March 2007

Grant Results

National Program

Robert Wood Johnson Foundation Local Funding Partnerships

SUMMARY

In 2002, the Kapi'olani Health Foundation created the Child-At-Risk Evaluation (CARE) program, a pediatric specialty clinic specializing in the diagnosis and treatment of child abuse.

The CARE program works to provide children who are entering foster care and those who have been physically abused or neglected with comprehensive medical and forensic evaluations in a compassionate manner.

The project was part of the Robert Wood Johnson Foundation (RWJF) national program Local Funding Partnerships (for more information see Grant Results).

Key Results

  • CARE staff provided medical and forensic medical services to 1,881 children entering foster care over the course of the grant.
  • Staff saw 1,501 children for pre-placement exams and diagnostic forensic exams and 380 children for comprehensive medical exams during the grant period.
  • The number of diagnostic forensic exams performed increased from 23 in year one of the grant to 103 in year three—a 348 percent increase.

Evaluation Findings

  • Foster parents reported that health and developmental status information gathered by CARE staff frequently were inaccessible to them. (CARE staff worked with Hawaii's Department of Human Services to allow CARE staff to communicate directly with foster parents.)
  • Child welfare staff are knowledgeable about CARE services and report that the quality of services provided and the information shared are superior to the services obtained through alternative sites.

Funding
RWJF provided a $500,000 grant to fund this project from August 2002 through July 2005.

 See Grant Detail & Contact Information
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THE PROBLEM

Child abuse is a significant social problem in the State of Hawaii. From 1990 through 2000, the number of reported cases of child abuse and neglect increased by 40 percent, from 4,407 to 6,184, according to Hawaii's Department of Human Services. Of these reported cases, the number of confirmed cases increased by more than 47 percent, from 2,392 to 3,533, over the same time period.

The medical diagnosis of child abuse and neglect is emerging as an area of expertise within the practice of medicine, according to Victoria Schneider, M.D., medical director of the Kapi'olani Child Protection Center, in Honolulu, and project director. Often, prior episodes of abuse go unrecognized or misdiagnosed as a result of not having physicians and nurses trained in the area of child abuse. For example:

  • A review of 40 cases of physical abuse of children at Honolulu's pediatric hospital—Kapi'olani Medical Center for Women and Children—revealed that 43 percent of the cases had prior reports of abuse or neglect that were not adequately evaluated.

Even when child victims of abuse and neglect are identified and placed in state-supervised foster care arrangements, their continuing physical and mental health needs may still go unrecognized or unmet, Schneider says. For example,

  • In 2002, staff from the Kapi'olani Child Protection Center evaluated 146 foster children to determine the health needs of this group. They found that:
    • 58 percent of the children had one or more medical problems.
    • Nearly half (47 percent) of the 74 children under the age of 5 who received a developmental assessment displayed developmental delays.
    • Of the 47 children over the age of 5 who received a mental health evaluation, 87 percent received a referral for mental health services.

Further compounding the issue is the fact that children are frequently placed in foster care arrangements without providing the foster parent with adequate information to ensure that the medical needs of the child are being addressed, Schneider says.

The Kapi'olani Health Foundation supports the medical centers and community programs of the Hawaii Pacific Health health care system, including the Medical Center for Women and Children and the Kapi'olani Child Protection Center.

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RWJF STRATEGY

In 1987, the RWJF Board of Trustees authorized $8 million to fund a two-year trial of a matching grants program to be called the Local Funding Partnerships program. Many matching grants programs set up by national foundations seek to replicate ideas formulated by the national institution itself. Local Funding Partnerships was to be different.

The local community would identify a pressing need, design the strategy for addressing it and put together a funding package that would provide at least one dollar of outside support for every one dollar of RWJF grant money. Each project would have one lead local funder, but additional supporters would be welcomed.

To be eligible, a project would have to fall within the general scope of RWJF's interest in health and health care. But a proposal would not have to meet the kind of specific criteria common to other RWJF programs.

