THE UTILIZATION AND EFFECTS OF HEALTH AND EDUCATION PASSPORTS
A Project
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Allison Stanfield
Heather Tyler
SPRING
2014
THE UTILIZATION AND EFFECTS OF HEALTH AND EDUCATION PASSPORTS
A Project
by
Allison Stanfield
Heather Tyler
Approved by:
__________________________________, Committee Chair
Francis Yuen, DSW, ACSW, Professor
____________________________
Date
ii
Student: Allison Stanfield
Heather Tyler
I certify that this student has met the requirements for format contained in the University format
manual, and that this thesis is suitable for shelving in the Library and credit is to be awarded for
the thesis.
__________________________, Graduate Coordinator ___________________
Dale Russell, Ed. D, LCSW
Date
Division of Social Work
iii
Abstract
of
THE UTILIZATION AND EFFECTS OF HEALTH AND EDUCATION PASSPORTS
by
Allison Stanfield
Heather Tyler
Many children enter foster care suffering from insufficient health care, poverty,
homelessness, exposure to alcohol and other drugs, difficulties in school, and of course,
physical abuse, sexual abuse, and neglect. Too many of these children are not receiving
adequate treatment for their health conditions and it is causing considerable distress.
Health and Education Passports were created to assist foster parents provide proper
medical treatment to the foster child. The goal of the Health and Education Passport is to
increase communication and provide a continuum of care to the child as he/she moves
from placement to placement. This study gathered research from foster agencies about
how effective and useful the Health and Education Passports are and its effects of the
healthcare given to the child. Thirty questionnaires were returned from foster agencies in
Sacramento County. Ages of the foster children ranged from 2 to 19 years old who have
been in their current placement between 2 weeks to 7 years. Findings from this study
show that Health and Education Passports are not following the child as he/she changes
placement, and if they are, they are not helpful or complete. Therefore, the child and care
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providers do not have a medical history for this vulnerable population. As a result, this
creates inconsistencies in health care coverage for foster children. The researchers
recommend the implementation of a more efficient and effective passport system that can
easily be accessed by caregivers and service providers.
_______________________, Committee Chair
Francis Yuen, DSW, ACSW, Professor
_______________________
Date
v
ACKNOWLEDGEMENTS
We would like to express our deepest gratitude to our thesis advisor, Professor
Francis Yuen. His advocacy, persistence, and guidance through the past two years have
been a great influence on our professional endeavors, as well as being a great role model
in all other facets of life. Professor Yuen’s support and excitement about research has
made this project what it is, without him this would not have been possible.
We consider it an honor to work with the foster agencies who provided the data
for this project. Your unwavering support and advocacy for foster children goes
unmatched. Your willingness to participate and add more work to your already busy
schedules is greatly appreciated.
We honor and admire your compassion for improving
the lives of foster children. If there were more like you in this world, we would all live in
a better place.
This thesis is dedicated to our family and friends who have been a great
inspiration to us. You keep us humbled, grounded, and always push us to be better and
do better. You make us feel like anything is possible, and without you we would not be
where we are today. We love you very much.
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TABLE OF CONTENTS
Page
Acknowledgements .................................................................................................................. vi
List of Tables ............................................................................................................................ix
List of Figures ........................................................................................................................... x
Chapter
1. INTRODUCTION ………………………………...…………………………………….. 1
Background of Problem ............................................................................................... 6
Statement of the Research Problem ............................................................................. 7
Purpose of Study .......................................................................................................... 7
Theoretical Framework ................................................................................................ 8
Definition of Terms .................................................................................................. 10
Justification ................................................................................................................ 11
Limitations ................................................................................................................. 11
Statement of Collaboration ........................................................................................ 12
2. LITERATURE REVIEW ................................................................................................. 13
History of Health and Education Passport (HEP) ...................................................... 13
Current HEP in Sacramento County ........................................................................... 15
HEP in Other Counties .............................................................................................. 18
Foster Children Under Medicaid ............................................................................... 19
Placement Permanency and Stability ......................................................................... 21
General Health Risks For Foster Children ................................................................. 23
Foster Children’s Use of the Emergency Room ........................................................ 26
Mental Health Risks................................................................................................... 28
vii
Educational Risks ...................................................................................................... 29
Services Available for Children: Foster Parent’s Perspective ................................... 30
3. METHODOLOGY ........................................................................................................... 33
Study Design .............................................................................................................. 33
Sampling Procedures ................................................................................................. 34
Data Collection Procedures........................................................................................ 34
Instrument - Questionnaire ........................................................................................ 35
Data Analysis Approaches ......................................................................................... 36
Protection of Human Subjects ................................................................................... 37
4. STUDY FINDINGS AND DISCUSSIONS ..................................................................... 38
Demographics of Foster Youth .................................................................................. 38
Presence of Passports During Doctor Visits .............................................................. 40
Advisement By Social Workers on Use of Passports ................................................ 41
Use of Emergency Room and Primary Care .............................................................. 42
A Composite Case Based on Study Findings ............................................................ 46
5. CONCLUSIONS AND IMPLICATIONS ........................................................................ 49
Recommendations For Future Studies ....................................................................... 50
Possible Solutions ...................................................................................................... 51
Electronic Database ................................................................................................... 53
Appendix A. Executive Summary ....................................................................................... 56
Appendix B. Consent Form/Cover Letter .............................................................................. 58
Appendix C. Questionnaire ................................................................................................... 59
References ............................................................................................................................... 63
viii
LIST OF TABLES
Tables
Page
1.
Days Passport Received.……………………………...……………………………......40
2.
Doctor Looked At Passport………………………….… …………………………….41
3.
Reason for Visit to PCP……………… .………….…………………………………. 44
ix
LIST OF FIGURES
Figures
1.
Page
ER Visits After Placement Change……………… ... .………………………………. 28
x
1
1
CHAPTER 1
INTRODUCTION
Doing research with other professionals who work in the foster child system it
was evident that there are many problematic situations caused by the ineffectiveness of
Health and Education Passports. An emergency room (ER) social worker discussed an
encounter she had with a fourteen-year-old foster boy was taken to the hospital for his
psychosis. His foster mom brought him in because they had run out of his medications.
Even though the boy had been living with this foster family for four months, there were
no medical or mental health records in his file and the family did not know anything
about his mental health disorder, other than he had some type of psychosis. He had been
in foster care for several years and all of the service providers he had come in contact
with had neglected to update his file and medical information did not follow him when he
changed placements. The boy ended up waiting in the emergency room for hours. If this
child’s medical records had been available to the foster parent, the trip to the ER could
have been avoided.
Many children enter foster care suffering from insufficient health care, poverty,
homelessness, exposure to alcohol and other drugs, learning problems in school, and of
course, physical abuse, sexual abuse, and neglect. As a result, most of these children have
psychological, emotional, medical and developmental problems that require extra support
and services to deal with their traumas and attachment. Due to a foster child’s unique
needs, children with these risk factors need to have stable access to consistent health care
as well as suitable medical facilities where foster children can be taken. Children also
2
need accurate and updated medical records in order to receive the best, most efficient,
care. Eighty percent of foster youth live with at least one chronic medical condition
(Pasztor, Hollinger, Inkelas, Halfon, 2006). Too many of these children are not receiving
adequate treatment for their health conditions and it is causing considerable distress. For
many reasons, this is a population whose medical needs so often go unnoticed. In
comparison to children not in foster care, children who are in foster care are more likely
to have health problems and are at a greater risk for developing medical conditions that
go unrecognized and therefore untreated (Pasztor et al., 2006). Whether a child is being
taken from their birth home or they are being removed from one foster home to be placed
in a new one, changing placements is a traumatic time for a child. This is a time when a
child is at risk for engaging in self-injurious behaviors and could end up needing
immediate medical intervention. The child could have also been taken abruptly from their
home because of some type of abuse and therefore may also need immediate medical
attention. For many reasons a move can result in necessary medical observation,
therefore, it is important to have the Health and Education Passport for service providers
to be able to refer.
Pasztor et al. (2006) asserted that while abused, neglected, and emotionally
maltreated children had a range of health and mental health problems, the health care
they received failed to address these issues. Health and Education Passports (HEP) were
created to keep track of foster children’s education and medical information.
Unfortunately, HEPs often lack information about the child’s health care because service
providers fail to update them. Another obstacle with HEPs is they do not always travel
3
with the child when they change placements. When children change placements, they are
more susceptible to getting sick, self-harming, or other health-care related issues. When
they get sick, they often end up in an emergency room because foster parents and service
