looking after children’s health in out of home care

Looking after Children’s Health in OOHC Consultation
Prof Lena Sanci
Department of General Practice
University of Melbourne
Oohchealth-consult@unimelb.edu.au

Dear Professor Sanci,

Re: Looking after children’s health in Out of Home Care

Thank you for the opportunity to contribute to the consultation to inform the development of a new state-wide Out of Home Care (OOHC) Health Strategy. 

Health of children in OOHC

Children and young people in OOHC experience higher rates of physical and mental health conditions, including developmental delays and disabilities, than other children and young people.  They often have limited and/or sporadic access to preventative or coordinated care, which contributes to increased risk of chronic disease, mental health issues, substance abuse and other ‘potential-limiting’ health concerns later in life.

Children and young people in OOHC sometimes relocate frequently and their lives are often shaped by change and instability.  The OOHC system is designed to prioritise the safety of children and young people and address their basic survival needs such as housing and supervision.  This can mean that there is limited ongoing or consistent focus on their health and wellbeing needs beyond ensuring basic health checks and responding to urgent care, which leads to potentially high unmet health needs.  Even when a more comprehensive plan is developed by a general practitioner, responsibility for coordination and sequencing this support falls between providers, meaning that accountability is unclear.  The complex needs of these children and young people mean that a much more coordinated and comprehensive approach is required.

Research and clinical practice guidelines now recognise that most children in OOHC need high-quality, well-coordinated health care to redress the health impacts of past maltreatment and minimise the impacts on their future health and wellbeing.  Improving the health of children in OOHC will support them to realise their potential and participate fully in education, employment and community life into the future.

cohealth services to children in OOHC

cohealth recognises the pressing physical and mental health needs of children and young people in OOHC and is committed to improving the care provided to this particularly vulnerable group.  In line with the Community health integrated program guidelines^[1], Child health services: guidelines for the community health program^[2] and priority access to public dental services^[3], children in OOHC are a priority group for a range of our services.  A such they access a variety of cohealth health and social support services. Beyond this, however, our specific responses to date for children in OOHC has been limited to a small number of programs.

A particular example is the Koolin Balit Out of Home Care Clinic that has been run from our Braybrook site since 2016.  This clinic provides culturally safe health care specifically for Aboriginal and Torres Strait Islander children aged 0-18 living in out of home care. The service aims to improve the health of Aboriginal and Torres Strait Islander children by looking at each child’s physical health, growth, speech and psychological wellbeing. Once the holistic needs of each child are understood a health and development management plan is created for child protection workers and carers.

The Koolin Balit health care team is made up of a paediatrician, an Aboriginal and Torres Strait Islander health worker, a speech therapist and a mental health worker. The team works with each child and their carer and/or case manager to develop a health management plan.  The team approach, incorporating physical and mental health and developmental status in a culturally safe setting, reflects the importance of a multi-disciplinary response to provide holistic care for children in OOHC.

Our experience with the Koolin Balit clinic has highlighted a number of challenges with ensuring that children and young people in OOHC receive the health care they need, including:

• Ensuring that children are referred to the clinic.  Children must be referred by a general practitioner, but the workloads on child protection workers, and focus of their role on the safety and immediate needs of children, mean that these referrals do not always occur.
• Receiving the relevant records for a child, such as health records and case histories, to complete a comprehensive assessment.  These may not be held by child protection workers or carers.
• Follow up of referrals and care plans. Coordinating this work may not occur due to capacity of child protection workers or carers.
• Changes in the care arrangements, child protection worker and out of home care provider can all result in referrals and care plans not being followed through.
• For carers of children with complex needs, the demands of attending multiple appointments, following treatment regimes and reinforcing therapy approaches can be a significant burden, in addition to day to day care responsibilities.  Without additional support it can at times be difficult to attend to these specialised needs.

Effective healthcare provision to children in OOHC

Key features of providing effective services to children in out of home care include:

• Ensuring comprehensive assessments are undertaken early on entry to care, and regularly thereafter.
• Follow up paediatrician appointments.  Paediatric medical assessments, predominantly a one-off appointment, require at least two appointments to allow blood tests to be taken and receive input from schools, child care, family, and others. Further follow up appointments should be available depending on the needs of the child, eg for children with complex medical, developmental or behavioural conditions; and those who require medication treatment of their condition.
• Providing an integrated, holistic response tailored to the particular needs of each child.  This includes a range of health, allied health and social support services, which can include: general practitioners, paediatricians, speech therapy, physiotherapy, occupational therapy, dietetics, optometry, audiology, counselling, mental health support and alcohol and drug services.
• Ongoing care coordination to support the navigation and coordination of health care.
• Extended GP consultation times, in recognition of the complex needs of children in OOHC and the work required to make and follow up referrals.
• Flexibility to respond to the varied needs of children of different ages and developmental stages.
• Providing timely diagnostic assessment for autism spectrum disorder. Early diagnosis while children are in OOHC is important to inform their care needs and to best respond to any behavioural or mental health issues a child may have as a result of autism that might compromise their OOHC placement. However, access to early assessment is currently difficult as public services have long waiting lists and may not be geographically accessible, while private assessments are more costly.
• Ability to provide outreach to children unable to attend centre-based appointments to ensure these children have access to health care services.
• Ensuring all health service providers involved have training in, and utilise, a trauma informed approach, recognising the significant trauma and disruption experienced by children and young people in out of home care.  Practitioners should be encouraged to include questions about child protection involvement in screening and assessment tools, recognising this as an indicator of vulnerability.
• Ensuring that child protection staff understand the importance of early intervention in improving health outcomes and have the capacity to arrange consistent and sustainable health assessment and care.
• Developing an integrated system to ensure continuity of care, treatment and information sharing in an environment where children have placement instability, health records may not move with the child, healthcare providers change, and carers and guardians have limited capacity to access healthcare.
• Capacity to engage the whole family in healthcare and planning. Parents often remain involved in health-related decision making while children are in OOHC and many children reunite with their families, so it is important they remain involved in all aspects of healthcare.

