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.

1. Comprehensive Assessment of
the Medical and Mental Health
Needs of Children in Maine
Feb 2012

2. Medical and Mental Health 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 Traumatic Stress
 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 Traumatic Stress
 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 of Children 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 PREP Provide?
 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 PREP Serve?
 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
1999 and 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
Placement Number
 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 for Maine 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
Medical Problems
 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
Behavioral and 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
Behavioral and 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
Psychotropic Medication
 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 of Children 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 Which Adverse 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 Foster Children with
Adverse Childhood Experience
70
60
50
40
30
20
10
0
Sex Abuse Physical
Abuse
Substance
Abuse
Domestic
Violence

33. PREP Data
Adverse Childhood 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 and Social 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 Drug Withdrawal
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, Service Use
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. To inform 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*
PREP Non-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 MaineCare Costs
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 Children with 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 MaineCare Costs
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 MaineCare Costs
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 Children with 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 Associated with
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, Ages 3-6 (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
 Although PREP 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.