providers do not have the child’s health care information.
The efforts to generate a health passport system dates back to the 1980’s. The
passport system was a result of a Massachusetts lawsuit that resulted in the mandate for
the state to collect health information for foster children. San Diego, located in Southern
California, developed a central computer database that contained important health
information for foster youth in 1989. Other states and counties have developed their own
tracking systems, but most systems are not operating at an adequate level (Lutz &
Horvath, 1997). Despite efforts that began over thirty years ago to create an effective
system to track the health records of foster youth, most counties continue to create
barriers in providing medical care for foster children by not implementing a functioning
system. Child welfare agencies around the country are worried that a centralized
computer system would be too costly. Instead, creating a more effective and efficient
system should be looked at as an investment that will improve the continuity of care and
general medical well-being of children in the foster care system. Refer to chapter five for
suggestions on how to create a cost effective computerized passport system.
When children are placed in the foster care system in California they receive
Medi-Cal medical coverage, which covers all their medical needs including medications,
visits to their primary care physician, and hospital visits. As foster children move from
home to home it is vital to the health of the child that their past medical history, allergies
4
to medications, and what to do when certain events take place, such as when a child has a
fever. To combat the lack of communication and poor continuum of care as the child
moves from placement to placement, the Health and Education Passport was created to
assist foster parents in providing proper medical treatment to the foster child. The Health
and Education Passport is a paper “booklet” that is to be updated every time the child
visits the hospital, doctor to receive immunizations, medications, or becomes ill. When
the child enters the medical establishment they should have the health passport with them
so the doctors can fill out or add to any new information. This is to assist the foster
parents in providing care to the child, know what medical procedures have happened in
the past, as well as know what medications work, or which medications the child is
allergic to. Once the doctor fills out his portion of the passport the foster parent is to
hand the passport to the social worker during the next visit. It is important to note here
that the social worker may only come see the foster family once a month, maybe even
less. Once the social worker receives the passport they give it to the public health nurse
to enter this updated information in the computer system. Then, after the information is
entered the social worker can return the passport back to the family. This can be
somewhat of a lengthy process, especially when the social worker only sees the family
once a month
Updating the passport can be an extensive process, and therefore, many times it
does not get done. Along with the difficulty of keeping the passport up to date, there are
many times the passport is not filled out, or it fails to move with the child from placement
to placement. Working with foster children for several years it is evident this is an
5
ongoing problem. One evening one of the authors was picking up my client, a 13-yearold girl, and all of her belongings to move her from a great foster placement to a group
home. She had lived with this family for over a year and had shown extreme
improvements academically, behaviorally, and finally felt she had found a home. She was
the only child living with a middle aged women and her foster grandmother. Her foster
mother was kicking her out of her placement because she was caught stealing money and
was no longer allowed to be part of the family. As I drove up to her home she waited,
with all of her clothes and possessions in black trash bags in the front yard of her, soon to
be, previous foster home. When I asked to speak to her foster mother she said she had
left to work and no one was home. We packed up the car and drove 45 minutes north to
her new home, an all female group home. During the drive she did not say a single
word. She had her head rested against the window of my car, her body slouched over,
and her watery eyes looking out the window. As we pulled up to the foster home she
complained of a headache so we got her some food, water, and tried to comfort her
anxious feelings. When a child moves into a group home every article of clothing and
personal belongings needs to be documented on paper. She and I sat in the living room
of the group home and unpacked, held up, and wrote down everything she owned in front
of all her new roommates. This took us 3 hours to do. Once we were done she again
complained of a headache. Group home staff took her temperature, which was over 101
degrees. Because we did not get the health passport from her last foster mother we could
not legally give her any medication to alleviate her pain. As I sat next to her in the
emergency room waiting area for 3 hours with ibuprofen in my purse we watch the clock
6
tick past 10pm before we were seen. She was then given ibuprofen to lower her
temperature and help her head. Not only did she receive the same medication I had in my
purse, but she also missed the next day of school because we were in the hospital
emergency room until 11:30pm.
Background of the Problem
Foster children’s inadequate health care has been an issue for over thirty years.
The very first attempts to develop health passports for children in foster care dates back
to the 1980’s, stemming from a Massachusetts lawsuit that resulted in the mandate for the
state to begin to collect health information of foster children. In 1989, Public Health
Nurses in San Diego were put in charge of coordinating a passport system. This included
having a central database to keep critically important health records. Although states have
implemented their own tracking systems since these two early attempts, most are not
functioning at an adequate level (Lutz & Horvath, 1997).
Paper passports are an unreliable way to keep track of such important information
like medical records. One study that took an in depth look at the passport system found
that only fifteen to twenty percent of paper passports contain all of the necessary health
information. Paper passports are prone to being lost, and expecting all service providers
to hand-write all necessary information is an inefficient task that are most are not willing
to undertake. Knowledge of health records is critical and the current manner in which the
information is accumulated and organized is not working (Lutz & Horvath, 1997).
The cost of not resolving the passport system directly impacts the health and wellbeing of foster youth. There are over 400,000 children in foster care, and with this group
7
comes a vast array of medical related issues. These are children who are more prone to
health risks, injuries and self-harm, yet their health care is being compromised because of
organizational issues. It is not a simple task for agencies to convert their records to an
electronic database, but it has been done in countless systems and needs to be
implemented in the foster care system. If this problem is left unfixed, it will continue to
affect the health care for foster youth (Lutz & Horvath, 1997).
Statement of the Research Problem
Health and Education Passports were created as a means to communicate a foster
child’s health and education history to new foster parents and schools. Although the role
of the passport is to provide continuity and better care for the child, due to the difficulty
in updating the passport and the complications in having it follow the child from one
placement to another, it is not as effective as it should be. Foster children are an
extremely vulnerable population. Some do not have family members, have experienced
extreme abuse and/or neglect, and do not have stable support systems. This puts this
population at risk for health problems due to stress, mental illness, and low performance
academically, all of which affect their future.
Purpose of the Study
Our interest in doing our research project on foster youth and their Health and
Education Passports is due to an identified need. We recognize that it is detrimental to
their health when foster youth do not have adequate HEPs and we want to bring
awareness to this problem. The research that has been reviewed has made it very clear
that foster children are one of the most at-risk populations, prone and vulnerable to
8
several health conditions, and contributing to these issues is the lack of medical records.
The primary purpose for the study and our hope for this project is that by bringing
awareness to this issue and by offering suggestions for improvements, we can bring about
a change in the passport system, and ultimately improve the health care for youth in
foster care.
Theoretical Framework
Children who are part of the child welfare system do not come from ideal home
situations. They likely have come from homes of abuse and neglect and are forced to
cope with traumatizing situations. From an evolutionary perspective, we can see how
children in foster care reflect the basic will to survive. According to the socio-cultural
perspective, the environment that the child is raised in has a big impact on the child’s
learning. When a child is brought up in a violent home where she witnesses or
experiences violence, she is more likely to use violence outside the home and when she
has a family of her own. Children can also be directly impacted by the environment in a
positive way and can learn valuable skills from the home they grow up in. For example,
a child who sees his parents read books on their own time could learn from their behavior
and read books on his own. “Human development starts with dependence on caregivers.
The developing individual relies on the vast pool of transmitted experiences of others”
(Steiner & Mahn, 1987).
Most people would agree that access to quality health-care is an important part of
life. Often times a diagnosis or severe injury can impact a person’s life so drastically that
that they influence a person’s development. The life span perspective describes how
9
children can be affected by life changing events on both global and personal levels.
Without proper documentation of health records, it can be difficult for foster children to
receive the medical attention that they require. This theory discusses how events can be
exemplified for children of divorce. If divorce can affect the development, it is very
probable that changing placements as a foster child causes severe developmental life
changes. Trauma and toxic stress disrupt brain development and increases the risk for
psychopathology and physical illness. “Advancing healthy development and well-being
for youth must focus on increasing promotive factors and reducing risk factors” (Blake,
2012, p.10).
Foster youth’s health care access is largely affected by the fact that they are in the
Child Welfare System. The Social Determinants of Health (SDOH) refers to the many
situations and circumstances that can impact the health status of people and their
communities. There is a clear link between differences in a person’s environmental,
social, and economic status and their access to health care. Some of the common social
determinants of health include education level, housing a food security, physical and
social environments, healthy child development, income, health care accessibility, and
early childhood stability (Healthy People, 2013). Foster youth happen to be affected by
most, if not all of the above factors and are therefore at a disadvantage to receiving
proper health care.
Closely related to the Social Determinants of Health theory, the Systems theory
acknowledges the link between individuals and their physical, familial, and social
environments. Human behavior can be analyzed when individuals, institutions, and
10
societies influence and affect one another. It can be a daunting task for foster youth to
navigate the various systems when they are unfamiliar with the existing resources and
lack sufficient supports. For example, a foster families’ income can prevent them from
being able to seek adequate and timely medical care for their foster child. If a foster child
is placed in a new foster home and their medical passport does not follow them to their
new home, it will likely delay establishing a new primary care physician. If this foster
child needs to see a doctor before the physician can be established, this child is often
forced to go to the emergency room. These circumstances can make it difficult for foster
families to navigate the system, and their options are typically costly and limited
(SickKids, 1999).
Definition of Terms