Care coordination

Ongoing care coordination is critical to ensuring children in OOCH receive the health services they need.  Over time, many children experience changes in care arrangements – moving between home and OOHC, between foster carers, and residential care – which can result in a loss of continuity of knowledge about their health needs and plans.  Changes with the child protection workers assigned to the child compounds this situation.  As a result, referrals to specialised health, allied health and mental health services may not occur, and treatment plans cannot be followed.

The missing role in responding to the health needs of children in OOHC is someone who has long-term oversight of their physical and mental health needs, responsibility to ensure these are met and an ability to support carers and families in their understanding of health needs and assist them to meet these needs.  A health care coordinator (a role that could also be known as a clinical care coordinator, health navigator or case coordinator) would be able to navigate systems on behalf of children in OOHC and ensure health needs are addressed over time.

Potential role of community health

Traditional medical and allied health services are devolved and separate, with limited ability for information sharing or integration of services.  In contrast, community health services provide many key services within the one organisation, improving integration of care and information sharing. cohealth sees significant potential for community health services to play a key role in the delivery of healthcare to children in OOHC.

As described above, cohealth provides a wide range of medical, nursing, allied health, child health, mental health, oral health, health promotion and social support services.  We have strong links to external services such as paediatric specialists, hospital services, and other specialised services such as optometry, audiology and maternal and child health.   We have an explicit commitment to working with people who experience disadvantage, and as such have lengthy experience working with those with complex needs.  Other organisational experience relevant to meeting the health needs of children in OOHC includes: care coordination; goal directed care planning embedded across the organisation; working with diverse communities; developing partnerships with other organisations to maximise health outcomes; chronic disease care coordination; and a commitment to codesigning programs with consumers and communities.

While recognising that community health services all offer a different range of physical health, allied health, mental health and social supports services, they each provide a range of services that mean they are well positioned to provide a systematic response to the health and primary care needs of children in out of home care.  The multidisciplinary approach and internal linkages enables more effective care planning, and services have strong links with a range of external health and social support services.  Community health services can provide training to all their staff involved in providing health care to children in OOHC, ensuring all practitioners have a sound understanding of the needs of this group.

As such, community health services are well placed to provide a ‘child-centred health home’ for children in OOHC, whereby an integrated health system wraps around the child and uses a team-based approach to fulfil their care.  The state-wide coverage of community health services also has the potential to be the foundation for a systemised, consistent network of care across the state.

Resourcing

Providing integrated care for children in OOHC requires investing in the capacity of the system to provide the necessary health care coordination.  Coordinating health assessments and appointments, tracking care plans, following up on referrals, maintaining the relationships between the child, child protection, health providers, carers and family members is work that is not resourced in current funding arrangements for any of the key sectors – child protection workers, medical or allied health practitioners.

In addition to investing in care coordination/navigation, effectively meeting the needs of children and young people in OOHC requires adequate resourcing for:

• Compensating doctors for the additional time for consultation and professional development needed to work effectively with children in OOHC.  Medicare schedule fees are not sufficient for this. Additional block funding would support community health centre doctors to provide the care required by children with complex needs.
• Outreach to respond to children unable to attend health services.
• Brokerage funding to ensure carers can meet transport and other out of pocket costs involved with meeting children’s health care needs.
• Well-developed digital systems to enable integrating health records and improved information sharing to ensure that health information is kept up-to-date and accessible by those involved in the care of the child.
• Provision of training on trauma informed care and cultural safety for all involved in the care of children and young people in OOHC including general practitioners, allied health practitioners and client services officers.

I would welcome the opportunity to discuss this submission with you and can be contacted on Nicole.Bartholomeusz@cohealth.org.au.

Yours sincerely,

Nicole Bartholomeusz
Interim Chief Executive

Footnotes

[1] https://www2.health.vic.gov.au/primary-and-community-health/community-health/community-health-program/chip-guidelines

[2] ibid

[3] https://www2.health.vic.gov.au/primary-and-community-health/dental-health/access-public-dental-services