January/ February 2011

AN RANCISCO EDICINE S F M VOL.84 NO.1 January/February 2011

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Health Care for Kids In the Foster and Juvenile Justice Systems

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In This Issue SAN FRANCISCO MEDICINE January/February 2011 Volume 84, Number 1 Health Care for Kids in the Foster and Juvenile Justice Systems FEATURE ARTICLES

MONTHLY COLUMNS

10 My Mental Health: A Foster Care Alumni Perspective Misty Stenslie, MSW

4 Membership Matters 7 Executive Memo Mary Lou Licwinko, JD, MHSA

11 San Francisco’s Child Welfare System: An Overview Debby Jeter, MFT

9 President’s Message George Fouras, MD

14 The Healing Team: Bringing a “Lost” Foster Care Child Home Mia and Sharon Behrens

29 Hospital News

16 Task Force on Foster Care: Getting Kids the Care They Need Sarah Springer, MD

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129

17 The CASA Program: San Francisco Court Appointed Special Phone: (415) 561-0850 extension 261 Advocate Program Profile e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

Maya Durrett 19 Health Care for Kids in Foster Care: An Overview Linda Medeiros, RN, PHN, BS HED

About the Cover Image

22 There’s a SPY in Our House: Special Programs for Youth in the San Francisco Juvenile Probation Department William Sifferman

Throughout this issue you will see postcards created by foster care alumni reflecting their feelings on the foster care system. These postcards have been provided to us by Foster Care Alumni of America. Cards appear on the cover, below, and on pages 13, 15, and 25.

23 Orpheus in the Underworld: A View into Special Programs for Youth at the San Francisco Juvenile Justice Center Justin Morgan, MD, and Judith Sansone, RN, MS 25 A View from the Bench: A Judge Tells Her Story Donna Hitchens, JD

26 Common Health Concerns: Health Care for Youth in the Juvenile Justice System William Arroyo, MD 28 A Young Man’s Story: A Youth Worker Recounts the Story of a Memorable Young Man Breana Marino

30 Public Health Report: Legal Drug Pushers—Hooking Kids in the Haight Steve Heilig, MPH

www.sfms.org

January/February 2011 San Francisco Medicine 3

Membership Matters January/February 2011 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 84, Number 1 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

Editorial Board Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD

Erica Goode, MD, MPH

Toni Brayer, MD

Shieva Khayam-Bashi, MD

Linda Hawes Clever, MD

Arthur Lyons, MD

Peter J. Curran, MD

Stephen Walsh, MD

SFMS Officers President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Director of Administration Posi Lyon Director of Communications Amanda Denz, MA Director of Marketing and Membership Jonathan Kyle Board of Directors Term: Jan 2011-Dec 2013

Lily M. Tan, MD

Jennifer H. Do, MD

Shannon Udovic-

Benjamin C.K. Lau, MD

Constant, MD

Man-Kit Leung, MD

Joseph Woo, MD

Keith E. Loring, MD Terri-Diann Pickering, MD

Term: Jan 2009-Dec 2011

Marc D. Rothman, MD

Jeffrey Beane, MD

Rachel H.C. Shu, MD

Andrew F. Calman, MD Lawrence Cheung, MD

Term: Jan 2010-Dec 2012

Roger Eng, MD

Gary L. Chan, MD

Thomas H. Lee, MD

Donald C. Kitt, MD

Richard A. Podolin, MD

Cynthia A. Point, MD

Rodman S. Rogers, MD

Adam Rosenblatt, MD CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

Save the Date! Young Physician Mixer Coming Soon On May 19, 2011, we will host another Young Physicians Mixer. Watch for details to follow next month.

Upcoming CalHIPSO Webinar

February 10th, 2011, at 6:00 p.m.

Find out how to access federal stimulus funds to assist in the implementation of EHR and learn more about CalHIPSO services, eligibility for free services, and guidelines for achieving meaningful use.

This is a great opportunity for physicians in all stages of HIT adoption to learn more.

To RSVP, please contact Jonathan Kyle at (415) 561-0850, extension 240, or jkyle@ sfms.org.

Palliative Care/POLST Coalition Receives Funding

An ongoing effort to improve palliative and end-of-life care in the Bay Area has been awarded new support by the California Health Care Foundation. The new grant, to be administered by the San Francisco Medical Society, will support efforts to increase and improve use of the “Physician’s Orders for Life-Sustaining Treatment” (POLST) form—that bright pink one—which allows clinicians and patients to discuss and fully document patients’ wishes regarding decisions for treatments in life-threatening illnesses and toward the end of the patient’s life.

Our primary partner in the project is the Sutter Health Institute for Research and Education, headed by Jeff Newman MD, outgoing SFMS board member. All San Francisco hospitals are already part of the coalition, along with a growing number of long-term care facilities and other groups.

The joint grant is for two years at $20,000 per year and will support educational meetings, materials, and outreach, with research to document best approaches and results. There were many applications for these grants and we are grateful to the funders for their confidence. For

4 San Francisco Medicine January/February 2011

more information contact Steve Heilig at heilig@sfms.org or (415) 561-0850 extension 270.

CMS Launches EHR Incentive Program Enrollment Website

The Official Web Site for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs went live in January.

The Medicare and Medicaid EHR Incentive Programs will provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology.

Registration began January 3, 2011.

Participate early to get the maximum incentive payments. Visit: www.cms.gov/ EHRIncentivePrograms.

Medicare Releases New Fee Schedule for 2011

The Centers for Medicare & Medicaid Services recently released a revised 2011 physician fee schedule. The 2.2 percent update that took effect on June 1, 2010, was the starting point for the 2011 payment update. The Medicare and Medicaid Extenders Act of 2010, signed by President Obama in December, established a payment update for 2011 of 0 percent, which means that the 2.2 percent update from last June continues throughout 2011. This payment update replaces the 25 percent pay cut that otherwise would have been imposed due to the sustainable growth rate (SGR) formula.

Although the physician payment rates are not being cut, the final rule included a reweighting of practice expense Relative Value Units (RVU), malpractice RVUs, and work RVUs. Other modifications that affect payment are relative values for services that were identified as misvalued, updated data being used in the geographic practices cost indices, and multiple procedure payment reductions www.sfms.org

for therapy and imaging services.

In order to maintain budget neutrality, the numerical value of the conversion factor was set to $33.9764.

These changes may affect the payment physicians will see for 2011, and may result in increases or decreases to individual codes. Some specialties may see more of an impact, as reflected in the impact table from the 2011 final rule.

Physicians are encouraged to use the California Medical Association’s Financial Impact Worksheet (available in the member-only section of www. cmanet.org)to determine the impact the RVU and other factors will have on your practice. Medicare fee schedules for 2010 and 2011 are posted on Palmetto GBA’s website (www.palmettogba.com) and can be used for the calculations.

Additional information about these

changes is explained in a Centers for Medicare and Medicaid Services transmittal sent to contractors along with the updated files.

SFMS and CMA are pleased that Congress acted to stop the devastating 25-percent payment cut that physicians faced on January 1, and is exploring a long-term fix to the flawed SGR formula.

Contact Michele Kelly for more information, (213) 226-0338 or mkelly@ cmanet.org.

Save the Date: CMA’s Legislative Leadership Day is April 5

Physician advocacy is most effective when doctors meet directly with legislators to share the realities of working on the front lines of health care.

Don’t miss the opportunity to participate in the California Medical Associa-

tion’s 37th Annual Legislative Leadership Conference, which will be held on Tuesday, April 5, at the Sheraton Grand Hotel in Sacramento.

Participants will hear from, and talk with, influential members of the state Legislature and their key staff who are working to shape health care policy. Advocacy efforts are especially important this year, as CMA reaches out to a new governor and scores of new legislators. Look for more details in the coming weeks.

Contact Jonathan Kyle for more information, jkyle@sfms.org or (415) 561-0850 extension 240.

SFMS ADVOCACY UPDATE: Advocacy for Physicians, Patients, and Our Community On behalf of all SFMS physicians, the San Francisco Medical Society continues its commitment to the following agenda: • Preserving the health care safety net and public health programs in times of severe budget cuts. Fighting cuts in Medi-Cal and other programs.

• Developing and sponsoring the San Francisco Health Information Exchange to electronically link health records of institutions and physicians in San Francisco. With the Local Extension Center, assisting physicians in adopting electronic medical records and reaching meaningful use in order to receive federal funding.

• Working with Mayoral Task Force to develop and support the Healthy San Francisco program and participating in lawsuit to preserve the program.

• Providing physicians for medical consultation for the San Francisco Unified School District.

• Participating as a partner in the Hepatitis B Free program in San Francisco and educating physicians and patients on prevention and treatment.

Other Ongoing SFMS Community Health Activities ACCESS TO CARE: SFMS leaders have long advocated that every San Franciscan should have access to quality medical care, and our representatives served on the Mayoral Task Force that designed the Healthy San Francisco program.

ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership

www.sfms.org

roles in the banning of tobacco smoking in San Francisco restaurants; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more.

HIV PREVENTION AND TREATMENT: The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more.

SCHOOLS AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and worked on improving school nutritional standards.

ENVIRONMENTAL HEALTH: SFMS’s many environmental health efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures.

REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for women’s reproductive health and choice, including access to all medically indicated services.

PUBLICATIONS: The SFMS’ award-winning journal, San Francisco Medicine, has long been recognized as one of the very best local medical publications. We also send e-alerts and maintain a blog.

For more information, see www.sfms.org or call (415) 561-0850 extension 0.

January/February 2011 San Francisco Medicine 5

Independent But Not Alone.

James Yoss, M.D. Hill Physicians provider since 1994.

Uses Hill inSite and RelayHealth services for ePrescribing, eReferrals and secure online communications with patients.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.

Get more information about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

Executive Memo Mary Lou Licwinko, JD, MHSA

Medical Leadership Council

O

n behalf of the SFMS, I have participated in the Medical Leadership Council on Cultural Proficiency (MLC) since its inception nine years ago. During that period, the MLC has grown in size and stature and has focused attention on solutions to language and cultural barriers that often hinder access to and quality of health care for a large segment of our population. The MLC held its most recent meeting in Los Angeles on November 17, 2010. The MLC’s ultimate goals were to eliminate health disparities based on race and ethnicity and to develop a more diverse health care workforce, efforts that will continue.

For the past nine years, the California Endowment convened semiannual meetings of the elected presidents and staff leaders of the state’s medical specialty societies and county medical associations, joined by health plan and health system leaders and advocacy organizations. The Endowment also funded numerous pilot projects undertaken by these organizations.

Projects included developing materials and making in-person visits to assist solo and small medical practices in improving language access and cultural responsiveness; assisting statewide health systems to do the same; and designing Decision Medicine, a program to encourage a more diverse pool of prospective medical students (www.DiversityRx.org). The wide range of videos, tool kits, health care professions pipeline projects, and other work are profiled on the Council’s website, www.MedicalLeadership.org.

The website also is home to the Language Access Database, which can be searched by county to find interpreters, health education materials in languages other than English, and other resources.

Meeting Presentations

The California Academy of Family Physicians unveiled two fifteen-minute videos about ways medical assistants can help practices provide culturally responsive care. The videos are available free for viewing online at http://vimeo.com/15822032) or contact Marion Yee at myee@familydocs.org.

Medical Malpractice Claims and Language Barriers

Kelvin Quan, MD, lead author of a new report published by the National Health Law Program, and Linda Matson, vice president of claims for the Medical Insurance Exchange of California, described cases in which language barriers resulted in death or harm to patients and in subsequent malpractice claims. Dr. Quan’s report, The High Costs of Language Barriers in Medical Malpractice, presents a www.sfms.org

study he did with the University of California at Berkeley School of Public Health. They examined claims made to an insurance carrier that insures in four states, including California. The goal was to identify malpractice claims in which language barriers had an impact on patients’ health outcomes.

