Effective Date: 7-1-2023
An out-of-home foster care placement shall be the least restrictive placement setting to meet the specific needs of the child (an individual under twenty-one years of age, also referred to as “youth”). In the event that the youth’s condition or behaviors indicate that the youth may require a higher level of care (LOC), the Children’s Division or the contracted foster care case management (FCCM) agency will assess the youth’s current needs to determine the least restrictive, but most appropriate level of care to meet the youth’s specific needs based on available resources.
The Children’s Division or the assigned contracted FCCM agency may conduct a LOC needs assessment at the recommendation or request from one of the following:
- Youth’s family support team;
- Any member of the family support team;
- Written request by the youth’s resource provider;
- Clinician, such as a primary care physician or psychologist, who has treated the youth; or
- If ordered to do so by the court.
When a youth’s case manager receives a request for assessment, or identifies that a youth has a documented medical, developmental, emotional or behavioral need that requires individualized intervention, the case manager shall begin the process of assessing the least restrictive level of care (LOC) needed for the youth to succeed in a community-based family setting and successfully transition to permanency.
The case manager will prepare and submit a referral packet to the LOC Specialist or contracted FCCM agency designee that includes the following completed documents:
- Residential & Specialized Placement Referral (CS-9) and attached documents which may include:
- mental health/psychological evaluations
- medical and/or psychiatric reports
- therapy/counseling reports
- social summary/court progress report
- school records
- Childhood Severity of Psychiatric Illness scale (CSPI) assessment tool
If applicable, the following additional current records should be included:
a. criminal or delinquency history
For any youth age 16 and over:
- CS-3 Life Skills Inventory,
- Daniel Memorial Life Skills Inventory or
- CS-1 Attachment
Note: Failure to include all required and applicable supporting documents and fully completed CS-9 may cause a delay in the screening process. Reach out to the youth’s SMHK assigned care manager to request assistance in acquiring current medical and behavioral health records for the youth.
The Childhood Severity of Psychiatric Illness scale (CSPI) is a required component of the CS-9 packet. The CSPI assessment tool not only assists in the planning of services and treatment for the youth, but also is a requisite of the Medicaid Rehabilitative eligibility determination process.
Level of Care (LOC) Staffing Process
The LOC Specialist or contracted FCCM designee will complete a staffing within 30 days of the receipt of the referral packet and/or written request from a resource parent (whichever occurs first). The following individuals may be invited to participate in or be consulted as part of the staffing process:
- LOC Specialist/ Contracted FCCM Designee (Required Facilitator)
- Case Manager (required participant)
- Youth (as appropriate)
- Case Manager’s Supervisor
- Current Resource Provider
- Current therapist
School Personnel (with knowledge of the youth’s behaviors and functioning level)
- Guardian Ad-Litem (GAL)
- Juvenile officer
- Court Appointed Special Advocate (CASA)
- Licensing Worker for the Family (current or potential)
- Other persons as appropriate for a child specific review including parents.
Level of Care Placement Types
The purpose of the staffing will be to review the referral and obtain information about the youth’s history and current behaviors (within the last 30 days) to determine whether the youth may be eligible and appropriate for a higher level of foster care that is listed below:
- Medical Foster Care
- Elevated Needs Foster Care
- Elevated Needs Level A
- Elevated Needs Level B
- Treatment Foster Care (TFC) Program
- Relative TFC
- Level 2 TFC
- Level 2 Relative TFC
- Transition TFC
The LOC Specialist or contracted FCCM designee will complete the Level of Care Determination staffing based on the assessment of youth’s current treatment needs utilizing form (CD-137) to document the staffing decision and may recommend that the youth:
- Is not appropriate for a higher level of care; or
- Is appropriate for a higher level of care, but a compatible home is not available in the county of origin or nearby counties; or
- Is appropriate for a higher level of care, and there is a compatible home, or
- Is not appropriate for a family foster home due to the youth’s current level of functioning and intensive behavioral/mental health needs pose a significant safety risk of harm to the youth or others which requires a referral to the RCST unit and professional clinical assessment by an Independent Assessor for possible congregate care setting.
LOC staffing is not required when a youth with significant behavioral needs is placed in emergency residential care within the first 30 days of entering foster care.
2.4.2 Medical Foster Care
A youth in foster care with medically diagnosed extraordinary medical condition(s) and/or physical or mental disabilities is eligible to be placed in a resource provider home that is contracted to provide elevated medical needs foster care if the following statements regarding the foster youth is supported with documentation.
- The youth must have a diagnosed medical, mental, or physical condition that requires twenty-four (24) hour availability of a resource provider specifically trained to meet their unique medical needs;
- The diagnosed serious or chronic medical condition that significantly and substantially impairs the youth’s ability to function on a daily basis in a foster family home;
- The youth’s diagnoses and conditions must be included on the Medical Foster Care Assessment Tool, CS-10, or a physician’s certification for medical foster care.
Medical Foster Care Approval Process
All youth referred for a LOC staffing should be screened for eligibility for medical foster care; however, a LOC determination staffing is not required for approval of Medical foster care. A regional director may elect to allow designated local supervisory staff to conduct the Medical foster care eligibility determinations. If approval to determine eligibility for medical foster care is granted to local staff, the regional LOC, HIS management team, Resource Licensing Program Specialist, and Adoption Program Specialist will be provided an updated listing of the local designated staff for the region.
The Medical Foster Care Assessment Tool (CS-10) is used by the child’s case manager and medical professionals to document the diagnosed medical/developmental needs of the foster youth and obtain approval for medical foster care placement. The CS-10 should be submitted through supervisory channels for approval of placement in the home of a licensed resource provider contracted for medical foster care. Supporting documentation includes legibly written statement by the foster youth’s physician or designee of the foster youth’s special needs. Written documentation from other professionals (i.e., physical therapist, speech therapist, nurse) that outlines the task and responsibilities of the resource parents and the needs of the foster youth. The youth’s managed care plan (SMHK) or MO HealthNet may be able to assist case manager in locating medical documents/reports with medical history. The managed care plan (SMHK) is a valuable team member and can also assist resource provider in locating medical or other community services to meet the child’s unique medical concerns.
