Michealle Gady, JD
President, Founder, & CEO
After receiving input from stakeholders in response to its policy paper, the North Carolina Department of Health and Human Services (NC DHHS) announced that it would delay the implementation of the Foster Care Plan (FC Plan) until July 2023. In our opinion, this is a very smart decision by the NC DHHS and will enable more meaningful engagement and design of a critically important program.
As we stated in our initial article discussing North Carolina’s proposed Medicaid managed care plan for children in foster care, given the widely varying and extraordinarily complex needs of children in foster care, the care management model is central to the success of the program. There are many people and organizations that must work in close collaboration, share data, and somehow avoid duplicating effort or letting things fall through the cracks.
FOSTER CARE PLAN GUIDING PRINCIPLES
Before I dive into each of these, let’s begin with the guiding principles for the FC Plan design that the NC DHHS has articulated:
- Seamless, person-centered care is critical to the long-term well-being of children and youth currently and formerly involved in the child welfare system.
- The FC Plan and its provider network must be prepared to meet the heightened behavioral health care needs and other challenges faced by children and youth currently and formerly involved in the child welfare system.
- The FC Plan must accept joint responsibility with the Division of Social Services for the physical and mental health of children and youth in foster care and adoptive placement.
- The FC Plan must support members during transitions in placements.
- The FC Plan must support members aging out of foster care.
- The FC Plan must demonstrate accountability through robust data reporting and clear quality standards.
- The FC Plan must account for the multiple transitions that children and youth in foster care experience, both within foster care and in and out of foster care.
- The FC Plan must promote health equity.
And, of course, the FC plan must support the goals of Medicaid Transformation, which is to “improve the health of North Carolinians through an innovative, whole-person-centered and well-coordinated system of care that addresses medical and non-medical drives of health.”
While we all can likely agree that these are the right guiding principles, stakeholders should not underestimate the difficulty in genuinely achieving these. In my experience, creating a truly coordinated system where all parties effectively work together and information is shared in a meaningful and timely manner, is a difficult undertaking. There are legitimate reasons, such as what state and federal law will permit regarding information sharing and the process that must be followed to enable this truly coordinated system.
However, there are also elements of human nature, such as “turf wars,” that get in the way. Stakeholders must be careful not to confuse the two. The former can be resolved. The latter must be avoided at all costs, as simply unproductive and not in any way about the children and youth who should be the priority.
DEVELOPING AN INTERIM PLAN
In its announcement that the FC Plan would not start until July 2023, the NC DHHS stated that they will work with stakeholders on an interim plan which will rely on Medicaid Direct (aka fee-for-service) and the LME/MCOs.
One such option is to implement the Health Home model, which NC DHHS planned to implement along with the FC Plan. The Health Home Model in Medicaid was established in section 2703 of the Affordable Care Act and is meant to be a comprehensive care coordination model for individuals with chronic conditions, including (importantly) behavioral health conditions. States that implement this model for Medicaid enrollees that meet eligibility criteria receive 90% federal matching funds for two years (or eight quarters).
The Health Home services include comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow-up, patient and family support, and referral to community and social support services. These services align with the needs of children in foster care and with the NC DHHS priorities for Medicaid Transformation. Importantly, this model does not have to be implemented in the context of managed care but can be transitioned to a managed care environment when that program launches.
According to NC DHHS, about a quarter of the foster care population is eligible for Health Home services. Implementing this model now would be a good step in the direction of improving coordination and care management for children in foster care.
A caution to stakeholders though, including NC DHHS: Starting something new will not be the solution to the problem. North Carolina has made investments in other programs and models to improve outcomes for children in foster care. This includes the System of Care Framework and in Fostering Health North Carolina. Before moving on to a new, shiny approach, we need to evaluate what is working in the existing programs and what isn’t and ensure that we don’t walk away from investments that have already been made that are, in fact, working. But let’s also not get stuck in what is. If it isn’t working, let’s move on.
Two components of the existing paradigm that we know are not working and must be addressed both in the short term and the long term are the regionality of the LME/MCOs and the closed behavioral health networks of the LME/MCOs.
NC DHHS must find solutions to resolve these limitations.
THE LONG TERM PLAN
I fully support the NC DHHS’s plan to implement a single, statewide FC Plan. I believe it is an essential step forward in addressing the needs of children in foster care. I believe this, in part, because it will address the two concerns I identified above regarding significant limitations of the LME/MCO infrastructure (which is being carried over into the Tailored Plan program). It will also allow for standardization and centralization of important supports for children in foster care.
As the NC DHHS works to design a model that will meet the needs of children in foster, I encourage the NC DHHS to focus on three areas of particular importance:
- Single point of accountability
- Portable health record and information sharing
- Care Management interventions that address the full spectrum of needs
Single Point of Accountability
One of the guiding principles of the NC DHHS is that “[t]he FC Plan must accept joint responsibility with the Division of Social Services for the physical and mental health of children and youth in foster care and adoptive placement.” The NC DHHS intends to address this in a couple of ways.