Among thirty-five language-barrier-associated claims made between 2005 and 2009 (comprising 2.5 percent of the carrier’s claims), Quan found that: “In thirty-two of the thirty-five cases, the health care providers did not use competent interpreters. In twelve cases, family members or friends were used as interpreters, including minor children in two cases.”

The carrier paid nearly $2.3 million in settlements and damages and nearly $2.8 million in legal fees for the thirty-five claims.

Dr. Quan and others believe the incidence of complications caused by language barriers is actually much higher than this study found but that many patients are afraid to file a claim.

Promises of Health Care Reform and HIT

Health policy consultant Ignatius Bau, JD, outlined ways in which federal health information technology funding initiatives and the Patient Protection and Affordable Care Act are designed in part to advance patient centeredness and equity among patients of all races and ethnicities. By increasing access, quality, and coordination of care while decreasing costs, the many changes expected in health care over the next several years can improve care for patients across America. For more information, see www.ignatiusbau.com and the California Endowment’s website, www.CalEndow.org.

Inspiration to Keep on Keeping On

Jeff Ring, PhD, director of behavioral sciences at White Memorial Medical Center and its Family Medicine Residency Program in Los Angeles, talked about personal and organizational commitments to continue the work the Council began nine years ago.

Reflecting on the physician pledge to “First do no harm,” Dr. Ring reminded the group of each person’s dedication to patients’ wellbeing and of each organization’s dedication to the business cases for improving care and eliminating disparities, and he pointed to future possibilities.

Reflecting on their improved understanding and increased commitment to change after these nine years of MLC work, group members left Los Angeles with inspiration and momentum to keep moving forward.

January/February 2011 San Francisco Medicine 7

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President’s Message George Fouras, MD

A Welcome Message

W

elcome to 2011’s first issue of San Francisco Medicine.

I’m honored to have been elected President of your medical society and hope that I earn the trust that you have bestowed upon me.

Our first issue is about youth in the foster care and probation systems. Data from the Department of Health and Human Services, Adoption and Foster Care Analysis and Reporting System (AFCARS), indicate that in FY 2002 there were 523,000 youth in foster care nationally. This has steadily decreased to 424,000 in FY 2009. In my opinion, a major factor has been the trend toward using community-based organizations to deal with family issues as opposed to bringing youth into care. The end result has been fewer youth in care, but a higher acuity for those youth receiving services.

When I tell people what I do for a living, their first response is often, “That must be so difficult.” In fact, it is not. While the stories of the individuals are often horrendous, and in some cases hard to fathom, I never cease to be amazed at the strength and resilience these kids display.

My interest in health care delivery to children first began in medical school, when it became apparent to me that participating in their mental and physical development would have the greatest positive impact on the future of our society. In residency, I developed an affinity for youth in foster care after having several such patients on my caseload. More recently, I have begun to work in the juvenile justice system, focusing on kids in foster care. Despite the crimes that these youth have been charged with and the psychosocial burdens they bear, it is surprising how they turn into average teenagers with typical problems once in a highly structured setting.

Both of these groups of kids face unique challenges. For youth in foster care, it is the struggle of coping with the loss of family, their disappointment in those whom they have trusted, the development of reaching normal milestones such as a sense of independence, and preparing for their futures. For youth on probation, it is facing the consequences of the crimes they have committed, surviving in an environment that is often hostile and dangerous, and also preparing for their futures. What unites them is their vulnerability to the whims of society and the lack of support that they receive. One could say that youth on probation have it even harder, as we tend as a society to be unforgiving of

www.sfms.org

those who commit crimes and often see them as unsalvageable.

The SFMS has been very busy working on your behalf over the past year. During the last several months of 2009, Drs. Peter Curran, Mickey Rokeach, and I testified before the City’s Health and Planning Commissions regarding the Campos ordinance. As written, this ordinance would establish a master health plan that would be administered by the Planning Commission. Despite our best efforts, the ordinance was approved by the Board of Supervisors. We do not yet know what its final version will be.

Our position, though, is clear: Any ordinance regarding a health master plan should be overseen by the Health Commission, not the Planning Commission. Nor should any projects currently in process be affected.

Our health information exchange project, SFHEX, has achieved a major milestone in the form of two substantial donations. Special thanks go to Arieh Rosenbaum and to our Executive Director Mary Lou Licwinko for all their hard work.

An effort to improve palliative and end-of-life care in the Bay Area has been awarded new support by the California Health Care Foundation. The new grant, to be administered by the SFMS, will support efforts to increase and improve use of the “Physician’s Orders for Life-Sustaining Treatment” (POLST) form—that bright pink one—which allows clinicians and patients to discuss and fully document patients’ wishes regarding decisions for treatments in life-threatening illnesses and toward the end of the patient’s life.

See the complete announcement on page 4.

The SFMS has also created a website task force to completely revamp our site. As the years pass, it has become clear that a website, be it social or professional, is often the first place that someone will go for information about an organization. You can expect to see a fresh face for the SFMS site in the second half of 2011.

The CMA anticipates a challenge to MICRA during the upcoming legislative session. MICRA saves physicians, hospitals, and other health care organizations millions in liability premiums.

We will work hard with the CMA to rise to the challenge posed by any new legislation. You can expect that we will be asking you to call and write your legislators, when the time comes, to address this issue.

Finally, my thanks to all of you members. Without your continued support over the decades, we could not have achieved all we have at the SFMS. January/February 2011 San Francisco Medicine 9

Health Care for Kids in the Foster and Juvenile Justice Systems

My Mental Health A Foster Care Alumni Perspective

Misty Stenslie, MSW

D

uring my childhood, I spent twelve years in foster care, with approximately thirty placements in Minnesota, North Dakota, South Dadkota, Idaho, Utah, Montana, Wyoming, and Nebraska. I experienced foster homes, group homes, shelter facilities, detention and correctional institutions, kinship care, and psychiatric/residential treatment. Through those unstable years, more than 100 people were responsible for me—yet none became my family. I emancipated with no permanent connections and very few resources.

My time in care resulted in a long list of diagnoses, including Posttraumatic Stress Disorder, Oppositional Defiant Disorder, depression, and a sleep disorder.

Because of the instability in my living situation, it seemed that the only option the professionals in my life were able to take for treating all of the diagnosed conditions was prescribing medication. Over the years I was on more medications than I can count—usually without my knowing what the meds were for, how I should expect to feel, what side effects to watch out for, or any plan for follow-up.

It was not until I was a senior in high school and in my last foster home that I even knew that I could question the medications or challenge the diagnoses. In that home, the foster parents dutifully gave me my handful of pills each night for the first week or two, and then they finally asked what they were for. I said I didn’t really know, other than that they were supposed to help me sleep. My foster father asked, “Why don’t you sleep well without them?”

I told him, “I get so anxious at night when I hear noises that I can’t get any rest.”

These foster parents did something

incredible. They skipped the medication one night, made cocoa, and sat around playing cards with me late into the evening. As we got into the deepest part of the night, we sat together and listened to all of the noises in the house. I could feel the familiar anxiety—but my foster dad patiently helped me figure out what all those noises were. This one was the dog getting a drink of water upstairs.

That one was the furnace turning on.

Hear that? That’s was the water softener regenerating.

My foster parents reassured me of my safety. They listened to my stories about how unsafe I had been in the home I came from. They acknowledged that I was actually very smart to be so vigilant and protective of myself that I didn’t fall into such deep sleep that I could be hurt at my home. They helped me make sense of my reaction—which on paper looked like a disorder, but in the reality of my life had been the very best thing I could do for myself. They helped me learn and believe that I didn’t have the same reality anymore. They encouraged me to let go of some of that vigilance.

Because of the insight and creativity of those foster parents, I was able to see my world in a brand-new way. I was able to ask that my medications be decreased and eventually discontinued, and my foster parents supported me in getting the kind of treatment that would make a sustainable difference in my life: learning new ways to cope, recognizing what was good and right in myself so that I could do more of it, identifying ways to keep myself safe without having to hide or fight. By the time I went off to college, I was no longer on any medications and I actually had the

10 San Francisco Medicine January/February 2011

skills and knowledge I needed to take the place of the medications.

My experience is not unique. We know from alumni stories that youth in care routinely receive diagnoses and medications in response to their disordered lives.

We know that sometimes the medication serves as a lifeline—it makes it possible for the young person to get through a particular crisis.

We know that children, youth, and alumni have psychiatric needs due to the trauma of abuse and neglect, which can be compounded by the additional trauma of being removed from their homes or living the instability of multiple foster care placements.

We also know that foster youth often come from families of origin that face significant mental health issues.

Whether as a result of crisis, trauma, a matter of genetic predisposition, or a collision of those factors, many youth in care do have valid mental health disorders that require treatment, including, sometimes, medication.

Research conducted by Casey Family Programs has shown that mental health outcomes for adult alumni of foster care are disproportionately poor compared to the general population. Among the findings: The rates of Posttraumatic Stress Disorder (PTSD) among foster care alumni are about twice as high as PTSD rates in war veterans and nearly five times the rates of the general public. Alumni experience panic disorder at rates of more than three times that of the general population. People in and from foster care have Continued on page 13 . . . www.sfms.org

Health Care for Kids in the Foster and Juvenile Justice Systems

San Francisco’s Child Welfare System An Overview

Debby Jeter, MFT

S

ince its founding, San Francisco has grappled with the best way to protect children who have been abandoned, abused, or neglected. Within a few years of the Gold Rush, the city had an informal system of religious orphanages and an asylum for foundlings, where the care was rough and impersonal. Eighty percent of infants died before their first birthdays. The foundling asylum was finally closed in 1902, and children began to be placed with foster families who could provide a home atmosphere and personal care. In just a few years, the infant mortality rate dropped below 1 percent.

The child welfare system continues to evolve and look for ways to provide both for children’s physical safety and for their emotional security and need for a sense of belonging. Today’s system emphasizes prevention and family preservation and, when foster care is necessary, it tries to place children with relatives, minimize their time in care, and secure a permanent home as early as possible.

Each year the San Francisco Human Services Agency (SF-HSA), the city’s social service department, investigates more than 5,000 reports of child maltreatment.

Seven percent of these reports come from medical staff. School personnel form the largest group of reporters, at 24 percent.

SF-HSA investigates by reviewing physical evidence, interviewing the reporter and other involved adults, visiting the family home, and, when appropriate, interviewing the child alone. About one in five reports is substantiated and found to reach the legal threshold for child abuse or neglect. The accompanying chart illustrates the frequency of different types of substantiated reports. The most common www.sfms.org

allegation is neglect of the child’s basic needs, often related to parental addiction or mental illness. “At-Risk Sibling” designates situations in which children are found to have suffered a pattern of abuse that is likely to have also affected their siblings.

Historically, SF-HSA only helped families when they had mistreated their children and a case was opened. Families who did not meet the legal threshold did not receive services, even if they were otherwise in crisis. Today SF-HSA uses standardized assessment tools to gauge children’s safety and risk and, even if a case is not opened, families that need help are linked to nonprofit agencies that provide outreach and family support.

When a case is opened, SF-HSA holds primary responsibility for the safety of children, but in recent years it has broadened involvement in the process of making decisions. It now uses a team decisionmaking model, convening the important adults in children’s lives to confer on key choices about whether or not to remove

a child from the family home, where the child should be placed, and whether or not to reunify. These meetings assemble the adults who know the family best, including teachers, physicians, therapists, relatives, and supportive figures invited by the parents. By broadening responsibility for the child’s well-being, SF-HSA mobilizes more support for the family, builds on strengths, and lessens authoritarian conflict. The process improves the family’s chances of rising to the crisis. Teams often make arrangements that keep children safely at home and prevent removal.