If a youth approved for Medical Foster Care is placed in a resource provider home that is not contracted to provide medical foster care, the resource provider shall be given consideration to continue placement if they are able to meet the child’s medical needs. The CS-10 should be forwarded to the resource provider’s licensing worker to determine eligibility for an Amendment to Provide Medical Foster Care.
The CS-10 shall be completed based upon the child’s disability and not his/her age.
The CS-10 shall be reviewed annually regarding the status of the foster youth’s eligible conditions with the following exceptions:
- The CS-10 does not need to be reviewed if the eligibility for medical foster care was determined using only Section II subsection A, unless the medical condition has changed.
- The CS-10 can be reviewed at any time regarding the status of the foster youth’s eligible conditions if a FST member requests.
2.4.3 Elevated Needs Foster Care
Foster Youth with Elevated Needs—A program designed for youth with identifiable and documented moderate or serious emotional and/or behavioral needs requiring intensive and individualized intervention to succeed in a community-based family setting and to achieve their permanency goal. There are two (2) levels available to meet the child-specific needs: Level A and Level B.
Foster Care for youth with elevated needs is a program designed for the youth with identifiable and documented moderate or serious emotional and/or behavioral needs. Such a youth requires intensive and individualized intervention to succeed in a community-based family setting and to achieve their goal of permanency. Resource providers of youth with elevated needs have received specific training in addition to required pre-service training to enable them to work with youth with elevated needs.
Placements for youth with elevated needs neither are emergency placements nor are they immediate placements. These placements are transitional placement resources to prepare youth to function adequately and safely in a less restrictive and/or a permanent family setting. It is not intended to be a long-term or permanent placement resource. A pre-placement phase is essential, meaning that the youth should visit the home prior to being placed to determine if the placement is an appropriate fit for the youth. ICPC resource providers are not eligible for elevated needs placements.
The elevated needs assessment shall be conducted by the selection/screening team which will decide if the youth is an appropriate candidate for the program by considering the individual needs of the youth, the presenting behaviors of the youth, and the impact such behaviors have in the placement setting. Youth eligible for elevated needs should have more than one (1) presenting problem as listed in Presenting Problems Displayed By the Youth with Elevated Needs—Level A and Presenting Problems Displayed By the Youth with Elevated Needs—Level B sections of this policy.
Characteristics of a Youth with Elevated Needs
Youth with elevated needs require greater structure, supervision, and are less able to assume responsibility for their daily care. These youth have typically experienced multiple out-of-home placements.
Youth appropriate for Level A foster care may fall into one of two categories:
- Youth presently in a residential setting who may be moved to a less intensive setting, but not to a traditional resource home or to their parents’ home; or
- Youth who lack a viable placement in a traditional resource home and because of their presenting problems would be placed in a residential setting unless an available Level A resource home can be found.
Presenting problems displayed by the Level A foster care candidate may include the following:
- Behaviors which if not modified could result in the youth being designated as a status offender
- History of irresponsible or inappropriate sexual behavior, which has resulted in the need for extraordinary supervision
- Threatening, intimidating, or destructive behavior which is demonstrated by multiple incidents over a period of time
- Problems of defiance when dealing with authority figures
- Significant problems with peer relations
- Significant problems at school that affect academic achievement or social adjustment
- Significant problems with lying, stealing, or manipulating
- Significant problems of temper control
- Mild substance abuse related problems
- Oppositional behavior that contributes to placement disruptions and inability to function productively with peers, parent figures, birth family, etc.
- Any of above behaviors, coupled with medical problems
- Any of above behaviors displayed by one or more youth of a sibling group, qualifying the entire sibling group for placement together, if appropriate. However, not all youth would be eligible for the Level A maintenance rate.
Youth Who May Not be Appropriate for Level A. Youth who may not be appropriate for Level A may include, but are not limited to, the following:
- Youth who may function successfully in a traditional foster home or adoptive or
- guardianship placement;
- Youth who qualify for a higher level of care and meet the criteria for Youth with
- Elevated Needs Level B;
- Children under the age of three (3) who cannot be treated effectively through the
- behavior modification treatment model;
- Youth who exhibit severe psychiatric behavior, as diagnosed by a psychiatrist/psychologist,
- such as an obvious lack of emotional contact, affect disturbances, and/or severe thought distortions;
- Youth with a recent history of extreme or dangerous physical aggression;
- Youth with a recent history of fire setting;
- Youth who have recently attempted suicide and continue to have suicidal ideations;
- Youth with an IQ score below sixty-five (65);
- Youth who are medically diagnosed as chemically dependent;
- Youth with severe medical or physical handicaps which present barriers that the child cannot or will not overcome;
- Youth whose primary presenting problem, as diagnosed by a psychiatrist/psychologist, is sexual addiction and who need extremely structured treatment and unusually close supervision; or
- Youth with personality disorders, as diagnosed by a psychiatrist/psychologist, who have severe problems forming attachments with caretakers and significant others.
Youth appropriate for Level B foster care have serious emotional and/or behavior problems that require the 24-hour availability of a highly skilled Level B resource parent who is capable of assuming the role of primary change agent. These youth-
- Because of their presenting problems would be placed in a level III or above residential treatment facility or psychiatric hospital;
- Have been discharged from a residential treatment facility or psychiatric hospital and who are unable to function effectively in a traditional foster home.
