Medical foster care: what happens when children with medical complexity cannot be cared for by their families?

Evaluating the effectiveness of mandala coloring on post-operative anxiety in mothers of children undergoing congenital anomaly surgery: A randomized controlled clinical trial

PURPOSE OF RESEARCH

The purpose of this study was to investigate the effectiveness of mandala coloring on post-operative anxiety in mothers of children undergoing congenital anomaly surgery.

RESULTS

In this randomized controlled clinical trial, 92 mothers of children undergoing congenital anomaly surgery were randomly assigned to the intervention or control groups. Standard care was provided for both groups. The intervention group participated in a mandala coloring activity for 30 min/day for three consecutive days following their children's surgery. Anxiety levels were measured using the State-Trait Anxiety Inventory (STAI) before and after the intervention. The data were analyzed by SPSS-23. The mean state anxiety score in the intervention and control groups was 38.43 ± 6.76 and 51.65 ± 6.34, respectively, and subsequent to the intervention, the mean trait anxiety score in the intervention and control groups was 41.28 ± 8.71 and 47.07 ± 8.82, respectively. The study found that mothers who engaged in mandala coloring experienced a significant decrease in state and trait anxiety compared to the control group (p < 0.001). Large effect size (η2 > 0.14) indicates mandala coloring significantly reduced the anxiety of mothers of children with congenital disorders.

CONCLUSION

Mandala coloring appears to be an effective intervention for reducing anxiety level in mothers of children undergoing surgery for congenital abnormalities. The study suggests that therapeutic art activities can improve psychological well-being post-operatively, urging further research to explore their long-term effects.

Promoting Health Equity for Children With Special Health Care Needs and Child Welfare Involvement

Noah, an 18-month-old infant with trisomy 21, was brought to the emergency department for adenovirus bronchiolitis. He was found to meet criteria for severe malnutrition, and his medical team called Child Protective Services (CPS) with concern for neglect. He remained hospitalized for 1 month while a safe discharge was coordinated by the medical and CPS teams. Through this case, we explore racism as a root cause of discharge delays among children with special health care needs who interact with the child welfare system. Our discussion delves into the origins and consequences of racial disproportionality within the child welfare system. We describe how Black children, including those with special health care needs, are disproportionately involved with the child welfare system and highlight the potential role of the health care system in these inequities. Ultimately, this racial disproportionality in CPS involvement may contribute to a cycle of oppression for Black families, undermining family and child health, well-being, and trust in the health care system. Understanding the role of racism in both the child welfare and health care systems can empower pediatric providers to be agents of change. Noah's case underscores the potential for pediatric providers to either perpetuate or mitigate racial disparities. We propose actions at the individual, institutional, and structural levels, emphasizing the importance of equitable family-centered care practices and trauma-informed care, establishing protocols for the management of potential abuse or neglect, and advocating for policies that reduce racial disparities in child welfare referral, support families, and prevent abuse and neglect.

Home Health Care Research for Children With Disability and Medical Complexity

Pediatric home health care represents a vital system of care for children with disability and medical complexity, encompassing services provided by family caregivers and nonfamily home health care providers and the use of durable medical equipment and supplies. Home health care is medically necessary for the physiologic health of children with disability and medical complexity and for their participation and function within home, school, and community settings. While the study of pediatric home health care in the United States has increased in the last decade, its research remains primarily methodologically limited to observational studies. Dedicated funding and research efforts are needed to transform American home health care research to address multifaceted outcomes valued by families and providers as well as payers and government programs. In this paper, we review the recent literature in pediatric home health care and then propose an actional agenda that could address its missing evidence base. We posit that pediatricians should partner with family caregiving experts and patients to advance knowledge about child and family health outcomes, home health care use, new models of care, and optimal approaches to education and training while also considering meaningful approaches to address disparities. The creation of an American pediatric home health care data-sharing consortium, patient registry, and reproducible access and quality measures is also needed. Most importantly, efforts should center on patient- and family-centered health priorities, with the goal of ensuring equitable outcomes for every child and family.

