Fontanella, C. A., Gupta, L., Hiance-Steelesmith, D L., & Valentine, S. (2015). Continuity of care for youth in foster care with serious emotional disturbances. Children and Youth Services Review, 50, 38-43.
There is a significant amount of evidence indicating that children in foster care have higher rates of serious emotional disturbances (SED) including: Post Traumatic Stress Disorder (PTSD), abuse related trauma, Attention Deficit Hyperactivity Disorder (ADHD), depression, and substance abuse. Current evidence indicates that children in foster care may not receive mental health services and when they are referred, they do not receive appropriate care. Research suggests that continuity of care is an important part of high quality mental health services but for children in foster care, discontinuity in care is common. Continuity of care or regularity of care was defined as having had attended at least monthly outpatient mental health appointments throughout the 1 year study period. Possible reasons for discontinuity in care for youth in foster care include placement instability, changes in health care coverage, and the fragmented health system. Current evidence indicates that continuity in care is associated with benefits; however, there is a lack of research addressing the factors associated with continuity of care for youth living in foster care.
This study examines various factors associated with continuity of care for youth in foster care with SED. Data included all youth aged 5-17 years in foster care with a diagnosis of SED and who were continuously enrolled in Ohio’s Medicaid program for an 18 month period during 2007-2010. Medicaid is a government insurance program in the United States designed for individuals who do not have the funds or resources to pay for health care. Authors defined SED in the current study as a diagnosis of schizophrenia, psychosis, or bipolar disorder as they are often more chronic, have complex needs, and require ongoing maintenance. Youth were regarded as having SED when they had 2 or more claims for a primary diagnosis of SED. International Classification of Disease (ICD-9-CM) codes included in the diagnosis of SED consisted of, a diagnosis of schizophrenia (295, 297, 298), psychosis (297, 298), and bipolar disorder (296.00–296.1, 296.4–296.9, 296.99, 293.83).
Descriptive statistics were used to describe demographic and clinical characteristics of the sample (N = 952) and random effects logistic regression was used to examine the relationship between individual and contextual-level factors on continuity of care.
- Regularity of care was significantly higher for youth who had a co-occurring psychiatric disorder of anxiety or conduct disorder in comparison to youth without a co-occurring diagnosis (OR = 1.76 and 1.57, p = 0.002 and p = 0.007 respectively).
- Regularity of care was significantly higher for youth with prior chronic medical illness in comparison to youth who did not have a chronic medical illness.
- Regularity of care was significantly related to prior psychotropic medication use with youth using 2 or more drug classes receiving care more frequently (OR = 1.55, p = 0.02).
- Prior service history was associated with regularity of care with prior outpatient mental health care being the most significant predictor of regularity of care (OR = 7.43, p < 0.001).
- Regularity of care was significantly higher for youth living in micropolitan areas (i.e., urban areas with a population of at least 10,000 but less than 50,000) that were adjacent to large metropolitan areas (OR = 1.97, p = 0.04) in comparison to youth living in large metropolitan areas with a population of at least 1 million.
- Areas with an increased number of psychiatrists was also significantly associated with increases in the regularity of care (OR = 1.22, p = 0.05).
An increased understanding of the factors associated with continuity of care for youth with SED in foster care may help to inform clinician interventions and programming aimed at improving continuity of care for these youth.
Data were obtained from three sources: Medicaid claims, the Area Resource File, and the Ohio State Psychology and Social Work Licensure Boards.
The authors note various limitations. First, the data examined was based on a single state therefore influencing the studies generalizability to youth in foster care in other geographical areas. Second, the data examined was from 2007-2010, before the reform by the Affordable Care Act (ACA), meaning that patterns in health and mental health care may have changed. Third, by using administrative data the authors were unable to examine other important dimensions of continuity of care that have been suggested in other literature (e.g., consistency of provider contact, coordination among providers and service systems). Further, data was not available for additional factors that are believed to be associated with continuity of care (e.g., patient-provider relationship, child placement characteristics, involvement of family and support networks, and history of maltreatment). Medicaid, the main source for individual-level data also does not provide information on other non-billable community based services that the sample may have utilized for their mental health. Fourth, due to the absence of outcome variables authors were unable to know the impact of varying levels of continuity of care on clinical outcomes. Fifth, researchers assumed that youth with schizophrenia and bipolar disorder would need monthly visits although it is possible that their condition improved so that they did not require regular treatment. Last, a diagnosis of SED (i.e., schizophrenia, psychosis, bipolar) was given based on the number of Medicaid claims made and ICD-9-CM codes used with no additional information describing how young children in the sample (i.e., 5-year olds) were diagnosed with SED. Given the average age of onset for mental health conditions like schizophrenia it is unclear exactly what was being measured in the younger portion of this sample to provide a diagnosis of schizophrenia, or SED.