Kathleen G. Noonan

Achieving better health care outcomes for children in foster care

This article reviews the challenges health care systems face as they attempt to improve health care outcomes for children in foster care. It discusses several of the promising health care strategies occurring outside the perimeter of child welfare and identifies some of the key impasses in working alongside efforts in child welfare reform. The authors posit that the greatest impasse in establishing a reasonable quality of health care for these children is placement instability, in which children move frequently among multiple homes and in and out of the child welfare system. The authors propose potential strategies in which efforts to improve placement stability can serve as a vehicle for multidisciplinary reform across the health care system.

Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families

IMPORTANCE An increasing diversity of childrens health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Childrens Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children. OBJECTIVE To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes. DESIGN, SETTING, AND PARTICIPANTS A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Childrens Health, comprising 80,655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015. EXPOSURES Insurance type was ascertained using a caregiver-reported measure of insurance status and each households poverty status (percentage of the federal poverty level). MAIN OUTCOMES AND MEASURES Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care. RESULTS Among the 80,655 children, 51,123 (57.3%) had private insurance, 11,853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P < .01; CHIP, 88% [87%-89%]; P < .01) and dental (Medicaid, 80% [78%-81%]; P < .01; CHIP, 77% [76%-79%]; P < .01) visits than were privately insured children (medical, 83% [82%-84%]; dental, 73% [72%-74%]). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% [24%-32%]), problems obtaining a referral (23% [18%-29%]), and frustration obtaining health care services (26% [23%-28%]). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% [26%-33%]) and frustration obtaining health care services (36% [32%-41%]) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the childs needs (63% [60%-67%]) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% [75%-78%]) than were caregivers of children insured by Medicaid (26% [23%-28%]; P < .01) or CHIP (38% [35%-40%]; P < .01). CONCLUSIONS AND RELEVANCE This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.

Mental Health, Behavioral and Developmental Issues for Youth in Foster Care

Youth in foster care represent a unique population with complex mental and behavioral health, social-emotional, and developmental needs. For this population with special healthcare needs, the risk for adverse long-term outcomes great if needs go unaddressed or inadequately addressed while in placement. Although outcomes are malleable and effective interventions exist, there are barriers to optimal healthcare delivery. The general pediatrician as advocate is paramount to improve long-term outcomes.

Adoption of a portal for the primary care management of pediatric asthma: a mixed-methods implementation study

Background Patient portals may improve communication between families of children with asthma and their primary care providers and improve outcomes. However, the feasibility of using portals to collect patient-reported outcomes from families and the barriers and facilitators of portal implementation across diverse pediatric primary care settings have not been established. Objective We evaluated the feasibility of using a patient portal for pediatric asthma in primary care, its impact on management, and barriers and facilitators of implementation success. Methods We conducted a mixed-methods implementation study in 20 practices (11 states). Using the portal, parents of children with asthma aged 6-12 years completed monthly surveys to communicate treatment concerns, treatment goals, symptom control, medication use, and side effects. We used logistic regression to evaluate the association of portal use with child characteristics and changes to asthma management. Ten clinician focus groups and 22 semistructured parent interviews explored barriers and facilitators of use in the context of an evidence-based implementation framework. Results We invited 9133 families to enroll and 237 (2.59%) used the portal (range by practice, 0.6%-13.6%). Children of parents or guardians who used the portal were significantly more likely than nonusers to be aged 6-9 years (vs 10-12, P=.02), have mild or moderate/severe persistent asthma (P=.009 and P=.04), have a prescription of a controller medication (P<.001), and have private insurance (P=.002). Portal users with uncontrolled asthma had significantly more medication changes and primary care asthma visits after using the portal relative to the year earlier (increases of 14% and 16%, respectively). Qualitative results revealed the importance of practice organization (coordinated workflows) as well as family (asthma severity) and innovation (facilitated communication and ease of use) characteristics for implementation success. Conclusions Although use was associated with higher treatment engagement, our results suggest that achieving widespread portal adoption is unlikely in the short term. Implementation efforts should include workflow redesign and prioritize enrollment of symptomatic children. ClinicalTrial Clinicaltrials.gov NCT01966068; https://clinicaltrials.gov/ct2/show/NCT01966068 (Archived by WebCite at http://www.webcitation.org/6i9iSQkm3)

