Out-of-Home Care

Health of children in out-of-home care: The Missoula Foster Child Health Program

The Missoula Foster Child Health Program, a tri-agency collaboration, aims to address the complex needs of children in out-of-home care by providing timely, coordinated care. Children enrolled in the program had fewer medical needs between the time of admission to discharge for physical, psychological and behavioral health problems.

By J. Bart Klika, Lisa Schelbe, and Peter Pecora

Tim entered out-of-home care at the age of 13 months due to maternal drug dependency.  Upon removal from his mother, Tim was diagnosed with a complex array of acute and chronic health conditions including hypospadias, an umbilical hernia, tibial torsion, bilateral club feet, and a perianal abscess.  At his initial Early and Periodic Screening, Diagnostic and Treatment (EPSDT) exam, Tim was treated for allergies, eczema, diarrhea, coughing and vomiting.  In addition, Tim was assessed as having significant developmental delays and behavioral problems.  With referrals for specialized medical and developmental treatment, Tim’s health conditions were stabilized and he began making impressive strides in his development.  Unfortunately, Tim’s behavioral problems continued to escalate, causing concern for his foster family and his treatment team.  Through close consultation and ongoing care plan monitoring, Tim’s primary care provider, therapist and public health home visiting nurse suggested that Tim’s foster family should experiment with a gluten, casein and red-dye-free diet to avoid being placed on psychotropic medication.  Within three days, his foster family noticed marked improvements in Tim’s behavioral problems, triggering a formal evaluation for celiac disease.  Sure enough, Tim tested positive for celiac disease and was referred to a gastrointestinal specialist for ongoing care and treatment.  As a result of coordinated care and a high-quality foster placement, Tim was able to avoid being placed on unnecessary psychotropic medications to control the behavioral manifestation of celiac disease. At 3 ½ years of age, Tim was adopted by his foster family and continues to thrive.  

The story of Tim provides hope for the many children in out-of-home care who experience disproportional rates of physical, developmental and behavioral problems.  Over 400,000 children are in the foster care system at any given point in time in the United States (USDHHS, 2016) and research shows that these children have high rates of physical and mental health conditions, many of which are acute in nature (Szilagiyi et al., 2015; Ringelsen et al, 2008; Jee et al, 2010; Gorski et al, 2002; Florence, Brown, Fang, & Thompson, 2013).  Both the Child Welfare League of America (CWLA) and the American Academy of Pediatrics (AAP) provide guidelines for addressing the health needs of this vulnerable population, yet fewer than half of child welfare agencies have formal policies outlining the provision of this care (Leslie et al, 2003). Further, children in out-of-home care frequently miss necessary medical appointments (Levinson, 2015) and have incomplete or missing medical records (Griener et al, 2015).  Ensuring the health of children in out-of-home care is a national imperative.

Tim was enrolled in the Missoula Foster Child Health Program (MFCHP), a tri-agency collaboration between Child and Family Services Division (CFSD) of Missoula County, the Missoula City-County Health Department (MCCHD), and Grant Creek Family Medicine - Foster Care Clinic (FCC). FCC serves as a medical home for children in out-of-home care and provides medical care and works with the partners to coordinate children’s health needs.  The goal of the MFCHP is to address the complex needs of children in out-of-home care by providing timely, coordinated care.  Children enrolled in the MFCHP visit the specialized providers at FCC for an EPSDT exam within days of entering care or changing placements.  In addition, the child and foster family are visited by a public health home visiting nurse who summarizes the child’s medical history, helps the foster family understand the health conditions of the child in their care, provides anticipatory guidance to the foster family, assists in coordinating referrals for specialized services, and continuously monitors the child’s plan of care.

Recent analysis of data from children enrolled in the MFCHP (n=416) demonstrates the staggering health needs of children in out-of-home care as well as impressive gains in physical and mental health outcomes for children enrolled in the program.  Nearly 75 percent of children entered care with at least one unmet physical health problem.  Significant differences in terms of fewer medical needs were noted between the time of admission to discharge for the following: eye/vision problems, skin conditions, feeding concerns, obesity, frequent colds, ear infections, asthma, heart conditions, mental health problems, depression and ADHD.  Program factors such as collaboration between child welfare and public health, and coordination of services were identified as key factors in improving the health of children enrolled in the MFCHP.

