFSA keeps the complete record. The medical information gets entered in at Children's, and then has to be manually re-entered into the CFSA system. Placement information gets entered into the CFSA file, and then has to be manually re-entered into the medical record. There is a lot of exchanging of information and data that could be completely eliminated if the two systems were integrated.
Dedicated Transportation Service
We also can envision a program that makes health care for foster children as easy and convenient as possible for the foster family. Transportation is one of the biggest barriers for our foster families, and we know that it contributes substantially to our “no-show” rate. If a foster parent is unable to get the foster child to a scheduled appointment, it is a delay in care for that child. Although the DC KIDS program helps make transportation arrangements, it is an ongoing problem. We believe that if we owned a DC KIDS shuttle and driver that was dedicated solely to providing free transportation for foster families and children to their medical appointments, more foster children would receive their care in a more timely manner.
Education and Training
We also believe there would be great benefit and improvement of the system if there were opportunities for outreach and education--to families, to judges, to social workers, and other partners who touch the lives of these children. Annual training for all these groups, we are certain, would go a long way.
Mental Health Models
One of the most difficult pieces of this is the mental health capacity issue. Because of our physical limitations at our institution, we know that we must develop partnerships with other community providers. But there are some things that could be done immediately as well. For example, we are planning to pilot a new program to operate a mental health urgent care center at Children’s Hospital for nights and weekends. It would be housed in the outpatient psychiatric department as a mental health urgent care center in the off hours. We believe this will help alleviate some of the strain that is being felt by our emergency room. When St. Elizabeth’s closed, we were told to anticipate an increase of about 10 percent in our emergency room. Instead, emergency room visits for mental health crisis have tripled in the last ten months. We believe this mental health urgent care center will help to redirect patients that are currently occupying medical/surgical beds in the emergency room that are needed for children with physical issues. Our proposal is currently being considered by the DC Department of Mental Health, and they have agreed to provide funding for one social worker. But the rest we are scraping together for this pilot, to see whether or not it would be beneficial for the patients and for the facility. Ideally we need funding for three social workers, a security officer, a disposition staffer, and one full-time physician to operate an ideal program.
We also would support the expansion of the DC Department of Mental Health 24-hour access help line and mobile teams. This would allow patients to contact DMH directly, and receive care right in their community. Not every child needs to come to the hospital—they do now because that is the only place they know to get services. But expansion of community services like the mobile teams could be very helpful.
Another component that is lacking for the DC KIDS population is a day treatment program. Often a child is not in need of hospitalization, but they also need more structure and care than weekly therapy. A day treatment program is a structured “in-between” step that could be very valuable for those children who are in between hospitalization and less rigorous treatment they can receive in the community.
Above all, the DC KIDS population needs stability. They come to us with developmental issues, and problems with attachment and trust. What is best for this kind of vulnerable population is a comprehensive mental health system that addresses their emotional, medical, and educational needs. It is critical to have the involvement of stable foster families, and consistency with the providers that they see for treatment. Those children that face disruption in their placement, coupled with fragmented care that shuffles them from provider to provider, only worsens their problems with attachment and trust. Stability is key.
Children’s hopes to utilize current research that suggests more targeted cognitive behavior psychotherapy, carefully re-evaluated every 3-4 months, will lead to better outcomes—better resilence, better social skills, and better adjustment in the future.
Dental Care
Our current facilities will not cover all the dental needs of the children. We are land-locked, and have no room for expansion. Our vision of the future of dental services includes a system of community based partnerships to provide all the services needed by DC KIDS children.
Thank you very much for the opportunity to testify before you today. We are very proud of our efforts in caring for this vulnerable population, and look forward to even greater successes with the DC KIDS program in the future.
We would be happy to answer any questions you may have.
