Principal researcher & assistant professor Mathematica & Vanderbilt Nashville, Tennessee, United States
Background: Children entering foster care (FC) often have complex physical and behavioral health needs. To identify and address these needs, children entering FC benefit from a timely comprehensive health assessment (CHA), usually within 30 days, but states struggle to meet this goal. Objective: To support states in improving the rate of timely CHAs for children entering FC and identify factors affecting states' success. Design/Methods: From 7/2021-8/2023, we conducted a virtual quality improvement (QI) learning collaborative (LC) with Medicaid programs and partnered child welfare agencies from 11 states. The LC was sponsored by the Centers for Medicare & Medicaid Services. The LC team included an improvement advisor and experts in pediatrics, child welfare, and Medicaid. The LC curriculum included: (1) monthly workshops focused on QI methods and peer learning, (2) individual monthly coaching meetings for state teams, and (3) on-demand QI resources. We identified qualitative themes related to states' efforts from interactions during the LC. Results: Key themes included: (1) Collaboration: Sustained coordination between Medicaid and child welfare was foundational. This also required agencies to engage local child welfare and Medicaid managed care staff to conduct and learn from plan-do-study-act cycles (PDSAs). (2) Implementation: Both Medicaid and child welfare agencies required longer timeframes than typical clinical QI. Process mapping was a helpful tool for identifying opportunities for PDSAs specific to the state context. (3) Data and measurement: Many states did not have existing data or measures for CHAs and needed to develop approaches. Most states used general billing codes making it challenging to differentiate CHAs from other visits. (4) Access and Enrollment: It was often challenging to identify a clinician who could see a child within 30 days. Several states had delays in Medicaid enrollment for children which delayed CHAs. (5) Facilitators: Several states successfully set target timeframes for key processes. The most successful states designated a specific child welfare or managed care staff as responsible for scheduling and tracking CHAs.
Conclusion(s): The LC demonstrated success in engaging state Medicaid and child welfare agencies in QI methods and identified a mix of common QI challenges and barriers specific to the state policy context. States built a strong foundation for continuing QI collaborations between the state agencies using process mapping and implementing PDSAs to improve care for children in foster care.