Evaluation of the MFCHP is on-going with plans for future process and outcome studies.  The MFCHP is working to develop a classification system for tracking medication use for children in the program, recognizing that children in out-of-home care are prescribed psychotropic medication at higher rates than their peers who remain in their homes (Cohen, Lacasse, Duan, & Sengelmann, 2013; Raghavan, Zima, Andersen, Leibowitz, Schuster & Landverk, 2005; Steele & Buchi, 2008).  Future evaluations will employ a control or comparison group to examine whether those in the MFCHP experience improved outcomes compared to children in out-of-home care who receive “care as usual” (i.e., standard case management).

In an ideal world, no child would ever experience abuse or neglect and all children would be provided with the conditions and contexts necessary to achieve optimal health and well-being.  However, even with the best prevention efforts, some children will experience maltreatment and be placed in out-of-home care.  Through ensuring there is a coordinated system of care in place to address complex health needs, the impact of maltreatment can be mitigated and children like Tim can be given an opportunity to grow and thrive.

For more information about the MFCHP, please contact Vicki Dundas.  For questions regarding the evaluation of the MFCHP, please contact J. Bart Klika.


Cohen, D., Lacasse, J. R., Duan, R., & Sengelmann, I. (2013). CriticalThinkRx may reduce psychiatric prescribing to foster youth: Results from an intervention trial. Research on Social Work Practice, 23(3), 284-293.

Florence, C., Brown, D. S., Fang, X., & Thompson, H. F. (2013). Health care costs associated with child maltreatment: Impact on Medicaid. Pediatrics, 132, 312–318.

Gorski, P.A., Borchers, D.A., Glassy, D., High, P., Johnson, C.D., Levitsky, S.E., Palmer, S.D., Romano, J, & Szilagyi, M. (2002). Health care of young children in foster care. Pediatrics, 109(3), 536-541.

Greiner, M.V., Ross, J., Brown, C. M., Beal, S. J., & Sherman, S. N. (2015). Foster caregivers’ perspectives on the medical challenges of children placed in their care: Implications for pediatricians caring for children in foster care. Clinical Pediatrics, 1-9.

Jee, S., Szilagyi, M., Blatt, S., Meguid, V., Auinger, P., & Szilagyi, P. (2010). Timely identification of mental health problems in two foster care medical homes. Children and Youth Services Review, 32, 685-690.

Leslie, L., Hurlburt, M.S., Landsverk, J., Rolls, J.A., Wood, P.A., & Kelleher, K.J. (2003). Comprehensive assessments for children entering foster care: A national perspective. Pediatrics, 112, 134-142.

Levinson, D.R. (2015). Not all children in foster care who were enrolled in Medicaid received required health screenings (OEI-07-13-00460).  Washington, D.C.: Department of Health and Human Services, Office of Inspector General.

Raghavan, R., Zima, B. T., Andersen, R. M., Leibowitz, A. A., Schuster, M. A., & Landsverk, J. (2005). Psychotropic medication use in a national probability sample of children in the child welfare system. Journal of Child and Adolescent Psychopharmacology, 15, 97–106.

Ringelsen, H., Casanueva, C., Urato, M., & Cross, T. (2008). Special health care needs among children in the child welfare system. Pediatrics, 122, e232-e241. 

Steele, J.S., & Buchi, K.F. (2008). Medical and mental health of children entering the Utah foster care system. Pediatrics, 122, e703-e709. 

Syilagyi, M.A., Rosen D.S., Rubin D., Zlotnik, S. (2015). Health care issues for children and adolescents in foster care and kinship care. American Academy of Pediatrics, 136(4), 1142-1166.

U.S. Department of Health & Human Services, Administration for Children and Families, Children's Bureau. (2016). The AFCARS Report Preliminary Estimates for FY 2014 as of July 2015 (22), Page 6. Retrieved from http://www.acf.hhs.gov/sites/default/files/cb/afcarsreport22.pdf