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Prep rationale and_cost_benefit
The document discusses the medical and mental health needs of children in foster care in Maine. It finds that children in foster care have high rates of chronic medical conditions, developmental delays, and behavioral disorders. Placement instability is also associated with worse health and mental health outcomes. A program called PREP provides comprehensive health assessments for children entering foster care. Data on thousands of children shows that those receiving PREP assessments have better health outcomes, lower rates of obesity, dental problems and use of psychotropic medications compared to children not receiving PREP assessments. PREP participants also have lower average monthly health care costs for the state Medicaid program.
Prep rationale and_cost_benefit
- 1. Comprehensive Assessment of the Medical and Mental Health Needs of Children in Maine Feb 2012
- 2. Medical and MentalHealth Needs of Children in Entering Care in Maine Stephen Meister MD, MHSA Medical Director Edmund Ervin Pediatric Center National Child Traumatic Stress Network www.NCTSNet.org
- 3. Maine Child TraumaticStress 1996 – Abusive Head Trauma Inter-hemispheric hemorrhage Seizure Severe Neurologic Sequelae – Parade of foster children No medical records No known medical history
- 4. Maine Child TraumaticStress 1998 Needs of Children Entering Foster Care – Conference in Augusta, Maine Baylor Texas – Sandy Hodges – Mary Dionne – Nancy Desisto – Ann Marden – Lisa Cavanaugh
- 5. Medical Needs ofChildren in Foster Care Szilagyi, M. The Pediatrician and the Child in Foster Care, Pediatrics in Review. 1998;19:39- 50 80% have at least one chronic medical condition 25% have three or more chronic problems 60% of preschool children in foster care have a developmental disability Nearly 40% of older children qualify for special education services Children in foster care tend to be underimmunized, even compared with other poor children
- 6. Barriers to Care 1983 AAP Committee on Adoption reports that children in foster care are not likely to receive: – Routine health care – Immunizations – Dental care – Hearing or vision screening
- 7. Barriers to Care Children move in and out of care Move between foster homes and residential facilities Multiple providers may be involved Diffusion of responsibility A pattern of inadequate, fragmented, sometimes redundant health care
- 8. Barriers to Care Lack of Records/Information on entry to care – Delayed identification of providers – Difficulty acquiring consent to access records – Time to review and summarize records – Delay in appropriate evaluations
- 9. Specialized Programs 1988 CWLA – Standards for Health Care Services for Children in Out-of-Home Care – Initial screen for immediate health needs – Comprehensive assessment within one month – Developmental and mental health assessment – Medical Passport
- 10. Specialized Programs 1994 Study showed little evidence the CWLA recommendations were implemented – Absence of clear State policies – Medicaid managed care – Lack of funding 1994 AAP Committee on Early Childhood, Adoption and Dependant Care recommend a comprehensive and coordinated treatment approach
- 11. What is PREP? Pediatric Rapid Evaluation Program Centralized evaluations Medical Home Physical and Psychosocial Screening early in foster care for abused/neglected children Public/Private Collaboration: DHHS & MaineGeneral Medical Center
