BILL ANALYSIS Ó
AB 1133
Page A
Date of Hearing: April 30, 2013
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Mark Stone, Chair
AB 1133 (Mitchell) - As Amended: April 8, 2013
SUBJECT : Small Family Homes: Foster Children with Special
Health Care Needs
SUMMARY : Requires social workers to give preference to a
licensed foster parent who is also a health care practitioner
for purposes of placement of a foster child with special health
care needs. Specifically, this bill :
1)Requires preference be given to a foster parent who is a
health care practitioner who is authorized to provide home-
and community-based services under the Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) program.
2)Requires the preference to be subordinate to the preference
granted to a relative or nonrelative extended family member
(NREFM).
EXISTING LAW
1)Establishes the California Community Care Facilities Act
(CCFA) to provide a comprehensive statewide service system of
quality community care for people who have a mental illness, a
developmental or physical disability, and children and adults
who require care or services by a facility or organization.
2)Defines a "Community care facility" (CCF), under the Health
and Safety (H&S) Code as a facility, place, or building
maintained and operated to provide nonmedical residential
care, day treatment, adult day care, or foster family agency
services for children, adults, or children and adults,
including, but not limited to, the physically handicapped,
mentally impaired, incompetent persons, and abused or
neglected children.
3)Defines and requires for licensure, under the CCFA, the
following facilities to serve youth in foster care:
a) Foster Family Agency (FFA), which recruits, certifies
and trains foster parents and oversees certified family
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homes for the temporary placement of children in foster
care;
b) Certified Family Home (CFH), which is a family residence
certified by a FFA as meeting CCFA licensing requirements
to serve as a temporary placement for children in foster
care;
c) Foster Family Home (FFH), which provides 24-hour care
for six or fewer foster children and is owned, leased or
rented and is the residence of a foster parent; and
d) Small Family Home (SHA), which provides 24-hour care for
six or fewer foster children who have mental disorders or
developmental or physical disabilities and require special
care and supervision, including foster youth with
specialized health care needs.
3)Defines, under the Welfare and Institutions (W&I) Code a
"specialized foster care home" (SFCH) as any CFH, FFH or SHA
that provides specialized in-home health care to foster
children, and limits their capacity to no more than two
children, as specified.
4)Defines "Specialized in-home health care" to include, but not
be limited to, services identified by the child's primary
physician as appropriately administered in the home by any one
of the following:
a) A parent trained by health care professionals where the
child is being placed in, or is currently in, a specialized
foster care home;
b) Group home staff trained by health care professionals
pursuant to the discharge plan of the facility releasing
the child; or
c) A health care professional where the child is placed in
a group home and health care services are not considered to
be reimbursable costs for the purpose of determining the
group home rate, as specified.
5)Defines "Child with Special Health Care Needs" a person who is
22 years of age or younger who is completing a publicly funded
education program, who has a condition that can rapidly
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deteriorate resulting in permanent injury or death or who has
a medical condition that requires specialized in-home health
care, and who either has been adjudged a dependent of the
court, is in the custody of the county welfare department, or
has a developmental disability and is receiving services and
case management from a regional center.
FISCAL EFFECT : Unknown
COMMENTS :
Maintaining the Family
Historically, it has been the stated policy of California that
when a child is removed from the home, first preference should
be given to placing the child with another parent, or with his
or her relatives whenever possible and appropriate. This has
helped to preserve and strengthen the social bedrock of our
society, by keeping families together and reducing society's
reliance on its social welfare system.
Child Welfare Services
The purpose of California's Child Welfare Services (CWS) system
is to provide for the protection and the health and safety of
children. Within this purpose, the desired outcome is to
reunite children with their biological parents, when
appropriate, in order to help preserve and strengthen families.
However, if reunification with the biological family is not
appropriate, children are placed in the best environment
possible, whether that is with a relative, through adoption, or
with a guardian, such as a nonrelative extended family member
(NREFM).
In the case of children who are at risk of abuse, neglect or
abandonment, county juvenile courts hold legal jurisdiction, and
children are served by CWS through the appointment of a social
worker. Through this system, there are multiple stages where
the custody of the child or their placement are evaluated,
reviewed and determined by the judicial system, in consultation
with the child's social worker, to help provide the best
possible services to the child.
