Children’s Division (CD) shall ensure that children in the agency’s custody receive appropriate medical and behavioral health care. Each child’s care must include:

• Emergency treatment, whenever necessary;
• Timely examination and treatment of nonemergency injuries and illnesses;
• Provision of ongoing allied health services, like physical or occupational therapy, when recommended. Allied health professionals are not doctors, dentists or nurses, but others who aim to prevent, diagnose and treat a range of conditions and illnesses and often work within a multidisciplinary health team to provide the best patient outcomes;
• Proper assessment and care of behavioral health issues; and
• Regular preventive care appropriate to the child’s age and condition, including immunizations

Initial Family Support Team (FST) Meeting: At the first FST meeting following the child’s placement in alternative care, the case manager shall inform the parent(s) that CD will expect them to take an active role in health care decisions about the child, unless the FST determines that would be contrary to the best interests of the child.  An active role would include, but is not limited to:

1. Attending the child’s appointments;
2. Demonstrating an understanding of the child’s health status and recommendations of any providers; and
3. Providing necessary care and medication during visitation and trial home placement.

The case manager shall keep the parent(s) informed of the child’s medical and behavioral health decisions.  The case manager is responsible for the child’s medical and behavioral health care while the child is in CD custody.  The case manager shall partner with the parent(s), the child (to the extent reasonable for the child’s age and understanding), resource providers, and primary health care providers. The case manager will attempt to contact these partners prior to the provision of any treatment.  The parent(s) will be asked to return the completed Child/Family Health and Development Assessment (CW-103) within a week of the Initial FST if not returned at the time of the meeting.

If the parent does not return the completed CW-103, the case manager shall engage the parent to obtain the necessary information to complete the CW-103 and share information with resource provider.

All information about the child’s medical or behavioral health care while in alternative care shall be shared with the parent/caregiver on an ongoing basis unless Termination of Parental Rights (TPR) has occurred or the court has issued an order preventing the parent/guardian access to the information.

Ongoing Case Management

Provision of Appropriate Care: The health of a child in alternative care is of paramount importance throughout the child’s placement. The resource provider shall obtain a medical examination for the child immediately following initial placement and at least annually thereafter    in cooperation with CD. This requirement is satisfied by completion of Initial Health Examination    or the Full Healthy Children and Youth (HCY) Screening.

• Initial Health Examination: An initial health examination should occur when the child enters care. When possible, this should be completed by the current primary care physician as they are already familiar with the child’s medical history.  If a provider is not readily accessible, this exam must occur within seventy-two (72) hours of the initial placement. The case manager need not attend these initial examinations; however, they should receive documentation of the results of the examination of the appointment and ensure compliance with any recommended follow-up treatment/interventions.
• Full HCY Screenings: A full HCY screening consists of a physical examination, and other developmental components, including but not limited to vision, hearing, social/emotional and dental screenings. The screenings shall be completed no later than thirty (30) days after the child is placed in (CD) custody. If it is not possible to schedule the appointment within thirty (30) days, the reason for the delay shall be documented in FACES and the screenings completed at the earliest possible date. Staff should promptly follow up on any recommendations from the screening.

An Initial Health Examination may be considered a Full HCY screening if the Initial Health Examination contains a review of all sections within the HCY screening.

Ongoing Medical Assessments: Children’s Division shall maintain best practices in monitoring the child’s health as required by federal and state laws, and as recommended by the American Academy of Pediatrics (AAP) and the Child Welfare League of America (CWLA), which set forth that certain medical appointments occur timely to assess and monitor the child’s health.

All children in the custody of the Children’s Division shall receive medical assessments   in accordance with the “Bright Futures /American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care” also known as the “Periodicity Schedule.” The periodicity schedule is based on age and may require some children to have more frequent visits than children in other age groups.https://web.archive.org/web/20230126132131/https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf

• Some medical care, even though standard or routine, may be controversial in some families.  With respect to those issues, the case manager shall follow CD policy as set forth below.

Dental Examinations:

Immediately following placement the resource provider should obtain a dental examination for the child as recommended by the dentist or every six (6) months; but at least annually.

Dental exams are performed by dentists or qualified dental professionals. During a dental exam, the dentist or hygienist will check for cavities and gum disease and may clean the child’s teeth. The exam involves a more comprehensive oral health evaluation and may include dental X-rays or other diagnostic procedures, when indicated. Oral hygiene habits and anticipatory guidance are typical points of discussion during each visit.              