Health and Education Passports (HEP): Each foster youth in the Child Welfare
System has their own “booklet” of information, which is a paper document where
all medical and education information is recorded.
o
For the purpose of this study the use of “HEPs” and “passport(s)” will
only be referring to the health portion of the passport.

Service Providers: People who provide direct services for foster youth, including
doctors, nurses, social workers, behavioral and mental health agencies, therapists,
and teachers.

Foster youth: a minor who has been placed into a ward, group home, or private
home of a state-certified caregiver.
11
o
For the purpose of this study foster youth will refer to children who are in
foster care and are between the ages of 2-19.

Caregivers: a person who works at a foster agency or group home and who helps
care for foster children.
Justification
This research project was developed with the hope that it will improve health care
for all foster youth in the Sacramento County. Exclusively based on observation, it
appears the current system for the Health and Education Passports is not only inefficient,
but also problematic and detrimental to foster children. Currently, all medical records are
tracked in a paper system which is not up to date and often fails to stay with the foster
youth when they change placements. We believe that caregivers and the foster children
would benefit from the organization of an readily accessible database for the passports.
This research study is intended to examine the current passport system and to identify
ways to improve it. In doing so, we believe this research will improve health care for
foster youth.
Limitations
The researchers of this project faced some significant limitations in the process of
gathering data. Researchers initially partnered with Sacramento County Child Protective
Services (CPS) to conduct this research study. The chaos of working with CPS was a
logistical limitation that prevented us from reaching all foster parents in Sacramento
County, our intended data source. This limitation forced us to reach out to other
individual agencies, including group homes and foster family agencies. Due to the change
12
in data collection, we were limited by our sample size because we had access to a much
smaller number of individuals. Our initial plan was to interview foster parents, who
would be the best historian of their foster child’s doctor visits. Due to the change in data
collection, our respondents changed from foster parents to group home and foster agency
caregivers.
The homogeneity of the respondents proved to be a limitation because the
respondents were all concentrated to a few specific geographic locations. If we had been
able to survey our intended population, we would have seen more variety in the responses
to the questions about where the caregivers would take their foster children to the
hospital. The researchers did not ask the caregivers where their foster youth lived before
their most recent placement. Not having this piece of information limited our project
because we were unable to determine if the distance of the most recent move had
anything to do with the type of doctor that the caregivers were more likely to take the
child to (primary care physician versus an emergency room).
Statement of Collaboration
The two researchers working on this project are Allison Stanfield and Heather
Tyler. Both researchers are passionate about working with children and have recognized
a problem in the foster care system that can hopefully be fixed. Having both worked with
foster youth, we recognize that this is a vulnerable, at-risk population who needs better
access to improved services. We have both done extensive research on this subject and
have collaborated together on each section of this project.
13
CHAPTER 2
LITERATURE REVIEW
The goal of placing a child in foster care is to prevent abuse, neglect, and promote
healthy child development. Foster care is seen as a lifeline that saves thousands of
maltreated children each year from unjust living environments. Nevertheless, taking a
child from their home and placing them into state custody is an extremely invasive
intervention. By doing this, the government takes special responsibility for this
child. When the government does this, it is implicitly saying the state can do a better job
of caring for, protecting, and providing for this child than his or her biological parents
can. When children are placed in foster care and continue to suffer from harmful
situations, it undermines the government interventions and as a result, hurts the youth
more than it helps (Bass, Sheilds, & Behrman, 2004). Although we, the authors of this
paper, support our foster care system, we recognize that there are changes that can be
made to make the foster youth experience less traumatic.
History of Health and Education Passport (HEP)
The very first attempts to develop health passports for children in foster care dates
back to the 1980’s, stemming from a Massachusetts lawsuit that resulted in the mandate
for the state to begin to collect health information of foster children. San Diego put Public
Health Nurses in charge of organizing the passport system, which began in 1989. San
Diego’s early innovations consisted of a central computer database with health
information they saw as extremely important. States have since implemented their own
14
tracking systems, but the issue is that the majority of the systems are not functioning at a
high, or even adequate level (Lutz & Horvath, 1997).
Computerization would benefit child welfare and other service providers by
allowing them to administer meaningful planning, identify specific needs, and to find
gaps in service delivery. In 1997, Massachusetts was the first state to try and create an
effective online passport system that would link child welfare and Medicaid by allowing
immediate access of foster children’s Medicaid files to service providers. The idea behind
this system was that once a child was entered into the social services system, all of the
child’s Medicaid information, including former primary care doctors, phone numbers and
addresses, would be entered into the online passport and be made available to service
providers. Foster parents and social workers would have immediate access to information
that could have taken much longer to find without an efficient system (Lutz & Horvath,
1997).
In an attempt to improve the health care of children in foster care, statewide
guidelines were developed by the Child Health and Disability Prevention (CHDP) in
1997. The guidelines are intended to provide social workers and public health nurses with
a framework for how to assess, plan, intervene, and evaluate the health status of children
in foster care. In these guidelines, nurses and social workers are to promptly identify
medical, dental, developmental and mental health needs in a timely manner, and to ensure
the child’s medical care is being evaluated regularly. The guidelines were developed by
the CHDP during a series of group meetings that they called forums. The forums were a
way for participants to share knowledge and their concerns regarding the guidelines, and
15
to tailor the procedure to their specific county as well (Foster Care Nurses Network,
1999). Special care and consideration went into the guidelines for foster children’s health
care and similar consideration needs to be given to creating a more efficient passport
system in order to maintain the intended goal of improved health care set in place by the
CHDP.
The CHDP and child welfare services mandate that children in foster care need to
have a comprehensive well-child examination within the first 30 days of placement.
There are cases where children may have needs that require immediate linkage to
services. The risk of unrecognized and untreated medical, dental, and mental health
problems is high for foster youth because they are part of a fragmented system that does
not seem to have the time or personnel necessary to attend to their needs (Foster Care
Nurses Network, 1999). CHDP programs are meant to assist social workers in locating
necessary services for children in foster care, including finding other local CHDP
programs. CHDP programs are in sixty-one health departments statewide. It is
extremely important that the information from the well-child exam be documented in the
child’s HEP so he/she can continue receiving medical care for identified needs
throughout their stay in foster care.
Current HEP in Sacramento County
Sacramento County’s Health and Education Passports are a paper packet that
consists of several pages of information about the child’s immunization history, allergies,
past doctor and medical visits along with their past educational information. The
instructions on the passport are as follows:
16
Please keep this Health and Education Passport while this child is in your
care. Please keep the child’s Medi-Cal card, health eligibility identification cards,
Medical Consent form, Birth Certificate and immunization record with this
Passport.
Take this passport to all medical, dental, and educational visits pertaining
to the child. Remind doctors, dentists, teachers, mental health care providers,
vision care providers and other health-care providers to add or correct information
on the form after each visit. Please give the corrected Passport to the social
worker at your next meeting. When the child leaves your care, the latest update
of this passport will go with the child to aid the next care provider (San Diego
County Interagency Agreement, 2011 p.123).
Although the instructions above are very clear and give specific directives,
following these instructions is much more difficult than it sounds. It would be beneficial
for the purpose of the research, if you can imagine yourself as a foster parent. In your
home you have a child who has just come down with a high temperature, congested nose,
and a throbbing headache. You decide to look in the HEP to see if he has any allergies to
medications in an attempt give him anything to relieve his symptoms. You decide to take
him to the doctor the next morning, the first appointment you can make. According to
directions listed above, you take the passport with you to the doctor and have him/her fill
out and update the passport with the diagnosis and the medications he was given. The
next step to updating the passport would be to give the updated passport to the social
worker. The only problem is that you do not see the social worker for another three
17
weeks. Somehow, you remember to give the social worker the passport so she can
update the information with the county. Presenting yet another roadblock, the social
worker takes the passport from you and will return it at your next visit, but your next
appointment with her is not for another month. Because the process to update a passport
is lengthy and drawn out, they are often forgotten, lost, or not updated properly. If this
particular child were to get sick again within now and the next time the social worker was
seen, you, the foster parent, would not have the passport with you to be updated. Not
only does this put the current foster parents in a difficult situation, this makes it difficult
for future foster parents of this particular child to have the correct and accurate
information to help with this child’s needs regarding health, mental health, and even in
education.
Paper passports are an unreliable way to keep track of such important information
and can pose serious risks pertaining to medical needs. According to a study on the
ineffectiveness of the passport system in 1997, only 15-20% of case files were found to
contain all necessary health information that should be included. The reason for the
shockingly low number of accurate case files is due to the paper passports being lost, the
inefficiency of entering information in a timely manner by service providers and foster
parents, and the unorganized way in which the information has been accumulated and