Medicaid Home and Community Based Services Spending and Nursing Home Use by Individuals Under the Age of 44

Prior studies of the role of state spending on home and community-based services (HCBS) in nursing home use focused on adults over the age of 65. However, medically complex children and adults under 50 years old represent a small (about 5%) but highly vulnerable subset of nursing home patients. We measured the impact of HCBS spending on short-term and long-term nursing home stays by children and adults under 44 years old and compared the impact between Non-Hispanic White (NHW) individuals and Black, Indigenous, and People of Color (BIPOC). We used the Minimum Data Set to measure nursing home stays in each state per year in 2012 to 2019. The Medicaid Long Term Services and Supports annual expenditure reports were used to measure HCBS expenditures per state resident with a disability. Our outcome was nursing home use by children (<18 years old) and adults (18-43 years old) associated with a change in HCBS expenditures per state resident with a disability (measured in $1000 increments) estimated using linear regression. Higher HCBS expenditures per resident were associated with fewer short-term and long-term nursing home stays among NHW children. We did not find statistically significant association between changes in HCBS expenditures and nursing home stays among BIPOC children. Investments in HCBS are necessary to reduce nursing home use among younger adults. However, to mitigate racial disparities in nursing home use among children, HCBS spending alone may not be sufficient.

Do Reasons Matter? Navigating Parents' Reasons in Healthcare Decisions for Children

Bioethics has dedicated itself to exploring and defending both reasons for and against certain aspects of clinical care, biomedical research and health policy, including what decisions must be made, who should make them, and how they should be made. In pediatrics, it's widely acknowledged that parents' reasons may matter pragmatically; attending to parents' reasons is important if we want to work with families. Yet the conventional view in pediatric ethics is that parents' reasons are irrelevant to whether a decision is permissible or impermissible according to accepted ethical standards. In this paper, we explore whether parents' reasons matter ethically and, if so, in what way and for whom. First, we clarify what we mean by 'reasons.' Second, we provide an overview of how reasons are typically treated in medical decision-making and pediatric ethics. Third, we analyze a hypothetical pediatric case to illustrate how changing reasons can transform ethical analyses, including by contributing to where and how clinicians and ethicists draw the boundaries intrinsic to common pediatric ethical frameworks. We push back against the conventional view and argue that parents' reasons matter ethically in several ways. We call for further research on the role of parents' reasons in clinical ethics deliberation.

Management of Vertebral Defects, Anal Atresia, Cardiac Defects, Tracheoesophageal Fistula or Atresia, Renal Anomalies, and Limb Abnormalities (VACTERL) in a Child With Complex Medical Needs in the Foster Care System: A Pediatric Case Study

Vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula or atresia, renal anomalies, and limb abnormalities (VACTERL) association is a complex congenital condition characterized by the presence of malformations that affect various organ systems. Most children born with VACTERL association require surgery shortly after birth, often undergoing multiple procedures during infancy, which can lead to a wide range of physical challenges. The unique combination of malformations in these children in addition to having complex care needs that need to be met can result in physical and social difficulties in their daily lives, affecting both their own and their caregivers' quality of life. In some cases, children with complex medical needs are placed in foster care. When children with complex health needs enter the foster care system, there is a risk of overwhelming the caretaker, leading to their needs continuing to be unmet. Pediatricians have a role not only in helping support families but also in knowing what resources are available to meet these needs, which can be dependent on what their communities offer. Pediatricians require current training to navigate their state's foster care system. This training allows pediatricians to effectively collaborate with foster families while also assisting and coordinating complex care to support these families. We present a case of a child with complex health needs placed in the foster care system, facing multiple healthcare challenges, with care delayed due to difficulty attending appointments. Highlighted is the importance of delivering supportive, personalized, and multidisciplinary care to families with children who have complex health needs, including when caretakers are within the foster care system.

Defining Pediatric Chronic Critical Illness: A Scoping Review

OBJECTIVES

Children with chronic critical illness (CCI) are hypothesized to be a high-risk patient population with persistent multiple organ dysfunction and functional morbidities resulting in recurrent or prolonged critical care; however, it is unclear how CCI should be defined. The aim of this scoping review was to evaluate the existing literature for case definitions of pediatric CCI and case definitions of prolonged PICU admission and to explore the methodologies used to derive these definitions.

DATA SOURCES

Four electronic databases (Ovid Medline, Embase, CINAHL, and Web of Science) from inception to March 3, 2021.

STUDY SELECTION

We included studies that provided a specific case definition for CCI or prolonged PICU admission. Crowdsourcing was used to screen citations independently and in duplicate. A machine-learning algorithm was developed and validated using 6,284 citations assessed in duplicate by trained crowd reviewers. A hybrid of crowdsourcing and machine-learning methods was used to complete the remaining citation screening.