When parents cannot keep them safe, children are removed. Any decision to remove a child from his or her family requires a judicial review in which the family receives legal representation. While the child is in care, the parents may be mandated to complete substance abuse treatment, parent education classes, or therapy before their children can be considered safe at home. At regular intervals, case plans are reviewed in court. SF-HSA Continued on following page . . .

January/February 2011 San Francisco Medicine 11

SF Child Welfare System Continued from previous page . . . uses standardized risk assessments when recommending removal or reunification.

SF-HSA manages the care of more than 1,200 foster children. To minimize the trauma of removal, it first tries to place children with stable relatives. Fifty-one percent of San Francisco foster children are placed with kin, compared to a statewide rate of 32 percent. If no relative can be found, and no other familiar adult in the child’s life steps forward, SF-HSA next tries to find a foster family, either one recruited

by SF-HSA or by a nonprofit foster family agency. The last resort is group homes.

About 10 percent of San Francisco’s foster children live in group homes, and these are mostly adolescents whose behavioral challenges make it difficult to find them family homes.

One of the drawbacks of emphasizing placement with relatives is that SF-HSA has no control over where those relatives might live. San Francisco’s cost of living and the other factors that make it difficult for families to live here also make it challenging to find foster families. As a result, the majority of foster children live outside of San Francisco. To ensure that parents and children maintain their connection, the agency does, when necessary, provide transportation.

SF-HSA tries to minimize the time children spend in foster care. While supporting the parent’s efforts to reunify, the

San Francisco Foster Children by Placement Type as of August 4, 2010

Out of county Placement type

Foster Family Home & Foster Family 253 Agency Group Home

Guardian Home

With Relatives

Small Family Home Total

88

12 San Francisco Medicine January/February 2011

158

Total 411

0

47

66

135

361

271

632

704

543

1,247

2

Source: Child Welfare System / Case Management System

agency is also planning for where the child will live if the parent does not improve.

While the parent is trying to stabilize his or her life, the child continues to grow and develop, and languishing in foster care damages a child’s sense of security. Parents have a twelve-month period to meet case requirements, with the possibility of an extension to eighteen months if they show significant progress. After that time, however, SF-HSA proceeds with arrangements for children to have secure, permanent homes. This often means that the relative whom the child was placed with either adopts or assumes legal guardianship, which provides them the same legal rights as a parent.

In county

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San Francisco achieves permanency for its foster children sooner than most of the state. Its median time to reunify children with their birth parents is 5.3 months, far sooner than the state average of 8.2 months. The agency also outperforms most of the state on finding adoptive homes in a timely manner. The cumulative impact of SF-HSA’s reforms—emphasizing prevention and team decision-making, using standardized risk assessments, and finding permanent homes as early as possible—is that the city’s foster care caseload has dropped dramatically. SF-HSA forecasts that it will continue to decline.

Medical professionals are important partners in the child welfare process. Some aspects of the partnership are bureaucratic. SF-HSA asks physicians to complete health forms. Though a nuisance, these forms help SF-HSA ensure that all foster children are receiving attention for their medical needs. Some foster children may have moved and had multiple doctors, and the completed forms help SF-HSA track their care. Public health nurses review them for outstanding concerns. When considering prescribing a foster child a psychotropic medication, the medical professional needs to communicate with the child’s caretaker and social worker to obtain a court order. Each psychotropic medication must be included in the court order and, when approved by the judicial review process, it is prescribed for six www.sfms.org

months. All psychotropic medications must be reapproved by the court every six months. Long before it became state law to have a judicial review, SF-HSA sought professional consultation from the medical community, and today a child psychiatrist continues to review all requests for psychotropic medications and consult with the court.

More deeply, physicians are trusted figures in the lives of families, observing children’s growth and development over time and providing valuable insight and advice. They help parents and caretakers understand their children’s needs. They talk to them about discipline. Physicians may be the only ones to see signs of child abuse or neglect, including among children who are already in foster care. When discussing health issues with youth, physicians can ask about the home environment. A youth may disclose problems at home to a physician that he or she would be hesitant to discuss with anyone else.

Physicians can play an invaluable role in case planning. Even if they cannot attend a team decision-making meeting, physicians can let the social worker know their recommendations. SF-HSA would like to partner as closely as possible with medical professionals to guarantee children’s health, safety, and well-being.

A deputy director at SF-HSA, Debby Jeter manages the city’s child welfare program. She has worked in social services for thirty years, including twelve years as a caseworker, and she has an unusual blend of perspectives, having also worked in juvenile probation, CalWORKs, mental health, and drug and alcohol services. Jeter’s vision and leadership has enabled SF-HSA to participate in numerous statewide and nationwide reform initiatives, including standardized assessments, team decision making, management by client-based performance outcomes, and a wraparound service model that addresses a family’s multiple needs. Jeter received her master of sociology degree from Pepperdine University and holds a Marriage and Family Therapist Certificate. www.sfms.org

My Mental Health Continued from page 10 . . . particularly high rates of ADHD, chemical dependency, conduct disorder and depression, and other mood disorders.

There are no easy answers, but there are some recommendations we’d like to share, as a community of alumni: Consistency is the key to adequate and appropriate mental health care.

We need stable placements, we need a “medical home,” and we need professionals who know us and our circumstances—and who care about us enough to be effective advocates.

Medication should not be the first option considered and should never be the only mode of support we receive.

Pills cannot change the experiences we’ve faced or the life situations we’ve been put into. Medications should not be given as a substitute for what we really need: stability, love, power, hope, and someone who sees us and hears us.

We need access to well-trained and supported professionals who can provide culturally competent services.

The culture of foster care includes both challenges and victories that need to be recognized and supported by the people responsible for our care.

We need power to access to our records and information about our diagnoses and medications. We need the power to seek or refuse treatment based on an educated and supported knowledge about ourselves.

We n e e d t o k n ow t h e t r u t h about our lives and need to be the primary voice in planning and decision making.

Misty Stenslie, MSW, is the deputy director of Foster Care Alumni of America.

She has worked in the child welfare field since 1988. Her professional experience has included developing a peer youth worker program; providing clinical social work for young people in treatment foster care and their families; providing child protection services, advocacy, and community organizing around foster care issues; and training foster/adoptive/kinship caregivers and professionals. In addition to her years of professional experience with and on behalf of people in and from foster care, Stenslie also has a personal connection.

She spent many years in care as a child, in nearly thirty placements. As an adult, she went on to become a licensed foster parent and has maintained a lifelong commitment and love for the three teens she was so lucky to have parented. All three of Stenslie’s children are now adults and are her inspiration.

This article first appeared in Fostering Families Today.

January/February 2011 San Francisco Medicine 13

Health Care for Kids in the Foster and Juvenile Justice Systems

The Healing Team Bringing a “Lost” Foster Care Child Home

Mia and Sharon Behrens

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here are more than 500,000 children in foster care in the United States right now. These children often come into and leave the system with the residual symptoms and damage of physical and emotional trauma. At eighteen, some foster children “age out” of a system that clearly failed to provide any knowledgeable, comprehensive, and coordinated medical and psychiatric services that would have allowed for effective intervention.

There are many stories within the population of an estimated 12 million-plus foster care alumni in America that speak to a system that failed them. I am Mia. I am one of the fortunate foster children who did find a permanent family, “emotional wellness,” and effective medical intervention through the development of a “Healing Team.” I have a story of hope that I want to use to encourage others to continue the struggle toward wellness. If I can motivate one more family, supporter, or medical personnel member to get appropriate training and continue to hang in there with kids like me, I will feel my life will have counted.

I was placed into foster care as a one-year-old with horrible emotional and medical trauma. One of the first physicians to see me told my foster mother that he had never before seen a child in such poor emotional and physical condition. His advice to her was to do what was necessary but not to invest herself in my life too much because I was likely to end up extremely emotionally damaged and in need of lifetime care. The dire warning to my foster mother was that I could “bring no happiness” to her family. This, in his opinion, was a “gene pool issue.” No advice, support, referral, or coordinated services were offered. He was not a bad person, just

a man who felt overwhelmed and undertrained to deal with this strange, damaged child who was tearing up his exam room.

There was no hope in that room that day.

My now-adoptive family learned quickly, as the various diagnoses rolled in, that this was a journey that could not be taken alone. They knew that their foster home was initially a safe place to be and hoped that, with training and support, they could become a part of my healing process.

The search for knowledgeable experts began. My court-appointed therapist knew she was not an expert in treating this type of childhood trauma. While she consulted with the agency and helped my foster family with resources and referrals, she sought out a psychiatric expert well known in the field. A truly valuable team member has the ability to know when a consult or referral to another provider lies in the best interest of the child.

The development of the team started with my new psychiatrist. She became the team leader who helped coordinate my medical and educational services, collaborated with various providers, clarified issues, and taught my foster family intervention techniques. This team-leader approach kept me from falling through the cracks with agencies and other specialists.

My family and I came to understand that there was a knowledgeable person watching the plan. We were not left alone to work this out ourselves.

Some specialists were there briefly to provide a service, intervention, or encouraging support; others have walked the entire journey with me. Most of these people were a blessing and became what we call the “Healing Team.” The philosophy they shared was the belief that individuals

14 San Francisco Medicine January/February 2011

do have the ability to change, heal, and be resilient. During some hope-filled moments along the way, I reached out and let them help me find “wellness.”

There were many lessons learned along the way about effective treatment of childhood trauma victims: First, it can be a bumpy treatment road that plays out over time, but it is the commitment of the team to stay through all the struggles that helped me build trust in others. We learned to have patience with ourselves and the team. It is important to not regret past failed interventions. They are part of a process, not a failure. We had to eliminate many techniques or treatments and revisit them at a later date, and be open to new concepts. Traumatized children are asked to be resilient, flexible, open to new ideas, and to hang in there for the long haul. Then why don’t service providers ask that of themselves?

We learned to use my medical issues and treatment as an attachment exercise.

In my biological home, I was powerless and my terror and pain went unnoticed.

With my medical team, I learned how to say, “Stop it, I don’t like it this way.” And they listened. I was taught ways to negotiate options and express my fears. I was no longer a silent victim. With these medical team members, I did learn to cooperate, but something more important happened.

I found the words to say, “I have the right to be heard; I have the right to have influence over my life and care.” It was life-changing.

Learning to let go of my fear and allowing myself to trust others to help me played a big part in my journey toward a place of healing.

In order to treat me you have to recognize me as a whole person with both www.sfms.org

emotional and medical needs. At age five, one doctor didn’t think I needed a referral for rapid heart rate because he felt it was an emotional issue. After a change of doctors, I got the proper diagnoses. I had atypical atrioventricular node reentry. I had two heart ablations. It made me feel good to know it wasn’t in my head. It wasn’t my fault. Just because you have emotional problems doesn’t mean you can’t have health issues as well.

The best team doctors I have known were empathetic and funny. When I was five, I had an emotional breakthrough at my neurologist’s office. To stop my usual constant screaming and fight-or-flight mode, he began drawing a funny picture of himself. I suddenly laughed, startling all of us. He thanked me and said my laughter was the best thing that had happened to him all day. I liked him for saying that. From then on he called me his “little friend.” I learned to trust him. Over the years we had quite a few laughs. It is the gift he gave me. Doctors like this changed the tone of the exam and were better able to treat me.

There are the small comments from

www.sfms.org

doctors that made all the difference in my feelings of self-worth. One doctor who kept trying new treatments said, when they kept failing, “Mia, you know that none of this is your fault? You didn’t cause this. I will just have to work smarter for you.” I am not a problem or a mistake. One of my favorites was the gastric doctor who said, “I am like a mechanic that works on Fords and Chevys. I don’t do Ferraris. Mia, you are a Ferrari. I am sending you to a Ferrari doctor.” It was funny and true. A good dose of humor with the truth helps.

