Medical Decision-Making in Foster Care: Considerations for the Care of Children With Medical Complexity

Does Early Life Adversity Limit Delivery of High-Quality Health Care Among Children?

BACKGROUND

Adverse childhood experiences (ACEs) have been associated with poor health and underuse of preventive health services. However, less is known about how ACEs are associated with quality of care that children receive, like care that involves shared decision-making.

METHODS

Using data from the 2021-2022 National Survey of Children's Health (n = 47 179) the association between ACEs, both individual and cumulative and (1) needing medical decisions made in the past 12 months and (2) three different measures of always receiving care that involved shared decision-making. Logistic regression models were used to calculate odds of each outcome. Each of the 11 ACEs and the cumulative number of ACEs served as independent variables each in separate models.

RESULTS

After accounting for confounders, the number of ACEs experienced, and most individual ACE items were associated with higher odds of needing medical decisions made, and lower odds of receiving health care that involved providers always engaging in the three measures of shared decision-making.

CONCLUSIONS

This study expands the research showing a deleterious impact of ACEs on utilization of health care by showing that ACEs are associated with lower quality health care. This can be particularly determinantal to children with a history of ACEs because they have a greater need for health care and are less likely to use many types of health care. Efforts to improve health care quality for all children will be of particular benefit to vulnerable groups, like those with a history of ACEs.

Specialized programs employing different models of care delivery work collaboratively to address the health care needs of children in foster care

Specialized knowledge and skills applicable to caring for children in foster care include guidelines developed to address this population's special health care needs, cross-system collaboration, and helping families cope with the health impacts of trauma. This paper begins with a review of the special health care needs of children in foster care and relevant guidelines. We discuss different models of health care delivery that can be employed to meet the special health care needs of children in foster care. We then provide examples of two programs employing different models of care that work collaboratively to deliver care to children in foster care in our community.

A gap in the data: Defining, identifying, and tracking children with medical complexity in the child welfare system

BACKGROUND

Among nearly 400,000 children in US foster care, an estimated 10 % are medically complex. Yet, population-level data about children with medical complexity (CMC) served by the child welfare system, both for prevention and foster care services, are largely unavailable.

OBJECTIVE

To understand how US child welfare agencies define, identify, and track CMC.

PARTICIPANTS AND SETTING

Child welfare agencies across the US.

METHODS

Agencies were recruited to complete a survey as part of a larger study exploring how CMC are served by the child welfare system. Survey responses related to defining, identifying, and tracking CMC were included in analysis. Descriptive statistical analysis was conducted with Stata. Qualitative content and thematic analysis were applied to free text responses.

RESULTS

Surveys were completed by agencies from 28 states and 2 major cities. Nearly half of the agencies did not have a clear definition to identify CMC; those that did have a definition often lacked standardization. The majority of agencies could not easily identify CMC or access CMC-related data within data systems. Agencies described lack of a clear definition as a barrier to collecting population level data.

CONCLUSIONS

Many US child welfare agencies lack a clear definition to identify and track CMC, impacting the ability to tailor care and service delivery to meet their unique needs. To address this, a clear definition for CMC should be developed and consistently applied within child welfare data systems. Once CMC are identifiable, future research can collect population-level data and provide recommendations for best practices and policies.

Clinically Indicated Genomic Sequencing of Children in Foster Care: Legal and Ethical Issues

There are approximately 400 000 children in foster care in the US, approximately one-half of whom have chronic health problems and approximately 10% of whom have complex healthcare needs. Given the increasing relevance of genomic sequencing to guide clinical care for children with rare, chronic, and undiagnosed conditions, it may be an important component of diagnostic evaluation for children in foster care. Clinically indicated genomic sequencing may provide information that has health implications for children in foster care, as well as for their biological parents and other relatives. Whether and how genomic sequencing results impact legal decision making and family court outcomes is not yet well-understood. We describe scenarios that highlight legal, ethical, and policy issues surrounding genomic sequencing for children in foster care using 3 cases adapted from real-world events. Together, these cases highlight important yet underexplored issues that arise when genomic information has legal relevance in family court and ethical implications for child and family well-being. As genomic sequencing becomes more routine for the general pediatric population, additional research is needed to better understand its impacts on children and other stakeholders within the foster care system.