Instead of top-down, Local Funding Partnerships would be bottom-up—with an emphasis on innovation. RWJF hoped this local "ownership" would ensure sufficient support to keep the project going long after the RWJF grant ended.

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THE PROJECT

In 2002, the Kapi'olani Health Foundation created the Child-At-Risk Evaluation (CARE) program. CARE is a pediatric clinic specializing in the diagnosis and treatment of child abuse.

The CARE program works to provide children who are entering foster care and those that have been physically abused or neglected with comprehensive medical and forensic evaluations in a compassionate manner, according to the project director. The clinic is located in Honolulu, on the island of Oahu, with a satellite office in Ewa Beach, located on the west coast of Oahu.

The goals of the project were to:

  • Identify the medical signs and symptoms of abuse at the child's entry into the Child Welfare System.
  • Improve the ability of a foster parent to provide care for the child by ensuring the child has a medical home.
  • Prevent the risk of re-abuse by gathering forensic evidence. Forensic evidence includes the documentation of a child's bruises, scars and other evidence of abuse through photography.

Other Funding

The Consuelo Zobel Alger Foundation, Robert F. Lange Foundation and the Victoria S. and Bradley L. Geist Foundation provided matching funds to support this project.

Activities

  • CARE staff conducted pre-placement examinations on children entering foster care. (See the Appendix for details on this exam.) The purpose of the exam is to:
    • Identify immediate health needs of the child.
    • Document physical signs of abuse and neglect.
  • For foster children without an identified primary care provider, CARE staff conducted comprehensive health evaluations within 45 days of the pre-placement examination, as required by state law. (See the Appendix for details on this exam.) The purpose of this exam is to:
    • Identify physical, developmental and behavioral needs the child may have.
    • Provide pediatric medical services such as immunizations.
    • Gather and organize past and current health information.
    • Refer the child to a primary care provider for ongoing care.
    • Provide recommendations for community-based health services.
  • Project staff conducted diagnostic forensic evaluations. This evaluation is designed to examine a child when there are reports of physical abuse or severe neglect, and when the child has marks on the body that may be indicative of abuse. (See the Appendix for details on this exam.) The purpose of this evaluation is to:
    • Obtain a thorough medical history.
    • Complete a physical examination to identify signs of abuse and neglect.
    • Document the injuries (scars, bruises) with photography.
    • Prepare a written report to Child Welfare Services.
    • Request further medical tests if needed.
  • Initiated psychosocial and developmental screenings during the pre-placement exam.
    • All children over the age of 3 receiving a pre-placement exam at the CARE clinic have their case reviewed by a mental health consultant from Kapi'olani Child Protection Center. Based on this information, the mental health provider can arrange either a psychosocial assessment at the time of the comprehensive health evaluation, or refer the child to a community-based setting for psychological evaluation and treatment.
    • All children under 3 years old are referred to early childhood developmental services at the time of the pre-placement exam. The Hawaii Department of Health designates children under 3 entering foster care as being environmentally at-risk and eligible for early childhood developmental services.
  • Identified primary care providers to ensure continuity of health care for foster children.
  • Communicated health information to social workers, primary care providers and foster parents.
  • CARE staff provided expert testimony in both family court and criminal court cases. The project director reported that CARE expert testimony was identified by attorneys in both courts as a crucial element in family case plans. Case plans identify services to help the family provide a safe home for their child.
  • Subcontracted with Johns Hopkins University to conduct an evaluation of CARE.

Challenges

  • CARE staff planned to assess the social costs associated with child abuse.
    • Staff quickly realized that it was beyond the scope of CARE's resources to be able to perform an analysis of the social costs of child abuse in Hawaii.
    • Rather, CARE staff worked to create systemic change within the Child Welfare System through education of child welfare personnel in the complexity of health care needs of foster children and in the importance of forensic medical information in family court cases where abuse and neglect is suspected.