Today, as a twenty-one-year-old college student with plans to teach disabled kids, I understand that the team headed by our team leader saved my life. The empathetic interaction with me, and the open collaboration and knowledgeable and coordinated services among all of my specialists, made it possible for me to receive the best care. They gave of themselves. None of these doctors had magic dust that took away all my issues.

They had something better. They helped me learn how to trust, and they gave me the power to push through difficult things

and come up with solutions. I learned that I was not alone. I was a part of a “Healing Team.”

Sharon Behrens, child advocate and foster and adoptive parent, discovered the miraculous ability of children to heal through her own experience in raising Mia. Mia’s journey from wild child to a caring, productive woman has been documented in literary accounts and her Emmy-nominated story aired on February 17-18, 2009, on CBS Evening News with Katie Couric.

Mia and her mother now speak on the intervention needs of abused children, as a way of helping health professionals understand what can happen if physicians, psychiatrists, and parents work together to build a “Healing Team.” They have spoken at the American Academy of Child and Adolescent Psychiatry (2010) and the American Academy of Pediatrics (2009) conferences.

Today Mia is a twenty-one-year-old college student majoring in child development who plans to teach children with disabilities.

January/February 2011 San Francisco Medicine 15

Health Care for Kids in the Foster and Juvenile Justice Systems

Task Force on Foster Care Getting Kids the Care They Need

Sarah Springer, MD

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small boy is brought to the emergency room with a fever.

Clearly terribly ill, he is admitted to the pediatric intensive care unit, where he dies two days later of a brain abscess, a complication of tooth decay. The boy was in foster care, and his new foster parents did not know that he had never seen a dentist.

They did not have a health insurance card for him yet and so had delayed taking him to a doctor. A teenage girl arrives at her fifteenth foster home with a bag full of pills.

Asked by her foster parents what they are for, she replies, “I don’t know, they just tell me I have to take them.” With coordinated help from her child psychiatrist and foster parents, she is able to be weaned from all of the medications within a year. Her sleep improves, her grades soar, and she is adopted by her foster parents.

These are but two of many true stories of how health needs impact children and youth in foster care. In 2007, the leadership of the American Academy of Pediatrics (AAP) voted the health needs of children and youth in foster care to be among its top-ten most pressing issues, and it established a task force to help address those needs. Recognizing that children and youth in foster care have a host of unmet physical, mental, dental, and developmental health needs, the Task Force on Foster Care (TFOFC) includes not only pediatricians but also partners from the American Academy of Child and Adolescent Psychiatry, the National Foster Parents’ Association, Foster Care Alumni of America, the Child Welfare League of America, the National Medical Association, and the National Council of Juvenile and Family Court Justices. The mission of the TFOFC has been to increase the capacity of pediatricians and other

health care providers to meet the health needs of children and youth in foster care, to improve systems of care at the community and state levels, and to advocate at state and federal levels for policies that will improve the health and well-being of children and youth in foster care.

The TFOFC has worked to raise the awareness, knowledge, and skills of pediatricians, other health professionals, and multidisciplinary partners. Toward that end, we have developed a number of tools, strategies, and resources to help physicians to understand how the experience of foster care affects a child’s health, and to help other professionals understand the health issues that affect a child’s overall well-being and likelihood of achieving permanency. The TFOFC launched a new website, Healthy Foster Care America (www.aap.org/ fostercare), to share these tools. The website is designed for a multidisciplinary audience, including youth and families, and contains tools, strategies, and other resources for addressing the health and well-being of children and youth in foster care.

In October 2008, federal legislation called the Fostering Connections to Success and Increasing Adoptions Act was signed into law. Among many other important provisions, the law mandates that states develop a plan for oversight of the health of children and youth in foster care. The health provision piece of the law was authored by the TFOFC, and it requires states to include child health professionals on the teams that develop and oversee these plans. Toward this goal, the TFOFC supported five AAP chapters in pilot projects to connect with state colleagues to facilitate the development of these plans. The TFOFC is also recruiting AAP member contacts from each

16 San Francisco Medicine January/February 2011

chapter who will serve as liaisons between their respective chapters and the national AAP. The champions will raise awareness about the needs of children and youth in foster care, as well as the resources available from the AAP for addressing those needs. In addition, the chapter foster care contacts will take the lessons learned from the pilot projects and connect with state-level colleagues to help implement state plans to oversee the health care of youth in foster care in their respective states.

In October of 2009, the TFOFC hosted the half-day preconference to the AAP’s annual national meeting, which was attended by more than 400 pediatricians. The conference highlighted the diverse health needs of children and youth in foster care, as well as strategies to help meet those needs.

There were also presentations by alumni of the foster care system, putting a human face on the issues. We are continuing to work to integrate meeting these needs into every aspect of the AAP’s work. Continuingeducation programs now regularly include case scenarios of children and youth in foster care. We have worked with the American Board of Pediatrics to have foster care health issues included on the pediatric certification and recertification exams. In 2011, the tenure of the TFOFC will end, but the work on behalf of children and youth in foster care will continue throughout all areas of AAP work.

Sarah Springer, MD, a general pediatrician, is medical director of the International Adoption Health Services of Western Pennsylvania. Dr. Springer, an adoptive parent herself, is co-chair of the Task Force on Foster Care for the American Academy of Pediatrics and a regular speaker on adoption-related health concerns. www.sfms.org

Health Care for Kids in the Foster and Juvenile Justice Systems

The CASA Program San Francisco Court Appointed Special Advocate Program Profile

Maya Durrett

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here are 423,773 children in foster care in the United States (Adoption and Foster Care Analysis and Reporting System, or AFCARS), with 59,509 of these children living in the State of California (Center for Social Services Research, University of California at Berkeley). In San Francisco, there are approximately 1,300 children in the dependency court system: One child out of ten in San Francisco is a foster child.

These children are made dependents of the court due to abuse or neglect from their parent(s) and through no fault of their own.

Once placed in the foster care system, children often experience multiple challenges, including removal from their families, separation from siblings, relocation from familiar neighborhoods (more than half of San Francisco foster children are placed out of county), medical and mental health issues, frequent placement and school changes, and inconsistency in service providers and other professionals involved in their case.

The San Francisco Court Appointed Special Advocate Program receives clients only through referral by a juvenile court judge, a Human Services Agency (HSA) child welfare worker, or an attorney involved in dependency court proceedings.

Within a vulnerable population, these are children deemed by the court and by court professionals to be most urgently in need of special assistance. SFCASA’s client children, as a group, tend to be learning disabled, to suffer emotional disturbances because of impermanency and exposure to violence, and to have chronic and often untreated health problems. www.sfms.org

What Is a CASA? CASA stands for Court Appointed Special Advocate. The San Francisco CASA Program is a volunteer-based 501(c)(3) nonprofit agency that recruits, screens, trains, and supervises community volunteers to serve as advocates and mentors for abused and neglected children under the jurisdiction of San Francisco’s juvenile dependency court. SFCASA serves dependent children from birth to eighteen years of age.

The History of CASA

The first CASA program began in Seattle in 1976. Concerned by the scarcity of information available about the abused and neglected children for whom he was making decisions of major importance, Judge David Soukup searched for a way to ensure that a child’s best interests would be consistently represented to the court. He found that few court-appointed attorneys had the time to get to know the children in his courtroom well enough to supply the information the court wanted.

Judge Soukup decided to use trained community volunteer advocates willing to make a long-term commitment to an individual child. This Seattle program was so successful that judges across the country began using citizen advocates to address the urgent needs of courtdependent children. Today more than 1,000 CASA programs exist in the United States. The San Francisco CASA program has been in operation since 1991.

CASA Volunteer Selection and Training Individuals interested in becoming SFCASA volunteers are interviewed by the

SFCASA staff and their backgrounds are checked through the California Department of Justice, the FBI, the Child Abuse Central Index, and the California Department of Motor Vehicles. Applicants also provide professional references. They receive thirty-seven hours of training on topics relevant to court-dependent children’s needs, including child development, cultural awareness, educational advocacy, dependency law, substance abuse, and domestic violence. At the end of their training, CASAs are sworn in as officers of the San Francisco Superior Court.

When matched to a case, a volunteer is supervised by a professional case supervisor. The case supervisor maintains regular contact with the volunteer and works with him or her to determine case plans, problem-solve, and ensure that the volunteer is adhering to CASA rules and policies. Active volunteers are required to complete twelve hours of continuing education annually.

What Does a CASA Do?

• Commits to spend a minimum of eighteen months on the case of one child (or in some cases, a sibling group), whom they visit on a regular (usually weekly) basis • Supports the child throughout the court proceedings • Establishes a relationship with the child and gains an understanding of that child’s needs • Reviews all available records regarding the child’s family history, school behavior, medical or mental health history, and placement history • Advocates for resources that will Continued on following page . . .

January/February 2011 San Francisco Medicine 17

CASA Continued from previous page . . . help family preservation, family reunification, or permanency planning • Communicates his or her observations and concerns to the court in written reports and recommendations at each hearing • Ensures that the court-approved plans for the child are being implemented • Collaborates with the child’s social

worker, attorney, and other professionals involved in the child’s case • Maintains confidentiality, except when a child’s safety is at risk, and adheres to California’s mandated reporting laws • Works with the child’s school to ensure that the child’s educational needs are being met (the CASA is eligible to serve as the responsible adult in an IEP proceeding)

Number of Children Served by SFCASA

very seriously.

I also became her responsible adult for education, holding legal rights for her education, when she entered ninth grade. During her first semester of high school she was disengaged and emotionally stressed, and she became truant, leaving campus every day for hours and wandering the city. During that time, she went AWOL from her group home for more than seven days; to this day, no one knows exactly where she was during that time. Any academic concerns we had were pushed aside: Our only priority was keeping her safe.

I faced many challenges in advocating for my child’s educational right for an appropriate IEP (Individualized Education Plan) and to specialized services. She eventually qualified for special education under the category of Emotional Disturbance, which brought access to resources but also the stigma attached to the label.

Throughout the entire process, I have often contrasted my CASA child’s experience with my own high school experience.

I had “real” teenage concerns, including coping with my mother’s cancer and moving across the country in between my sophomore and junior years; but mostly I worried about getting good grades, making varsity on the cheerleading squad, and wondering if any boy I liked would ever like me back. For my child, caring about grades and college readiness has often been sidelined by thinking about where she will live next and why her family hasn’t come for her.

I am immensely proud of my child for sticking with her education, when

there were many times she could have given up—many young people faced with similar circumstances do. She has dealt with challenges in her life that most of us cannot fathom. She lives with uncertainty at almost every turn.

I don’t want to sugarcoat reality or to suggest that graduating from high school is the golden ticket that will ensure a successful transition to adulthood. It is a huge accomplishment, but her challenges will only intensify as she emancipates from foster care.

Her current foster placement will end on her eighteenth birthday. She craves freedom and independence, which is understandable both as natural teenage stuff and as a rebellion against the “system.” But she lacks many of the basic life skills needed for successful, independent adulthood, so there are greater risks for her to leap out on her own. Her cushion to fall back on doesn’t exist the way it did for me, or for many of us. Her imagination of what her life can be remains limited, even as those of us in her life have tried—and will continue to try—to expand her sense of what is possible by informing her of the services available to youth transitioning from the foster care system.

My formal role as her CASA will also end upon her emancipation from foster care, but I will continue to support her to the best of my ability. I believe that every child deserves at least one person in her life who commits to love her and to be there, simply be there, unconditionally. I am proud to be that person for my CASA child, and that won’t simply end on her eighteenth birthday.