entered. Complaints have also been made that the information, particularly the medical
terminology, is not user-friendly. Despite efforts having begun in the 1980’s, states have
yet to develop an effective health passport system (Lutz & Horvath, 1997).
18
“The computerization of the health passport system may in some states be the key
to the advancement and consistent inclusion of medical information in the child’s case
records and generation of abbreviated health information reports for the foster parents”
(Lutz & Horvath, 1997, p.5). The computerization of the passport system would
encourage consistent health care and would be an effective way to track records between
multiple agencies and providers. This collective effort of computerization should utilize
today’s advanced computer technology.
HEP in Other Counties
San Diego Child Health and Disability Foster Care Program, located in
California, have implemented a computerized Health and Education Passport system.
This program is so effective because it is an interagency, interdisciplinary, collaborative
effort between the Departments of Health and Social Services. All health and education
records for children are stored in the centralized passports and serve as accessible records
(Lamm, 2011). In Tennessee, the Department of Child Services is in close collaboration
with the state Medicaid agency, and is therefore able to immediately assign a primary
care doctor to the foster child as soon as he or she enters into the custody of the state
(Allen & Hendricks, 2013).
Pennsylvania’s attempts to improve health care for children in foster care are
notable and show the positive effects of collaboration between various service
departments. After receiving a grant from the Center for Health Care Strategies, the
Office of Children Youth and Families (CYF) partnered with University of Pittsburgh
Medical Center’s (UPMC) Medicaid Managed Care program to facilitate the Foster Care
19
(Health Information) Program. The program identified all foster children eligible under
the Medicaid program and made sure that they were being provided with well-care,
dental, and behavioral health visits annually. This program resulted in the formation of
electronic health records for foster children, which dramatically improved the consistency
of the children’s medical records. When children switch homes, there is no longer a
concern about retrieving the child’s paper records, including information regarding
medications, immunizations, allergies, and other pertinent medical information. The
electronic medical records create continuity among service providers, and ensure better
care coordination. “Over the past three years, there has been a 48% increase in target
foster care children who had an annual well visit, and a 25% increase in children who had
an annual dental visit” (Hoover, 2012, p.1)
Foster Children Under Medicaid
Approximately one in five children in foster care in the United States reside in
California (San Diego County Interagency Agreement, 2011). With very few exceptions,
all children in foster care are eligible for Early, Periodic, Screening, Diagnosis, and
Treatment (EPSDT) under Medicaid (called Medi-cal in California). All foster youth are
eligible for Medicaid/Medi-Cal and receive health benefits including dental benefits
(Resource Directory: A Guide For Current and Emancipated Foster Youth, 2009). It is
recommended that children in foster care receive four different types of health care
benefits: initial health screening, comprehensive medical and dental assessment,
developmental and mental health evaluation, and ongoing primary care. Even though all
of the above domains are covered under Medicaid, a gap still exists in the coverage and
20
foster children often miss out on certain reimbursable services, such as treatment
planning, peer support, recreational therapies, and intensive in-home services (Allen &
Hendricks, 2013).
Because most foster children are insured under Medicaid, the lack of adequate
health care and the inefficiency of health passports is not due to a lack of coverage, but
can be attributed to insufficient effort of all service providers, including physicians, social
workers, foster parents, etc (Lutz & Horvath, 1997). The health care needs of children in
foster care are significant and include a wide range of needs, including mental,
behavioral, and physical. “Nearly ninety percent of young children entering the foster
care system have physical health problems, and fifty-five percent have two or more
chronic conditions” (Allen & Hendricks, 2013). Some of the most common physical
health problems are asthma, anemia, skin conditions, malnutrition, and physical abuse.
Although it is recommended by the American Academy of Pediatrics (AAP) that children
receive a dental evaluation within thirty days of placement, dental care is often
overlooked because other issues overshadow the need for oral care, especially when it is
preventative care (Allen & Hendricks, 2013).
Some states do not cover all services needed by foster children in their Medicaid
plans. If states were to find ways to expand their access, it would improve the quality and
cost-effectiveness of health care for foster children. By limiting the use of emergency
services and increasing access to preventative care, foster children would be healthier and
the amount of money spent on their health care would decrease. One key component of
improving health care is the collaboration among child welfare, behavioral health,
21
Medicaid, and other service providers. Policies related to health care for foster children
should include goals for the child’s well-being and safety, as well as permanency (Allen
& Hendricks, 2013).
State Medicaid systems rarely cover all of the services that children in foster care
require. It is often very difficult to obtain health care records of children for things that
occurred before their current placement. This is in part due to the inconsistent contact that
children have had with several different providers. Removing a child from their
biological parents is a tumultuous time that can be difficult, if not impossible, to obtain a
complete health history of the child. Pediatricians have the ability to play an important
role in decreasing the foster child’s amount of traumatization following a placement
change. In many cases, they are required to provide the necessary care to the child,
despite having very little, if any, previous health information (American Academy of
Pediatricians [AAP], 2002).
Placement Permanency and Stability
“All children in foster care should have a medical home in which they receive
ongoing primary care and periodic reassessments of their health, development,
and emotional status to determine any changes in their status or the need for
additional services and interventions” (AAP, 2002, p.537).
Children are taken from their homes and placed into foster care for many different
reasons, some of the most common being abuse and neglect. As a result, most of these
children have psychological, emotional, medical and developmental problems that
require extra support and services to deal with their traumas and attachment issues. Given
22
the fact that these children have multiple needs, it would seem logical to ensure they have
access to adequate health care, as well as developmental and psychological evaluation
and treatment. It would also make sense for foster families to be given updated and
accurate information regarding their foster child’s medical records to ensure the child
receives quality health care (Lutz & Horvath, 1997).
Approximately one quarter of the children who are in foster care have had the
unfortunate reality of experiencing three or more changes in placement. The turbulent
nature of placement changes for a foster child often results in a loss of health information
that does not have one central location. Health information becomes spread across many
different systems and information is not always recovered. Medical passports were
developed to mend this problem of a lack of consistent care. The passport is intended to
ease the transfer of necessary information among different health care providers. Foster
parents are supposed to keep a file with copies of these records and bring it to all
appointments for the child in order to keep all health information current. If a child
changes placements, the medical passport should follow the child and be transferred to
their new caregiver. Like any paper document, the possibility of this information being
misplaced at some point is probable, therefore a computerized system is much more
reliable (AAP, 2002).
When foster children change placements, it makes it more difficult to access
information among various providers, which makes the idea of continuity of care nearly
impossible. It is important that these children establish a “medical home” at the time of
placement. This serves as a reliable provider at the center of the child’s health care.
23
Foster families will benefit from having a medical home as well, especially if they
consolidate their child’s health needs to one primary doctor. “Access to health coverage
means healthier kids; healthier kids mean healthier, more productive adults” (Thompson,
2008, p.1).
The unfortunate truth is that these medical records do not act as a source of
current and reliable information. Foster parents are commonly in the dark when it comes
to their foster child’s medical needs and history. Foster children’s medical records lack
adequate record keeping, have poor communication between service providers, have
inadequate health care supervision, including health and psychological screenings, and
lack reimbursement services. Even though there are mandates in place that require
children to have health screens within a certain number of hours after being removed
from a house, these rules are rarely abided by, thus putting the child’s health in further
danger. When children have multiple placement changes and changes in physicians and
social workers, their health care becomes inconsistent and the focus is put only on
immediate medical needs rather than the entire well-being of the child (Lutz & Horvath,
1997).
General Health Risks for Foster Children
In comparison to children not in foster care, children who are in foster care are
more likely to have health problems and are at a greater risk for developing medical
conditions that go unrecognized and therefore untreated. Although children in foster care
are more likely to have access to health insurance than other children in high-risk
situations, they often receive spotty or inconsistent care (Bass, Shields & Behrman,
24
2004). Eighty percent of foster youth live with at least one chronic medical condition. For
many reasons, this is a population whose medical needs so often go unnoticed. Treatment
needs are often identified, but due to the fragmented health care that these youth receive
and the lack of access to services, it is still difficult for them to get the care that they
need. Adolescents who are in foster care are especially vulnerable, often dealing with
eating disorders, substance abuse issues, asthma, reproductive concerns, and much more
(Lamm, 2011). General Accounting Office (GAO) found that 12% of children in care had
not received routine health care, 34% had not received any immunizations, only 10%
received services to address developmental delays, and even though three-quarters of the
children were at high risk of exposure to HIV, fewer than 10% had been tested (Bass et
al., 2004).
The majority of children placed in foster care are taken from their homes due to
issues of abuse or neglect, which often occur because of parental substance abuse, mental
illness, or extreme poverty. This results in an overwhelming number of children in the
system who represent the population with the least amount of financial and psychosocial
resources as well as the families who typically have less support from extended family.
Typically, the goal is to reunify children with their biological families if possible, but