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RESULTS

Project staff documented the following results in a report to RWJF:

  • CARE staff provided medical and forensic medical services to 1,881 foster children over the course of the grant.
  • Staff saw 1,501 children for pre-placement exams and diagnostic forensic exams and 380 children for comprehensive medical exams.
  • At the time of entry into foster care:
    • Some 45 percent of children were male and 55 percent female.
    • Some 62 percent were of Native Hawaiian descent or other Pacific Islander.
    • Some 10 percent had marks of abuse on their bodies.
  • At the time of the comprehensive medical examination:
    • Some 57 percent of children had dental caries (decay requiring fillings).
    • Some 15 percent of children had poor vision.
    • Some 12 percent of children without immunization records were behind on immunizations.
    • Some 4 percent of the children failed their hearing screening.
  • The number of diagnostic forensic exams increased from 23 in year one to 103 in year three—a 348 percent increase. The increase in the number of diagnostic forensic exams performed is due to:
    • Child welfare social workers' increasing understanding of the importance of obtaining forensic medical information on children that have been abused or neglected.
    • CARE and Kapi'olani Child Protection Center staff increasingly cross-referred patients for services. The Child Protection Center now sends CARE a copy of all intakes from Child Welfare Services regarding reported physical harm to children.
    • Based on the increase in the number of diagnostic forensic exams, CARE staff called child welfare social workers and offered CARE services.
  • Despite the increase in forensic evaluations, the number of child abuse and neglect cases prosecuted in criminal court did not change appreciably.
    • The CARE board of advisors suggested that a more meaningful indicator of the program's impact might be to look at family court outcomes. Specifically, the group suggested that CARE examine whether information obtained during CARE medical examination had an impact on the recommendations that become part of family case plans. CARE plans to pursue the board of advisors' suggestions during a two-year collaborative project with the Waianae Coast Comprehensive Health Center. (See After the Grant.)

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EVALUATION

In July 2004, evaluators from Johns Hopkins University conducted an evaluation of the CARE program through:

  • Six 90-minute focus groups with Child Welfare Services staff persons (social workers, social service assistants and social service aides).
  • Individual interviews with 12 foster families.

Evaluation Findings

The Johns Hopkins University evaluation team reported the following findings in a report to CARE staff (See Bibliography):

  • Foster parents reported that health and developmental status information gathered by CARE staff frequently was inaccessible to them.
    • CARE staff had been communicating directly with Hawaii's Department of Human Services for fear of violating federal privacy laws.
    • CARE staff worked with Hawaii's Department of Human Services to allow CARE staff to communicate directly with foster parents.
  • Child welfare staff are knowledgeable about CARE services and report that the quality of services provided and the information shared are superior to the services obtained through alternative sites.
  • Social workers expressed a more comprehensive understanding of the CARE program than assistants and aides. This is consistent with the social worker's role as the case manager responsible for making referrals and accessing services.
  • Aides and assistants expressed more concern regarding CARE's operating hours than did social workers. Again, this is consistent with the assistants' and aides' role of transporting foster children to appropriate sites for pre-placement, comprehensive and forensic exams.

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LESSONS LEARNED

  1. Secure sustainable funding sources early on in the grant period. In the first year of the grant, the state Department of Human Services assured CARE staff that CARE would receive funding beyond the final year of RWJF funding. Although the department staff had anticipated that the department would be able to use Medicaid funds to cover the cost of CARE services, staff discovered toward the end of the grant period that this was not possible. CARE staff later submitted a proposal to the state legislature in 2005 and obtained additional funding for the program. (Project Director/Schneider)
  2. Be flexible. Analyze what does and does not work and make necessary changes. CARE staff initially provided a full array of pediatric medical services, including immunizations. Staff learned that primary care physicians in the community saw this as competition, since vaccine-related services are reimbursable though Medicaid and insurance. CARE staff decided not to administer vaccinations and worked to educate the medical community about their child-welfare-related services. (Project Director/Schneider)
  3. It was important for child welfare staff to feel a sense ownership of the CARE program. At the start of the grant, CARE staff estimated that the majority of patients would be seen through the main clinic in Honolulu. Staff found, however, that the Ewa Beach office, located within a Child Welfare Services office, is utilized with greater frequency. The CARE nurse practitioner interacts daily with the child welfare social workers and has come to be seen as part of the office staff. The nurse trained the social workers on using a camera as part of their child abuse investigations. The social workers now regularly take pictures at the scene and review them with the nurse as part of the investigation. The Child Welfare social workers in Ewa Beach display ownership of the CARE program in their community. (Project Director/Schneider)