Last year San Francisco CASA served 300 children. There are an additional 120 children on the waiting list for CASA volunteers.

Maya Durrett, EdM, is the San Francisco CASA program director. She was sworn in as a CASA volunteer in 1998 and has been a CASA volunteer to seven children.

CASA Volunteer Snapshot Liz Vogel has been a CASA volunteer assigned to advocate for the same child for the last nine years. Liz works fulltime at a local nonprofit and spends many hours on nights and weekends working for and with her assigned child. She has dedicated more than 2,300 hours to her CASA child’s case.

I have been serving as a volunteer for the San Francisco Court Appointed Special Advocate program (SFCASA) since 2001. As a CASA, I work one-on-one with a child in foster care. I get to know her caretakers, physicians, teachers, therapists, lawyers, family members, social workers—everyone in my assigned child’s life. We spend time together each week, doing fun activities as well as working on life skills and other needs. An important part of my role as a volunteer is to ensure that the court acts in the best interest of the foster child that I am working with.

There are 1,300 foster children in the city of San Francisco alone. I serve as the voice for one of them. I’ve been working with the same child since I was first sworn in by the court in 2001. She was nine years old when we met; she will turn eighteen soon. She is a sweet-natured, beautiful girl whose resilience never ceases to amaze me. She will earn her high school diploma this year.

Graduating from high school was not inevitable for my child. She has lived in fifteen foster care and group home placements since entering the dependency system at age five. Until high school, she changed schools at least once per year as a result of her placement changes. As her CASA, I quickly became the single consistent adult in her life, a role I take

18 San Francisco Medicine January/February 2011

www.sfms.org

Health Care for Kids in the Foster and Juvenile Justice Systems

Health Care for Kids in Foster Care An Overview

Linda Medeiros, RN, PHN, BS HED

T

he American Academy of Pediatrics (AAP) and the Child Welfare League of America (CWLA) have long recognized that the health of the individual child is the product of myriad social, environmental, and genetic factors, and that adverse conditions in any of these areas undermine the wellness of the child. Children and adolescents in foster care are a singularly disadvantaged and vulnerable population known to be at high risk for chronic physical, emotional, and developmental conditions because of multiple and cumulative adverse events in their lives. Children and adolescents in foster care have a higher prevalence of physical, developmental, dental, and behavioral health conditions than any other group of children and adolescents. Typically, these health conditions are chronic, underidentified, and undertreated and have an ongoing effect on all aspects of their lives.

Prior to foster care, the vast majority of these children lived with families devastated by substance abuse, mental health disorders, poor education, unemployment, violence, lack of parenting skills, and involvement with the criminal justice system.

High rates of premature birth, prenatal drug and alcohol exposure, and postnatal abuse and neglect contribute to the extremely poor health status of children and adolescents entering foster care. In addition, health care prior to foster care placement often is inadequate, meaning that children and adolescents entering foster care have multiple unmet health care needs, far exceeding the needs of even those children who live in poverty. Once children and adolescents are placed in foster care, health care often can be sporadic, crisis-oriented, and complicated by long waiting times for publicly funded health and mental health www.sfms.org

services. The high mobility of the foster care population among placements, ongoing issues of separation and loss, and the complexities of the foster care and public health care systems can exacerbate these problems.

It is estimated that there are more than 500,000 children in foster care annually in the United States, and recent studies estimate that there are approximately 60,000 children under age eighteen in foster care in California. Different communities have different resources and models of delivery of health care services but, in general, there is no systematic approach to the health care needs of this highly mobile, medically highrisk, complex population. Some states make all children entering foster care eligible for Medicaid (Medi-Cal in California), but there is no cohesive system of health care for this population and no mechanism to identify, recruit, and train health care professionals in foster health care. Attempts to ameliorate this situation are well-intentioned but often piecemeal. For example, most children who are removed from a parent’s custody are automatically eligible for Medi-Cal, and this process is initiated by the foster care social worker. However, some children living away from home must apply separately for Medi-Cal through Cal Works, a process that can be confusing for relatives providing kinship care.

In addition, placement moves for children in foster care are complicated by the fact that care managed by Medi-Cal is typically organized to serve children and families who stay in one place and see one provider. Frequent placement changes make it difficult for children to access health care when they are placed outside their county of origin. Consider this recent case

of a fourteen-year-old boy with type I diabetes who fell and fractured his humerus.

Care for his chronic insulin-dependent diabetes was assigned to California Children’s Services for case management and authorization. CCS services are provided by the county of residence, based upon the address maintained in the Medi-Cal file.

Diabetic health care was authorized by CCS of his county of residence for specialty care at the children’s hospital in the adjoining county. Diabetic training for the new foster caregivers had to be arranged and authorized at the specialty endocrine center by the CCS case manager. But when he fell and broke his arm, acute care was provided by a local orthopedist and authorized by his county managed care system. A placement change occurred postoperatively. However, with a placement change to a new county, managed care Medi-Cal would not cover acute orthopedic care in the prior county of residence, impeding continuity of care and adding a significant delay to follow-up care. Enrollment in a new county Medi-Cal system required transfer of the orthopedic care to a new, local orthopedist, but waiting times for an appointment would have caused a significant delay in care. AB 1512, which began January 1, 2009, requires foster care children who have moved to a new county of residence to be disenrolled from the County Organized Health System in the previous county of residence within two working days of a request for disenrollment by the county child welfare services agency (and reenrolled in the new county of residence). Thus, while AB 1512 was authorized to address the lag between placement changes and county Medi-Cal assignment, it does not address the complications of Continued on following page . . .

January/February 2011 San Francisco Medicine 19

Health Care for Children in Foster Care Continued from previous page . . . fragmenting chronic and acute health care, which can also lead to interrupted care and poor outcomes.

Another complication of health care for foster children is the lack of tracking or monitoring of the health care that does exist. The past expectation was that caseworkers or foster parents would plan and coordinate the child’s health, mental health, and developmental services, but there was limited integration of health care and permanency planning agendas. However, many child welfare agencies and local health departments recognized that public health nurses (PHNs) are positioned to develop and implement the recommendations for improving the health care of children in foster care long outlined by the AAP and CWLA. In response to this need, the California Budget Act of 1999 appropriated state general funds to the California Department of Social Services (CDSS) for the purpose of increasing the use of PHNs in meeting the health care needs of children in foster care. Assembly Bill 1111 established the Health Care Program for Children in Foster Care (HCPCFC), effective January 1, 2000.

It was initiated as a voluntary program, implemented in most counties throughout California. In 2010 it became a mandatory program after the state recognized the need for greater oversight of the complex and multiple health care needs of the foster care population. HCPCFC is a public health nursing program ideally located in county child welfare service agencies and probation departments to provide PHN expertise in meeting the medical, dental, mental, and developmental needs of children and youth in foster care. Health care coordination services must be provided to every child in out-of-home foster care placement via assignment to a HCPCFC public health nurse.

The CHDP (Child Health and Disability Prevention) program, under the direction of the Children’s Medical Services Branch of the California Health and Human Services Agency, works with community programs and agencies to identify the major obstacles children in foster care face in gaining access to coordinated, multidimensional services.

The CHDP program is administratively re-

sponsible for the HCPCFC program, which uses a multidisciplinary team approach to meet the complex needs of children in foster care. PHNs are hired and supervised by the local health department but are mostly located at county child welfare offices (in smaller counties, the PHN may be located in the local Public Health Department and not have as close a working relationship with Child Welfare.) PHNs in the HCPCFC program work closely with the child’s caseworker or probation officer and medical home to ensure health care oversight for the physical, behavioral, dental, and developmental needs of children in foster care, including those in out-of-county and out-of-state placements. They provide consultation and assistance in the collection and interpretation of health care information; in development of health resources; and in planning and providing training programs for health, child welfare, probation, and juvenile court staff. These program funds enhance and expand each county’s capacity to provide comprehensive services to children in foster care, but PHNs are not funded through this program to provide direct services to children.

Through the HCPCFC program, PHNs, under the guidance of a supervising public health nurse (SPHN), provide the following services in consultation and collaboration with social workers and probation officers: medical and health care case planning; help for foster caregivers in obtaining timely comprehensive health assessments and dental examinations; expedition of referrals for medical, dental, mental health, and developmental services; coordination of multispecialty care for physically handicapped children in conjunction with case managers at California Children’s Services; coordination of referrals to Regional Centers for children with significant developmental delays; coordination of health services for children in out-of-county and out-of-state placements; provision of medical education, through the interpretation of medical reports and training for foster team members, covering the special health care needs of children and youth in foster care; participation in the creation and updating of the Health and Education Passport for every child, as required by law.

20 San Francisco Medicine January/February 2011 21 San Francisco Medicine

Because the framework for physical, psychological, and dental health is developed in the earliest years of life, early investments in preventive health and mental health care can greatly improve long-term health outcomes. It has been extensively documented that children in foster care have a high prevalence of untreated acute and chronic illnesses, developmental delays, and poor nutritional status, as well as problems with vision, hearing, and dentition.

Despite overwhelming documentation of health deficits, children in foster care continue to experience serious gaps between needs and services. Access to health care is impeded by multiple obstacles, including complex health care coverage, low reimbursement rates for providers, delays in service provision, and poor transfer of medical records. Placement changes can result in a process of enrollment/disenrollment in managed care plans and discontinuity in medical care, as well as changes in school enrollments and interrupted educational goals. For primary care clinicians, the enormity of the health and developmental problems that a typical child in foster care presents can be daunting. While management of the complex health and developmental needs of these children is challenging, PHNs are available to assist providers to serve these vulnerable children. Priorities for clinical practice include well-child care coordination and specialty referrals, referral for early and ongoing dental health and maintenance of up-to-date health records, communication regarding health care issues with appropriate child welfare workers, and health-targeted advocacy.

CHDP/Foster Care Unit Practices in San Francisco County

The CHDP/Foster Care unit in San Francisco consists of a nurse manager, a medical consultant, eight PHNs, and four supporting clerks. The staffing is based on the state nonfunded recommendation of one PHN to two hundred cases (in some other counties the ratio is much higher).

The clerks are necessary to assist the PHNs in sending letters to parents and entering basic health information into the computer.

The unit is located in the Family and Children’s Services Division (formerly known as www.sfms.org

CPS) of the Human Services Agency (HSA) in the CHDP/Foster Care Program. They are based in the various units in direct contact with the social workers they support to make care coordination and communication more effective. The PHNs have direct access to the state computer system, the Child Welfare System/Case Management System (CWS/CMS), by which the PHNs and PSWs can read each other’s documentation and keep informed about each child’s condition and progress. Health information is entered into a section of CWS/CMS known as the Health Passport by PHNs and their clerks only, for the purpose of maintaining thorough and accurate records. This Health Passport becomes the child’s permanent record, transfers with the child if any change in placement occurs, and is given to the child upon emancipation. The health information entered into the Health Passport includes well-child exams (PM160 forms), county PM 160 equivalent exams (1132 forms), and records of office visits, hospital records, specialty appointments, sick visits, prescriptions, and psychotropic medication prescriptions that require court orders.

Court orders are also required for dental work performed under anesthesia and surgery. It is important to note that foster parents do not have the legal authority to sign for the above-listed conditions requiring court orders. The PSW obtains the court orders. It is also important for medical and dental providers to send requested medical records to the PHN to enter into the Health Passport. Since the PHNs have taken over entry of health information into the Health Passport as of 2006, many more children are up to date on their Health Passports and receive them on the occasions previously mentioned. The PHNs are also practicing QA and tracking the psychotropic medication renewals with reminders to PSWs, resulting in an improved rate of renewals and accuracy of documentation as to who is taking these meds.

