The Foster Care Clinic at Texas Children’s Hospital

The Foster Care Clinic at Texas Children’s Hospital

Located within the Texas Children’s Hospital, the Foster Care clinic is dedicated to primarily caring for infants prenatally exposed to opioids and other substances, and who’s birth parents have open cases with the Harris County substance use and reunification court. An obstetrics clinic also located at Texas Children’s Hospital provides specialized care and referrals to pregnant patients and new mothers with substance use disorders (SUD). Many of the infants seen at the clinic are in foster care, and the clinic aims to bring together family advocates, birth parents, and caregivers, to promote the health and well-being of the mother-infant dyad. The clinic also places a strong emphasis on public health and prevention.

Background and Collaborations

The Foster Care clinic was supported by a grant from the Centers for Disease Control and Prevention that funded Baylor College of Medicine. Researchers, public health experts, primary and specialty care physicians, and others used this opportunity to find out more about the way in which different sectors (i.e., child welfare courts, hospitals, birthing centers) are responding to the needs of birth parents with SUD and infants with neonatal abstinence syndrome (NAS) and neonatal opioid withdrawal syndrome (NOWS). The collective effort generated mapped out patterns of substance use in different cities and explored how different sectors can collaborate and create a coordinated system of care that can meet the needs of families affected by prenatal substance use.

The main finding was that different sectors across the state were working in silos. For example, child protective services did fully trust and coordinated services with primary care physicians, and vice versa. The common ground among all sectors was they all acknowledged the need for more education and training when working with this patient population. As a result, the working group developed a set of 25 cross-sector recommendations to improve care for families affected by prenatal substance use.

A notable finding was that primary care physicians reported challenges in identifying pregnant patient with SUD and who could benefit from treatment and recovery services. This challenge was partially due to that fact that treatment facilities and obstetric clinics were not referring patients to primary care pediatricians or family physicians. To overcomes this issue, the working group suggested and facilitated an improved process for cross-sectors referrals. Today, referrals to the clinic mainly come through the Harris County Courts, and which initially are received from the Santa Maria Hostel, a residential treatment facility.

At first the clinic mainly treated infants placed in foster care, and later on, their patient population expanded to include infants with NAS/NOWS who were in not in foster care and were referred by the court. The main challenge the clinical team was looking to overcome, was to support families early on families can stay together and be connected to the clinic through the referral from the court. As a result, the clinic adopted a public health approach focused on prevention. Staff from the Baylor College of Medicine guided this collaboration and the clinic’s prevention work.

Coordinated Multidisciplinary Care

The clinic mainly sees infants whose birth parents have an active case with the child protective services (CPS). The clinic partners with the obstetric clinics who provide care for the pregnant patients with SUD. After an infant is born and leaves the neonatal intensive care unit NICU, the family is referred to the clinic for long term primary and specialized pediatric care and for ongoing support for the families.

Children in foster care are generally reunified with their biological parent within six months of a case being opened, even in the cases when the state continues to have the custody of the child. If families have multiple cases with the CPS along the years, the clinic advocates and works to prevent other cases. Pediatric patients are seen at the clinic while the court case is open, generally for about 6-12 months. After a case is closed, children are referred to community-based primary care pediatrician.

Plans of Safe Care

After researching how other states approached the development and implementation of their plans of safe care (POSC) the collaborative at Baylor College of Medicine piloted the development of the state’s POSC. Working through a quality improvement process, the working group created a POSC toolkit. This toolkit is fundamental to developing an individualized POSC in collaboration with the family and ensure that birth parents will continue their recovery and treatment. The POSC are designed in a format that birth parents can own and can use to help during their recovery.

Trauma-informed Care

The clinical team at Foster Care clinic uses trauma-informed approaches that considers mothers’ health history, and recovery goals. Pediatricians and nurse practitioners at the clinic know that infants and children will have better health outcomes, when their parents are supported during recovery. Clinic and community partner staff are trained about trauma-informed care and the science of addiction as a chronic condition. Some of this training is provided through the AAP. Clinicians and community providers are trained about the adoption and use of clinically accurate terminology when communicating about addiction and addiction treatment. Traumatic experiences, domestic abuse and polysubstance use are sometimes part of the of the lives of the birth parents seen through Saint Mary. Parents often offer insightful feedback about their experiences and how Foster Care clinic can work with families and community partners to decrease stigma related to substance use. The information and qualitative data collected through this research collaborative is also featured in the statewide training offered to CPS workers.