about 35% of children end up re-entering the foster care system after being reunified with
their families (AAP, 2002).
The barriers faced by foster children to receive routine health care,
immunizations, dental care, and other screenings are not new problems. In fact, they have
been issues for over thirty years, according to the American Academy of Pediatrics
25
(AAP). A recent review of state child welfare systems concluded that only half of the
states provide acceptable physical and mental health services to children in foster care.
Placement changes are usually accompanied by physician changes, which exacerbate the
already difficult task of routine health care (Allen & Hendricks, 2013).
All children in foster care should have a medical home in which they receive
ongoing primary care and periodic reassessments of their health, development,
and emotional status to determine any changes in their status or the need for
additional services and interventions (AAP, 2002, p.539).
Children in foster care are more likely than children who are not in foster care to
utilize more restrictive, and consequently more expensive services because of the high
level of need for physical and behavioral health services. Some of these more restrictive
services include residential treatment, inpatient psychiatric treatment, and the emergency
room. There is a disparity in the seriousness of the needs of these children and the access
to services (Allen & Hendricks, 2013).
According to the U.S. Children’s Bureau, the child welfare system emphasizes
that the primary goals are safety, permanence, and child well-being. However, some
would argue that while the system does a good job in terms of protection, placement and
permanence, the issue of the child’s well-being and healthy development is often
overlooked. One of the reasons that more focus is not put on healthy development is due
to the fact that when a child has a health issue, it is not always recorded in a centralized
file for other service providers to see. In most states, specific information about the health
of a foster child is recorded into individual case files, and typically not on a shared
26
database. Child welfare agencies may also be reluctant to record the well-being of a
foster child because they may think it will reflect negatively on their performance as
service providers (Bass et al., 2013).
Health care for foster children would improve if there were more standards to
analyze child well-being. Standardized data is imperative to examine the development of
children. Implementation of child well-being indicators into state systems would allow
providers an easier time monitoring the child’s health status and access to needed
services. San Diego is an example of how a computerized health and education passport
system works efficiently to improve the well-being of children in foster care and to
ensure that they are receiving appropriate care (Bass et al., 2013).
In a national study that focused on the healthcare policies for foster children, 37%
of states reported they do not require any training around healthcare issues for foster
families. Over 52% did not have any recognizable responsibilities for caseworkers to
evaluate the current health of the child (Pasztor et al., 2006).
The health care these children receive while in placement is often compromised
by insufficient funding, poor planning, lack of access, prolonged waits for
community-based medical and mental health services, and lack of coordination of
services as well as poor communication among health and child welfare
professionals (AAP, 2002, p.537).
Foster Children’s Use of the Emergency Room
Poor continuity of health care for foster children increases health risks. The
increased number of foster home placements put the child at higher risk for health care
27
problems and higher use of the Emergency Room (ER) than their peers who have less
placement changes. As a foster youth changes home placement he/she often loses his/her
primary care physician, thus forcing the foster parents and foster child to use the
emergency room and urgent care as a primary care provider and a source of outpatient
care. Figure 1 (below) shows that the timing of emergency room visits used by foster
children more than doubles 21 days after placement changes or after the child enters the
foster care system (Rubin, Alessandrini, Feudtner, Localio & Hadley, 2004a). This
suggests that placement changes were precipitating, in part, subsequent utilization of the
ER. Furthermore, children who had more than four placements use the ER more than
twice as much as other children in foster care. It is also important to note that the number
of children in foster care who used the ER far surpassed the ER use of other children in
the Medicaid/Medi-cal program (Rubin, Alessandrini, Feudtner, Mandell, Localio, &
Hadley, 2004b).
28
Figure 1. ER Visits After Placement Change*
*Timing of ER visits that occurred within 21 days before or after a placement change (n
= 298 visits, of a total of 1206 visits during the follow-up period).
Mental Health Risks
Along with the physical health problems foster children face, they are also at high
risk for mental health issues as well. Because the number of children under the age of
five placed in foster care has increased so dramatically over the years, it is important to
address the issues of brain development during the early stages. “Recent brain research
has shown that infancy and early childhood are critical periods during which the
foundations for trust, self-esteem, conscience, empathy, problem solving, focused
learning, and impulse control are laid down,” (AAP, 2002, p.538). During this critical
time in the infant’s life, abuse, neglect, drug exposure, and other negative environmental
factors can cause severe and lasting damage to the child.
Although children in foster care comprised only 4% of all children enrolled in
Medi-Cal in 1988, they accounted for 55% of all visits to psychologists and 45% of visits
29
to psychiatrists paid for by the program (Simms, Dubowitz, & Szilagyi, 2000). It is
evident that foster youth experience a high level of risk in all aspects of life including
mental and physical health. Multiple placements and episodic foster care is associated
with increased mental health usage and costs. Studies show that children with increased
general health care needs increased the probability of mental health needs for all children
(Rubin et al., 2004a). This correlation exhibits the importance of addressing the child’s
general health needs in hopes of decreasing mental health issues that are often
experienced by foster youth.
Although the child’s mental health history is an important aspect in providing care
to a foster child, it is often forgotten in the HEP. Often foster parents receive children
who have extensive mental health history and/or mental health needs but often are
unaware of them. As a result, mental health needs are often un-addressed which leaves
the youth suffering from several mental health problems, and as stated above, more
general health care needs.
Educational Risks
According to San Diego’s Interagency Agreement (2011), nationally, only 51% of
students in foster care graduate from high school, 26% - 40% repeat one or more grades,
and 31% are below grade level in math or reading. These academic difficulties are
attributed to the nature of the abuse and trauma children in foster care have experienced.
Difficulties adjusting to these changes of care and school environments often result in
stress and behavioral problems, which also increase likelihood of a child becoming
sick. Frequent changes in home and school placements can also have a detrimental effect
30
on children in foster care’s academic performance and future success in life. As a result
to frequent placement changes, foster children have a loss of education records. This
results in potential loss of academic credits and time spent in school, as well as an
increased risk of dropping out of school (San Diego County Interagency Agreement,
2011). Foster children’s health also plays a vital role in their educational success. As a
foster child moves to a new placement, his/her updated HEP is, theoretically, supposed to
follow him/her. Lost health records result in possible delay in the youth beginning school
due to not having records to prove they have received the appropriate immunizations.
The Urban Institute conducted a national study on the well-being of children who
are in the child welfare system. It found children placed in foster care were “more likely
to have behavior problems, to have been suspended or expelled from school, and to have
received mental health services” (Pastzor et al., p.39).
Services Available For Children: Foster Parent’s Perspective
The barriers that exist for foster parents to find appropriate physicians for their
foster child are substantial. Foster parents are supposed to find a provider for their child
to receive an initial health screening within a certain number of days of being placed. The
provider will also be used for preventative care and treatment for illness and injuries. For
several reasons, it can be an extremely frustrating task to find a provider who is willing to
work with foster youth. One of the barriers foster parents report is trying to find a
physician who accepts Medicaid. Some physicians even flat out refuse to treat foster
children due to their unique and often very complex needs. The fear of having to testify
31
in court also scares physicians away from providing care for foster youth (Pastzor et al.,
2006).
Foster parents also complain that there can be long delays for receiving the
Medicaid cards and that providers are not afraid to turn children away if they cannot
present their card. Even though there are numerous hurdles to jump over in order for
foster children to have access to health care, foster parents report receiving mental health
services for their children are considerably more difficult and scarier. The complaints
they had about medical and mental health records were that information rarely followed
the child. Lack of documentation for medications was commonly missing, which had
considerable consequences to the child’s well-being. Additionally, parents were
concerned about potential side effects to the medication.
Some of the most concerning information about foster parent’s perceptions on the
passport system was the withholding of medical information by child welfare agencies
for fear that the parent would not want to accept the foster child into their home. One
example in particular, which was told by a CPS worker, discussed a foster parent’s
agreement to take an infant on an emergency basis. It happened to be during a time when
the weather was very cold and the baby came dressed in a big snowsuit. The worker
delivered the baby and left promptly. Upon taking the baby’s snowsuit off indoors, the
new foster parent discovered the baby was in a full body cast. Caseworkers are often able
to hide behind revealing such important medical issues as well as instances of sexual
abuse and destructive behavior by hiding behind rules of confidentiality. Some foster
parents did not use the passports because they felt there was missing information,
32
information they did not understand, or because they heard negative comments about the
passports from providers. “Foster parents generally understood that the value of the
healthcare passports was linked to the willingness, ability, and resources of those
responsible for entering and transferring information.” (Pastzor et al., 2006, p.45).
33
CHAPTER 3
METHODOLOGY
The purpose of this study is to determine the effectiveness of the Health and
Education Passports (HEPs) and how they relate to foster youth’s use of the Emergency
Room (ER) and Urgent Care. From the caregivers’ perspective, we will explore how
complete foster youths passports are, whether they are up to date, and what the effects of
having an outdated, incomplete, or missing passport has on the health care provided to
the youth. We hypothesize the following:

Youth who do not have updated passports tend to use the ER/Urgent Care
more frequently.

The high use of ER/Urgent Care by foster youth who have recently made
placement changes is due to current foster parent(s) not receiving the passport
in timely manner and/or passport is not up to date.

Passports tend to not follow the youth from foster home to foster home and
are rarely updated.

Passports are useless for the foster parents who are receiving the foster youth
due to them being absent or incomplete.
Study Design
This study aims to explore how timely foster parents receive the youths passport
after a youth has a placement change, and the frequency the foster youth enters the ER
and/or Urgent Care after a placement change. The correlation between youths who have
minimal information on passport and their use of ER and/or Urgent Care is the focus of
34
this study. This study gathered quantitative data through multiple choice surveys
distributed to foster agencies and group homes of foster youth in Sacramento County.
Sampling Procedures
The group home and foster agencies assisted the researchers in distributing a
cross-sectional survey. Through the process of criterion sampling, the caregivers in
Sacramento County in 2014 were chosen based on specific information regarding the
foster youths home placement. Caregivers who received the questionnaire from their
agencies were asked to fill out the form and return it to their supervisor, to be picked up
by the researchers.
Data Collection Procedures
Caregivers of various group homes and foster family agencies were asked to
complete a questionnaire about their foster child. The researchers met with staff members
to further discuss the reason for the study and hypotheses. The twenty-three question
survey was made available online and in hard copy, not to exclude those caregivers who
do not have access to a computer. In order to ensure all participants maintain anonymity,
the questionnaires were sent out through the agencies and no identifying information was
collected. Researchers have no way to contact or identify who the foster parents are, or
who their foster child is. A consent form was presented in the beginning of the study,
which informs participants of the purpose, goals, how this information will be used, and
their ability to discontinue participation in the study at any time. Informed consent was
sent out via email for those who chose to complete the survey online. Consent letters
contain a link which directs participants to the survey on surveymonkey.com and those
35
filled out by hand have a consent form stapled on top of the survey. Informed consent is
implied by the completion of the survey, as described in the consent form.
Surveymonkey.com was one tool that was used to create the survey and was a
means to collect data from participants. Data collection was encrypted to ensure that data
cannot be decoded or linked to respondents. The highest level of data encryption was
used, within the limits of availability and feasibility. Data collected through
SurveyMokey is recognized as safe and secure through online trust seals, including
Norton, TRUSTe, McAfee and Better Business Bureau. Once surveys were completed
they were sent back to the agencies to ensure information given to researchers had no
identifying factors on the survey.
All collected data was downloaded using an encrypted secure channel to the
researcher’s personal computer. The data on this researcher’s computer is only accessible
to these researchers and the computer is password protected. Any hard copies of data are
to be kept in a locked fireproof/waterproof safe to which only this researcher has access.
Data was be properly disposed of at the completion of this project.
Instrument - Questionnaire
The participants were asked to partake in the study by completing a multiplechoice questionnaire. The questionnaire is available through surveymonkey.com online
or by hard copy and requires approximately 10-15 minutes. Items on questionnaire
identify when HEPs were received and whether or not they found the content of the
passport useful. Through the process of qualitative analysis we examined if having an
updated HEP had correlation to the foster youth’s number of ER or Urgent Care visits.
36
A 23 item questionnaire was used to gather data for this research topic. The
questions asked were guided by information gathered from current literatures and
conversations with current care providers like CPS and foster parents. Researchers met
with CPS staff to discuss relevant questions that were aimed to satisfy the focus of the
study. It was important for both CPS and researchers that the possible findings from this
study be used to create a better medical tracking system for foster children, therefore it
was vital that the questions fit the goal of the project. As result from current research (See
Chapter 2) it is apparent foster youth are a very vulnerable population and tend to seek
medical care often. Questions posed were directly related to the child’s use of the
medical resources available to him/her and if having medical records affected the care the
child received. For example, questions regarding the presence of the HEP and the type of
medical care the child received such as emergency services versus primary care. Please
see Appendix C for full questionnaire.
Data Analysis Approaches
After receiving completed questionnaires, data was input into the Statistical
Program for Social Science (SPSS) for analysis. Qualitative information was sorted and
organized for common themes and frequency count and in some cases quantified.
Descriptive statistics such as measurement dispersion and frequency were used to provide
a general understanding of information collected.
The mean was found for the average
age of foster youth, and median numbers were used to determine the length of time the
foster children have been in their current placement. Inferential statistics including Chi
37
squared and on sample t-test, were employed to test against the predetermined hypotheses
established for this study.
Protection of Human Subjects
All participants are kept anonymous and all information is kept confidential.
Participation is voluntary and not required. Should the caregivers decide not to
participate, they may discontinue participation at any time. Refusal to participate will not
in any way affect the caregivers’ relationship with the participating agencies. Any
information obtained in this study will be treated as confidential. No individual
information will be disclosed and only group information will be included in the report.
Information gathered in this study was destroyed after completion of the thesis project
(June 1, 2014).
The survey did not contain any questions that can identify participants or
participating agencies. Participants have the option to complete the survey by hand or
online by clicking a link sent to them in an email. After completing the survey online,
results will be sent to the researcher’s account created on Surveymonkey.com. Data
collection will be encrypted to ensure that data cannot be decoded or linked to
respondents. The data on this researcher’s computer will only be accessible to these
researchers and the computer will be password protected. Any hard copies of data will be
kept in a locked fireproof/waterproof safe to which only these researchers have access.
38
CHAPTER 4
STUDY FINDINGS AND DISCUSSIONS
The initial design of the study predicted approximately 3,000 on-line survey
requests to be sent out and yield 300 respondents. This research project was approved by
both the University’s Human Subjects Review Committee and the Sacramento County
Health and Human Services’ Institutional Review Board. Even with the support from
CPS leadership, delays and other difficulties resulted in the authors gathering data from a
focused sample size through selected foster agencies. Although the sample size was not
as large as originally predicted, yielding 30 responses, the findings still show impactful
results about health and education passports.
A result to having a smaller sample size, researchers were allowed to focus on the
needs of foster youth in a specific area of Sacramento. A majority of the population
sampled in this study was from the 95821 area code and said they would take the foster
youth to Mercy San Juan Hospital for emergency medical services. Due to all foster
youth in Sacramento County having the same Health and Education Passport system, the
struggles and findings found in this study can be generalized to the entire foster youth
population in Sacramento.
Demographics of Foster Youth
Ages of the foster youth presented in this study were evenly distributed between
ages 2 to 19 years old (the mean age being 11.6 years old). Having an evenly distributed
sample size allows our findings to be applied to all foster youth in this age
range. Statistical analysis did not show a difference in ER visits or primary care
39
physician (PCP) visits between foster youth when taking their age into consideration, nor
did the age of the child or length of stay in a foster home correlate with whether the foster
child did or did not receive his/her HEP. The foster youths length of stay in the current
placement ranged from 2 weeks to 364 weeks with the median amount of time being 13
weeks.
The Health and Education Passport (HEP) was created primarily to make healthcare streamlined for foster youth and to improve access to care by creating a document
where the children’s medical records could be recorded and shared between providers.
However, the results from our study show that the passport system is not doing what it
was intended to do. We started this project with the hypothesis that the HEP system is not
consistent. We thought that the study would show that passports failed to follow foster
children in a timely manner, or at all, after placement changes. Results from this study
show that out of 30 respondents, only 8 received the passport (26%). According to the
directions on the Health and Education Passports, the passport is to follow the child with
them to every placement. Of the 8 youth who received the passport, 7 of the passports
did not travel with the youth to their new placement but instead showed up at a later date
(See Table 1). This finding supports the researcher’s hypothesis that passports do not
follow the youth while they are in foster care.
40
Table 1: Days Passport Received
Received HEP
Never received
HEP
Total
Same
1-5
11-15
16+
Never
Day
Days
Days
days
received
1
4
1
2
0
8
0
0
0
0
22
22
1
4
1
2
22
30
Total
In cases when foster children did have passports, we hypothesized that they would
be incomplete and lacking in important information. Results from the study showed that
80% (n=24) of respondents say passports are not updated or complete, therefore not
helpful. As we discussed in the literature review, having an incomplete passport creates
substantial barriers to a foster child’s medical care. This finding supports the researchers
hypothesis that passports are not updated and/or complete. As a result of this, passports
are useless for the foster parents who are caring for the child, which therefore affects the
health of the child.
Presence of Passports During Doctor Visits
One of the questions from our study asked caregivers if doctors (either primary
care or emergency room) read or reviewed the passport during the visit. We wanted to
know if passports were typically brought to doctor visits and if they were found useful
when they were present at the visit. We found that, of the 19 children who visited their
primary care physician, 13 (68%) did not have the passport present at the visit and 4 had
the passport present but the doctor did not refer to the passport. Of the 10 children who
41
visited the ER, seven (70%) had no passport present at the visit and two did not have the
passport referred to (See Table 2). The results from this question show that regardless of
if foster children are going to the emergency room or to their primary care physician, the
passports are not typically present during the visit. This creates a problem because the
doctor visit does not get recorded into the passport and therefore important information is
lost. The reality is, this foster youth is likely to change placements again, and the new
foster parents will not have any record of their past medical visits, including
immunizations, prescriptions, illnesses, etc.
Table 2: Doctor Looked at Passport
Did not
refer to
Passport
Passport was
not Present
Have not
taken youth
Total
to Doctor
Received HEP
5
1
2
8
Never received HEP
0
14
8
22
Total
5
15
10
30
Advisement by Social Workers on Use of Passport
We were unsure when we began this study how informed foster parents and
caregivers were of the passports. We wanted to know if foster parents and caregivers
were being advised by the social workers on how to effectively use the passports. Our
literature review discusses how proper use of the passport can improve health care of
foster youth exponentially. From our study, we found that 100% (n=30) of caregivers
were not advised by social workers on how to use the passport. Caregivers cannot be
42
expected to know how to use the passports or to know how important they are to the
child’s health care if they have not been advised properly.
Research from our literature review showed that recent placement changes are
correlated to a higher rate of hospital use, particularly the emergency room. It is a
tumultuous time for a foster youth during placement change, and they are more prone to
self-injury, sickness, and high anxiety. Our study showed that of all foster youth who
visited the emergency room, 100% (n=8) went within the first month.
Use of Emergency Room and Primary Care
We were curious to know if a child has a passport, were they more likely to use
the emergency room or a primary care physician. Of the respondents who do not have
passports, 17% (n=5) say they are more likely to take their foster child to the emergency
room, while 3% say they would take the child to a primary care physician. For those
respondents who have a passport for their foster child, 97% say they would take the child
to the primary care physician or that they could treat the child’s medical needs at home.
Respondents are more likely to take their foster child to the ER when they do not have a
passport than when they do have a passport.
For those foster youth who visited the emergency room (n=8), the reasons for
their visits included: injury, object extraction, vomiting and unresponsiveness, severe
illness (pneumonia and flu), and general physical illness. As indicated by the statistics
presented in Chapter 2, ER visits for foster youth almost triple after placement change
(refer to figure 1 in Chapter 2). Making conclusions from that statistic, it appears
changing placement affects the general health of foster children. Statistics found in this
43
study show that only 26% of foster youth received their passport after placement
change. Therefore, a majority of foster children (74%) do not have their medical history
available to them, their doctors, and even their schools. Due to ER visits being most
frequent after a change of placement it is extremely important the passports accompany
the child during this adjustment.
Sixty-six percent of foster children who visited their primary care physical went
for CHDP visits. CHDP, standing for Child Health and Disability Prevention Program,
provides free health check-ups for all foster children. These health check-ups cover
vision, dental, and hearing screenings, mental and physical health, growth and
development check, and all needed shots and labs. In previous chapters we discussed
how children sometimes end up in the emergency room for menial things like a headache.
Because caregivers do not have readily available information in the passports, they are
unaware of their allergies. If all health information was available online, caregivers could
quickly and easily access this information. We questioned caregivers on this issue, and
100% of respondents said that it would be beneficial to have their foster child’s medical
records available online.
Preventative care for foster children means they need to have access to health care
services for routine and emergent needs, which is the reason CHDP began. Child welfare
services require evidence of a comprehensive well-child examination within thirty days
of placement to identify needs and provide preventative care. Findings from this study
found that of the 20 children who went to their PCP went for the CHDP visit, but only 4
of them did it within the 30 day period (20%). Research also found that 6 out of 8 ER
44
visits were for CHDP (and other reasons), yet only half were done within the 30 day
period of placement change (See Table 3 below). There are two systems in place to
ensure foster children are receiving proper, continuous, medical care, CHDP and
HEP. Yet, through the findings of this study it is apparent both systems are not
efficient. Due to the fact children are not having their CHDP within the 30 day time
frame, as well as not receiving passports that possess their medical records, the
researchers concluded that the continuity of medical care for foster children is
unsatisfactory.
Table 3: Reason for Visit to PCP
Went to PCP within
the first 30 days
Did not go to PCP
within the first 30
days
Total
Mental Health
Needs
He/ She Never
Went to PCP
CHDP
Total
0
8
4
12
0
2
16
18
0
10
20
30
The researchers hypothesized that youth who did not have updated (or absent)
passports tend to use the ER/Urgent care more frequently as a result of the passport
status. Findings from this study show that although it is more likely that these youth visit
the ER/Urgent Care if they have absent passports, most foster parents continue to say
they would take their child to the primary care physician even if the youth does not have
a passport. For future studies it would be important to note where the previous placement
for the child was, perhaps the distance from one placement to another would affect
45