- 12. What Does PREPProvide? Medical, dental and psychosocial records Physical examination Psychosocial screening Current problem list and recommendations Behavioral and developmental guidance Follow-up medical/psychosocial evaluation
- 13. Who Does PREPServe? Children in Temporary State Custody Families providing the care Primary Care and Mental Health Providers Maine’s DHHS workers Guardian Ad Litem Court/District Attorney Birth parents/Family
- 14. PREP Catchment Area Somerset, Kennebec, Waldo, Knox, Lincoln, Sagadahoc Referrals by DHS Region: Skowhegan 36% Augusta 42% Rockland 22%
- 15. PREP Activity 350 300 250 400 200 300 150 200 100 0 1999 2001 2003 2005 Referrals Intakes Followups Total visits PREP Activity 100 50 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Referrals Intakes Follow ups Total visits
- 16. PREP Data 1999and 2006 996 children entered foster care 246 infants age 0-1 222 children age 2-5 285 children age 6-11 243 teens age 12-17
- 17. PREP Data PlacementNumber Children with first placement in an agency setting were more than twice as likely to have placement instability 25% of the children had 3 or more placements in a year 42% of the teens had 3 or more placements in a year There was an association between placement instability and PTSD
- 18. Placement Turnover forMaine Teens within a Year of Entering State Care 243 Teens evaluated between 1999 and 2006 136 (56%) had one or 2 placements 60 (25%) had 4 or more placements 11 (4%) had 7 or more placements
- 19. PREP Data MedicalProblems 3 or more chronic medical problems – 37% Age 12-17 – 27% Age 6-11 – 19% Age 2-5 Immunization delay (27%) Obesity (20%) Asthma (18%)
- 20. PREP Data Behavioraland Developmental Problems Developmental delay age 2-5 – 48% boys – 31% girls LD/MR age 12-17 – 21% boys – 13% girls Behavioral disorder – 33% age 2-5 – 60% age 6-11 – 73% age 12-17
- 21. PREP Data Behavioraland Developmental Problems PTSD age 12-17 – Females (31%) – Males (23%) ADHD age 12-17 – Females (6%) – Males (26%) Depression age 12-17 – Females (24%) – Males (12%)
- 22. PREP Data PsychotropicMedication Age 0-1 1% Age 2-5 4% Age 6-11 13% Age 12-17 35% Teens: Boys: 21% stimulants, 13% SSRI, 8% antipsy Girls: 8% stimulants, 23% SSRI, 11% antipsy
- 23. PREP Data Obesity(>95%) 22% of the teens were >95% BMI, double the 10.9% rate reported for Maine HS students Adjusted for age & sex, depressed children were twice as likely to be overweight Children with PTSD and depression were 3 times more likely to be overweight SSRI use was not associated with overweight, stimulant use was negatively associated with overweight
- 24. PREP Data Outcomes Dental Problems Exam 1 Exam 2 < Age 5 10% 10% Age 5-9 50% 33% Age 10-14 44% 22% Age 15-17 44% 23%
- 25. PREP Data Outcomes Active Mental Health Problems Exam 1 Exam 2 < Age 5 41% 37% Age 5-9 79% 62% Age 10-14 81% 60% Age 15-17 88% 67%
- 26. PREP Data Outcomes Psychotropic Medications Exam 1 Exam 2 < Age 5 2% 4% Age 5-9 12% 28% Age 10-14 23% 36% Age 15-17 37% 47%
- 27. Medical Needs ofChildren in Foster Care Aggressive, reactive behavior Secondary enuresis Sleep deprivation Attend to the threat, not school work Constipation Increased injuries
- 28. Adverse Childhood Experiences ACE Study Weight-loss program SD Kaiser-Permanente Vincent Felitti, MD (Internist) notices relapse – Patients with adverse childhood experiences Health risk assessment 18,000+ – Partners with Centers for Disease Control Ongoing series of studies correlating ACEs with adult health and behavioral outcomes. www.ACEstudy.org