DATA EXTRACTION

We extracted details of case definitions, study demographics, participant characteristics, and outcomes assessed.

DATA SYNTHESIS

Sixty-seven studies were included. Twelve studies (18%) provided a definition for CCI that included concepts of PICU length of stay (n = 12), medical complexity or chronic conditions (n = 9), recurrent admissions (n = 9), technology dependence (n = 5), and uncertain prognosis (n = 1). Definitions were commonly referenced from another source (n = 6) or opinion-based (n = 5). The remaining 55 studies (82%) provided a definition for prolonged PICU admission, most frequently greater than or equal to 14 (n = 11) or greater than or equal to 28 days (n = 10). Most of these definitions were derived by investigator opinion (n = 24) or statistical method (n = 18).

CONCLUSIONS

Pediatric CCI has been variably defined with regard to the concepts of patient complexity and chronicity of critical illness. A consensus definition is needed to advance this emerging and important area of pediatric critical care research.

Child Welfare Reform: A Scoping Review

While there have been ongoing calls to reform child welfare so that it better meets children's and families' needs, to date there have been no comprehensive summaries of child welfare reform strategies. For this systematic scoping review, we summarized authors' recommendations for improving child welfare. We conducted a systematic search (2010 to 2021) and included published reviews that addressed authors' recommendations for improving child welfare for children, youth, and families coming into contact with child welfare in high-income countries. A total of 4758 records was identified by the systematic search, 685 full-text articles were screened for eligibility, and 433 reviews were found to be eligible for this scoping review. Reviews were theoretically divided, with some review authors recommending reform efforts at the macro level (e.g., addressing poverty) and others recommending reform efforts at the practice level (e.g., implementing evidence-based parenting programs). Reform efforts across socioecological levels were summarized in this scoping review. An important next step is to formulate what policy solutions are likely to lead to the greatest improvement in safety and well-being for children and families involved in child welfare.

Pediatrician Guidance in Supporting Families of Children Who Are Adopted, Fostered, or in Kinship Care

The child welfare system strives to provide children and adolescents in foster care with a safe, nurturing environment through kinship and nonkinship foster care placement with the goal of either reunification with birth parents or adoption. Pediatricians can support families who care for children and adolescents who are fostered and adopted while attending to children's medical needs and helping each child attain their developmental potential. Although this report primarily focuses on children in the US child welfare system, private and internationally adopted children often have similar needs.

Comorbidity patterns and socioeconomic inequalities in children under 15 with medical complexity: a population-based study

Background

Children with medical complexity (CMC) denotes the profile of a child with diverse acute and chronic conditions, making intensive use of the healthcare services and with special health and social needs. Previous studies show that CMC are also affected by the socioeconomic position (SEP) of their family. The aim of this study is to describe the pathologic patterns of CMC and their socioeconomic inequalities in order to better manage their needs, plan healthcare services accordingly, and improve the care models in place.

Methods

Cross-sectional study with latent class analysis (LCA) of the CMC population under the age of 15 in Catalonia in 2016, using administrative data. LCA was used to define multimorbidity classes based on the presence/absence of 57 conditions. All individuals were assigned to a best-fit class. Each comorbidity class was described and its association with SEP tested. The Adjusted Morbidity Groups classification system (Catalan acronym GMA) was used to identify the CMC. The main outcome measures were SEP, GMA score, sex, and age distribution, in both populations (CMC and non-CMC) and in each of the classes identified.

Results

71% of the CMC population had at least one parent with no employment or an annual income of less than €18,000. Four comorbidity classes were identified in the CMC: oncology (36.0%), neurodevelopment (13.7%), congenital and perinatal (19.8%), and respiratory (30.5%). SEP associations were: oncology OR 1.9 in boys and 2.0 in girls; neurodevelopment OR 2.3 in boys and 1.8 in girls; congenital and perinatal OR 1.7 in boys and 2.1 in girls; and respiratory OR 2.0 in boys and 2.0 in girls.

Conclusions

Our findings show the existence of four different patterns of comorbidities in CMC and a significantly high proportion of lower SEP children in all classes. These results could benefit CMC management by creating more efficient multidisciplinary medical teams according to each comorbidity class and a holistic perspective taking into account its socioeconomic vulnerability.

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

OBJECTIVE

To explore how medical decision-making for children with medical complexity (CMC) occurs in the context of foster care (FC).