Presenting problems displayed by the Level B foster care candidate may include the following:
- History of suicide or currently having suicidal thoughts, statements and/or gestures
- Affective disorders
- Attention Deficit Disorder
- Post-Traumatic Stress Disorder
- Eating disorder
- Panic disorders
- Obsessive/Compulsive Disorders
- Oppositional Defiant Disorders
- Dissociative behaviors, blank out, pass out, seizure
- History of fire setting
- Destructive of property
- Failure to form emotional attachments
- Multiple short-term placements
Youth who may not be appropriate for Level B may include, but are not limited to, the following:
- Children who may function successfully in a traditional foster home or adoptive or guardianship placement;
- Youth who qualify for a lower level of care and meet the criteria for Elevated Needs Level A;
- Actively suicidal;
- Compulsive fire setter;
- Sexual abuse offender which might endanger other family members;
- Require around-the-clock awake supervision;
- Unable to function in school and alternative program (day treatment) is not available; and
- Youth who have demonstrated behaviors that pose a significant risk of harm to the youth or others that require professional treatment in a hospital or institutional or structured residential care setting.
Working with Youth with Developmental Delays
Youth with developmental delays may, or may not, be appropriate for Level B Foster Care. Appropriateness for Level B Foster Care should be based on the selection/ screening team and/or the family support team (FST) evaluation of all the circumstances surrounding that particular youth.
Youth should not be ruled out for Level B based solely on the singular characteristic of an IQ score falling below sixty-five (65). Instead, the team should consider a variety of information including, but not limited to, the following:
- Youth’s functioning level;
- Severity of developmental delays;
- Ability for self-care;
- Type of behavior problems;
- Level of physical aggressions;
- Compliance; and
- Need for supervision.
The resource licensing worker of potential elevated needs resource home placement families will share all referral information with the prospective resource parents and assess with them their ability to meet the youth’s needs.
The youth’s case manager will then carry out any of the following actions, as appropriate to the youth being placed:
- Coordinate all planning with the service county, if the county of current placement is different from the case manager county
- Receive notification when a resource becomes available
- Notify the licensing worker if the placement is no longer needed
The youth’s case manager will communicate with the potential elevated needs placement regarding pre-placement visits and any other information required.
Level B Resource Parents may be reimbursed via a payment request for transportation costs of pre-placement activities. The actual number of visits is governed by the needs of the youth and the Level B resource family.
The Children’s Service Worker must gain commitment from both the youth and resource family and then proceed with the placement. The worker will assure the youth’s arrival at the resource home when all parties agree the child is ready.
Ongoing Procedures to Maintain Placement
The Children’s Service Worker will assess the youth’s overall treatment needs, including educational and emotional needs and will obtain evaluations if needed. The worker will develop a treatment plan with the Family Support Team (FST) for stabilizing the child’s behavior, to improve their level of functioning at home, school and in the community and to achieve permanency.
Resource parents are the primary change agents for youth placed in their care. Support and guidance should be provided to the resource parents. However, on a case-by-case basis, other therapeutic support may be added for the youth based on the particular situation as recommended by the team working with the youth.
During placement home visits the worker will, if needed:
- Assess and monitor the youth’s progress toward treatment and permanency goals
- Assess and monitor the resource parent’s job performance
- Review and discuss reports maintained by the resource parent
- Arrange regularly scheduled respite care
The case manager will assess the level of care required by the youth at 90-day intervals and move the youth to a less restrictive environment as appropriate.
The resource licensing worker and youth’s case manager will provide the resource parent with feedback about how the placement and child are doing as needed.
The Resource Licensing worker will notify the elevated needs level B resource parent regarding access to purchase medical, dental, and vision insurance. The worker will inform the resource parent that the insurance company will provide enrollment information.
Periodic Reviews for Elevated Needs Youth
The goal for youth who qualify for the youth with elevated needs program is to stabilize their behavior, to help them function in a less restrictive environment and to achieve permanency. Level A and Level B care is not permanency but is designed to be a stepping stone for the youth to obtain a permanent home. As these youth do have a variety of special needs, the goal of successful permanency can be challenging. Accordingly, resource parents, staff, and other treatment team members must aggressively pursue permanency and use periodic reviews as one of the tools to assure progress toward permanency is occurring.
To assist youth in achieving permanency, it is important that the resource parent and the team tailor the level of intensity and intervention to their needs as youth achieve progress and success. Most youth in Level A and Level B care do make substantial improvement in their behavior during the first year of intervention and can function with a reduced level of intensity. Other youth may need the intensity of elevated intervention for longer periods of time to maintain stability in a family home setting.
In promoting permanency, the Elevated Needs Resource parent and case manager should involve the youth’s parents, relative, or other permanency family in the youth’s treatment. Elevated needs resource parents are the change agents, so they work with the youth and provide youth’s family with coaching, mentoring to assist family with understanding the youth’s behaviors and importance of past trauma, triggers, and treatment needs and skills to successful transition to permanency. The youth’s parents and/or other permanency placement would benefit from trauma informed parenting trainings that specifically address the higher levels of care treatment needs.
The dilemma for the teams may be how to move the youth to the appropriate level of intervention, such as Level A or traditional foster care, without moving the youth from the current resource home. Ideally, youth who improve in elevated needs Level A or Level B care and are ready for less intensive care could move directly to their permanent home. When that is not possible, the next best solution is to keep the youth in the same resource home under the category of Level A, traditional foster care (depending on the youth’s needs) or pre-adoptive home. Youth who are happy in their resource home and are experiencing success should not be moved to a different resource home solely due to no longer needing Level B intervention.
Staff, resource parents and the team members must assess each individual situation carefully and negotiate an outcome that is in that youth’s best interests. Periodic reviews are a critical tool for assuring the youth’s level of intervention is matching their needs and that permanency is on target. As always, the best interest of the youth is the guiding principal with these complex decisions.
Situations where there is disagreement among team members as to continuing need for intervention and/or the appropriate plan for the youth should be referred to the Regional Director or designee for consultation.
Periodic Review schedule:
- Six (6) months –LOC Review Staffing completed with the resource parents and/or the Family Support Team. The team will continue to review youth’s situation every 6 months on an on-going basis.
- Twelve (12) months reviews – Regional Office Review Team conducts a review based on local team review information. Regional Office Reviews are a critical tool in assuring consistency, accountability and progress with the Level B program. Also, Level B Foster Care status does not exclude youth and families from compliance with ASFA timelines.