- 29. Adverse Childhood Experiences Exposure to Domestic Violence Exposure to Parental Substance Abuse Exposure to family member with Mental Illness Neglect Emotional Abuse Physical Abuse Sexual Abuse Parent Incarceration Loss of a parent
- 30. Mechanisms by WhichAdverse Childhood Experiences Influence Adult Health Status Early Death Disease & Disability Adoption of Health-Risk Behaviors Social, Emotional, and Cognitive Impairment Adverse Childhood Experiences Death Birth Felitti, VJ, et al, 2004
- 31. ACE Score vs. Intravenous Drug Use 4 3.5 3 2.5 2 1.5 1 0.5 0 1 2 3 4+ ACE Score % IVDA
- 32. % PREP FosterChildren with Adverse Childhood Experience 70 60 50 40 30 20 10 0 Sex Abuse Physical Abuse Substance Abuse Domestic Violence
- 33. PREP Data AdverseChildhood Events 882 (89%) neglect 635 (64%) exposed to domestic violence 445 (45%) physical abuse Girls (32%) sexual abuse (Teens) Boys(21%) sexual abuse (Teens) 52 ( 5%) parent death (10% Teens) 35% had >/= 4 adverse childhood events
- 34. Adult Health andSocial Outcomes of Children Who Have Been in Public Care Viner Pediatrics 2005;115;894-899 British Cohort of 13,135 Children 343 had been in public care More likely to have been homeless (2) More likely to have a conviction (2.3) More likely to be unemployed (2.6) More likely to have psych morbidity (1.8) More likely to be in poor health (1.6)
- 35. Newborns Experiencing DrugWithdrawal Symptoms in Maine 13 27 38 79 83 124 158 180 215 0.1% 0.2% 0.3% 0.6% 0.6% 0.9% 1.2% 1.3% 1.6% 2.0 1.5 1.0 0.5 0.0 250 200 150 100 50 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 % of discharges # of discharges Discharge Year # of discharges % of discharges
- 36. Health Status, ServiceUse and Costs among Maine Children in Foster Care Muskie School of Public Service Prepared by: Erika Ziller, Tina Gressani, Catherine McGuire & Kimberley Fox for the Improving Health Outcomes for Children (IHOC) Program
- 37. Purpose 1. Toinform IHOC program planning with baseline data on the health care use and expenditures of MaineCare children in the foster care program. 2. To compare use and costs for foster care children that receive comprehensive health assessments through the Edmund N. Ervin Pediatric Center’s Pediatric Rapid Evaluation Program (PREP), and those that do not.
- 38. Design and Data Study population: All children (age 0-17) receiving foster care services in Maine between January 1, 2007 and December 31, 2009.* – PREP: N = 484 – Non-PREP: N = 3,566 Placement data source: Maine Office of Child and Family Services Foster Care Placement List Health care use and expenditure data: MaineCare claims from MMDSS (MeCMS) *To ensure that each child could be observed for at least 6 months, analyses include only foster children that had a placement or PREP evaluation by 6/30/2009.
- 39. Child’s Age* PREPNon-PREP 0-5 56.8% 43.4% 6-12 26.7% 25.5% 13-17 16.5% 31.1% Average 6.2 years 8.4 Age (Boys) Average Age (Girls) 6.5 years 8.2 Average Age (Total) 6.3 years 8.3 years Children that participate in PREP are, on average, 2 years younger than other children in foster care PREP children are more likely to be aged 0-5 and less likely to be teenagers. *At first observed placement between 2007-2009 and/or at PREP evaluation date.
- 40. Average Monthly MaineCareCosts Including PNMI (2007-2009) PREP Non-PREP Based on all $1,767 $2,925 MaineCare expenditures, including placement in private non-medical institutions (PNMI), children with PREP evaluations cost about $1,150 less per month on average.
