- Provision of Appropriate Care: The health of a child in out-of-home care is of paramount importance throughout the child’s placement. 13 CSR 35-60.050(2)(A)(1) states that the resource provider shall obtain medical and dental examinations for the child immediately following initial placement and at least annually thereafter in cooperation with the Children’s Division; this requirement is satisfied by the Initial Health Examination and the Healthy Children and Youth (HCY) Evaluation. Children’s Division shall maintain best practices in monitoring the child’s health as required by federal and state laws, and as recommended by the American Academy of Pediatrics (AAP) and the Child Welfare League of America (CWLA), which set forth certain medical appointments occur timely to assess and monitor the child’s health. Those include:
- Initial Health Examination: An initial health examination should occur within 24 hours of the child coming into care. When possible, this should be completed by the current primary care physician as they are already familiar with the child’s medical history. If a provider is not readily accessible, this exam must occur within 72 hours of the initial placement. The assigned case manager need not attend these initial examinations; however they should receive documentation of the results of the assessment within 72 hours of the appointment and ensure compliance with any recommended follow-up treatment/interventions.
- Full HCY Evaluation: A full Healthy Children and Youth (HCY) evaluation, including a physical examination, and other developmental components, including but not limited to vision, hearing, social/emotional and dental screenings, shall be completed no later than 30 days after the youth is placed in Children’s Division custody. If it is not possible to schedule the appointment within 30 days, the reason for the delay shall be documented in the case file and the examination completed at the earliest possible date. Staff should promptly follow up on any recommendations from the evaluation
- Ongoing Medical Examinations: Presently, pursuant to Section 210.110 RSMo, all children under the age of ten should receive a physical, developmental, and mental health screening every six months. This should be completed as part of the HCY examination as allowed through MO HealthNet for youth in CD custody. As of August 28, 2018, that schedule will be amended in law to require that all children in the custody of the Children’s Division continue to receive their initial HCY evaluation within the first 30 days but receive follow-up screenings in accordance with the periodicity schedule as recommended by the AAP. https://www.aap.org/en-us/Documents/periodicity_schedule.pdf Every child in the custody of the Children’s Division shall be seen at least annually by medical and dental providers. The periodicity schedule is based on the age of the child and, dependent upon the child’s age, may require visits to certain healthcare providers every six months.
- The examinations described above, as well as treatment for ordinary illnesses, routine dental care, immunizations, well child visits, preventative health services, and on-going treatment for chronic conditions, and necessary routine testing for those chronic conditions, such as asthma, diabetes, and ear infections are considered standard or routine medical treatment.
- Some medical care, even though standard or routine, may be controversial in some families. With respect to those issues, the case manager shall follow Children’s Division policy as set forth below:
- Dental Exams: All children receive dental screenings as part of the comprehensive assessment/HCY (Healthy Children & Youth) exam, (commonly known as a “well-child check”) completed at certain age intervals known as the HCY periodicity schedule. As part of the HCY screening, the primary care professional, or other appropriately trained professional, performs an oral health screening of the child’s mouth and teeth to identify oral disease or other oral conditions (delayed tooth eruption, premature tooth loss, trauma) and provides guidance for management. This screening is not a full dental exam. Primary care professionals identifying problematic oral health during the dental screening portion of an HCY exam will refer the child to a dentist for a dental exam, also known as a clinical oral examination.
Dental exams are performed by dentists or qualified dental professionals. During a dental exam, the dentist or hygienist will check for cavities and gum disease and may clean the child’s teeth. The exam involves a more comprehensive oral health evaluation and may include dental X-rays or other diagnostic procedures, when indicated. Oral hygiene habits and anticipatory guidance are typical points of discussion during each visit.
Dental Exam Periodicity Schedule – When and How Often Exams Should Occur
First Dental Exam: The AAPD recommends the first dental examination occur at the time of the child’s first tooth eruption, or no later than 12 months of age.