whether or not the new foster placement would have access to the child’s primary care
physician. For example, if a child moved out of county or across a county the new foster
placement may not have access to the child’s old primary care physician, which in turn,
may cause them to find alternate medical service providers for care.
An unanticipated finding, also a large hindering factor in obtaining research, is
how difficult it is to make steps towards creating a change in a large, complicated system,
such as the foster care system. Although Sacramento County CPS and all foster agencies
supported this research topic and expressed their gratitude for the light to be shed on the
difficulties of the HEP’s, it was extremely difficult to receive quantitative data to support
the verbal concerns we heard from workers across agencies. There are many reasons for
this difficulty, which can include: overworked employees, budget cuts which caused
workers to have less contact with foster parents, lack of communication across a large
system through canceled or infrequent meetings. The barriers to obtaining research was
evident to researchers in this study through the lack of communication and participation
of foster agencies.
After an in-depth literature review and after analyzing all of our data, we have
come to the conclusion that we were examining not one, but two broken systems. We
identified the major issues with Sacramento County’s Health and Education Passport
system, concluding that passports are not being taken to doctor visits, are not being filled
out properly, and do not follow the child during change in placements. The passports are
not doing the job that they were intended to do. They were created to help improve health
care for foster children, but the reality is that they are creating barriers and hindering
46
children’s medical care. We found it near impossible to fix a broken system (passports)
within a fractured system (CPS). Lack in communication and follow-up ultimately led to
a lack of support and forced us to break ties with CPS and gather our data elsewhere.
With the help of a few different providers, we gathered data from foster family agencies
and group homes. The logistic challenges that our research experienced is a reflection of
the limitations of the system. Even with our difficulties in reaching the intended data
source, the research findings still clearly show that the passport is not being properly
utilized. A summary of the research findings is presented in the Executive Summary
(Appendix A).
A Composite Case Based on Study Findings
To better understand how missing passports affect the health care given to foster
youth let us examine two parallel case examples of different foster children based on the
data collected from this study, one who received his passport and one who did not.
A composite case based on study findings:
Johnny:
Johnny is a 12-year-old boy who has been in foster care for 3 years. Within those
three years he has been in 4 different foster placements, the most recent placement before
your home he was there for 10 weeks. He is arriving to your home with all his
belongings in two garbage bags and a backpack. His social worker hands you his health
and education passport when she delivers Johnny to your house. As you look through the
health and education passport you feel that it is up-to-date. You can see that he is caught
up on all his immunizations, is one grade behind his peers in school, is allergic to bees
47
and has an EpiPen, gets “growing pains” in his legs at night which he take Tylenol for,
and that his last school and primary care physician are 45 minutes across town. You
decide to find Johnny a new primary care physician closer to home and are able to gather
any information from his last physician about past medical visits.
The next morning you take Johnny to his new school where they ask you for his
immunization history, his academic history, and ask if he has any allergies. You provide
them with the passport, and extra EpiPen, and he is able to attend his first class that
morning.
Two weeks later Johnny comes home with a headache and aching legs. He tells
you he was playing basketball in the sun all day, running up and down the courts. After
reviewing Johnny’s passport you see that Johnny takes Tylenol for aches and pains,
therefore you know he is not allergic and you can give him some. Johnny takes them as
prescribed and feels immediate relief. He is able to finish his homework, do his
nighttime chores and get to bed on time.
Jacob:
Jacob, another 12 year old boy has a very similar history yet his health and
education passport got lost 3 years ago after his first placement and has not been
updated. Jacob is delivered to your home with the same amount of belongings as Johnny,
but without his passport. You have no idea where his last placement was, his academic
level, immunization history, etc. The next morning you go to register Jacob at the school
near your house. Due to not having his immunization history he is not able to start school
until you are able to present those records. Jacob, already feeling high anxiety about
48
moving to a new school begins to stress even more. For the remainder of the week you
are trying to get the needed information to get Jacob into school. He has now missed 1
week of school, and unknown to you, he is extremely behind in school because this
scenario has happened to him on several occasions.
With stress and anxiety running high for Jacob, he comes down with a headache
and slight fever after dinner. You want to give him Tylenol but by law are not allowed to
because you do not know his allergies. Therefore, you take Jacob to the emergency room
where you wait for 3 hours to be seen by a doctor. The doctor does not ask to see the
passport, nor do you have a passport to show. You leave the hospital with Tylenol for
Jacob and no record that he even went to the hospital. Now you, as a foster parent, have
perpetuated the inefficiencies in the passport system without even meaning to.
These two parallel stories are not uncommon. They exemplify how important it is
to have medical information available, not only for the medical care of the foster child
but also in their ability to succeed academically. Jacob and Johnny are small examples of
the barriers these foster children experience. With Jacob and Johnny in mind, it is
important to note that many foster children have much more complicated medical
problems and needs. For those foster children who have a serious medical problems or
mental illness the HEP can actually hinder the child’s health and education needs rather
than help. The executive summary of all findings is listed in Appendix A on page 56.
49
CHAPTER 5
CONCLUSION AND IMPLICATIONS
We initially chose to research the Health and Education Passports because we
both had personal experiences while working with foster youth related to the passport
system. We noticed that this passport, which was created to help improve foster youth’s
health care, was actually acting as a barrier. The research that we found in the literature
review showed that very few counties have implemented an effective passport system,
but that it is possible and has been done in a few circumstances.
Some of the limitations of our study are due to the fact that our original plan for
data collection had to be altered. We gained approval from Child Protective Services
(CPS) in the beginning of the school year. After months of struggling to maintain
communication and still without any data, we reached out to individuals connected to
group homes and foster care agencies directly. The experience working with CPS, a
difficult system to infiltrate, was discouraging. This however, from a research
perspective, is a participant observation and experiential opportunity. It allowed us to
have first-hand experience of how the CPS system is affected by inefficiency and how it
has failed to respond to certain needs and demands. While we understand the breakdown
may be a result of the inefficiency of a small number of staff, the impact is big. Our
intention was to diagnose an issue in the child welfare system, and to conduct research to
identify ways to improve the welfare of foster youth across Sacramento County. We
believe that sharing our results can potentially bring about change for improvements in
50
the medical coverage of foster children. Despite the difficult time we had collecting data
for this project, we still feel passionate about improving the health care of foster children.
Recommendations for Future Studies
One of the limitations we faced was the geographical boundaries that respondents
lived inside. A large majority of respondents listed the same zip code, therefore also said
they would take their foster youth to the same hospital, Mercy San Juan. We would
suggest that future studies ask additional information about the foster child’s previous
placement to find out if they were in the same geographical area before their most recent
placement change. Knowing this piece of information would help us find out if foster
youth are more likely to use the emergency room if they have moved to a different city.
Moving a greater distance would make it more likely that they would need to set up a
new primary care physician. If they require medical attention before they are able to
establish a medical home, we predict they would likely be forced to go to an emergency
room.
Despite our sample size being smaller than initially planned, we are still able to
see valuable information and trends emerge from the data. Some of the most consistent
responses were the respondents’ feelings about the passports being incomplete, not
updated, and therefore not helpful. Eighty percent of respondents felt the passport was
unhelpful. This coincided with our hypothesis; we expected that passports would be
unhelpful due to missing and outdated information or that the child would not have one at
all. For those respondents who had foster youth that visited either a primary care
51
physician or an emergency room, seventy percent said that the passport was not present at
the visit.
Another limitation that affected our research is the fact that we ended up
questioning group homes and foster agencies as opposed to foster parents, who were the
intended respondents when we developed our questionnaire. This limited our study
because there is a chance that one caregiver may have taken the foster child to the doctor
and a different caregiver may have filled out the questionnaire. If information does not
have a reliable central database where information is stored, it can easily be lost or it can
fail to be documented.
We began this project with the idea that CPS in Sacramento County could benefit
from an online database for the Health and Education Passport system. Our goal was to
not only shed light on the inefficiencies of the health and education passports, but to also
present solutions to this ongoing phenomenon. Due to the financial crisis of county
programs we knew our “solutions” had to be cost efficient. After speaking with different
disciplines about this project, two agencies were presented.
Possible Solutions
Social Solutions is a non-profit software company that makes it possible to relate
service delivery to desired outcomes. Their collaborative community services software
pulls information from alliance community services to provide the best care for the
community being served. Because foster youth access several services from different
agencies such as mental health, education, medical coverage, home location, it would be
extremely beneficial for each agency to communicate with one another and have one
52
central location to do that. With access limitations for privacy (for example school does
not need to know about a child’s urinary tract infection), all entities could access and
input information about a child in one central location, making it easier to foster parents
and doctors to access needed information.
HHS Connect is a New York City program that improves service delivery through
inter-agency data sharing and collaboration. This has changed the way the city provides
services to its people. This program provides tools and solutions that help the agencies
break down silos and coordinate case management practices in order to provide more
effective and efficient services to clients. HHS brings together 30+ agencies/services
such as health care, child care, housing, finances, WIC, etc. through one computer
program. By doing this, services providers can see what resources their clients are
connected to, and can also see which ones they are eligible for. The sharing of
information pulls systems together to provide comprehensive services to those who need
it most. Foster children are part of that population that need it most. Although HHS is
only available to New York City providers, this program exhibits the potential and the
capacity of what inter-agency communication can do to support its people.
As stated above, there are programs to assist in making HEPs available
online. One readily available option is an AmeriCorps program that does information
technology for government agencies. Due to it being an AmeriCorps program services
are likely to be of very low cost or even free. By implementing this cost-effective
program, foster children’s education and medical information would be able to be
tracked, updated, and available to those who provide services to this population. It is
53
surprising with the technology that surrounds us today, and how many of us can access
our health information through an application (app) on our phone, that foster children are
still having difficulties with basic medical coverage.
Electronic Database
One of the main concerns about converting the passport system to an electronic
database is that it would be difficult to control who has access to the online records.
However, the foster care system would not be the first system to implement strict
confidentiality measures to protect the privacy of clients. Hospitals are just one example
of a large system that requires providers to adhere by specific rules to ensure
confidentiality. Because this online database would be most effective if service providers
from different professions had access to the information, implementing tiered-access
could help to keep certain information from being shared with all providers. Limited
access would allow more privacy for clients. This online database would benefit foster
children in many situations, including hospital or office visits for newly placed children
who have not established a medical home and who may not have their paper passports
with them. With this new system, staff would need to be trained on how to use the online
database to easily access client information.
Implementing a new record keeping system based on horizontal integration would
allow for improved health care for foster youth. If the electronic database were to be
available to all service providers that the foster child came in contact with, there would be
a much better continuum of care. All of the foster child’s health and education records
would be made available to ensure there is no overlapping or contradictory treatment
54
(such as re-immunization), and it would also make it easier to determine if the foster
youth is receiving all of the services that they are eligible for. For example, a foster youth
who comes into the emergency room for a broken foot may have come in purely for
medical reasons, but it is clear that the child is symptomatic of some type of depressive
disorder. Rather than relying on the paper passport that is likely not present or not
updated, or on the self-report of an adolescent about a heavy topic, the doctor can first
look into the child’s chart to see what mental health services the child is currently
receiving. If the child is not already linked to mental health services, the doctor can let
the child know what services he/she is eligible for. Horizontal integration is instrumental
in making sure individuals are aware of the services they are eligible to receive and in
improving the continuum of care.
Although the health passport was created to facilitate a more organized system for
keeping track of foster children’s health care, our research has proven that it actually
perpetuates the difficulties foster children already face. Our literature review supported
the findings from our data in multiple ways, including multiple sources that supported the
notion to move towards an electronic passport system. The most common reason was to
promote quality and consistent health care for children. This would bring organization to
the passport system and introduce an efficient method of tracking individual health data
by providing a detailed description of the health problems experienced by children in
foster care. The response we got from CPS when we proposed the idea of an electronic
passport system was not one of opposition, but they felt it would be too costly and
difficult to implement. We would argue that with today’s technology and access to
55
resources, not implementing an electronic system for passports would be creating
additional barriers to health care.
After meeting with foster agencies, CPS workers, and social workers, we verbally
received unanimous feedback about the health and education passport system. There is
undoubtedly a problem with the current system and every person involved knows it’s not
working. The next question is what does it take to change it? If all persons involved in
the care of these children are in agreement that HEPs are not helpful, it is astounding and
disappointing these issues continue to plague this vulnerable population. Researches
hypothesize that this broken system continues due to lack of funding, the absence of
research to prove that there is in fact a problem, or possibly the difficulty in changing a
component of a large, overworked system. We hope that through this thesis project we
have identified and provided the statistical information to support and enact a much
needed change.
56
APPENDIX A
EXECUTIVE SUMMARY