• Dental Exam Periodicity Schedule – When and How Often Exams Should Occur
• First Dental Exam: The American Academy of Pediatric Dentistry (AAPD) recommends the first dental examination occur at the time of the child’s first tooth eruption, or no later than 12 months of age.
• A child’s developing primary teeth (or “baby teeth”) are susceptible to decay as soon as they appear. This first visit provides the early opportunity to check existing teeth for decay and to assess any potential problems with the child’s gums, bite, oral tissues, and jaw. The dentist can provide guidance on baby bottle tooth decay, infant feeding practice, teething, pacifier habits, finger-sucking habits, and mouth cleaning.   
• Ongoing Dental Exams: Dental exams are recommended every six (6) months, or more frequently if recommended by the dentist based on the child’s risk status.

• Child’s First Dental Exam Following Entry in to Alternative Care

  All children entering alternative care must have a full, comprehensive HCY screening within thirty (30) days. Included in this physical health and developmental assessment are vision, hearing, and dental screenings.

  The dental screening may be completed by the physician performing the physical exam, or the child can be taken to a dentist to receive this screening. A full dental examination is not required during this thirty (30)-day timeframe solely due to the child’s entry into alternative care. However, if during the HCY dental screening the provider indicates a need for a full dental/oral examination, the physician will make a referral and staff shall ensure this exam occurs. This dental exam must be performed by a dentist or qualifying dental professional.

• Because dental exams are recommended every six (6) months, staff should promptly collect the child’s dental records upon entry into alternative care to ascertain when the child last had a dental exam and when he/she should visit the dentist next. These records can be obtained from the child’s dental provider, or by accessing the information via CyberAccess for MO HealthNet recipients.

• If the child has no history of a dental exam, the child’s first dental exam should be scheduled based on the anticipatory guidance given by the physician during the thirty (30)-day HCY screening, but no later than six (6) months from entering CD custody.

Immunizations: The case manager or resource provider will ensure that children in the agency’s custody are immunized against disease, in accordance with the Department of Health and Senior Services (DHSS) current guidelines.  The DHSS immunization guidelines are: 2022 Recommended Child and Adolescent Immunization Schedule for 0-18 years of age  and the 2022 Recommended Child and Adolescent Immunization Schedule for 19 and older.

• If a parent has an objection to the administration of an immunization based upon religious or health reasons, the parent should inform the case manager or resource provider and the parent may choose to address the issue with the Court.

   

• The administration of an immunization can be performed; unless there is a court order exempting the child from receiving the immunization. 

   

• Any information pertaining to an immunization will be documented in FACES and all documents uploaded to OnBase and a copy placed in the child’s physical file.

Emergency Use Authorization (EUA) currently granted for COVID-19: The case manager, resource provider, or youth 18 and older who provide their own consent, may provide consent for any vaccines approved by the Centers for Disease Control and Prevention.  The case manager will refer to following guidelines https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/covid-19.html, to determine if vaccine has been approved for a child specific age group.

The case manager and resource provider will talk with the child in an age and developmentally appropriate manner about receiving the EUA vaccine, just like other health care decisions, and ensure that the child understands:

• receiving the vaccine is voluntary;
• the physician can help answer any questions about the vaccine,  benefits, or potential side effects. 

The case manager will then consult with the child’s physician regarding whether it is appropriate for the child to receive the vaccine.

Upon the recommendation of the child to be vaccinated, the case manager will discuss the recommendation with the parent(s)/legal guardian.

• The case manager will make at least two (2) attempts to contact a parent (both parents if applicable)/legal guardian. Contact with the parent(s)/legal guardian will include a conversation about the recommended treatment and possible side effects.  The COVID-19 Vaccination Information  document may be used to assist the case manager with providing additional information to the parent(s)/legal guardian. 
• If contact is made the case manager will inform the parent(s)/legal guardian of the recommendation and confirm consent or opt-out of a COVID-19 vaccine. All direct contact and attempts to contact shall be documented in FACES.
• In the event that a parent(s)/legal guardian and the child are not in agreement whether to receive the vaccine or to opt-out, the case manager will facilitate a discussion with the family to attempt to reach a consensus, and may provide educational resources to inform the decision-making process. If a consensus is not reached, the case manager will make a referral to the Division of Legal Services.
• If the case manager is unable to contact the parent(s) within a reasonable timeframe the case manager may follow the physician’s recommendations regarding vaccination of the child and document consent. The consent document will be uploaded to OnBase and a copy placed in the child’s physical file.  
• The case manager will instruct the resource provider to monitor the child and contact the case manager as soon as possible, if the child is experiencing any side effects.

Reproductive Health: Information on sexual health, education, including information on sexually transmitted infections and birth control should be made available to a child, appropriate to their age and physical and emotional maturity.  The case manager shall document when and by whom this education was provided.  Educational information and prevention resources shall be made available to parent(s) and/or resource providers as requested for discussion with the child.

Birth Control: Children in foster care are afforded the choice to obtain or refuse birth control.  Missouri law does not require minors to have parental consent to obtain contraception, although it is the practice of some medical providers.  If the medical provider requires signed consent, CD may provide the written consent.