Termination of Elevated Needs Classification
Permanency planning shall continue throughout the Level A or Level B placement. The worker shall seek a less restrictive setting once the youth’s presenting problems have been replaced with appropriate coping behaviors. It may be necessary to involve a Children’s Service Specialist for consultation if the team is unable to reach a consensus regarding termination of the youth’s classification.
2.4.4 Treatment Foster Care (TFC) Program
Treatment foster care (TFC) is an individualized therapeutic intervention for youth with significant medical, developmental, emotional or behavioral needs who require a higher level of care, clinical support ,and case coordination along with individualized supports for the caregiver(s) than can be provided in a traditional foster home in order for the child to succeed in a community–based family setting. TFC exists to serve children and youth whose special needs are so severe that they are at risk of being placed in restrictive congregate care settings such as hospitals, psychiatric centers, correctional facilities, or residential treatment programs.
TFC services are provided by licensed Child Placing Agencies contracted with the Children’s Division (CD) to develop, support and oversee TFC homes and services. Treatment services are individualized to meet the needs of each youth and the TFC family; both receive flexible services over time to meet their changing needs. Treatment typically involves teaching adaptive, pro-social skills and responses that equip youth and their families with the means to deal effectively with the unique conditions or individual circumstances that have created the need for treatment.
2.4.5 Relative Treatment Foster Care (R-TFC)
Relative TFC is a specialized TFC service that allows the TFC eligible youth to remain or placed in a relative home setting with the addition of individualized training, support, and resources provided by the TFC agency. Relative TFC parents are provided flexibilities that allow the placement of the TFC youth with a relative caregiver prior to the completion the required trainings and licensing as is permitted in traditional relative foster care homes. The TFC Agency is responsible for providing and coordinating the required specialized trainings, services and resources to assist the relative family in gaining the skills and meeting the youth’s individualized therapeutic and rehabilitative needs.
2.4.6 Level 2- Treatment Foster Care (TFC)/Relative TFC
Level 2 TFC and Level 2 Relative TFC is a level of treatment foster care for youth whose needs and/or behaviors are so persistent and severe that they require the coordination of multiple services and interventions, including therapeutic and community-based services for the youth who could not otherwise be served in a community setting without that intensive level of individualized intervention.
Eligibility Determination and Authorization for Level 2 TFC and Level 2 Relative TFC services are completed by the youth’s managed care plan (SMHK) or MO HealthNet based on clinical assessment of the youth’s therapeutic and rehabilitative needs. The TFC agency is responsible for requesting and submitting the necessary referral information to the managed care plan (SMHK) or MO HealthNet for Treatment Foster Care authorization, see TFC Authorization Process section below.
Level 2 Eligibility Criteria
Youth who demonstrate one (1) or more of the following needs or behaviors may be eligible for Level 2 Treatment Foster Care/Relative TFC; this is not intended to be an inclusive list.
- Need for safety measures within the home, including, but not limited to:
- Alarm system;
- Cameras; or
- Physical separation from other children.
- Need for one-on-one supervision by the TFC parent at least seventy-five percent (75%) of the time, including both waking and sleeping hours (exception to this requirement to allow for a substitute care provider during times that the TFC parent is unavailable).
- Chronic elopement.
- Need for treatment of current substance abuse.
- Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of autism spectrum disorder (per DSM, Level 2 and Level 3 of autism spectrum disorder require substantial to very substantial support).
- DSM diagnosis of intellectual disability (IQ 70 or below, onset before 18, DSM 5 onset during developmental periods).
- DSM diagnoses of scatolia (feces smearing), incontinence, or enuresis.
- Need for additional supervision and services due to homicidal threats.
- Known or suspected history of child human trafficking.
- Dissociative behaviors.
- Periods of unconsciousness (blacking out, epilepsy, seizure).
- History of fire setting.
- Multiple short-term placements (taking into consideration number and types of placements in placement history).
- Medical condition requiring daily monitoring, dependence on mechanical support for mobility, or an appliance for breathing, feeding, or drainage, including, but not limited to:
- Diabetes requiring insulin;
- Medical condition requiring a lift; or
- Medical condition requiring assistance with bathing and toileting.
- Self-harm with suicidal ideation or self-harm resulting in injury that requires medical attention, including cutting and swallowing harmful objects or substances.
- Frequent utilization of 24/7 crisis intervention or acute hospitalization.
- Involvement with the juvenile justice system.
- Need for frequent respite above and beyond the approved level of respite.
- Inability to maintain traditional school setting, including, but not limited to:
- Homebound school;
- Day treatment;
- Non-traditional school setting;
- Specialized school transportation; or
- Extra-ordinary educational support.
The LOC Specialist does not make a determination on the Level of TFC, only if youth is eligible for TFC services.
TFC Authorization and Placement Process
1. A youth’s eligibility for treatment foster care may be identified through one of the following:
- Level of Care (LOC) Specialist or contracted FCCM designee recommends TFC services, provided case manager with the completed LOC staffing determination form, CD-137;
- An independent assessor recommends TFC services;
- Residential treatment care team recommends TFC as part of the youth’s discharge plan; or
- A clinician, such as a primary care physician or psychologist, who has examined or evaluated the youth, recommends TFC services.
2. Case manager will submit the TFC referral packet (CS-9/CSPI packet) and approved CD-137
- The LOC Specialist or FCCM designee will assist the case manager in:
- Submitting the TFC referral to available TFC agencies;
- Providing copy of TFC Agency Contacts and TFC Provider Coverage Map; and
- Locating least restrictive, relative or kinship potential placements;
- Setting up formal follow-up 30 day meeting if no Relative TFC or TFC placement to discuss possible placement ideas and strategies.
3. The TFC agencies will review the TFC referral packet to determine if their agency has any available TFC homes that can meet the needs of the youth and provide a written determination regarding acceptance within 72 hours of receipt of TFC referral.