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AFTER THE GRANT

The CARE program continues to operate and is fully funded by Hawaii's Department of Human Services.

The CARE program received two grants from the James and Abigail Campbell Family Foundation and the Harry and Jeanette Weinberg Foundation to support a two-year collaborative project with the Waianae Coast Comprehensive Health Center, in Waianae, Hawaii. This project will:

  • Provide training on child abuse issues to a designated health provider at the health center.
  • Provide telemedicine consultation from the CARE clinic in Honolulu to the health center.

Child Welfare Services has agreed to send all children within the geographic area who are being investigated for child abuse or neglect to the Waianae Health Center. Based on the outcome of this project, CARE staff hopes to expand the consultation services statewide.

In 2005, the United States military hired a pediatrician with expertise in child abuse issues who is charged with developing a child abuse consultation and training program for the military. CARE is working with this clinician to partner with the military in providing coverage for military cases.

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GRANT DETAILS & CONTACT INFORMATION

Project

Medical Intervention and Education for At-Risk Children or Victims of Child Abuse and Their Foster Caregivers

Grantee

Kapi'olani Health Foundation (Honolulu,  HI)

  • Amount: $ 500,000
    Dates: August 2002 to July 2005
    ID#:  046121

Contact

Victoria Schneider, M.D.
(808) 592-3255
VictoriaS@Kapiolani.org

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APPENDICES


Appendix 1

Examination Procedures

Pre-Placement Examination Procedures

  • Measurement and growth parameters as a measure of overall health status and to rule out failure to thrive.
  • Evaluation of the entire body, unclothed, for evidence of physical abuse.
  • Documentation of all injuries, including photo documentation when possible.
  • When physical abuse is suspected or documented, appropriate imaging studies (X-rays) are ordered and reviewed to document evidence of a recent unhealed fracture or a history of older healed fractures.
  • Examination of the external genitalia and cultures for sexually transmitted diseases when appropriate.
  • Evaluation and treatment for communicable diseases such as lice.
  • Documentation of evidence of chronic medical conditions, such as eczema, which need treatment and/or follow-up.

Comprehensive Health Evaluation

  • The gathering and review of the child's past medical history, including birth history, immunizations and chronic health problems.
  • An assessment of the child's emotional adjustment to foster care, including information supplied by the foster parents, structured interviews and standardized tests.
  • A review of school progress.
  • A physical examination, including vision and hearing evaluations when age appropriate.
  • A developmental evaluation.

Diagnostic Forensic Evaluation

  • History obtained and recorded in a way that is clear and defensible in court.
  • Full physical examination, including genital examination.
  • Photographs or record of injuries with accompanying descriptions of the photographs.
  • Written assessment of the likelihood of abuse and neglect.
  • Referrals for needed laboratory and X-ray studies as needed.
  • Arrangement for medical follow-up as needed.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Cordoni A. "Children Entering Foster Care." On The Edge, Official Publication of the International Association of Forensic Nurses, 10(1): Spring 2004. Available online.

Reports

McFarlane E, Hannum M and Duggan A. Summary Report: CARE Program Child Welfare Staff and Foster Family Focus Groups. Baltimore: Johns Hopkins University Department of Pediatrics, 2004.

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Report prepared by: Barbara Matacera Barr
Reviewed by: Richard Camer
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe

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