First, the FC Plan will administer a statewide care management program for its members. This is a divergence from the local care management model that NC DHHS champions in the rest of Medicaid Transformation, in which AMH Tier 3 providers have responsibility for care management.
However, this centralization is appropriate. It is a critical step to ensure that there is a standardized and centralized care management model for children in foster care. This ensures that when a child enters foster care in Wilmington but is placed in Winston-Salem, the care management follows the child with ease.
The second is by requiring co-location with county child welfare services agencies. FC Plan care managers are required to coordinate and collaborate closely with county Department of Social Services (DSS) offices (child welfare agencies). To achieve this, NC DHHS expects the FC Plan to locate care managers in the majority of DSS offices.
To make this approach work, the FC Plan care manager and DSS caseworker will need to have a good, working relationship. A critical component of that (even if we don’t like to admit it) is clearly identifying who has what responsibility and what authority (or, said differently, who is responsible for and in charge of what). This is one of those human nature areas that we just have to deal with. Logistically it makes sense: we do not want duplication of effort and we really don’t want things falling through the cracks because someone thought someone else was doing it. But it also is necessary to avoid these “turf wars” at all costs.
Portable Health Record and Information Sharing
One of the biggest challenges in providing appropriate health care to children in foster care is the lack of information about previous and current diagnoses and treatments. NC DHHS hopes to address this through the creation of a Health Passport. The Health Passport is described in the policy paper in the context of children in foster care transitioning to adulthood. Presumably, NC DHHS does not intend the Health Passport to have that limited application.
Texas is an example of a state that utilizes the Health Passport in its foster care plan. This can be a game-changer for children, their guardians, and providers. NC may want to evaluate the feasibility of creating such a digital record now as part of its interim planning, as opposed to waiting for the launch of the FC Plan.
One area that the Health Passport will help significantly is comprehensive medication management. There are a variety of studies that show children in foster care have higher rates of mental health diagnoses and are prescribed psychotropic medications at higher rates than other children. The Health Passport can help ensure that children who do need such medications have them even during placement transitions and that those who do not need them are appropriately assessed and changes to medication regimens are made.
In addition to ensuring that critical health information travels with the child across placements and out of the system into adulthood, there is a need to ensure that information is shared in real-time between the FC Plan care manager, DSS case manager, and other stakeholders.
One such critical piece of information is whether and to what extent the biological parent(s) can be included in communication regarding the child’s health. Some of this information may be available in the Health Passport, but much of it will not be. Therefore, the FC Plan, DSS, and many others will need to ensure appropriate MOUs or data-sharing agreements are in place, communication workflows are created and documented, and that, to the extent feasible, information can be shared through electronic means to enable real-time exchanges.
Care Management Interventions that Address the Full Spectrum of Needs
It’s likely the understatement of the year to say that children in foster care undergo a lot of transitions. Not only do children in foster care have transitions in placements, but also transitions in health care settings, providers, and coverage that often, but not always, correspond with changes in placements. The FC Plan care manager needs to be the party responsible for these transitions, with appropriate coordination and collaboration with the DSS caseworker. NC DHHS indicates in the policy paper that this is the intent and that the FC Plan care manager will notify and coordinate with the DSS caseworker, foster parents, biological parents, and providers.
NC DHHS also expects the FC Plan to minimize institutional placements for children in foster care and will require the FC Plan to provide in-reach and transition services to members that are admitted to institutional settings, as well as providing diversion interventions for children or youth at risk of admission to an institutional setting.
As youth transition out of foster care to adulthood, we must ensure that they are set up for success. The FC plan will need to support enrollees transitioning to adulthood, including ensuring more than just health care services and coverage are in place at the time of transition. The FC Plan care manager will also need to engage enrollees in programs that support independent living skills, help with education, housing, and employment, and enable the individual to build natural supports that will be critical during and after this significant transition.
To this end, I encourage NC DHHS and stakeholders to carefully identify the education, experience, and skills that the FC Plan care managers need in order to work in this role with this population. This will be similar to how NC DHHS has identified specific and unique requirements for care managers working with individuals with long-term services and support needs in the Standard PHPs. We need to acknowledge that not just anyone can do this job.
NEXT STEPS FOR STAKEHOLDERS
There is much work to do and NC DHHS plans to continue to engage stakeholders. NC DHHS indicates that the next source of information and engagement will be detailed on the Request for Proposals that they are working on to identify the health plan that will serve as the FC Plan. This will be a very illuminating document. We will continue to monitor developments on this key component of Medicaid Transformation and will continue this series on the FC Plan as developments arise.
In the interim, I encourage stakeholders to continue to engage with the NC DHHS because getting this right is very important. The NC DHHS is establishing a workgroup that will develop an interim solution as well as a long-term plan for children in foster care. If you are interested in joining this group, you can send an email to Medicaid.ncengagement@dhhs.gov.