Building a Therapeutic Alliance

Clinic staff use a strengths-based approach with mothers and appreciate the unique relationship each mother has with her child(ren). The pediatrician regards the infant’s health and well-being as the mutual concern and common ground with the parents. This is an opportunity to connect with the mother and establish a positive relationship focused on the health goals for the infant and for the family. Pediatricians discuss with the families and educate them on the expectations when caring for an infant with NAS/NOWS. While clinicians recognize the benefits of education and anticipatory guidance, the information is offered during the office visits, as opposed to handouts.

Even when children are in foster care the clinic invites the birth parent to come to the office visits. At all times, the clinical staff recognize and celebrate even the smallest successes a family has and emphasize all the positive aspects about parenting and attending the child’s needs. To maintain and strengthen the mothers into the clinic. All parents appear to be less guarded at the clinic.

Community Partner

Since pregnant patients and birth parents cannot receive direct treatment through the Foster Care clinic, they are referred to community-based provider for substance use treatment, adult medical care, and recovery services.  Many mothers are not open to discuss their treatment plan with the CPS workers, but they trust the staff at the clinic to step in and connect them with the services they need. When a mother needs a referral, or a direct connection to a resource/service, a team member is assigned to work closely with them and walk them through the process to ensure they understand each step needed along the way.

During the monthly meetings, the clinical staff, community service providers, and advocates discuss their pediatric patient cases. Also discussed are the birth parent recovery and treatment status, mental health, and other challenges the family may be experiencing such as, food and housing insecurity.

The clinic serves families in a medical home capacity by providing referrals and coordinating care to all the appropriate services. As needed, the pediatrician refers families to the Healthy Start home visiting program ran by the University of Huston, or to the Santa Maria Hostel. Santa Maria offers transportation services to mothers, and they ensure CPS is aware of the appointments with the court and the clinic. Most mothers receiving treatment at Santa Maria have a peer recovery coach with who they stay connected after leaving treatment. Santa Maria also supports those in stable recovery to become mentors themselves and support new mothers entering treatment.

The Harris County Court can facilitate connections for birth parents with the therapists employed by the court. Since only the families that are approved for reunification are involved in the court, the court is a partner, and women speak freely about their cases. The clinic also connects families with Court Appointed Special Advocate (CASA) coordinators and volunteers.

Financing and Evaluation of Services

The clinic operates on a fee for service model, but some non-clinical services are not billable. Sixty percent of children are covered by Medicaid, but many patients do not have any type of medical coverage. When families are referred through the Harris County Court, they receive free pediatric and mental health care. Unfortunately, these benefits expire when their case with the court is closed, and many families stop receiving medical care.

Some of the non-clinical work at the clinic is funded through private and federal grants. A grant that funded a pilot for a child mental health program at the hospital revealed a high need for these services. After the grant ended a child psychologist and psychiatrist were brought on board at the hospital, and they started a collaboration with the Foster Care clinic.

Now that more services are being provided, other outcomes are being measured. The clinical team is confident in their model of care, and they noticed the growing support for their work. To ensure program sustainability, the team is continuously looking for grant funding that supports families, community partners, and the hospital.

Advice for Other Practices

To ensure success of a model of care similar to Foster Care clinic, the team members emphasize the need of open communication between physician, families, child’s advocates, and especially with their attorneys. Communication with advocates is key because they are the child’s voice. Team members warn that when stakeholders operate in silos, much information is lost or miscommunicated. Everyone working in the best interests of the infant and the family, including family members, must be present at the discussion table. The clinic staff also recommends providers support bio parents.

Clinic staff acknowledge some physicians are reserved when working with families affected by substance use, and they want to highlight how rewarding this work can be. They advocate and recommend that supporting birth parents during their recovery is key to achieving positive health outcomes. The clinical team is open to discuss with others their collaborative model of care and their strategies of thinking outside the box. One pediatrician said, “there is no sense in obstetricians and pediatricians working separately, so come together.”