At the time a child is identified as needing child welfare
services and is in the temporary custody of a social worker, the
social worker is required to identify whether there is a
relative or guardian to whom a child may be released, unless the
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social worker believes that the child would be at risk of abuse,
neglect or abandonment if placed with that relative or guardian.
(W&I Code Sections 306 and 309)
The Welfare and Institutions Code also lays out the conditions
under which a court may deem a child a dependent or ward of the
court, including when the parent has been incarcerated or
institutionalized and is unable to arrange for care for the
child, such as placement with a known relative. If the child is
deemed a dependent or ward of the court, the court may maintain
the child in his or her home, remove the child from the home but
with the goal of reunifying the child with his or her family, or
identify another form of permanent placement. Unless the child
is unable to be placed with the parent, the court is required to
give preference to a relative of the child in order to preserve
the child's association with his or her family.
Associated with the placement process, the assigned social
worker develops a case plan for the child, which outlines the
placement for the child, sets forth services necessary for the
child, and outlines the provision of reunification services, if
necessary and appropriate.
Need for the bill
The author states:
AB 1133 is designed to improve the outcomes of
medically-fragile foster children. Use of the Nurse-foster
parent program for this population has been shown to
decrease the time that medically-fragile children are
waiting for placement in the foster care system, reduce
hospital re-admission rates, and improve medical,
psychosocial, cognitive, language, and motor
neuro-developmental outcomes for medically fragile foster
children through early intervention programs and dedicated
nursing care.
Writing in support of the bill as the sponsor, Angels-in-Waiting
states:
The mission of Angels-in-Waiting is to recruit qualified
nurses to care for California's medically fragile foster
care infants and children. As their foster parents and
nurses, Angels-in-Waiting recruits Independent Nurse
Providers, who provide loving homes, nursing care and the
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needed wrap-around services to medically fragile infants
and children. Otherwise, these same infants and children
would be placed into institutional care, group homes or
ill-educated, poorly supported foster care homes, a
lifestyle no child should endure, let alone innocent,
high-risk premature infants.
In California, nurses can become independent providers for
foster children, billing Medi-Cal directly for their
in-home nursing hours. Nurses can also become licensed
foster parents and have a child placed in their care. This
combination of nursing and foster parenting provides a
loving home environment, while offering nurses a special
way to serve the pediatric population. Within our program,
we see greater positive outcomes for medically fragile
babies and children and a decrease in hospital admissions.
Early Periodic Screening, Diagnosis, and Treatment (EPSDT)
ESPDT is a federal child health benefit under Medicaid for
children under the age of 21 that provides comprehensive and
preventive health care services to help ensure children and
adolescents receive appropriate preventive, dental, mental
health, and developmental and specialty services. Most children
who meet Medicaid eligibility requirements are from families
with annual incomes up to approximately 100% of the federal
poverty level, or have been removed from their homes and made
dependents of the court. For the most part, children and
adolescents who meet Medi-Cal medical necessity criteria have a
recognized mental disorder; are not developing appropriately;
and interventions have been identified that are likely to help
the child to progress developmentally as appropriate.
In cases where medical services can be provided in the home
rather than through a licensed institutional care, EPSDT funding
can support Medi-Cal eligible children to be served through home
and community based services (HCBS). Through HCBS, which are
not part of the Medi-Cal State Plan benefit, but are provided
under a waiver not typically part of the benefit package under
federal Medicaid, EPSDT-funded services can be provided in a
home or community based setting to specified populations, which
include assisted living and pediatric palliative care.
Services for children provided for in EPSDT-funded HCBS are
authorized through specified licensed or certified home or
community based facilities requirements. They are also required
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to have an identified support network system available to them
in the event the HCBS provider is unable to provide necessary
care.
"Failure to Thrive"
Failure to thrive is a medical diagnosis that refers to children
whose current weight or rate of weight gain is significantly
lower than that of other children of similar age and gender.