Caring for Hospitalized Children in Foster Care: Provider Training, Preparedness, and Practice

BACKGROUND AND OBJECTIVES

Children and youth in foster care (CYFC) have high rates of health care utilization, including inpatient care. The objective of this study was to explore the inpatient provider experience caring for CYFC.

METHODS

Semistructured interviews were conducted with inpatient pediatric providers from Mid-Atlantic hospitals. Interview questions focused on 3 domains: provider training and preparedness, practice challenges, and strategies to improve care for CYFC. Conventional content analysis was applied to interview transcripts.

RESULTS

Thirty-eight interviews were completed with providers from 6 hospitals, including 14 hospitalists, 1 advanced practice provider, 11 registered nurses, 10 social workers (SWs), and 2 case managers. Nearly all (90%) reported at least monthly interactions with CYFC. Themes related to training and preparedness to care for CYFC included: medical providers' lack of formal training, limited foster care knowledge, and feeling of preparedness contingent on access to SWs. Themes related to unique practice challenges included: identifying CYFC, obtaining consent, documenting foster care status, complex team communication, and navigating interpersonal stress. Participants' suggestions for improving their ability to care for CYFC included increasing SW capacity, expanding provider training, standardizing electronic medical record documentation and order sets, and improving team communication and information sharing.

CONCLUSIONS

There are unique medical, social, and legal aspects of caring for hospitalized CYFC; pediatric medical providers receive limited training on these topics and rely heavily on SWs to navigate associated practice challenges. Targeted educational and health information technology interventions are needed to help inpatient providers feel better prepared to effectively meet the needs of CYFC.

Pediatric Decision Making: Consensus Recommendations

Despite apparent disagreement in the scholarly literature on standards of pediatric decision making, a recognition that similar norms underpin many of the dominant frameworks motivated a June 2022 symposium "Best Interests and Beyond: Standards of Decision Making in Pediatrics" in St Louis, MO. Over the course of this 3-day symposium, 17 expert scholars (see author list) deliberated on the question "In the context of US pediatric care, what moral precepts ought to guide parents and clinicians in medical decision making for children?" The symposium and subsequent discussion generated 6 consensus recommendations for pediatric decision making, constructed with the primary goals of accessibility, teachability, and feasibility for practicing clinicians, parents, and legal guardians. In this article, we summarize these recommendations, including their justification, limitations, and remaining concerns.

Treatment Delays in Nonsyndromic Craniosynostosis: A 30-Year Retrospective Case-Control Analysis of the Impact of Socioeconomic and Family Status on Access to Care

BACKGROUND

Patients with nonsyndromic craniosynostosis (NSC) generally undergo corrective surgery before 1 year of age to the mitigate morbidities and risks of delayed repair. The cohort of patients who receive primary corrective surgery after 1 year and factors associated with their gaps to care is poorly characterized in literature.

METHODS

A nested case-control study was conducted for NSC patients who underwent primary corrective surgery at our institution and affiliates between 1992 and 2022. Patients whose surgery occurred after 1 year of age were identified and matched 1:1 by surgical date to standard-care control subjects. Chart review was conducted to gather patient data regarding care timeline and sociodemographic characteristics.

RESULTS

Odds of surgery after 1 year of age were increased in Black patients (odds ratio, 3.94; P < 0.001) and those insured by Medicaid (2.57, P = 0.018), with single caregivers (4.96, P = 0.002), and from lower-income areas (+1% per $1000 income decrease, P = 0.001). Delays associated with socioeconomic status primarily impacted timely access to a craniofacial provider, whereas caregiver status was associated with subspecialty level delays. These disparities were exacerbated in patients with sagittal and metopic synostosis, respectively. Patients with multisuture synostosis were susceptible to significant delays related to familial strain (foster status, insurer, and English proficiency).