4. Relative TFC referral acceptance is dependent on the following:
- TFC agency staff availability to serve the relative family’s geographical area.
- TFC agency conducting Relative In-home Assessment
- Relative must agree to training and support from TFC Specialist in the home;
- Relative and all HH members must pass background screening prior to start of services;
- Relative have capacity and willingness to provide rehabilitative interventions with the youth utilizing the supports and training provided by TFC Specialist/Agency.
5. Once a TFC family has been identified or Relative TFC Assessment is completed, TFC Agency will submit the TFC referral packet to youth’s managed care (SMHK)/Mo HealthNet plan requesting:
- Pre-authorization for TFC or Relative TFC or Level 2 TFC/Relative TFC
6. The managed care plan (SMHK) or MO HealthNet will review the youth’s TFC referral packet, evaluate the youth’s current conditions utilizing a clinic assessment tool, and makes the following determination:
- TFC/Relative TFC is the most appropriate and the least restrictive community-based family setting to meet the individualized therapeutic and rehabilitative needs of the youth; and
- TFC/Relative TFC is medically necessary based on Medicaid Rehabilitation criteria; and
- Authorizes either TFC/Relative TFC or Level 2 TFC/Relative TFC; and
- Provides written pre-authorization to referring TFC agency for the initial TFC treatment period, not to exceed 9 months, authorizing TFC rehabilitative services to begin.
- If Managed Care plan (SMHK) or MO HealthNet determine that the youth does not meet the medical necessity criteria for TFC Rehabilitative services, they assist case manager in accessing community resources for the youth. There will also be an opportunity for the TFC Agency to re-submit additional report to support the TFC request.
7. TFC Agency will notify case manager and LOC Specialist or contracted FCCM designee of the TFC determination.
- TFC agency will provide case manager a copy of TFC pre-authorization along with the TFC home’s names/DVN, date TFC/Relative TFC placement to begin; and
- TFC agency and case manager will make a placement plan, including arranging pre-placement visit.
8. Case manager will notify LOC specialist or contracted FCCM designee of the youth’s TFC determination and provide the following:
- Name of TFC agency, name of TFC home/DVN, TFC type and level approved (TFC/Relative TFC or Level 2 TFC/Relative TFC), and placement date.
9. LOC specialist will notify the Payment Specialist/Designee of the TFC placement date and approved TFC Level in order to authorize payment of room and board for the TFC agency.
TFC Program Services
The TFC provider agency is a licensed Child Placing Agency contracted with the Children’s Division (CD) that recruits, retains, and approves TFC resource parents. In addition, the TFC agency shall provide or arrange team-delivered therapeutic and rehabilitative services for each placed youth, appropriate to the individual needs of the youth. TFC Agencies must provide or arrange the following treatment services, as appropriate:
- Case Management: Activities specified in the treatment plan, which are aimed at linking the child to necessary medical, mental health, educational, vocational, social, and support services.
- Crisis Intervention: Crisis intervention and support must be provided for all TFC homes with placement twenty-four hours a day, seven days per week, including all holidays. The phone number, email address, or other means of communication to access this crisis intervention and support must be shared with the TFC resource parent(s), youth’s case manager, and LOC Specialist/contracted FCCM designee within twenty-four hours after the youth’s placement in the home.
- Mentoring: Mentoring and coaching to the child’s family or another permanency resource.
- Permanency: Preparing the child and their family or another permanency resource for a successful transition to permanency.
- Physical Maintenance Services: Food, clothing, personal incidentals, school supplies, and transportation.
- Psychiatric Services: If applicable, psychiatric services for the child, which include a review of the youth’s treatment and any medications prescribed by the psychiatrist.
- Respite Care: TFC resource parents must be provided with forty-eight hours of respite care each month.
- Relative TFC: Relative TFC resource parents must be provided with the option of increased in-person or virtual visits to meet the individual needs and supports of guidance and coaching from the TFC specialist to fulfill the responsibilities of a TFC resource provider.
- Supportive Services for the Child: Supporting services must be provided to each child, utilizing a combination of community support services, family rehabilitative services, and clinical therapy services. Services must be provided to encourage and support the child’s adjustment in the TFC home, school, community, and the child’s primary family relationships. These services must express the goals and objectives of the child’s treatment plan, and include individual psychotherapy, group therapy, and family therapy services, as needed. Supporting services include planned psychosocial interventions that promote increased individual and family self-sufficiency and positive empowerment of the child, and support of the child’s eventual transition from TFC to family reunification, other family permanency placement, or independent living.
- Support and Technical Assistance for the TFC Resource Parent: Regular, ongoing support and technical assistance must be provided to the TFC parent(s) in the implementation of the treatment plan and other TFC responsibilities.
- Fundamental components of technical assistance include the design or revision of in-home treatment strategies, including proactive goal setting and planning, and the provision of ongoing child and family-specific skills training and problem solving in the home during home visits.
- Other types of support and supervision include emotional support and relationship building, the sharing of information and general training to enhance the caregiver’s parenting knowledge and skill development, professional development and assessment of the child’s progress, observation and assessment of family interactions and stress, and assessment of safety issues.
Roles and Responsibilities
TFC agencies program staff must have competencies needed to engage relative families, and it may be helpful for agencies to designate specialized staff to work primarily with relative providers, if feasible, which can improve engagement with relatives. These competencies include, at a minimum:
- Understanding the complex family dynamics and emotions associated with caring for a relative child;
- Understanding that relatives have little preparation for their role as a foster parent; and
- Skills to engage the relative triad, which includes the child, the child’s parents, and relative caregivers.