The ages of foster youth were evenly distributed between the ages of 2 to 19 years
old.

Length of time in foster care varied between 2 weeks to 364 weeks with the
median amount of time being 13 weeks.

The age of foster child and length of time in foster care did not make a difference
on whether the child went to the ER or primary care physician.

Of 30 respondents, only 8 (26%) received the passport.

According to Lutz & Horvath (1997) there are over 400,000 children in foster
care. If we extrapolate our findings this means there are 304,000 children who do
not have access to their health records.

Of the 8 who received the passports, only 1 traveled with the foster child to their
new placement, all other passports showed up at a later date (Table 1).

Of the 30 respondents, 24 stated the passports were not helpful in providing care
to the child.

Of the 19 children who visited their primary care physician, 13 (68%) did not
have the passport present at the visit and 4 had the passport present but the doctor
did not refer to the passport.

Of the 10 children who visited the ER, 7 (70%) did not have the passport present
and two did not have the passport referred to (Table 2).
57

100% of caregivers were not advised by social workers on how to use the
passport.

Of all foster youth who went to the ER, 100% went within the first month of
placement change.

It is more likely that a child will visit the ER (17%) if they did not have a passport
versus a child who does have a passport (3%).

60% of children who visited their primary care physician went for CHDP visits.

CHDP visits should be done within the first 30 days of placement change; this
study showed that only 20% did this in the allotted time (Table 3).

100% of respondents say it would be beneficial to have the foster child’s medical
records available online.

Case study findings: having a present and updated passport not only affects the
health care given to the child, but it also affects their school performance, mental
health, and peer relationships.

The current health and education passports are hindering the child’s health and
education needs because they are not completed or following the foster youth
during placement change.
58
APPENDIX B
CONSENT FORM/COVER LETTER
Dear Foster Parents,
You are asked to participate in a child welfare study related to Health and Education
Passports. We are graduate students completing our Master of Social Work education at
California State University, Sacramento. This is our thesis research project. Sacramento
County Department of Health and Human Services is supportive of our project. The
information gathered from this questionnaire survey will be used to determine the
usefulness of foster youths Health and Education Passports and how they relate to foster
youths use of the Emergency Room and Urgent Care. Findings from this study will help
improve the implementation and utilization of health care among foster youth. We will
explore how complete and up to date the passports are and evaluate the usefulness of the
passports, based on the perspective of the foster parents.
All participants will be kept anonymous and all information will be kept confidential.
Participation is voluntary and not required. Should you choose to participate, you may
discontinue participation at any time. Your refusal to participate will not in any way
affect your relationship with the Sacramento County Department of Health and Human
Services. Any information obtained in this study will be treated as confidential. IP
addresses will not be collected; therefore, there is no way to trace who has participated in
this study. No individual information will be disclosed and only group information will
be included in the report. Information gathered in this study will be destroyed after
completion of the thesis project (no later than June 13, 2014). Thank you for taking the
time to help make this project possible, we appreciate your response.
The return of the completed survey questionnaire implies your understanding of the
nature of this study and consent to participate. Please complete a survey for each youth
that has moved into your home within the last 6 months. The survey will take
approximately ten to fifteen minutes to complete.
If you have any questions, please do not hesitate to contact the researchers,
Allison Stanfield- XXXXXXXXXXXXX@yahoo.com (707) XXX-XXXX
Heather Tyler-XXXXXXXXX@gmail.com (559) XXX-XXXX
or their thesis advisor Francis Yuen- Fyuen@csus.edu
Thank you for considering this request. Please click the link below to complete the
survey.
https://www.surveymonkey.com/s/SVJV3CT
59
APPENDIX C
QUESNTIONNAIRE
Utilization and Effects of Health and Education Passports: Foster Parents Perspective
1. How long has your child been in foster care? ___ Weeks ____ Months
2. How old is the child? __________
3. Were you advised by the social worker the use of the Health and Education Passport?
__ Yes
__ No
4. How long after receiving the child did you obtain their Health and Education passport?
__ Same day
__ 1-5 days after receiving youth
__ 6-10 days
__ 11-15 days
__ 16+ days
__ I never received the passport
5. Was the passport up to date to your knowledge?
__ Yes
__ No
__ I did not receive a passport
6. How long after being placed in your home did your foster youth visit the Emergency
Room or Urgent Care?
__ Within the first week
__ Within the first month
__ Within the first three months
__ Within the first six months
__ He/she has never gone to the ER or Urgent Care
7. How many times has this youth been to his/her or any primary care doctor while
residing in your home:
__ 0
__ 1-2
__ 3-5
__ 6+
60
8. What was the reason for the first visit to the primary care doctor? (check all that apply)
__ General physical illness (fever, cold, headache).
__ Mental health needs
__ Self harm
__ He/she never went to the primary care doctor
__ Other: _____________________________________________
9. Was the youth's health passport useful to you during this visit in discussing the child's
health care needs with the doctor?
__ Yes
__ Somewhat helpful
__ No
__ I did not have the passport
__ I have not taken my foster child to visit his/her primary care doctor
10. How many times has this youth been to the ER or to Urgent Care while residing in
your home?
__ 0
__ 1-2
__ 3-5
__ 6+
11. What was the reason for the first visit to the ER or Urgent Care? (check all that
apply)
__ General physical illness (fever, cold, headache)
__ Mental health needs
__ Self harm
__ He/she has not been to the ER or Urgent Care while in my care
__ Other: ____________________________________________
12. Was the youth’s health passport useful to you during this (ER/Urgent Care) visit in
discussing this child’s health needs with the doctor?
__ Yes
__ Somewhat helpful
__ No
__ I did not have the passport
__ I have not taken the youth to the ER or Urgent Care
61
13. Did doctors (either primary care or ER/Urgent Care) read or review the passport
during the youth’s visit?
__ Yes
__ No, they did not refer to the passport
__ The passport was not present at the visit
__ I don’t know
__ I have not taken my youth to see a doctor
14. If the passport was not present during a visit with the doctor, why was it not?
15. Do you think it would be beneficial to you and to your foster youth to have the
medical records available online?
__ Yes
__ No
__ I do not know
16. If you have any other foster youth in your home, have you found their passports
useful in regards to their health care?
__ Yes
__ No
__ I do not have any other foster children in my care
17. When your foster child gets sick and you have his/her passport, what is most likely to
happen?
__ I take him/her to the primary care doctor
__ I take him/her to the Emergency Room or Urgent Care
__ I can treat his/her medical needs at home (i.e., I can provide over the counter
medication)
__ Other: _____________________________________
18. When your foster child gets sick and you DO NOT have his/her passport, what is
most likely to happen?
__ I take him/her to the primary care doctor
__ I take him/her to the Emergency Room or Urgent Care
__ I can treat his/her medical needs at home (i.e., I can provide over the counter
medication)
__ Other: _____________________________________
62
19. What is your overall opinion of the Health and Education Passports? Check all that
apply
__ They have been helpful and useful in providing medical care for my foster
child
__ They are not updated or complete, therefore not very helpful
__ I wish the information was available online
__ Other: _____________________________________
20. What hospital ER or Urgent Care do you, or would you, take the child to?
21. What is your zip code?
22. What type of foster home are you?
__ County Home
__ FFA
__ Relative
__ Other (please specify)_________________
23. Please leave any comments or information you would like to share with us:
63
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Allen, K.D. & Hendricks, T. (2013). Medicaid and Children in Foster Care. State Policy
and Reform Center. Retrieved from
http://www.childwelfaresparc.files.wordpress.com/2013/03/medicaid-andchildren-in-foster-care.pdf
American Academy of Pediatrics (2002). Health Care of Young Children in Foster Care.
Committee on Early Childhood, Adoption, and Dependent Care. Retrieved from
http://pediatrics.aappublications.org/content/109/3/536.full.pdf
Bass, S., Shields, M. & Behrman, R. (2013). Children, Families, and Foster Care:
Analysis and Recommendations. The Future of Children, Princeton University.
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https://www.princeton.edu/futureofchildren/publications/journals/article/index.xm
l?journalid=40&articleid=132&sectionid=866
Blake, A. (2012). Task Force on Helping Youth Survive in Placement. Department of
Children and Families. Retrieved from
http://www.state.nj.us/dcf/providers/notices/nonprofit/HYTIPppt.pdf
Foster Care Nurses Network (1999). California Statewide Guidelines for Public Health
Nursing in Child Welfare Services. The Department of Health Services
Children’s Medical Services Branch Child Health and Disability Program.
Retrieved from
http://www.dhcs.ca.gov/formsandpubs/publications/Documents/CMS/pub12.pdf
64
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