Attendance at Health-Related Appointments: After a child is placed in the custody of CD, parent(s) and resource provider attendance at the child’s health-related appointments is expected and welcomed, in most instances.  The case manager should invite the parent(s) and resource provider to attend all health-related appointments at least three days in advance, whenever possible.  There may be special circumstances in which it is not in the best interests of the child for the parent(s) to be involved in health care decisions about the child.  In these cases, the case manager should speak to their supervisor and may consider a referral to the Division of Legal Services or CD attorney.  

If behavioral health therapy is arranged for the child, ideally the case manager will attend the initial appointment with the child.  If the case manager is unable to attend the initial appointment, s/he must communicate with the therapist prior to the appointment to discuss the child’s needs and provide consent to begin treatment.  If a child is referred for psychiatric assessment or care, the case manager or supervisor must attend all initial appointments.

Communication Regarding Health Care Needs: The case manager should recognize that continued collaboration with the parent(s), child, resource provider, and primary health care providers will lead to clearer communication and provision of services in the child’s best interests, resulting in a smoother transition in the event of any change, including at the time of reunification or, for an older youth, placement in independent living.

Family Support Team (FST) Meetings: FST meetings shall include a discussion of medical and behavioral health updates, unless the case manager has determined that such discussion is contrary to the child’s best interests.

A supervisor should be consulted regarding any such determination and an explanation provided to the FST, with appropriate documentation in FACES. Notice of the right to pursue being designated as an alternative consenter for psychotropic medications is to be provided to all members of the FST at each meeting. See Alternative Consenter in 4.3.3.

• Parent(s):  Unless termination of parental rights has occurred or the court has issued an order restricting parent(s) access to information, the case manager will routinely share information about the child’s health with the parent(s) during home visits and will timely respond to requests for information.  Additionally, the case manager shall engage the parent(s) promptly about any major change in the child’s health status, including, but not limited to, significant injury, new diagnosis or medication, or any emergency treatment or hospitalization.  The parent(s) should be asked to provide updates about any newly acquired knowledge of familial illness which might impact the child and to promptly inform CD of any illness or injury incurred by the child during visitation with the parent(s).
• Child: Children and youth should participate as much as possible in making decisions about their medical care.  Children should be encouraged by the team members to communicate information or worries about their health to parent(s), resource providers, the case manager, and to health care providers.  Case managers should ask a child’s opinion about proposed medical care and discuss safe use of medication, as developmentally appropriate.  Providing a child with information:
•  
  • helps the child achieve developmentally appropriate awareness of health status;
  • tells the child what to expect about treatment;
  • helps to prepare a child for assuming more responsibility for health care decisions as they develop;
  • aids the case manager and other adults involved in the child’s care to assess the child’s understanding of the situation; and
  • solicits the child’s willingness to accept the proposed care.

Children/youth age twelve (12) or older shall be provided written notice of their rights regarding assent as described in the Informed Assent section. The Guardian Ad Litem (GAL) and any attorney for every child shall also be provided written notice of children’s rights regarding assent. Staff shall document in the case record when and to whom the Learn Your Rights (CD-281) form was provided.

• Resource Provider:  The case manager will provide all available medical and behavioral health information to the resource provider as required by law.  The case manager and the resource provider will regularly review the child’s health care status throughout the duration of the child’s placement. The resource provider will notify the case manager as soon as possible of any significant injury or illness of the child.
• Court: The case manager shall provide a comprehensive summary regarding the child’s health in regular court reports and shall include any current diagnoses and medications, if any.

Children’s Division Responsibilities:  In addition to the historical documentation cited in this chapter and the provision of such documentation to a resource provider upon initial placement of a child, CD has an overarching responsibility to ensure that current medical information is documented throughout a child’s placement in care.

• CD shall exercise reasonable and diligent efforts to compile and maintain the medical records for each child in alternative care. Collection of medical history and updating the child’s medical records are continuing and shared responsibilities. 
• The case manager will obtain medical information for each child in their caseload. The case manager will upload any medical and/or behavioral health documents into the document imaging system and maintain a physical paper file, if the records were not received electronically. The Health Information Specialists (HIS) are available in each region to assist the case manager with coordination of obtaining the documents.
• All efforts to involve the child and parent(s) in decisions about the health care of the child shall be documented in FACES by the case manager.  Documentation should include the child’s response and the parent’s actual involvement or reasons why the parent could not or should not be involved.  If the parent(s) cannot be located, the case manager will document any efforts taken to notify them. Available documentation shall be uploaded into document imaging system.
• All medical, mental health, medication, behavioral and any other identified needs specific to the child should be documented in the Social Service Plan Child Section. Each identified need should include the plan to address the need, who will be involved to help meet the need and next steps. These needs shall be reviewed and progress documented in the FACES contact note during every home visit with the parent/caregiver/guardian, every visit with the child and placement provider and every FST. Any changes to the Social Service Plan Child Section should be reflected in the next reassessment.