The TFC agency also ensures that each youth is assigned a TFC specialist, who is responsible for the following:
- Developing and implementing the youth’s treatment plans in collaboration with FST team;
- Providing support to the TFC parent, TFC youth and their family;
- Preparing the treatment team to work with the resource parents and the child’s family in a manner that maintains the child’s safety, permanency, and well-being;
- Scheduling and providing weekly consultations, in person or by phone, with the TFC parent(s);
- Documenting the consultations in the case file;
- Visiting the TFC home in-person at least weekly for the first thirty (30) calendar days, then a minimum once every two (2) weeks for the duration of the placement; and
- Increasing the frequency of visits based on the child’s needs and capacities of the TFC caregiver;
- Ensuring in-home visits include direct communication with the TFC parent and direct observation of the foster child’s interaction with the members of the household; and
- Including direct and private interaction with the foster child to allow for youth to communicate any concerns;
- Making a direct assessment of the child’s progress as well as monitor the health, safety, and well-being of the child and work on age-appropriate life skills;
- Visiting the youth no less than thirty (30) minutes in duration;
- Allowing the TFC parent more frequent in-home visits upon request;
- Documenting all visits, including the date and duration, conducted in the child’s case record and shall include information on the child’s adjustment and development; and
- Documenting all visits/contacts with the TFC child and TFC parents in the monthly
This is accomplished through a trauma-informed care lens that recognizes the significant needs of children placed in TFC homes and views the TFC Resource provider as the primary change agent.
The TFC Agency shall ensure that the TFC parent(s) are supported and equipped to provide the following requirements:
- Assume primary responsibility for providing therapeutic interventions in the home and act as a liaison with clinical personnel. Interventions shall be therapeutic and provide for the child’s basic care.
- Implement in-home treatment strategies, assist the child in understanding treatment goals, objectives, and interventions, and help the child to achieve success.
- Collaborate with TFC program staff and the treatment team to revise interventions that may not be effective and receive assistance from program staff with implementation strategies as needed.
- Comply with all requests from the Department for visits, training, and meeting participation, including participation in all treatment plan meetings and TFC support group meetings.
- Provide room, board, and routine transportation for each placed child, including transportation for the child to/from treatment team meetings, court appearances, medical, and counseling appointments, etc.
- Maintain weekly or daily records, however, the Relative TFC parent(s) shall have the option to provide verbal updates to the TFC specialist who shall ensure the written records are being kept depending on the child’s treatment plan, that include the following:
- The child’s behavior and progress in targeted areas;
- Family contacts (i.e. phone contacts, letters or e-mails exchanged, face-to-face visitations);
- Appointments (i.e. medical or counseling);
- Community activities (i.e. community service activities);
- Face-to-face contacts with program staff;
- Medication administration and compliance; and
- Other activities, as required.
- Comply with all foster home licensing requirements as specified in 13 CSR 35-60 and the Children’s Division Child Welfare Manual.
- Relative TFC parent(s) shall be provided with the option of increased in-person or virtual visits to meet the individual needs and supports of guidance and coaching from the TFC worker in order to fulfill these requirements.
- TFC parent(s) maintain the confidentiality of all records and must only share information pertaining to the child and his/her family with members of the child’s treatment team in accordance with Children’s Division policy, as necessary for the proper care of the child as described in the Foster Parent Bill of Rights, 210.566, RSMo.
- TFC parent(s) shall work closely with the child’s biological family, planned permanency placement resource, visiting resources, and case managers to achieve permanency for the child, in accordance with the treatment plan.
- The TFC parent(s) shall appear in court and legal proceedings and provide testimony without being subpoenaed.
Monthly Progress Reporting Requirements
The TFC agency shall provide the LOC Specialist or contracted FCCM designee and TFC Program Specialist a monthly summary of the youth’s treatment along with support services to child and family within fifteen (15) days of each month following the month of service, which shall be submitted using the CD’s online invoicing system. This monthly summary shall include, at a minimum:
- An itemized statement describing the actual services provided to each child during the reporting period, including, but not limited to, a full accounting to include the type, subject matter (topic), and duration of all individual, family, and group therapies along with individualized coaching/training actually provided during the reporting period;
- Notations if the therapies or services are part of a specialized program such as chemical dependency/substance use treatments, youth with problem sexual behaviors;
- A summary of the child’s educational progress during the reporting period; and
- A summary of the child’s health, behavioral health, and mental health care during the reporting period, including compliance with the requirements of the Settlement Agreement in M.B. vs Tidball which can be found at: https://dss.mo.gov/notice-of-proposed-class-action-settlement.htm.
- Notations of the dates the TFC specialist/TFC Agency visited the TFC home and child’s home during Transition TFC services.
- While discharge and transition planning is started at the beginning of the child’s TFC placement, it shall be a part of the child’s monthly progress reports with focus and promotion of achieving permanency.
Children placed in TFC homes will receive direct treatment and services to address and ameliorate the specific needs associated with their placement. Treatment and services must also address the child’s social, emotional, cognitive, and physical needs. Treatment includes written plans that are specific, measurable, attainable, realistic, and timely. Treatment planning and services should be based on research findings that support the use and efficacy of the specific treatment activity.
Treatment planning services must actively involve the child’s family, TFC resource parents, relative caretakers, legal guardians, or adults who play a significant role and will continue to do so in the treatment and care of the child while in treatment foster care. Treatment services provided by the agency must be designed to:
- provide safe, nurturing care, and guidance in private family homes when children are unable to receive the parental care they need in their own home
- ensure the child is integrated fully into the community and provided opportunities for participation in community and extracurricular activities as well as the development of talents, interests, and hobbies
- provide a higher level of clinical support, intervention, and case coordination than those children eligible for traditional foster care
- prepare children for a successful transition to permanency from the TFC home to the child’s parent, relative, or adoptive home
- meet the individual child’s treatment needs
Within 30 days of youth’s placement in the TFC program, the TFC specialist in collaboration with the youth’s FST team must develop and implement the child’s treatment plan and submit to the youth’s case manager and LOC specialist/contracted FCCM designee. Treatment planning must include the child and family voice and be trauma-informed. Treatment planning must also extend beyond the time the child will be placed in the TFC home and must include discharge planning. The child-centered treatment plan must be based on the intake admission assessment, including the child’s presenting problems, needs and strengths, health history, provisional or admitting diagnosis, and evaluation or assessments. Additional information on previous placements, the cultural background of the family, and observations of the child’s adjustment in the TFC home, school, and community must be documented in the plan. Coordination of care must also be indicated in the plan, including other community clinicians, the youth’s treatment progress from community treatment and service providers shall be documented.