A child’s developing primary teeth (or “baby teeth”) are susceptible to decay as soon as they appear. This first visit provides the early opportunity to check existing teeth for decay and to assess any potential problems with the child’s gums, bite, oral tissues, and jaw. The dentist can provide guidance on baby bottle tooth decay, infant feeding practice, teething, pacifier habits, finger-sucking habits, and mouth cleaning.
Ongoing Dental Exams: Dental exams are recommended every six (6) months, or more frequently if recommended by the dentist based on the child’s risk status.
Child’s First Dental Exam Following Entry in to Out-of-Home Care
All children entering out-of-home care must have a full, comprehensive HCY assessment within 30 days. Included in this physical health and developmental assessment are vision, hearing, and dental screenings. The dental screening may be completed by the physician performing the physical exam, or the child can be taken to a dentist to receive this screening. A full dental examination is not required during this 30-day timeframe solely due to the child’s entry into out-of-home care. However, if during the HCY dental screening the provider indicates a need for a full dental/oral examination, the physician will make a referral and staff shall ensure this exam occurs. This dental exam must be performed by a dentist or qualifying dental professional.
Because dental exams are recommended every six (6) months, staff should promptly collect the child’s dental records upon entry in to out-of-home care to ascertain when the child last had a dental exam and when he/she should visit the dentist next. These records can be obtained from the child’s dental provider, or by accessing the information via CyberAccess for MO HealthNet recipients. If the child has no history of a dental exam, the child’s first dental exam should be scheduled based on the anticipatory guidance given by the physician during the 30-day HCY assessment, but no later than six months from entering CD custody.
- Immunizations: The case manager will ensure that children in the agency’s custody are immunized against disease, in accordance with the immunization schedule as recommended by the Missouri Department of Health and Senior Services.
- Reproductive Health: Information on sexual health, education, including information on sexually transmitted infections and birth control should be made available to youth, appropriate to their age and physical and emotional maturity. The case manager shall document when and by whom this education was provided. Educational information and prevention resources shall be made available to parent(s) and/or resource providers as requested for discussion with the child.
- Birth Control: Youth in foster care are afforded the choice to obtain or refuse birth control. Missouri law does not require minors to have parental consent to obtain contraception, although it is the practice of some medical providers. If the medical provider requires signed consent, the Children’s Division may provide the written consent.
- Non-routine medical treatment may also be necessary during a child’s placement in custody of the Children’s Division. Non-routine medical treatment falls outside the standard or routine care described above and might include surgery, inpatient hospitalization, extraordinary dental treatment, medical testing, behavioral therapy or mental health services and psychiatric treatment.
- Attendance at Health-Related Appointments: After a child is placed in the custody of the Children’s Division, parent(s) and resource provider attendance at the child’s health-related appointments is expected and welcomed, in most instances. The case manager should invite the parent(s) and resource provider to attend all health-related appointments at least three days in advance, whenever possible. There may be special circumstances in which it is not in the best interests of the child for the parent(s) to be involved in healthcare decisions about the child. In these cases, the case manager should speak to their supervisor and may consider a referral to the Division of Legal Services or Children’s Division attorney. If mental health therapy is arranged for the child, ideally the case manager will attend the initial appointment with the child. If the case manager is unable to attend the initial appointment, s/he must communicate with the therapist prior to the appointment to discuss the child’s needs and provide consent to begin treatment. If a child is referred for psychiatric assessment or care, the case manager or supervisor must attend all initial appointments.
- Communication Regarding Health Care Needs: The case manager should recognize that continued collaboration with the parent(s), child, resource provider, and primary health care providers will lead to clearer communication and provision of services in the child’s best interests, resulting in a smoother transition in the event of any change, including at the time of reunification or, for an older youth, placement in independent living.
- Family Support Team (FST) Meetings: FST Meetings shall include a discussion of medical and mental health updates, unless the case manager has determined that such discussion is contrary to the child’s best interests. A supervisor should be consulted regarding any such determination and an explanation provided to the FST, with appropriate documentation in FACES.