The San Francisco CHDP/FC Program, with support from Family and Children’s Services, uses the periodicity for foster children for well-child exams as recommended by the Child Welfare League and American Academy of Pediatrics, a stricter schedule than the CHDP periodicity, which www.sfms.org

is currently being used in most California counties. Per Mary O’Reilley, state CHDP consultant, it has always been the legal intention to do this, but the law only requires adherence to the CHDP schedule. The foster care periodicity schedule has well-child exams being done at intervals varying from one to six months from ages birth to twentyfour months, the same as CHDP periodicity.

From age one to eighteen years, the foster care periodicity schedule changes to once yearly. The CHDP schedule at ages two to three has well-child exams yearly, at ages four to five and every two years, at ages six to eight every three years, and at ages nine to eighteen every four years. The dental periodicity recommendation for CHDP starts yearly at age one but is mandated yearly at age three. Clearly, with the increased health needs of abused and neglected children, the Foster Care Periodicity Schedule is far more preferable and needed.

San Francisco Family and Children’s Services has applied for home visiting funding from the federal government to allow home visiting by PHNs. This would enable a PHN to obtain medical records from the foster parent, ensure that future appointments are scheduled, and assess the health of a child firsthand rather than in a secondhand report over the phone. These children have complex needs that require careful monitoring to avoid their “falling through the cracks.”

San Francisco CHDP/Foster Care Unit Recommendations to Improve Child Health Care

Foster care periodicity for well-child and dental exams should be adopted by all counties.

The State should fund its recommendation of one PHN per a caseload of 200 children.

Counties should apply for funds for home visits by PHNs. The State should fund PHNs to provide services to foster children who are in-home as well as those in out-of-home placements.

In regard to the fourth recommendation above, HCPCFC funding only covers children in out-of-home-placements. The trend in foster care is to keep children at home as much as possible due to research

findings that the outcomes for children removed from their homes are not as good as for those left in their homes with family support from the agency. Unfortunately, the health needs of these children do not diminish because they remain at home, and there is no oversight by PHNs for their health care needs. Increased funding from the State at a time of fiscal crisis is probably not feasible, yet it is important and needed, as soon as possible.

Linda Medeiros, RN, PHN, BS HED, is a school nurse who graduated from nursing school in 1977 and then worked in a variety of hospital settings. Since 1985 she has also worked in public health on a variety of campaigns, including a CDC Hepatitis B Pilot Immunization Project in both southeast Alaska and American Samoa. She began her current position as foster care nurse manager for San Francisco in 2006. She is the current chair of the Bay Area Deputy Directors’ Foster Care PHN Sub-committee and a member of the State Executive Foster Care PHN Sub-committee. Medeiros lives happily in Marin County.

Portions of this article were excerpted from the AAP’s Fostering Health: Health Care for Children and Adolescents in Foster Care, second edition, 2005.

Resources • Foster care public health nurses for San Francisco County can be reached by contacting the child’s protective services worker or calling the Nurse of the Day line at (415) 558-2656. Any correspondence can be mailed to CHDP/FC Unit J390, PO BOX 7988, San Francisco, CA 94120-7988.

• American Academy of Pediatrics: www. aap.org.

• Child Welfare League of America: www. cwla.org/programs/fostercare/default.htm • Consent to Medical Treatment for Foster Children: California Law, A Guide for Health Care Providers, www.teenhealthlaw.org/ fileadmin/teenhealth/teenhealthrights/ca/ CA_Foster_Care_Consent_Manual_4-09.pdf • California Foster Care Legislation, www. newwaystowork.org/publications/ fosteryouth/CAFosterCareLegislation.pdf • The Health Care Rights of Children in Foster Care, http://healthconsumer.org/ cs043FosterCareRights.pdf

January/February 2011 San Francisco Medicine 21

Health Care for Kids in the Foster and Juvenile Justice Systems

There’s a SPY in Our House Special Programs for Youth in the San Francisco Juvenile Probation Department

William Sifferman

T

he San Francisco Juvenile Probation Department is the only separate, stand-alone juvenile probation department in the State of California that is solely established to provide services exclusively to juveniles who are arrested and charged with legal violations. All other counties in California have only one probation department, addressing the needs of both adults and juveniles. The San Francisco model was intentionally created to preserve the rehabilitative underpinnings of the Juvenile Court parens patriae (in place of parents) philosophy, and to preserve the dedicated funding streams needed to support the comprehensive programming required to abate the development of delinquency into criminality. As such, while the scope of our responsibilities is focused only upon juveniles identified as delinquents, our work is framed within the context of their entire social milieu, including their families, peers, and educational and social networks.

Our responsibilities are bifurcated, carrying mandated duties associated with responsive law enforcement as well as the delivery of individually constructed rehabilitative social services. Both tracks are designed to serve the interests of public safety in the short and the long term.

Our commitment to ensure public safety in the short term is reflected in our joint interdiction efforts with the police, district attorney, and courts by providing for the safe and secure temporary detention of youth posing an urgent and immediate threat to public safety or themselves. The S.F. Juvenile Probation Department operates a secure, 150-bed Juvenile Justice Center (Juvenile Hall) and

the staff-secure, 24-bed Log Cabin Ranch School in La Honda.

Our commitment to ensure the public’s safety in the long term is reflected in our personal intervention efforts with youth and through the partnerships we have established with community-based agencies that directly engage the youth in positive, pro-social activities that produce productive lifestyles, supporting safer communities in the future. Probation officers develop comprehensive supervision plans for youth released to their homes under the Court’s supervision, including a variety of community support services addressing their substance abuse, mental health, and educational needs.

Our overall mission is to hold youth accountable for their antisocial behavior while at the same time providing them with opportunities and assistance in developing new skills and competencies to perform as responsible community members, active contributors in improving the overall quality of life for all residents of San Francisco.

Noble mission? Yes—and impossible to accomplish without help.

Annually, more than 3,000 youth (with families) make their way to the doors of the Juvenile Probation Department. Less than half walk through the front door with a parent or guardian for their first appearance before a probation officer or a judge. More than 50 percent of our youth enter the juvenile justice system in handcuffs, accompanied by a police officer, through our “back door,” the Juvenile Justice Center (JJC), formerly known as YGC (Youth Guidance Center or “You Got Caught”).

Youth presented for detention by po-

22 San Francisco Medicine January/February 2011

lice are typically charged with felony-level law violations including robbery, burglary, assault, delivery of controlled substances, and weapons charges. Minors charged with lesser offenses who do not have a parent or guardian available or willing to accept immediate custody of them are also admitted for their own safety and protection, until we have secured their safe release to a responsible adult and their promise to appear in Court.

The detained youth are assigned to one of six living units in the JJC, each housing up to twenty residents. Unit assignments are based on a variety of factors, including age, size, gender, criminal offense, history of delinquency, and criminal culpability or sophistication.

The culture, or “vibe,” of the institution is intrinsically connected to the efficacy of each resident’s initial classification and ultimate unit/room assignment. Efforts to segregate crime partners from each other, first offenders from “frequent flyers,” and previous victims from their previous assailants must include careful evaluation and practical assessment at the intake stage.

While maintaining a safe and secure institution relies in part upon comprehensive unit and room assignments, the key component in establishing a stable institutional culture is the provision of comprehensive medical services to all of our residents from the time they hit our door until they are released from custody. Since serious unidentified and untreated illnesses and conditions are accompanying our youth into detention at more alarming rates than ever before, it is extremely important for the JJC to have Continued on page 24 . . . www.sfms.org

Health Care for Kids in the Foster and Juvenile Justice Systems

Orpheus in the Underworld A View into Special Programs for Youth at the San Francisco Juvenile Justice Center

Justin Morgan, MD, Judith Sansone, RN, MS

E

ditor’s note: Unbeknownst to many San Franciscans, there is a small public health clinic nestled inside the Juvenile Justice Center (also known as Juvenile Hall), which sits—usually in the fog—at the top of Twin Peaks. The clinic, Special Programs for Youth (SPY), is run by the San Francisco Department of Public Health and provides multidisciplinary services to youth while they are detained.

Medical and behavioral health services are mandated by the statewide regulating body for juvenile halls, the California Correction Standards Authority. However, SPY routinely goes above and beyond the minimum standards and provides comprehensive services for the youth who pass through our locked doors.

The young men and women who are detained at the Hall range in age from eleven to eighteen years old, the majority of them fifteen to seventeen years of age.

Detainees are disproportionately people of color; come from socioeconomically challenged backgrounds; and struggle with the health issues of chronic stress, history of violence or witnessing violence, and poverty. Like all adolescents, SPY patients are also grappling with issues of identity, values clarification, risk taking, and making healthy choices.

Studies show that 65 to 70 percent of all youth in the juvenile justice system have at least one diagnosable mental health disorder (more than 60 percent of youth meet criteria for three or more diagnoses).

SPY’s robust array of services—from crisis intervention and acute medical visits to dental care and around-the-clock nursing services to ongoing psychosocial assessment and support—is highly valuable to these youth and their families, and it often www.sfms.org

serves as a bridge to ongoing care on the “outside.”

But the individuals who pass through juvenile hall are far more interesting than the walls that contain them, the statistics that label them, and the services they receive.

The following story is written

by Dr. Justin Morgan, a family practice physician reflecting on his work at SPY. ***** I’ve been a primary care provider with the San Francisco health department for the last five years. I trained in family medicine and was looking for an opportunity to do adolescent medicine when I joined the SPY clinic just under a year ago. Since taking the position, I’m often asked, “How do you like your new job?”

My reply is always the same: “I love it.”

I’m completely honest when I say it, but a little embarrassed, because I think people expect to hear about how my work is about me “giving back to the community I came from” or how hard it is working with “those kids,” the “delinquents,” the “gang-bangers,” the “repeat offenders,” or whatever comes to mind when you think of who’s usually in juvenile hall. Even the youth there have asked me, “Why do you work here? Aren’t you a real doctor?”

No one ever lights up and says, “Wow! Cool! It must be awesome to work at juvenile hall,” and I don’t think others expect me or the other clinicians I work with to be so happy and enthusiastic about it. So

it’s not so easy having to disappoint or surprise people with how much I enjoy each day I’m at the Juvenile Justice Center and how my days are always great.

One day, one of the kids I was admitting asked me, “What’s that?” He was pointing to the image on my computer desktop.

“That is a star map. Those are constellations. Their names are the names of the different stars,” I said, in a matter-offact sort of way. I added that I like stars, because I thought the seventeen-year-old should get the full story before we continued with the interview and exam—but there was more.

“That’s my mom’s name.”

He was pointing to the screen, and Continued on the following page . . .

January/February 2011 San Francisco Medicine 23

Orpheus in the Underworld Continued from previous page . . . as I turned back to ask him more about how his mom got the name “Vega,” I could see it tattooed on his neck, in large letters, though I hadn’t noticed it before: “LYRA.” He was pointing to the constellation Lyra, of which Vega is the brightest star.

So I asked him if he knew the story of Lyra, the lyre given by the gods to Orpheus, who played it so beautifully that when his lover, Eurydice, died, Orpheus used his music to travel safely into the land of the dead to find her. Hades was so moved by Orpheus’ music that he allowed Eurydice to follow Orpheus up and out of the Underworld, so long as Orpheus continued to play his lyre and didn’t look back to see his love until they both safely reached the land of the living together.

The youth was clearly disappointed by how the story ended. But he thought it would be cool to share with his mother.

We also talked about how he was like Orpheus, given probation but doing exactly what he was told not to do, and no better off because of what seemed to him to be a slight mistake.

He understood that even in stories of tragedy, we find something hopeful in them. And that’s why we tell the story of Orpheus and Eurydice, of Demeter and Persephone and all those others, as we look to the stars in the heavens to learn where an inspirational light in the midst of darkness can be found.