Increasing Pediatrician Participation in EHR Incentive Programs

Although the intent of the federal Meaningful Use (MU) program is to improve the health of children and adults through adoption and use of electronic health records (EHRs), pediatricians face unique obstacles to participation in this program.1 In addition to known problems with EHR functionality to support pediatric care and the alignment of MU incentives with child health priorities, evidence suggests that the current structure of the MU program puts pediatricians at a disadvantage compared with clinicians caring for adults, leading to wide variability in pediatrician participation in the program across states.2 Specifically, despite a national mean participation rate of <20% in 2012, pediatrician registration in the MU program varied considerably across states, from <10% in New Jersey, Georgia, and Hawaii to nearly 70% in North Dakota (Fig 1). By synthesizing participation data with a detailed policy analysis, the present commentary addresses potential causes of this variability and suggests specific solutions to support effective pediatric EHR implementation across all states. FIGURE 1 Pediatricians registered (by state) in the federal MU EHR adoption program, 2012. The graphic was created by using data from the AAP and the Centers for Medicare & Medicaid Services. Percentages were calculated from a … Address correspondence to Alexander Fiks, MD, MSCE, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, CHOP North, 15th Floor, Room 1546, Philadelphia, PA 19104-4399. E-mail: fiks{at}email.chop.edu

Mandates for Collaboration: Health Care and Child Welfare Policy and Practice Reforms Create the Platform for Improved Health for Children in Foster Care

Improving the health of children in foster care requires close collaboration between pediatrics and the child welfare system. Propelled by recent health care and child welfare policy reforms, there is a strong foundation for more accountable, collaborative models of care. Over the last 2 decades health care reforms have driven greater accountability in outcomes, access to care, and integrated services for children in foster care. Concurrently, changes in child welfare legislation have expanded the responsibility of child welfare agencies in ensuring child health. Bolstered by federal legislation, numerous jurisdictions are developing innovative cross-system workforce and payment strategies to improve health care delivery and health care outcomes for children in foster care, including: (1) hiring child welfare medical directors, (2) embedding nurses in child welfare agencies, (3) establishing specialized health care clinics, and (4) developing tailored child welfare managed care organizations. As pediatricians engage in cross-system efforts, they should keep in mind the following common elements to enhance their impact: embed staff with health expertise within child welfare settings, identify long-term sustainable funding mechanisms, and implement models for effective information sharing. Now is an opportune time for pediatricians to help strengthen health care provision for children involved with child welfare.

A procurement-based pathway for promoting public health: innovative purchasing approaches for state and local government agencies.

Through their purchasing powers, government agencies can play a critical role in leveraging markets to create healthier foods. In the United States, state and local governments are implementing creative approaches to procuring healthier foods, moving beyond the traditional regulatory relationship between government and vendors. They are forging new partnerships between government, non-profits, and researchers to increase healthier purchasing. On the basis of case examples, this article proposes a pathway in which state and local government agencies can use the procurement cycle to improve healthy eating.

What Do Romanian Children Living in Orphanages Manifesting Repetitive Behaviors and American Children in Foster Care With Abnormal Cortisol Levels Have in Common?: More Than You Would Think

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Information sharing between the child welfare and behavioral health systems: Perspectives from four stakeholder groups

ABSTRACT This qualitative study articulates the challenges, best practices, and facilitators to information sharing when addressing the behavioral health needs of children in out-of-home care. 13 interviews and nine focus groups were conducted to illuminate the perspectives of foster parents, mental health clinicians, provider agency social workers, and city-employed child welfare professionals. In total, 65 individuals participated in this qualitative study and data were analyzed using a modified grounded theory approach. Results indicate that challenges and best practices in cross-system information sharing articulated across the four stakeholder groups are attributed to variation in information accessibility, clarity in roles and protocols, ability in obtaining signatures for consent/release forms, and attitudinal differences towards collaboration. Implications to improve policy and practice are discussed.

A Better IDEA: Best Practice and Outcomes-Oriented Remedies in Public Impact Litigation for Students with Disabilities.

Class action lawsuits filed in violation of Individuals with Disabilities Education Act (IDEA) raise questions for those concerned with improving the education system for students with disabilities. First, do the lawsuits result in changes that can be directly linked to improved student outcomes? Second, do these lawsuits and the ‘consent decrees’ that settle them refer to best practices in educating children with disabilities? To date, no study has examined the remedies ordered as a result of these lawsuits in the disability education context, or proven how different types of remedies can impede or facilitate progress for students with disabilities. Class action lawsuits under IDEA filed in large, urban school districts between 1990 and 2011 and the remedies ordered under the final agreement were reviewed. This review suggests that the lawsuits against large, urban school districts tend to result in remedial activities that focus more on planning, supporting and monitoring than on outcomes or evidence-based practice.