- Parent(s): Unless termination of parental rights has occurred or the court has issued an order restricting parent(s) access to information, the case manager will routinely share information about the child’s health with the parent(s) during home visits and will timely respond to requests for information. Additionally, the case manager shall notify the parent(s) promptly about any significant change in the child’s health status, including, but not limited to, significant injury, new diagnosis or medication, or any emergency treatment or hospitalization. The parent(s) should be asked to provide updates about any newly acquired knowledge of familial illness which might impact the child and to promptly inform the Children’s Division of any illness or injury incurred by the child during visitation with the parent(s).
- Child: Children and youth should participate as much as possible in making decisions about their medical care. Children should be encouraged by the team members to communicate information or worries about their health to parent(s), resource providers, the case manager, and to health care providers. Case managers should ask a child’s opinion about proposed medical care and discuss safe use of medication, as developmentally appropriate. Providing a child with information:
- helps the child achieve developmentally appropriate awareness of health status;
- tells the child what to expect about treatment;
- helps to prepare a child for assuming more responsibility for health care decisions as they develop;
- aids the case manager and other adults involved in the child’s care to assess the child’s understanding of the situation; and
- solicits the child’s willingness to accept the proposed care.
- Resource Provider: The case manager will provide all information to the resource provider as required by law. The resource provider shall update the case manager of any new information regarding the child’s health care status throughout the duration of the child’s placement.
- Court: The case manager shall provide a comprehensive summary regarding the child’s health in regular court reports and shall include any current diagnoses and medications, if any.
- Parent(s) Responsibilities: Recognizing that parent(s) are an integral source of information regarding a child’s medical history and, as described in Section 24.2.1, parent(s) are requested to complete the CW-103 when a child enters Children’s Division custody. Parent(s) should maintain documentation of any questions they may have about the child’s health care and seek clarification about those issues promptly.
- Resource Providers: The law obligates resource providers to work with the Children’s Division to provide appropriate medical care for children and continue documentation of the medical care a child receives while in their care. 13 CSR 35-60.050(2)(A)(5) requires that resource providers maintain a medical file for each child placed in their home. 13 CSR 35-60.060 (2)(C) specifies that the medical portion of the file contain the information provided by the Children’s Division and be maintained by the resource providers throughout the child’s placement, to include: all medical and dental information, including but not limited to diseases, surgical history, allergies, immunizations, psychosocial history, and mental health history. Children’s Division has created forms to assist the resource provider in documenting health related needs and appointments regarding the child, CD-264 (Monthly Medical Log) and CD-265 (Healthcare Information Summary). The forms are to be maintained and supplemented by the resource provider throughout the child’s placement and are to be submitted to the case manager monthly, primarily during worker home visits. These visits also provide an opportunity for the resource provider to provide information about the child’s progress and needs related to the child’s health. Other placement providers, such as residential treatment centers and hospitals, shall routinely document the child’s medical care in writing and provide the information to Children’s Division on a regular basis and as requested.
- Children’s Division Responsibilities: In addition to the historical documentation cited in Section 24.2.1 and the provision of such documentation to a resource provider upon initial placement of a child, the Children’s Division has an overarching responsibility to ensure that current medical information is documented throughout a child’s placement in care.
- The case manager shall establish and maintain a medical record as a separate section in the file. To ensure continuity of care, this record shall include copies of the initial medical examination report, all medical records produced while the child is in foster care, all Children’s Divisions forms related to health (such as CW-103, CD-264 & CD-265) and any historical information that Children’s Division is able to obtain about the child’s health.
- Whenever a placement change occurs, the case manager will provide the child’s pertinent medical history (Forms CW-103 and/ or CD-264, as well as all relevant Monthly Medical Logs) to the new resource provider at the time of placement. This must include the name and dosage of any medication currently prescribed for the child.
- All efforts to involve the child and parent(s) in decisions about the health care of the child shall be documented in FACES by the case manager. Documentation should include the child’s response and the parent’s actual involvement or reasons why the parent could not or should not be involved. If the parent(s) cannot be located, the case manager will document any efforts taken to notify them. Available documentation shall be uploaded into Document Imaging.