HEALTH CARE

The Illinois Department of Children and Family Services (DCFS) is responsible for ensuring that all children in its care and custody receive documented quality health care services. Barriers that hindered wards from receiving documented health care services were:

• lack of access to health care services;

• lack of access to qualified providers;

• lack of receipt of health care services; and

• lack of documentation of health care services.

Adequate physical and behavioral health care are important factors in ensuring the long-term well-being of a child. As a result, provision of such care is a vital part of DCFS’ mission to ensure the well-being of the children in its care and custody.

To address the barriers identified above, the Department implemented HealthWorks of Illinois in September of 1993. The HealthWorks system includes special health services and documentation designed to meet the unique needs of children in substitute care. These include Initial Health Screenings within 24 hours of DCFS custody, Comprehensive Health Evaluations by the primary care physician within 21 days of DCFS custody, behavioral health and other screenings, age-appropriate well-child care (including immunizations), and documentation of receipt of health care services in a Health Passport and on DCFS Medical Record Forms. These services are mandated as part of the B.H. Consent Decree.

Illinois has implemented a comprehensive statewide health care system that meets the Child Welfare League of America’s Standards for Health Care Services for Children in Out-of-Home Care. Primary care providers participating in the system meet standards of the former Healthy Moms/Health Kids program and have agreed to complete DCFS forms to document receipt of health care services. The primary care providers have also agreed to cooperate with medical case managers.

The Department’s Office of Health Policy (OHP) is charged with the responsibility of developing, implementing, monitoring, and evaluating policies and systems to ensure that all wards have access to health care, obtain the services which are needed, and have accessible documentation regarding their health needs, services, and status.

At the end of FY99, the Department had approximately 39,000 children in substitute care; approximately 71% of these children are in Cook County. DCFS’ goal is to ensure that all wards statewide:

• are enrolled in HealthWorks;

• receive all medically necessary health care services from a qualified provider;

• are current on immunizations and well child exams;

• receive medical case management services and have documentation submitted to the caseworker, if the child is under age six;

• have all services documented in the child’s Health passport and on DCFS Medical Record Forms;

• have documentation of these services in a centralized file at the Lead Agency and the child’s caseworker and medical case manager files; and

• have all services incorporated into the child’s Client Service Plan.

There are 21 Lead Agencies across Illinois. In Cook County, DCFS has contracts with two Lead Agencies. In downstate Illinois, DCFS contracts with the Department of Human Services (DHS) which then contracts with nineteen Lead Agencies (local health departments) across the state. Each of the 21 Lead Agencies is responsible for:

• Provision of a network of Initial Health Screening (IHS) sites and primary care providers;

• Enrollment of all wards via selection of a Primary Care Provider by the child’s substitute care giver;

• Recruitment of qualified Primary Care Providers who are not part of the HealthWorks network;

• Provision of Interim Medical Case Management Services for 45 days for all new wards and ongoing Medical Case Management Services for wards under six years of age;

• Provision of linkage with appropriate medical specialty services (including vision, hearing and dental care);

• Documentation of the receipt of all health care services; and

• Provision of education and training to child welfare system participants.

All DCFS wards are Medicaid eligible. The HealthWorks program is a Medicaid fee-for-service program, and adheres to the standard Medicaid payment processing procedures. In Cook County, Primary Care Physicians who have joined the HealthWorks network receive $5 per month per ward from the Illinois Department of Public Aid (DPA) as a patient management fee.

Wards ages 0 through 5 receive medical case management services funded by the Illinois Department of Human Services (DHS), which certifies and monitors the community-based organizations providing the case management. Medical case management for wards ages 6 and older are performed by the child welfare case worker. Medical case management services include:

• Obtaining previous health care histories;

• Assisting in scheduling and arranging transportation to medical services;

• Coordinating referral for acute, chronic and/or specialty health services;

• Maintaining copies of medical records;

• Identifying, communicating and planning to address unmet health needs and barriers to accessing care;

• Ensuring that appropriate preventive and routine health services are obtained on a timely basis; and

• Educating substitute caregivers about HealthWorks and their responsibilities for seeking care and maintaining health.