That’s why I love working at the Juvenile Justice Center. Such experiences aren’t mentioned as part of the job description when you apply and interview.

And it may be hard to believe that the detention center is where the amazing is commonplace. But anyone who enjoys taking care of patients can tell you how rewarding it is to get to know them as people, beyond hypertension, mental illness, diabetes, juvenile delinquency, gang-banging or any other problem they may struggle with.

A few months later, the same youth, now eighteen, was back in detention. I told him that, after our talk about Lyra and Orpheus, I was kind of disappointed

in him for being back in detention—to which he replied, “After our talk about Lyra and Orpheus, I’m kinda disappointed in you for taking that star map off your computer.”

We shared a familiar look, then continued with the exam. There was nothing more to say about life in the Underworld.

Justin Morgan, MD, is a family physician with the San Francisco Department of Public Health and is president of the National Medical Association’s San Francisco chapter, the John Hale Medical Society.

Judith Sansone, RN, MS, is a nurse practitioner who has worked with the urban poor for over fifteen years, and has been the Director of Operations at SPY since November 2009.

The story has been altered slightly to protect the privacy of the patient and his family.

There’s a SPY in Our House Continued from page 22 . . . appropriate clinical support.

That’s precisely why JPD has a SPY in our house!

Special Programs for Youth, or SPY, is a specially designed medical services program created and delivered by the San Francisco Department of Public Health. It operates twenty-four/seven in the Juvenile Justice Center and at Log Cabin Ranch. SPY services are delivered in the onsite clinic and in the living units.

Any necessary conditions requiring treatment at S.F. General Hospital are arranged expeditiously.

If it were not for SPY’s generous partnership with the Juvenile Probation Department, our incoming residents would enter the general population without medical screening and without access to diagnostic services, medical prescriptions, emergent physical evaluations, first aid treatment, behavioral health evaluations and treatment, health education, and ordinary medical care.

Without our SPY, the trauma of detention would only exacerbate those undiagnosed and untreated traumas that residents bring with them into our house. Without

24 San Francisco Medicine January/February 2011

the skilled detection efforts and treatment plans arranged by enlightened SPY medical and behavioral health staff, our house would be a petri dish for decompensation.

If it were not for SPY’s responsive and vigilant attention, our house would have been a City center for the development and spread of the H1N1 virus last year.

A carefully developed plan was implemented in short order, defeating epidemic occurrence. Cedrick’s positive adjustment to the prospect of long-term out-of-home placement would never have occurred without the timely and sensitive interaction initiated by SPY staff. Monique’s selfexamination of her destructive lifestyle and pursuit of violent personal relationships, made in the context of helping her create her own safe release plan, would never have occurred without SPY’s intervention efforts. Ronald’s moving bullet fragments, Angelo’s broken arm, Royce’s STD, and Theresa’s prenatal needs are only a few of the examples of the matters that accompany our kids into our house, requiring SPY’s attention, SPY’s touch.

The overall health of our institutional culture at the JJC and at Log Cabin Ranch relies primarily on the health of our residents, not on the place where they sleep. SPY is the principal ingredient in JPD’s recipe for institutional stability. The Juvenile Probation Department remains indebted to the San Francisco Department of Public Health for its partnership and commitment to the youth and families we serve in San Francisco.

William P. Sifferman is the Chief Probation Officer of San Francisco’s Juvenile Probation Department.

www.sfms.org

Health Care for Kids in the Foster and Juvenile Justice Systems

A View from the Bench A Judge Tells Her Story

Donna Hitchens, JD

I

have been a judge in San Francisco for twenty years, many of which have been spent presiding over delinquency and child abuse cases. More than 2,000 children in San Francisco are in the “system.” These are children who have been physically, sexually, and/or emotionally abused. They are children who have been traumatized by violence in their homes and neighborhoods. They are children whose medical, physical, educational, and developmental needs have been severely neglected. It is often necessary to remove them from their parents. However, being removed from the only caretaker they have ever known, and being placed with a total stranger or distant relative, presents an additional trauma in the lives of these children.

The state is not a very good parent, and children who spend many years in foster care do not experience positive outcomes.

One of every three children entering foster care is under the age of four. At least 12 percent of two- and three-year-olds in foster care experience social and emotional problems that negatively impact their functioning and readiness for school. Children who are older when they come into foster care may have been the victims of abuse and neglect that has gone undetected for a considerable period of time. They may already be suffering the physical, emotional, and developmental consequences associated with a history of abuse and neglect. Because many of these children have behavioral problems, they may also have trouble maintaining a placement.

There are children who have been in ten foster homes by the time they reach their teen years. In attempts to regulate their behavior at home or school, they may be overmedicated or wrongly medicated. For www.sfms.org

example, some symptoms of ADHD are the same as those of childhood PTSD, yet the appropriate treatment can be quite different. Those who stay in foster care until they “age out” are much more likely than other young adults to experience homelessness, mental illness, and incarceration. Twenty percent of those who “age out” of foster care are incarcerated within two years.

Focus groups conducted by the Youth Law Center in San Francisco identified some specific issues related to medical care.

Sometimes foster parents aren’t informed of a child’s medical issues and therefore cannot provide an appropriate medical history when taking a child to the doctor. Foster parents complain that doctors ignore the problems they do report. Many doctors don’t understand the multitude of health, emotional, and developmental risks encountered by foster children. If a child is placed with a relative, he may not have had a comprehensive, multidisciplinary assessment at the time he came into care.

Luckily, San Francisco has many ex-

cellent services and providers available to address the special needs of foster children.

Early screenings and interventions are critical in order for these children to experience success in school, the community, and their relationships with peers and caregivers.

The medical community has a unique ability to assist in positive outcomes for foster children because almost every child sees a doctor. Medical professionals can be the most dynamic and helpful if they educate themselves about the risks faced by these children; identify patients who are in the foster care system; make sure those children have had comprehensive medical, emotional, and developmental screening; make sure the children are appropriately medicated; and refer those patients to other services when indicated. It really does take a village to raise a child, and we are all part of that village.

Donna Hitchens, JD, is a Superior Court Judge in San Francisco.

January/February 2011 San Francisco Medicine 25

Health Care for Kids in the Foster and Juvenile Justice Systems

Common Health Concerns Health Care for Youth in the Juvenile Justice System

William Arroyo, MD

T

he population of youth who, in 2006, were classified as juvenile offenders and temporarily detained or confined in juvenile residential facilities exceeded 92,000 nationally. California, at nearly 15,000, has many more such youth than any other state (in nearly 250 such facilities, including state and county facilities) and nearly double that of the next state, Texas, which has approximately 8,500.1 In general, these California youth are under the age of eighteen, the exception being those in the state institutions in the Division of Juvenile Justice (formerly California Youth Authority), where the age limit is twenty-five and which accounts for less than 10 percent of the statewide total.

The range of health care needs in the population of incarcerated youth is as broad a range as that of the general community. However, this population tends to have lower access to care and less health care insurance and tends to be from lower socioeconomic backgrounds than the general population of youth. These youth are disproportionately of minority backgrounds, especially from black and Latino communities. This population has been determined by the American Medical Association Council on Scientific Affairs as a “medically underserved population that is at high risk for a variety of medical and emotional disorders. These youth not only have a substantial number of preexisting health problems, they also develop acute problems that are associated with their arrest and with the environment of the correctional facility. Indicative of both their personal behavior and their lack of adequate prior health care services, youth in correctional institutions have a greater than expected rate of selected

physical and emotional problems, such as substance abuse, sexually transmitted diseases, unplanned pregnancies, and psychiatric disorders.�2 Several surveys conducted during the past few decades on the health status of youth in detention have concluded that this population suffers from a variety of health problems. In studies, the prevalence of any medical condition, including substance use and mental health problems, was 46 to 70 percent.3 The most frequent medical problems included respiratory infections, uncontrolled asthma, genitourinary infections (including asymptomatic gonorrhea), trauma, pregnancy, hepatic infections, headaches, substance overdose or withdrawal syndromes, and dental problems.

Less than one-third of detainees reported having had a regular source of medical care prior to detention.4 Pregnancy rates among incarcerated females have been found to be nearly four times that of their community counterparts.

The oral health of young people is this country is a very serious problem.

Tooth decay is one of the most problematic chronic health issues among youth.

Children from impoverished families are overrepresented in the juvenile justice population and are much more likely to have unmet dental care needs than those from higher-income families. A survey in the state of Washington found that dental problems were reported in more than 65 percent of youth involved in the juvenile justice system.5 Addiction and substance use disorders are also prevalent among the juvenile justice population. More than 75 percent of children and youth in the juvenile

27 San Francisco Medicine January/February 2011 26 San Francisco Medicine January/February 2011

justice system are under the influence of alcohol or drugs while committing their crimes, test positive for drugs, are arrested for committing an alcohol or drug offense, admit to substance use or an addiction problem, or share some combination of these issues.6 Fewer than 5 percent receive treatment services in the juvenile justice system for these problems.

A recent study concluded that nearly two-thirds of males and nearly threequarters of females in the juvenile justice system had one or more mental disorders.

Substance use and disruptive behavior disorders were the most common disorders for both sexes: Approximately half the males and females had a substance use disorder; more than 40 percent of both sexes met criteria for disruptive behavior disorders. More than 25 percent of females and nearly 20 percent of males had affective (mood) disorders. Females had significantly higher odds of having any mental disorder except conduct disorder or alcohol and/or marijuana use problems.7 Incarcerated youth are at much higher risk of self-injurious behaviors and suicide attempts than their counterparts in the general community.

Although studies suggest that medical intervention, including mental health and substance use treatment, may decrease recidivism among these youth, the definitive studies have yet to be completed for the broad range of medical problems. A decrease in recidivism is strongly suggested by a few studies restricted to mental health interventions. Despite the fact that institutions in which youth offenders are confined are not ideal health care settings, they do provide an opportunity for muchneeded health care. In order to address the www.sfms.org

inadequacy of health services for incarcerated populations, the American Medical Association established an independent not-for-profit National Commission on Correctional Health Care (www.ncchc.org), which has undertaken the responsibility for developing national standards of care for incarcerated youth. The American Academy of Pediatrics has recently issued a policy statement that promulgates the practice of establishing a medical home in the community, prior to release, for children and adolescents who are confined to correctional facilities. These youth, who have multiple needs, should also be linked with the array of social service agencies that would enhance their transition to the community and, we would hope, decrease recidivism rates. The establishment of benefits, including health insurance coverage, is paramount prior to release given the high prevalence of health problems.

William Arroyo, MD, is Medical Director of the Child, Youth and Family Program Administration, Los Angeles County Department of Mental Health. He is also co-chair of the Juvenile Justice Reform committee for the American Academy of Child and Adolescent Psychiatry.

A full list of references is available online at www.sfms.org/archives.

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January/February 2011 San Francisco Medicine 27

Health Care for Kids in the Foster and Juvenile Justice Systems

A Young Man’s Story A Youth Worker Recounts the Story of a Memorable Young Man

Breana Marino

E

ditor’s note: The following is a narrative from a student working on his master’s degree, who has been interning in the City Youth Now office for the past year. City Youth Now supports youth in the San Francisco foster care and juvenile justice systems by providing funds for services and programs that promote stability and personal growth. Originally founded in 1950 as the Volunteer Auxiliary of the Youth Guidance Center, it was the first nonprofit organization in the United States’ juvenile court system.

City Youth Now diligently works behind the scenes to address the unique needs of children and youth under the jurisdiction of the San Francisco Juvenile Court System.