The TFC specialist and supervisor must review the treatment plan weekly to continually evaluate the continued need for TFC services. The TFC specialist must:
- Evaluate the progress of a youth and their family at least every thirty days;
- Complete a written monthly summary of the youth’s treatment and services;
- Submit monthly summary to the case manager and LOC Specialist/contracted FCCM designee; and
- Ensure the treatment plan is reviewed by the treatment team and updated at least every 90 days or more often if the treatment needs change.
The agency must collaborate throughout the TFC placement with the child’s case manager and/or LOC Specialist on permanency planning for each placed child. Permanence for children and their families can take many forms, including reunification, adoption, and guardianship.
TFC resource parents also have a responsibility to assist the child in their care in reaching permanence. To do so, TFC resource parents must work closely with the child’s family, other family, visiting resources, and case managers to achieve permanency for the child, in accordance with the child’s treatment plan. TFC provider agencies should work closely with resource parents to promote permanency for every child. In planning for permanence, the TFC resource parent must:
- Maintain positive interactions with the youth’s parents or another permanent placement resource;
- Facilitate contact, such as visits and phone calls, with the child’s parents or another permanent placement resource;
- Discuss and address the needs of the youth, including discussion of service continuity, with the youth’s permanency resource;
- Providing updates to the child’s treatment team on the child’s treatment progress and well-being;
- Maintain positive interactions with supportive individuals in the child’s life who will continue a positive and active role as part of the child’s permanency;
- Assist in preparing the child for permanence by keeping the child informed of plans and progress toward permanence;
- Help the child build positive connections with people who will serve as long-term supports; and
- Assist the child in building developmentally appropriate life skills needed for the transition to adulthood.
Planning for permanence must also occur in coordination with the child to ensure stability and continuity of permanent and lasting relationships and connections. The child’s voice must be at the forefront of permanency-related conversations. Permanency planning with the child includes:
- Preparing the child for the transition to permanency;
- Assisting the child in building developmentally appropriate life skills needed for the transition to adulthood;
- Assisting the child in maintaining connections with relatives;
- Ensuring children attend treatment team meetings as appropriate;
- Planning in coordination with the child’s therapist or mental health provider;
- Engaging in family finding and other engagement activities;
- Recruitment for the permanency resource, such as an adoptive home, for the child, if reunification is not the child’s goal;
- Providing opportunities for children to connect with their identified permanency resource through phone calls, video calls, and in-person visits; and
- Supporting the child as they transition to permanency.
Planning for permanence with the child’s identified permanency resource will support lifelong permanence for the child and their family. Planning with the permanency resource will also ensure the child’s needs continue to be met and there is a continuity of services. The permanency resource should be a member of the treatment team and attend all treatment team meetings. Agencies may need to support the permanency resource through training, mentoring, and Transition TFC services.
TFC Reviews and Reauthorization
- The TFC agency shall set up a TFC Review meeting with the LOC specialist, FST team, and managed care plan (SMHK) or MO HealthNet to review the progress on the youth’s individual treatment plan and discuss the discharge/transition plan no later than seven (7) months from the date of the placement in the TFC or Relative TFC home.
2. If the FST Review team determines that the youth continues to require a TFC or Relative TFC services, the TFC agency shall seek re-authorization for continued TFC placement.
- TFC Agency will submit the TFC review packet to youth’s managed care (SMHK) or Mo HealthNet plan requesting:
- Pre-authorization for TFC or Level 2 TFC; Relative TFC or Level 2 Relative TFC
3. The managed care plan (SMHK) or MO HealthNet will review the youth’s TFC review packet, evaluate the youth’s current conditions utilizing a clinic assessment tool, and makes the following determination:
- TFC/Relative TFC is the most appropriate and the least restrictive community-based family setting to meet the individualized therapeutic and rehabilitative needs of the youth; and
- TFC/Relative TFC is medically necessary based on Medicaid Rehabilitation criteria; and
- Authorize either TFC/Relative TFC or Level 2 TFC/Relative TFC; and
- Provides written re-authorization to referring TFC agency for the approval of TFC for a treatment period, not to exceed 9 months, authorizing TFC rehabilitative services to continue.
- If Managed Care plan (SMHK) or MO HealthNet determine that the youth does not meet the medical necessity criteria for TFC Rehabilitative services, the managed care plan will assist case manager in accessing community resources for the youth and provide opportunity for the TFC Agency to re-submit additional reports to support the TFC request; and
- Discuss Transition TFC services for the youth (refer to Transition TFC, 2.4.8)
4. TFC Agency will notify case manager and LOC Specialist or contracted FCCM designee of the TFC determination.
- TFC agency will provide case manager a copy of TFC re-authorization along with the TFC home’s names/DVN, date TFC/Relative TFC placement re-authorized
5. Case manager will notify LOC specialist or contracted FCCM designee of the youth’s TFC determination and provide the following:
- Name of TFC agency, name of TFC home/DVN, TFC type and level approved (TFC/Relative TFC or Level 2 TFC/Relative TFC), and placement date.
6. LOC specialist will notify the Payment Specialist/Designee of the TFC re-authorization date and approved TFC Level in order to authorize payment of room and board for the TFC agency.
Discharge and Transition Planning
Discharge planning must begin at the time of placement and should include a review of treatment and any treatment recommendations that are likely to facilitate successful discharge from the TFC placement. The TFC agency must coordinate discharge and transition planning with the case manager and treatment team, with the intent to seek reunification or other family permanency placement. Less restrictive settings should only be considered when the child’s family or potential kinship arrangement is not immediately conducive. In either case, the child’s presenting problems must be alleviated with appropriate coping behaviors.