CONCLUSIONS

Patients from socioeconomically strained households face systemic barriers to accessing optimal NSC care; disparities may be exacerbated by the diagnostic/treatment complexities of specific types of craniosynostosis. Interventions at primary care and craniofacial specialist levels can decrease health care gaps and optimize outcomes for vulnerable patients.

Initiating technology dependence to sustain a child's life: a systematic review of reasons

BACKGROUND

Decision-making in initiating life-sustaining health technology is complex and often conducted at time-critical junctures in clinical care. Many of these decisions have profound, often irreversible, consequences for the child and family, as well as potential benefits for functioning, health and quality of life. Yet little is known about what influences these decisions. A systematic review of reasoning identified the range of reasons clinicians give in the literature when initiating technology dependence in a child, and as a result helps determine the range of influences on these decisions.

METHODS

Medline, EMBASE, CINAHL, PsychINFO, Web of Science, ASSIA and Global Health Library databases were searched to identify all reasons given for the initiation of technology dependence in a child. Each reason was coded as a broad and narrow reason type, and whether it supported or rejected technology dependence.

RESULTS

53 relevant papers were retained from 1604 publications, containing 116 broad reason types and 383 narrow reason types. These were grouped into broad thematic categories: clinical factors, quality of life factors, moral imperatives and duty and personal values; and whether they supported, rejected or described the initiation of technology dependence. The majority were conceptual or discussion papers, less than a third were empirical studies. Most discussed neonates and focused on end-of-life care.

CONCLUSIONS

There is a lack of empirical studies on this topic, scant knowledge about the experience of older children and their families in particular; and little written on choices made outside 'end-of-life' care. This review provides a sound basis for empirical research into the important influences on a child's potential technology dependence.

Measuring care coordination by social workers in a foster care medical home

A social worker coordinated medical care for children in foster care in a foster care medical home (FCMH) and tracked care coordination (CC) activities using a modified Care Coordination Measurement Tool© (mCCMT). Of the 60 subjects, most were younger than 5 years, and 60% had a behavioral and/or medical condition. Primary CC activities included behavioral support for families and health system navigation. The CC prevented 11 emergency department (ED) visits, 9 placement disruptions, and 42 patient privacy violations. Children assigned to a FCMH have diverse CC needs and benefit from social workers' specialized skills.

Research Participation of Minor Adolescents in Foster Care

STUDY OBJECTIVE

In this study we evaluated published studies about foster care to: (1) determine the types of data used; (2) describe the degree to which a sexual/reproductive health topic was addressed; and (3) describe the consent process.

DESIGN

Analysis of published literature.

SETTING

PubMed was searched using "foster care" for English articles published between January 1, 2017 and September 4, 2019.

PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Articles were coded into 4 data source categories: primary, secondary, peripheral, or perspective data. Articles with a primary data source were coded for participant ages: only 9 years old and younger, 10- to 17-year-olds (minor adolescents), and only 18 years old and older. Articles using a secondary data source were coded for the source of the data registry. All articles were coded for presence of a sexual/reproductive health outcome. The primary data articles that included minor adolescents were coded for the study topic and consent process.

RESULTS

Of the 176 articles about foster care, 72/176 (41%) used primary data, 53/176 (30%) used secondary data, and 51/176 (29%) used peripheral/perspective data. Forty-eight of the primary data articles included minor adolescents. Secondary data sources included few national research surveys. Sexual/reproductive health outcomes were measured in 17 articles, 4 of which used primary data. The consent process for minor adolescents varied and had no consistent pattern across studies.

CONCLUSION

Research on best practices for consent processes and use of registries could be developed to increase research on sexual/reproductive health outcomes among adolescents in foster care.