Six Month Variation in Physical, Behavioral and Chronic Health Condition Prevalence Among Children with Initial Foster Care Entry

Background: Understanding early health trends following foster care entry is critical to eliminate disparities but understudied. The Pediatric Medical Complexity Algorithm, version 3.0 (PMCA) is validated and publicly available, uses Medicaid claims data and includes organ system-specific physical (physical) and behavioral health conditions in health status stratification but has not been applied to a foster care population. Therefore, we describe the physical, behavioral and chronic health condition (CHC) prevalence, measured by the PMCA, for children experiencing initial foster care placement at care entry and after six months in care.

Methods: The retrospective observational study used administrative, medical claims, and behavioral health encounter data for all Colorado children, age 0 to 18 years, with ≥1 month of Medicaid coverage between July 2011 and October 2019. Using Medicaid eligibility codes denoting foster care placement to identify children with initial foster care experience during the study period, we excluded children with <1 month of Medicaid eligibility, initial foster placement less than 6 months and prior foster care experience. We used the PMCA to identify physical and behavioral health conditions and to classify children into 3 mutually exclusive chronic health categories, no chronic health disease (no CD); noncomplex, chronic disease (NC-CD); and, complex, chronic disease (C-CD), during the month of initial foster care placement and at 6 months after placement. We defined CHCs as the sum of NC-CD and C-CD. The Colorado Multiple Institutional Review Board deemed the study exempt.

Results: We identified 28,465 Colorado children with their first foster care entry. Children were predominantly male (53.6%) and 6 years old or younger at time of initial foster care entry (55.4%) (Table 1). Among physical health conditions, pulmonary/respiratory conditions were most prevalent at foster care entry and after six months, but neurologic conditions had the greatest rate difference (Table 2). Behavioral health condition prevalence was highest among those who entered foster care as teens (36.3%); more than half (51.7%) had a behavioral health condition diagnosed after six months in foster care. However, children entering foster care at 2 years of age or younger had the largest percentage increase (476%) in behavioral health condition diagnoses after six months (1.3% at entry and 6.4% after 6 months). CHC prevalence, both with and without behavioral health condition inclusion, increased in the six months after foster care entry: 13.5 and 8.5 percentage point increases, respectively.

Conclusion: Health status is dynamic for children and youth during the six months following foster care entry. Findings support future study focusing on universal, proactive and evidence-based behavioral health interventions for children entering foster care and parsing out whether health conditions were present but not identified at foster care entry or whether they were exacerbated during the early months of foster care.