Based on the child’s approved treatment plan, the agency must recommend discharge to the treatment team when discharge planning is warranted. The agency will set up a meeting to review the progress on the child’s treatment plan and discuss the discharge plan from Transition TFC no later than seven months from the date of the placement in the TFC home or 60 days prior to the end of the TFC authorization period. To prepare for the child’s discharge, a review will also be conducted by the LOC specialist or contracted FCCM designee at the end of seven (7) months to ensure a successful transition.
Upon a child’s discharge from the TFC services, the agency must provide thirty calendar days of transition planning. As part of transition planning, the agency will provide mentoring and support to the child’s parent(s) or other family permanency placement to promote a successful transition to permanency. If the child has not been discharged to permanency, but instead has moved to a new placement, the agency will coordinate and participate in a transfer conference with the next placement provider.
The agency must prepare a discharge report for every youth exiting their TFC program. Discharge reports must include, but are not limited to the following:
- Description of the identified treatment needs when placed with the program;
- Summary of the services provided;
- Analysis of the youth’s progress in treatment;
- Statement of the youth’s status, diagnosis, and prognosis on discharge; and
- Recommendation for TFC Transition Services
2.4.8 Transition Treatment Foster Care (TFC) Services
Transition TFC services are individualized therapeutic services designed to help children in TFC successfully transition to permanency from a TFC home to the youth’s parent(s), a less intensive relative/foster family, adoptive family, independent living, or other community setting. The contracted TFC agency is responsible for providing the services and provides
- TFC Agency shall provide Transition TFC Services for all eligible youth and the youth’s parent(s) or other family placement continuing to move towards permanency. Less restrictive settings should only be considered when the child’s family of origin or potential kinship arrangement is not immediately conducive.
- In the event the child transitions to a traditional or less intensive relative/foster home, pre-adoptive home, licensed under 13 CSR 35-60, the youth’s Children’s Division or contracted FCCM case manager.
- The TFC Agency shall submit the detailed Transition TFC Services plan thirty (30) calendar days prior to the child’s planned discharge/transition from the TFC/Relative TFC home.
- TFC transition services shall utilize an approved TFC model that assists the child in meeting their permanency goals.
- The TFC Agency shall utilize community resources to meet the needs of children and families authorized to receive Transition TFC Services.
Transition Treatment Foster Care (TFC) Transition Services may include:
- Assessment, monitoring, and on-going management of medication regimen;
- Therapeutic, clinical treatment services which target trauma recovery and is not covered separately through the managed care plan (SMHK) or MO HealthNet (MHD) Healthy Children and Youth (HCY) or Physician’s Services Program;
- Monitoring and evaluating day to day activities to assist with the reduction of the disability and restoration of the child’s functional level;
- Services designed to expedite and increase the child’s inclusion into the family and community;
- Services to ameliorate emotional trauma;
- Supportive services to provide the child opportunities to attend and have an educational program; and
- Services to ensure a safe and stable home environment.
- Support of the child’s eventual transition from TFC to family reunification, other family permanency placement, or independent living.
Transition TFC Referral Process and Placement
- If the review team determines that the youth no longer requires the intensive therapeutic treatment of a TFC home, the TFC agency will:
- Provide the TFC discharge plan and the detailed Transition TFC services plan with planned move date to the case manager, managed care plan (SMHK)/MO HealthNet, LOC Specialist or contracted FCCM designee, and the TFC Program Specialist.
- Coordinate with the case manager and treatment team, to prepare youth and youth’s family for discharge and move from TFC home to youth’s family home or other family placement continuing to move towards permanency.
- Provide managed care plan (SMHK)/MO HealthNet, LOC Specialist or contracted FCCM designee with the Youth’s Discharge Summary and the following:
- TFC or Relative TFC home name and discharge date, Start Date for Transition TFC, TFC Agency DVN, and youth’s permanency placement (if not with parents, name of relative or foster home and DVN#)
2. Transition TFC services initial authorization shall be for up to 6 months of services provided in the youth’s permanency home, less restrictive family foster home, or other community family-like setting.
- Transition TFC services does not require pre-authorization from the youth’s managed care plan (SMHK) or MO HealthNet plan for the initial 6 month approval, only a copy of the youth’s discharge/transition plan.
3. Requests for re-authorization of Transition TFC Services beyond 6 months, TFC agency shall:
- Submit current updated Transition/Discharge Plan with supporting documentation to the managed care plan (SMHK) or MO HealthNet, supporting documentation to demonstrate that the youth and youth’s family continues to require this level of care and services to maintain the youth in community family setting and/or continue to work towards achieving permanency for the youth.
2.4.8 Termination of Services
Based on the child’s approved treatment plan, the agency must recommend discharge to the treatment team when discharge planning is warranted. The agency will set up a meeting to review the progress on the child’s treatment plan and discuss the discharge plan from Transition TFC no later than four (4) months from the start date of Transition TFC services or 60 days prior to the end of the TFC authorization period. To prepare for the child’s discharge, a review will also be conducted by the LOC specialist or contracted FCCM designee at the end of four (4) months to ensure a successful transition to permanency.
Upon a child’s discharge/termination of TFC services, the agency must provide thirty calendar days of transition planning. As part of transition planning, the agency will provide mentoring and support to the child’s parent(s) or other family permanency placement to promote a successful transition to permanency. If the child has not been discharged to permanency, but instead has moved to a new placement, the agency will coordinate and participate in a transfer conference with the next placement provider.
The agency shall prepare a discharge report for every youth exiting their TFC program. Discharge reports must include, but are not limited to the following:
- Description of the identified treatment needs when placed with the program;
- Written summary of the services provided;
- Analysis of the youth’s progress in treatment; and
- Statement of the youth’s status, diagnosis, and prognosis on discharge.
TFC Agency shall provide copy of TFC discharge summary to case manager, managed care plan (SMHK) or Mo HealthNet, LOC specialist or contracted FCCM designee, and TFC Program Specialist within 30 days of discharge.
Related Practice Points and Memos:
07/26/2023 – CD23-18 – Levels of Care