Medical Records – Compilation and Access

• Case Record: The case manager and HIS may collaborate to obtain and upload any historical and current medical and/or behavioral health documents. These documents are maintained in the document imaging system and can be retrieved to compile a medical record for the child.  This medical record shall include full and accurate medical information and history, including but not limited to the following:  Medical and surgical history, dental history, psychosocial history, past behavioral health and psychiatric history, including medication history and documented benefits and adverse effects; past hospitalization or residential treatment history; allergies; immunizations; current and past medications, including current dosage and directions for administration; family health history; treatment and/or service plans, and results of any clinically indicated lab work.
• Process and Documentation: To the extent applicable, such efforts shall include, but not be limited to, accessing Medicaid claims data, requesting information from current and past medical care providers known to CD, reaching out to the child’s health insurance plan, gathering records from past foster care episodes, and gathering records and information from parents (whose rights have not been terminated) or guardians and other family members involved in the child’s health care.
• Access to Medical Records/Providing Medical Information

When a child is placed in alternative care, the case manager placing the child will request pertinent medical information from the parent(s) or other caregiver, to include information necessary to provide immediate care for the child, including current medications, if any, and complete the Health Care Information Summary (CD-264).  Ideally, the CD-264 should be provided to the resource provider at the time of the child’s placement.

The case manager will obtain comprehensive health and developmental information about the child from the parents or other significant adults in the children’s life and/or health care providers, using the Child/Family Health and Development Assessment (CW-103). The case manager should begin the process of completing these forms with the family at the time of initial contact; but should continue to engage the family to gather information during subsequent visits until the form is complete.

The Monthly Medical Log (CD-265) was created to assist the resource provider and residential facilities in documenting health related needs, informed consent decisions for routine care, medications, and appointments regarding the child.

The CD-265 is to be maintained and supplemented by the resource provider throughout the child’s placement and is to be submitted to the case manager monthly, primarily during the case manager’s visit with the child in the child’s placement. The CD-265 also offers an opportunity for the resource provider to provide information about the child’s progress and needs related to the child’s health.

The residential treatment provider must provide the case manager with the completed CD-  265 as well as the Medication Administration Record (MAR) by the 5th day of the following   month. The written documentation must contain all medication administered for the month,   including the dosage and any new medications prescribed, including the dosage.

Initial Placement: When a child has been placed in any alternative care setting for the first time since coming into the legal custody of CD, the case manager will ensure that the CD-264 and the Child/Family Health and Developmental Assessment (CW-103) are provided to the resource provider or residential care providers within seventy-two (72) hours whenever possible but no later than thirty (30) days following placement. While the parent or legal guardian should be primarily responsible for completing the CW-103, it is the case manager’s duty, even if the parent does not assist in completion of the assessment paperwork, for ensuring that both forms are as accurate and complete as possible, and are given to the resource provider within thirty (30) days.

Case managers shall also document when and to whom the health information (CD-264 and CW-103) was provided.

Subsequent Placements: If a placement change must occur, the case manager will provide to the new resource provider or residential care provider the CW-103, an updated version of CD-264, and a copy of the resource provider or residential care provider’s medical file, including all CD-265s, from the child’s prior foster care placements. This information will be made available at the time of placement, but no later than seventy-two (72) hours following placement. This history shall include all information gathered and provided at the time of initial placement and all additional information maintained by the previous resource provider (including information that has been provided to the case manager). Any medication previously prescribed for the child should be delivered in the original container with written instructions. Case mangers shall document when and to whom the health information (CD-264, CW-103 and CD-265) was provided.

The case manager will provide the names and contact information for all of the child’s current and past behavioral health, dental, and medical providers, and upload all signed forms i.e., CW-103, CD-264, CD-265 and CD-275 into the document imaging system. Efforts to obtain the information described shall be documented in FACES. 

The case manager is not required to perform the initial and subsequent placement process for hospital placements.

Related Practice Points and Memos:

7-9-19 – PP19 CM-01 – Timely Informed Consent – Inpatient Hospitalizations and Medication Management Checkups

7-26-19 – CD19-47 – Informed Consent for Psychotropic Medication (Form CD-275)

10-11-19 – DK19-04 – Immediate Implementation of Best Practices Regarding Behavioral Health Care and Medical Records

4-9-20 – PP20-CM-03 – Mandatory Psychotropic Medication Reviews

7-23-20 CD20-34 –Introduction to Child Welfare Manual policy updates to align with best practices and comply with Joint Settlement Agreement requirements.