While the youth come from different communities around the city, they all have one thing in common: They have each endured more than their share of trauma and hardship. The organization hopes that by providing them with opportunities they might not otherwise have, they will not only feel a sense of immediate fulfillment but will develop into responsible adults. ***** Rahqwan entered the foster care system at the age of ten and began to get into trouble immediately. He joined a gang and was in and out of jail by the time he was fourteen. Due to multiple moves from one group home to another, he had no family support. His only friends and family were his gang. Although he was behind in school and constantly in and out of juvenile hall, Rahqwan knew there had to be more to life than fighting and hanging out on a street corner. He realized early on that gang life was not what he wanted.

Before he had the chance to make any changes, Rahqwan was arrested and

found himself in jail once more. This time he was sent to Log Cabin Ranch, a secluded placement for young men, located in the hills of La Honda, California. At Log Cabin he experienced a different world, and he saw this placement as an opportunity to begin making positive changes. He met other young men his age with similar backgrounds and began to see the downward spiral his life would continue to take if he failed to make better decisions. He realized that he needed to make those changes immediately.

He started to dream about his future, something he had never considered before, and he thought about creating his own ranch to help others. Rahqwan successfully graduated from Log Cabin Ranch and, upon his release, he continued to work closely with his probation officer to make positive life choices. Soon he was introduced to City Youth Now’s internship program.

Rahqwan decided to work in our office for his internship, and after learning about the positive directions he was taking, we were happy to have him.

During his time with us at City Youth Now, Rahqwan was always ready for a new project and was excited to learn. He started to put his dream of creating his own ranch into reality by conducting a research project comparing different probation ranches and camps, such as Log Cabin Ranch and the Muriel Wright Residential Center. He did online research and conducted interviews with probation officers, social workers, and court judges. He also interviewed teachers and counselors who worked at various ranches, getting their personal experience and insights. He used the information he gathered to create a

28 San Francisco Medicine January/February 2011

thoughtfully designed ranch, one that took every troubled young man’s individual needs into consideration. Based on his own experiences, Rahqwan was able to develop what he felt would be a complete plan that would fulfill the needs of every young man who was sent to his Ranch. Although this was only a project, we hope that he will be able to take it one step further when he attends college in the fall.

After his work in the City Youth Now office, Rahqwan was also able to start work at a local Boys & Girls Club. He attended weekly workshops on conflict resolution, study skills, career choices, personal finances, college preparation, and leadership training. He also helped out at the Boys & Girls Club tutoring program, assisting fourth, fifth, and sixth graders with their homework assignments.

Rahqwan’s supervisor described him as a hardworking young man who arrived daily with a smile on his face and a great attitude. His playful personality made him easily approachable by the younger members, and they formed attachments to him. He was such an important asset to the Boys & Girls Club that his supervisor asked him to stay after the internship was over.

Rahqwan is still in foster care and living in a group home. But he is no longer a gang member and is studying hard to take his GED. Rahqwan is one of City Youth Now’s hardest-working youth. We are happy and proud to see him turning his life around.

Breana Marino is a Program Assistant at City Youth Now.

www.sfms.org

Hospital News Kaiser

Robert Mithun, MD

For 2011, quality is the name of the game when it comes to goals. At the San Francisco Medical Center, we take a systematic approach to reaching our annual goals with distinct inpatient and outpatient teams, which include physician leads, project managers, and other dedicated staff. The quality goals we pursue reflect, and often exceed, those set by the National Committee for Quality Assurance (NCQA) and other organizations.

Examples of the center’s outpatient quality goals include multiple cancer prevention initiatives (colorectal, cervical, breast), osteoporosis management, cardiovascular health (control of blood pressure, diabetes, and cholesterol), asthma and depression management, and childhood immunization programs. Specifically for 2011, providers and staff will conduct extensive “in-reach” for breast and cervical cancer screening. This means that at every visit, to no matter what the department, a patient’s screening status to determine if he or she is coming due, or overdue, will be reviewed. If a screening is necessary, the appointment will be booked for that day or for another date in the near future, at the patient’s convenience. Conversely, the strategy for outreach breast and cervical cancer screening consists of a systematic, multipronged, and multimedia approach. Each quarter of the year, a woman who is coming due or overdue for these critical screenings will receive a letter, a secure e-mail message, and an automated phone call from her primary care provider.

For those who remain overdue at the end of the year, the patient’s physician will make a personal phone call to alert her that it’s time to be screened.

We feel that these initiatives, and many others, will enhance the care we provide and also save lives. The new year will provide us not only opportunities to improve how we care for our patients but also lessons that will inform our goals for 2012 and beyond. www.sfms.org

UCSF

CPMC

David Eisele, MD

Michael Rokeach, MD

CPMC is pleased to announce the opening of its new Digital Imaging and Lab Center.

The Center has the most advanced 1.5T MR scanning equipment, and CPMC radiologists interpret all radiology studies. The digital report is available in your office, the same day, with STAT results within fifteen minutes! The Center accepts all walk-ins and appointments and handles registration onsite. All lab work is performed in reclining phlebotomy chairs. The lab, open Monday through Friday from 8:30 a.m. to 5:00 p.m., is located in San Francisco at 1375 Sutter St., Suite 101. For more information, contact the lab at (415) 600-4140.

Congratulations to the following MEC members-at-large who have been elected by the active staff for the term January 1, 2011, through December 31, 2012: Oded Herbsman, MD; Kasra Rastani, MD; Ovidiu Dumitrescu, MD; and Anita N. Demas, MD, incumbent.

Thanks to all the other candidates for your interest and participation.

CPMC has available a Fine Needle Aspiration Biopsy (FNAB) clinic. Dr. Ian Jaffee, medical director of the clinic, is board certified in cytopathology and provides expert consultation in the evaluation of palpable, superficial masses for cytologic diagnosis.

Because a portion of the FNA sample is rapidly analyzed by the cytopathologist at the time of the procedure, a preliminary impression or assessment for specimen adequacy can often be immediately provided to the patient and the referring physician. A final diagnosis is typically available within one to two business days.

The FNAB Clinic is located at 3700 California St. in the Department of Pathology on the fourth floor, open 9:00 a.m. to 4:00 p.m., Monday through Friday. Patients may be scheduled in advance, have same-day appointments, or drop in. Contact Client Services at (415) 600-2200 to schedule appointments, to send notice of drop-ins, or for any further inquiries.

Last June, Marc Benioff, chairman and CEO of salesforce.com, officially announced that he and his wife, Lynne, would be donating $100 million to the new UCSF Benioff Children’s Hospital at Mission Bay. This gift supports a 183-bed facility that will surely advance the health of thousands, perhaps millions, of children in multiple ways and for years to come.

There will, of course, be the continued presence of some of the world’s finest clinicians and most advanced medical technologies, but there will also be a transformative design that enhances healing through connections to nature; a focus on sustainability; and a renewed emphasis on patient, family, and staff support.

For example, all rooms maximize natural sunlight and views, while providing individualized lighting and temperature controls. A media wall provides a lifeline to the familiar world outside the hospital by delivering access to a myriad of services, including meal orders, housekeeping requests, games, and connections to work or a classroom via webcam. To decrease falls, bathrooms are just feet away from patient beds, with assistive devices such as handrails lining the path from bedside to bathroom. Natural rubber flooring is comfortable for staff, attenuates noise, and reduces toxicity and maintenance through the elimination of waxing. Ceiling-mounted patient lifts reduce the potential for staff injuries during transfers. All patient rooms include materials that are not just durable and recyclable but also have undergone unprecedented chemical assessment to create an environment that is as toxin-free as possible. Finally, staff hand washing and work zones are located conveniently just inside patient rooms, and a “porch” just outside every patient room offers staff a place to enter or read data on a computer without disturbing the patient and family—and saves travel back to a more centrally located nurse base. For more on the Mission Bay hospitals project, visit missionbayhospitals.ucsf.edu.

January/February 2011 San Francisco Medicine 29

Public Health Report Steve Heilig, MPH

Legal Drug Pushers: Hooking Kids in the Haight “The Summer of Love, protests to be civil and a rainbow of counterculture. Whether you started here or put flowers in your hair, grabbed a drum and hitched a ride on a painted minibus, Camel lights up this little piece of San Francisco that pulses with the spirit to evolve, revolve or revolt and follows the force to break free.”—Text from Camel Ad (pictured right)

S

omebody got paid to write that—probably paid well.

It’s drivel, of course, but drivel with a purpose. And that purpose? Addicting people—starting with young people—for cash.

Not so long ago, “Big Tobacco” promoted their products with impunity—see the wonderful retro-series Mad Men for more on that. By the 1970s, it was clear that tobacco was our greatest addictive hazard and that even secondhand smoke was dangerous. But still in the 1990s, here in “liberal” San Francisco, taking now-obvious steps like banning smoking in restaurants earned us epithets such as “public-health fascists.”

Most recently, it was a real battle to remove tobacco products from pharmacies—which are supposed to be vendors of healthy products—and the effort to minimize San Franciscans’ exposure to secondhand smoke continues. Attempts to get smoking out of movies and to further restrict its advertising at sports events, in magazines, and so forth, also continue, resisted each step of the way by “smoker’s rights” groups funded by Big Tobacco’s money.

The vast majority of smokers start as teenagers, or at least while still quite young. A decline in smoking from about half of all American adults to about half that was only achieved over the long haul by slowing the rate of those who stop smoking. Big Tobacco knows all this and thus concentrates its marketing on the young. Unfortunately, that too often still works, even with all the restrictions that have been gradually been placed on marketing. One of the tactics that bugs me most is the “healthy” or even “politically correct” cigarette—brands such as American Spirit, owned by Big Tobacco, no less damaging than others and using the image of Native Americans to hook hipsters. For years now I’ve seen otherwise smart and health-minded young people get gradually addicted to such brands. I rarely feel it’s my place to say anything, but when I do, the responses are on the order of, “I only smoke a couple a day,” “I don’t buy packs, just singles or borrow from friends,” “It’s just a social thing”—the same lines that have been spoken for generations now by early tobacco addicts. It’s saddening, and maddening. And Big Tobacco

30 San Francisco Medicine January/February 2011

encourages such delusion.

Back to the Camel’s nose entering the Haight: When this new advertising campaign first surfaced, San Francisco’s city attorney Dennis Herrera and health director Mitch Katz cowrote a strongly worded letter to the president of RJ Reynolds Tobacco company, maker of Camels, pointing out that despite all our progress, “smoking remains the number-one cause of preventable death for San Francisco residents” and urging them to cancel the “Break Free Adventure” Camel campaign. The terse letter in response said, in effect, “Tough luck.”

One might think, or hope, that this time the tobacco pushers misjudged the hood—most real hippies are now far too old to be fooled, and I think young people in the Haight either don’t care or outright disdain the whole ancient “Summer of Love” hippie mythology. But I’m not so sure, alas; tobacco marketers tend to be tragically good at their jobs. That ridiculous poster and pack just might work in some cases, and another of the 400,000 Americans who die each year due to tobacco will be recruited.

So, a modest proposal: Any billboard company, store, publication, eatery—anyone—who helps carry big tobacco’s message and/or product should be boycotted. Not just in the Haight, but anywhere in San Francisco. Our mayor, supervisors, and other leaders should call for such market pressure to be applied. As Big Tobacco advises, let’s “follow the force to break free”—and kick the Camels out of the Haight and San Francisco.

Steve Heilig, MPH, is the Associate Executive Director of the San Francisco Medical Society and former co-chair of the San Francisco Tobacco-Free Coalition. www.sfms.org

The San Francisco Medical Society is pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000!

Now is the time to take a good look at the SFMS plan if:

• You think you may be paying too much

• It has been more than one year since you last reviewed your life insurance protection

• The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave

• You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your financial planning no longer seem as secure as they once did Sponsored by:

Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance!

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Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice.

54721 (1/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

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