- 41. Percent of Childrenwith High Costs over 3 Years (2007-2009) 40% $100K to < $500K $500K to $1 million 60% 4% 15% PREP Non-PREP MaineCare costs for foster care children are skewed, with a small number having extremely high costs This is particularly true for non-PREP children, of whom 15% had costs of more than $500 thousand (compared to 4% of PREP children)
- 42. Average Monthly MaineCareCosts by Age (2007-2009) $1,055 PREP Non-PREP One reason for the $2,145 $3,406 $1,092 $3,100 $5,112 0-5 6-12 13-17 difference appears to be the greater percent f young kids (0-5) in PREP Yet age does not appear to explain the full difference in costs because, within age groups, PREP kids are lower cost
- 43. Average Monthly MaineCareCosts Excluding PNMI (2007-2009) $823 PREP Non-PREP PNMI costs contribute $1,767 $1,112 $2,925 Excluding PNMI Including PNMI substantially to average monthly costs (50-60% of total costs) When PNMI costs are excluded, PREP participants remain lower cost ($823 versus $1,112 for non-participants)
- 44. Average Monthly Costs, by Placement Type (2007-2009) Placement Non- PREP Type PREP Adoption $302 $577 Bridge Homes* $7,869 $10,596 Congregate $7,994 $11,104 Care (PNMI) Foster Care $676 $721 Kinship Care $779 $891 Therapeutic Foster Care $3,246 $4,010 Unlicensed Placements $554 $813 Other $2,511 $3,750 Monthly costs vary substantially based on where a child is placed. Within each placement type, children receiving PREP assessments have lower costs than non-PREP children. *NOTE: Bridge Homes are no longer a placement option
- 45. Percent of Childrenwith Service Use, by Service Type (2007-2009) Service PREP Non- PREP PNMI 31% 39% Mental Health 59% 58% Agency Pharmacy 80% 86% General Inpatient 5% 8% Psychiatric 3% 7% Inpatient Physician 87% 82% Speech Therapy 12% 9% Occupational 11% 8% Therapy PREP children are less likely to be placed in PNMIs, have a prescription, or to have general or psychiatric inpatient stays PREP children are more likely to see a physician, and to receive speech or occupational therapy
- 46. Primary Diagnoses Associatedwith Service Use (2007-2009) Service PRE P Non- PRE P Upper resp. infection 43% 44% Ear infection 27% 28% Nutritional/metabolic 22% 21% Adjustment disorder 39% 33% Developmental 29% 35% Disorders Anxiety Disorder 30% 35% Mood disorder 17% 28% ADD/ADHD 30% 35% Asthma 9% 12% Medical diagnoses for PREP and non-PREP children are similar Psychiatric diagnosis differ: PREP children have fewer diagnoses of anxiety, developmental & mood disorders or ADD/ADHD, and are more likely to be diagnosed with an adjustment disorder
- 47. Adolescent Well-Care Visits(2007) 65.3% 58.6% 58.9% PREP Non-PREP Total Adolescents participating in PREP are more likely to have a well-care (preventive) visit than are non-participants.
- 48. Well-Child Visits, Ages3-6 (2007) 85.7% 71.4% 72.9% PREP Non-PREP Total Young children (3-6) participating in PREP are more likely to have a well-child (preventive) care visit than are non-participants.
- 49. Preliminary Findings Children that have received PREP services are generally lower cost than those that have not; however, it is not clear whether this is due to PREP, or to underlying differences between the two populations. MaineCare costs for foster care children are skewed by a small number of extremely high cost users, a group that is over-represented in the non-PREP group.
- 50. Preliminary Findings PREP children are somewhat younger than non- PREP children (6.3 versus 8.3). Age may explain some of the cost differences between PREP participants and non-Participants. Younger children are generally less costly than older children, and teens are the most costly. However, even within each age grouping, PREP children continue to have lower costs (particularly among the older age groups).
- 51. Preliminary Findings PNMI expenditures are a sizeable proportion of all MaineCare expenditures for children in Foster Care and non-PREP children are more likely to receive these services. Yet, when PNMI costs are excluded, PREP children’s MaineCare expenditures are about 25% lower than non-PREP ($823 per month versus $1,112 per month)
- 52. Preliminary Findings PREP children are more likely to see a physician, and to receive speech or occupational therapy. Non-PREP children are more likely to have received PNMI, pharmacy, and general or psychiatric inpatient services PREP participants and non-participants have similar medical diagnoses, but psychiatric diagnoses differ somewhat.
- 53. Preliminary Findings Average monthly costs for children vary substantially by placement type. However, within placement types, PREP children were generally lower cost than non-PREP children. Children receiving PREP were also more likely to have a well care, or preventive, visit during 2007.
- 54. Limitations AlthoughPREP participation appears to be generally associated with lower costs and better access, the cross-sectional design limits ability to make conclusions about causality. We know that PREP children are somewhat younger than non-PREP children, and that they are limited to the 6-county area that PREP serves. However, there may be other important, unmeasured, differences between the groups that are affecting costs.
- 55. Limitations Finally,the relatively limited number of PREP participants across the study period (n = 484) meant that some estimates are based on very small numbers.