METHODS

Together with a medical FC agency, we identified 15 CMC in medical FC and recruited eligible care team members (biological and foster parents, medical FC nurses, caseworkers in medical FC/child welfare, and pediatricians) for each child. Semistructured interviews were conducted, and conventional content analysis was applied to transcripts.

RESULTS

Fifty-eight interviews were completed with 2-5 care team members/child. Serious decision-making related to surgeries and medical technology was common. Themes regarding medical decision-making for CMC in FC emerged: 1) Protocol: decision-making authority is dictated by court order and seriousness of decision, 2) Process: decision-making is dispersed among many team members, 3) Representing the child's interests: the majority of respondents stated that the foster parent represents the child's best interests, while the child welfare agency should have legal decision-making authority, and 4) Perceived barriers: serious medical decision-making authority is often given to individuals who spend little time with the child.

CONCLUSIONS

Medical decisions for CMC can have uncertain risk/benefit ratios. For CMC in FC, many individuals have roles in these nuanced decisions; those with ultimate decision-making authority may have minimal interaction with the child. Pediatricians can assist by clarifying who has legal decision-making authority, facilitating team communication to promote truly informed consent, and serving as a resource to decision-makers. Further research should explore how to adapt the traditional model of shared decision-making to meet the needs of this population.

Exploring Medical Foster Care as a Placement Option for Children With Medical Complexity

BACKGROUND

Medical foster care (MFC) offers a family-home setting for children with medical complexity (CMC) who cannot be cared for by their parents. We explored MFC as a placement option for CMC via in-depth interviews with the individuals providing and monitoring care.

METHODS

In collaboration with an MFC agency, we recruited care team members for 15 CMC. Semistructured interviews were audiotaped and transcribed. Descriptive analyses were performed on care team composition and roles, the placement process, and child medical, placement, and quality of life (QoL) characteristics. Foster parents completed child QoL questionnaires. Conventional content analysis was applied to participant suggestions for MFC improvements.

RESULTS

Fifty-eight interviews were conducted; a median of 4 care team members interviewed per child. An extensive network of individuals and systems are involved in providing care. Each child received care from multiple subspecialists (median = 5). Most children were technology dependent (87%), developmentally delayed (87%), and entered MFC from the hospital (73%) because of medical neglect (86%). Nearly half were in care for >2 years. Changes in placement and/or care team were common. QoL scoring showed impairments in multiple domains, whereas respondent interviews described positive aspects of QoL. Participants provided suggestions to improve care within MFC.

CONCLUSIONS

MFC is a promising placement option for CMC. Because many CMC are entering MFC directly from the hospital and require ongoing care from pediatric subspecialists, pediatricians should be familiar with MFC, the placement process, and the various systems and individuals involved. Pediatricians can play important roles in ensuring that children in MFC receive coordinated and high-quality care.

Foster Care Involvement Among Medicaid-Enrolled Children with Autism

The prevalence and risk of foster care involvement among children with autism spectrum disorder (ASD) relative to children with intellectual disability (ID), children with ASD and ID, and typically developing children were examined using 2001-2007 Medicaid data. Children were followed up to the first foster care placement or until the end of 2007; a discrete time logistic regression analysis was conducted. Both the prevalence and risk of foster care involvement were greatest for children with ASD, and the prevalence increased substantially over the study period among children with ASD. Continued examination of the factors contributing to the higher risk of foster placement is warranted to unravel the complex circumstances facing these vulnerable children and their families.

Very Preterm Infants with Technological Dependence at Home: Impact on Resource Use and Family

OBJECTIVE

To examine the impact of medical complexity among very preterm infants on health care resource use, family, and neurodevelopmental outcomes at 18 months' corrected age.

METHODS

This observational cohort study of Canadian infants born < 29 weeks' gestational age in 2009-2011 compared infants with and those without medical complexity defined as discharged home with assistive medical technology. Health care resource use and family outcomes were collected. Children were assessed for cerebral palsy, deafness, blindness, and developmental delay at 18 months. Logistic regression analysis was performed for group comparisons.

RESULTS

Overall, 466/2,337 infants (20%) needed assistive medical technology at home including oxygen (79%), gavage feeding (21%), gastrostomy or ileostomy (20%), CPAP (5%), and tracheostomy (3%). Children with medical complexity were more likely to be re-hospitalized (OR 3.6, 95% CI 3.0-4.5) and to require ≥2 outpatient services (OR 4.4, 95% CI 3.5-5.6). Employment of both parents at 18 months was also less frequent in those with medical complexity compared to those without medical complexity (52 vs. 60%, p < 0.01). Thirty percent of children with medical complexity had significant neurodevelopmental impairment compared to 13% of those without medical complexity (p < 0.01). Lower gestational age, lower birth weight, bronchopulmonary dysplasia, sepsis, and surgical necrotizing enterocolitis were associated with a risk of medical complexity.