For Cook County cases, OHP produces quarterly reports of unenrolled wards listing each child’s name and case number, caseworker, and the substitute care giver’s name and address. These reports are sent to DCFS Regional Administrators and private agency Executive Directors for follow up and monitoring to ensure enrollment. Downstate enrollment data is collected on a quarterly basis by DHS and provided to DCFS through paper reports.

DCFS is also working with DHS staff to identify technical issues regarding the transfer to DCFS of DHS’ Cornerstone health information on wards when the health information component of SACWIS (Statewide Automated Child Welfare Information System) is operational.

A primary care provider (PCP) is required to do a mental health screen for children over 5 years of age as part of the Comprehensive Health Evaluation, or at any other time the PCP judges to be appropriate (a PCP also is required to do an alcohol and substance abuse screen if he or she feels a child or adolescent has a substance abuse problem). The PCP then makes a referral to the ward’s caseworker, who is responsible for arranging for additional behavioral health assessments and services. Several issues have been identified related to this process:

• PCPs have varying expertise in evaluating behavioral health issues;

• Although DCFS solidly funds a wide variety of mental health services, there is a general shortage of behavioral health service providers for Medicaid clients;

• Caseworkers have varying expertise in making referrals and arranging for behavioral health assessments and services;

• There is no formal linkage between behavioral health and medical primary care providers. As a result, PCPs often are not aware of the behavioral health services and psychotropic medications being provided to the wards in their care.

These issues are a concern for children of all levels of behavioral health needs. In order to address these issues, OHP is chairing an internal workgroup with broad representation (including the DCFS Medical Director) to discuss:

• Promoting quality by determining the baseline skill/training level needed to effectively conduct assessments;

• Standardizing assessments by establishing a menu of appropriate assessment tools;

• Designing a system of access to and delivery of consistent assessments;

• Building and maintaining a preferred network of qualified providers participating in Department funded mental health services, Medicaid funded services, and willing to adhere to the program process; and

• Creating and implementing mechanisms to link behavioral health and medical primary care providers.

DCFS is undertaking a number of initiatives to further improve the system of health care for wards.

• To eliminate the duplication of effort related to monitoring and coordinating with two separate Lead Agencies, beginning in FY2000, DCFS will contract with a single provider in Cook County to carry out the Lead Agency responsibilities described above.

• To enhance coordination between the DCFS Chief Nurse and OHP, the DCFS Chief Nurse was reassigned from the Division of Clinical Services to OHP. The DCFS Regional Nurses will work with OHP on a quality assurance effort targeting health care needs and service utilization.

• An evaluation will be conducted of the impact of medical case management on wards who receive this service.

• A review will be conducted of children with complex medical needs, including those children with specialized technologically advanced equipment which may be vulnerable to Year 2000 issues.

• A policy is being developed which will provide standardized guidance on the approval process for special medical equipment, devices, supports and home modifications.

• The new Health Issues Review Panel will address health care issues that are possibly conflictive and/or controversial.

• DCFS is developing a new Year 2000-compliant automated health information system. The first phase will replace the present information system in Cook County. It is scheduled to be installed in November, 1999.

• DCFS’ internal workgroup on behavioral health issues will prepare recommendations as part of a decision memo to Director McDonald regarding the issues which were described in the Current Steps section.

The current and future efforts in physical and behavioral health will enable DCFS to fulfill its responsibilities for ensuring the well-being of the children in its care and custody.

DCFS currently uses several process measures to gauge its progress in ensuring Wards’ physical well-being. These measures are: enrollment with a HealthWorks Primary Care Provider, immunization, and well-child examinations.

DCFS’ long term goals related to physical health care are:

• Outcome measures which evaluate a child’s actual health status;

• A Health Information system which is available to all caseworkers that can provide health data drawn from DPA Medicaid Payment files, DHS Cornerstone health data and health care services prompts.

• Improved access to specialty services such as obstetrics and gynecology, dentists, special medical equipment, etc.

DCFS’ long term goals related to behavioral health care are to have:

• Better integration between behavioral health and physical health providers;

• Process measures for service referrals and feedback of information regarding wards’ behavioral health care and medications to medical primary care providers; and

• Outcome measures for wards’ behavioral health status.