Behavioral Health Service Utilization and Cost for North Carolina’s Foster Children: A Report for Partnering For Excellence

Executive Summary Introduction The foster care population in North Carolina, which hovered around 8,882 children as of August 2013, is of special interest to policymakers, politicians, Medicaid officials, child welfare professionals, and healthcare providers. This group of infants through young adults faces unique challenges in their educational, social, emotional, developmental, and physical growth. Their elevated needs put extra pressure on already stressed systems with limited financial resources. High levels of behavioral health and emotional problems lead to placement disruptions, costly interventions, and require extra diligence on the part of caseworkers, foster parents, and professionals to manage crises and keep foster children safe. It is essential to identify strategies to address the behavioral health needs of foster children within the constraints of limited resources, and in ways that take advantage of the most recent research on evidence-based treatments. These strategies should aim to reduce placement disruptions and promote healthy outcomes for foster children. By using existing data collection systems within the Department of Social Services and Local Management Entity-Managed Care Organizations (LME-MCOs), we can gain important insight into this population’s health and mental health needs, access to services, utilization, and cost. These data will also provide us with an opportunity to improve the existing systems and recommend policy changes.

Policy Question How can county Departments of Social Services (DSS) and Local Management Entity-Managed Care Organizations (LME-MCOs) use existing data to better manage the foster care population and improve mental health outcomes?

Policy Recommendations

1. Stakeholders should focus on increasing the frequency and quality of trauma-informed comprehensive clinical assessments for children in contact with child welfare.
2. Cardinal Innovations and behavioral health providers should continue to expand the service array of Evidence Based Practices available in Rowan County.
3. Cardinal Innovations should expand their use of care coordination to all children in DSS custody.
4. Cardinal Innovations and Rowan County DSS should identify high-cost and high utilization indicators in cases and target them with wraparound services like care coordination and additional case management at DSS.
5. DSS should implement data collection systems to monitor and track every placement change for children in DSS custody and note the specific reason.
6. DSS and Cardinal Innovations should encourage continuity of care with behavioral health providers and insist that barriers to treatment or placement stability be addressed.
7. DSS workers should be trained to recognize the different types of evidence-based therapies available and how to access them in their community.

Methodology The data required for this project was obtained by Dr. Rosanbalm and the Partnering for Excellence pilot through Benchmarks and de-identified for analysis. The data come from four major databases from the State Data Warehouse and Cardinal Innovations Healthcare Solutions. These data include Child Protective Services (CPS) Data, Service Information System (SIS) Data, Child Placement and Payment System (CPPS) Data, and Medicaid Behavioral Health Services Data. The analysis conducted was intended to be exploratory, not causal, in nature. The goal was to obtain a thorough understanding of the baseline relationships between child welfare and behavioral health services in Rowan County. Without a counterfactual group or quasi-experimental design, it was not possible to make causal inferences about the effect of behavioral health services on the child welfare population. After the available data was analyzed, a reported was created based on initial interpretations and shared with Benchmarks, Cardinal, and county DSS stakeholders for further analysis and to guide final recommendations. The recommendations are informed by the existing literature from academia, child welfare practice, evidence-based treatments, and advocacy and policy groups. The data analysis from Rowan County has led to specific recommendations to improve county practices and policies, inform the Partnering for Excellence pilot, and suggest recommendations that could be implemented statewide in North Carolina.

Discussion Children in foster care, by definition, have experienced trauma including the removal from their family and entry into foster care, and have likely experienced child abuse or neglect. We know from the research and experience that these foster children have increased mental health issues and psychiatric diagnoses. There may be barriers that delay or prevent foster children from receiving timely, comprehensive, and useful mental health assessments and further delays in entering evidence-based treatment to address their mental health issues. The data analysis in this paper confirms what the literature on foster children across the United States has found: foster children have significantly greater behavioral health issues, utilize more services, and account for a disproportionate amount of behavioral health expenditures. The analysis presented in this paper highlights a concern that there may be inadequate and inconsistent behavioral health assessments of high-risk children who have contact with CPS, and particularly for children in DSS custody. There may be practical barriers or case coordination issues that are preventing timely and comprehensive clinical assessments of these children. For example, the decreased rates of assessment among Hispanic children may indicate linguistic, cultural, or insurance barriers for undocumented children. Prior to the development of Partnering for Excellence the workforce in Rowan County was unable to accommodate the need for trauma-informed comprehensive clinical assessments. This may explain the use of developmentally inappropriate diagnostic labels or treatment services in the data. For example, it’s concerning that twelve 6 to 11 year old children received substance abuse treatment services. While these children may have been experimenting with substances, substance abuse treatment models are developmentally inappropriate for young children and their issues may have been better addressed by behavioral health services. Additionally, diagnosis of personality disorders in children under 18 years old, MST with children under 12 (as was the case with 10 children), and bipolar diagnoses in young children are all concerning practices that may stem from a lack of experience or resources in the community. It is well established in the literature and anecdotally that foster children’s undiagnosed and untreated mental health issues can lead to challenging externalizing behaviors (tantrums, aggression, lying, etc.) that strain their relationships with their foster parents and can lead to placement disruption. Foster care placements also frequently disrupt for administrative or policy reasons. Either way, the effect and feelings of rejection and instability are the same for the foster child. Research has shown that placement disruptions, particularly in the first 100 days of care, exacerbate foster children’s mental health issues and are associated with more frequent placement changes in the future. Placement disruption may also be associated with increased reliance on the Medicaid-funded residential treatment placements. Placement disruptions and entry into the residential treatment pipeline can delay reunification, prevent adoption or guardianship, and may be correlated with re-entry into foster care. DSS placement disruptions create administrative costs for the Department, disrupt behavioral health service delivery, and can lead to expensive reliance on residential treatment. This entire chain of negative events fails to capture the real and intangible costs to the child’s education and physical and emotional well-being, nor the increased costs associated with administrative procedures, school changes, court procedures, and informal case management. The analysis presented in this paper highlights the concerns about placement stability for children in DSS custody. Children with short first placements (less than 100 days) and more than one placement go on to have more placements overall and these placements are short, indicating that these children are “bouncing around” through placements. Placement instability is also associated with increased average behavioral health expenditures. It follows then, that these children have likely received multiple psychiatric diagnoses and are receiving a wide spectrum of behavioral health services with limited success. Finally, this paper emphasizes the value in utilizing wraparound services such as care coordination by the LME-MCO or Multisystemic Therapy (MST) prior to or following more expensive and intensive residential treatment options. Care coordination can improve the communication between providers, help ensure continuity of care during placement changes, and delay or prevent hospitalizations and other crises. MST has demonstrated effectiveness in preventing out-of-home placements and can effectively address conduct disorder behaviors that can lead to placement disruption and later reliance on institutional care or criminal behavior.

For further information regarding this report please contact the author, Susan Cohen Foosness, MSW at sdc28@duke.edu.