CONCLUSION

Medical complexity is common following very preterm birth and has a significant impact on health care use as well as family employment and is more often associated with neurodevelopmental disabilities. Efforts should be deployed to facilitate care coordination upon hospital discharge and to support families of preterm children with medical complexity.

Children's complex care needs: a systematic concept analysis of multidisciplinary language

Complex care in the arena of child health is a growing phenomenon. Although considerable research is taking place, there remains limited understanding and agreement on the concept of complex care needs (CCNs), with potential for ambiguity. We conducted a systematic concept analysis of the attributes, antecedents, and consequences of children's CCNs from a multidisciplinary perspective. Our data sources included PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO. Inclusion criteria included publications in peer-reviewed journals between January 1990 and December 2017, written in the English language. One hundred and forty articles were included. We found that children's CCNs refer to multidimensional health and social care needs, in the presence of a recognized medical condition or where there is no unifying diagnosis.Conclusion: Children's CCNs are individual and contextualized, are continuing and dynamic, and are present across a range of settings, impacted by family and healthcare structures. There remain extensive challenges to caring for these children and their families, precluding the possibility that any one profession can possess the requisite knowledge or scope to singularly provide high-quality competent care. What is Known: • Complex care is a growing phenomenon and population prevalence figures show that there is an increasing number of children with complex care needs (CCNs). However, the concept has not been systematically analyzed before, leaving it generally ill-defined and at times confusing. What is New: • This is the first time this concept has been systematically analyzed and this analysis provides a much-needed theoretical framework for understanding the multidimensional nature of CCNs in children. • Children's CCNs refer to multidimensional health and social care needs in the presence of a recognized medical condition or where there is no unifying diagnosis. They are individual and contextualized, are continuing and dynamic, and are present across a range of settings, impacted by family and healthcare structures. It is clear that the very nature of CCNs precludes the possibility that any one profession or discipline can possess the requisite knowledge or scope for high-quality competent care for this population.

End-of-life trends and patterns among children in the US foster care system: 2005-2015

Drawing on national, longitudinal Adoption and Foster Care Analysis, and Reporting System data (2005-2015), demographic, health, foster care, and geographic characteristics of decedents (N = 3653) aged 1-17 years were examined. On average, decedents were 6 years old, the highest proportion died as infants, and experienced significant trauma in their short lives either through maltreatment or exposure to parental substance use. A noted increase in Medicaid coverage among decedents over time suggests critical access to concurrent treatment and hospice care, but this is unavailable to children with private insurance. This study has policy implications related to the 2010 Affordable Care Act.

Improving Hospital-to-Home Transitions for Children Entering Foster Care

BACKGROUND AND OBJECTIVES

Hospital-to-home transitions present safety risks for patients. Children discharged with new foster caregivers may be especially vulnerable to poor discharge outcomes. With this study, our objective is to identify differences in discharge quality and outcomes for children discharged from the hospital with new foster caregivers compared with children discharged to their preadmission caregivers.

METHODS

Pediatric patients discharged from the Barbara Bush Children's Hospital at Maine Medical Center between January 2014 and May 2017 were eligible for inclusion in this retrospective cohort study. Chart review identified patients discharged with new foster caregivers. These patients were compared with a matched cohort of patients discharged with preadmission caregivers for 5 discharge quality process measures and 2 discharge outcomes.

RESULTS

Fifty-six index cases and 165 matched patients were identified. Index cases had worse performance on 4 of 5 discharge process measures, with significantly lower use of discharge readiness checklists (75% vs 92%; P = .004) and teach-back education of discharge instructions for caregivers (63% vs 79%; P = .02). Index cases had twice the odds of misunderstandings needing clarification at the postdischarge call; this difference was not statistically significant (26% vs 13%; P = .07).

CONCLUSIONS

Hospital-to-home transition quality measures were less often implemented for children discharged with new foster caregivers than for the cohort of patients discharged with preadmission caregivers. This may lead to increased morbidity, as suggested by more frequent caregiver misunderstandings. Better prospective identification of these patients and enhanced transition improvement efforts targeted at their new caregivers may be warranted.