According to the National Institutes for Health, failure to
thrive can result from a variety of medical problems or factors
that range from developmental disabilities to physical or mental
afflictions or abuse and neglect.<1>
Children who demonstrate symptoms of failure to thrive,
typically display developmental delays, are slow to develop
motor and cognitive functions, abnormal social development and
physical delays. If not treated, normal growth and development
may be affected. However, if treated early, normal growth and
development may not be affected.
Specialized Foster Care
Unlike general foster care placements, such as foster family
homes, specialized foster care is a form of care that provides
for and supports the medical, developmental, or mental health
needs of the child. Services can range from acute level medical
care to therapeutic and behavioral services depending on the
needs of the child. Foster parents who operate licensed foster
homes that provide specialized foster care are required to
undergo increased levels of training and receive a greater array
of support services to provide for the outcomes of the child.
Foster family homes licensed to provide specialized foster care
are limited to two children or less and are required to be
provided in a family environment, in close proximity to the
parent's home, and consistent with the best interest and special
needs of the child. Specialized foster care homes are also
provided a higher foster care rate to help support and
accommodate the greater level of need associated with the care
provided.
According to the Department of Social Services, California's
county welfare departments are responsible for developing,
---------------------------
<1> "Failure to thrive." U.S. National Library of Medicine:
National Institutes of Health. Updated August 2, 2011.
http://www.nlm.nih.gov/medlineplus/ency/article/000991.htm
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maintaining, and administering county-specific specialized care
systems. The State provides technical assistance to counties to
modify or adopt a system. Currently 54 counties have specialized
care systems.
Relatives and Nonrelative Extended Family Members (NREFMs)
As a part of the state's goal to reunite a child who has been
removed from the home with his or her family, when possible,
child welfare agencies are required to give preference to a
child being placed with his or her relatives or a NREFM. Rather
than placing a child in a foreign environment where there are no
emotional or historical ties to a child's family, placement with
a relative, such as an uncle, aunt or grandparent can help to
improve the chances that a child can be reunited with his or her
parents. However, in cases where children cannot be reunited
with their parents, a blood relative can also provide a child
with a nurturing, familial environment; an environment that has
been proven to often improve the child's outcomes.
The purpose of establishing a NREFM as an appropriate placement
for a youth was to provide another valuable option to meet the
state's policy goal of placing children with relative
caregivers. NREFMs have become valuable and important
individuals in the state's CWS system. In cases where a parent
or relative is either not present or unsuitable for placement, a
NREFM can provide the next best family-like environment for a
child who has been removed from his or her home. Unlike a group
home or related facility, a NREFM can provide a homelike setting
that is less disruptive and more familiar and emotionally
supportive of the child's needs. Under current law, a NREFM is
defined as a person who has an established familial or mentoring
relationship with a child, and can be considered an individual
with whom a child or youth under temporary custody or a
dependent or ward of the court may be placed. They can be a
godmother or godfather, a coach, a close friend of the family,
or anyone who has an established relationship with the child.
Supply versus Demand
As of January 1, 2013, there were approximately 56,495 children
in foster care, according to the California Welfare Dynamic
Report System, a statewide child welfare database operated in
collaboration by DSS and the University of California at
Berkeley. This number far outweighs the availability of
licensed foster care homes in the state. According to DSS, as
of January 1, 2013, there were 7,007 licensed foster care homes
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with a capacity to serve 15,731 foster youth.
Additionally, there are another 6,422 certified family homes
operated by foster family agencies. Because DSS does not
license certified family homes, it does not track their total
statewide licensed capacity. However, the number of certified
family homes is less than the total number of licensed foster
homes, which indicates that even if they were operating at the
maximum licensed capacity of six children, there would still not
be enough to provide family home environments for all foster
youth.
These numbers demonstrate that, although the state has
significantly reduced its foster care population over the past
12 years, it still leaves much progress to be made in
identifying and maintaining home-based placements that can
provide family-like environments for our foster youth.
RECOMMENDED AMENDMENTS
According to the author, this measure is intended to only apply
to "medically fragile" infants who are in need of appropriate
care to ensure their successful development. Under current law,
a "medically fragile" child is defined as having an acute or
chronic health problem which requires therapeutic intervention
and skilled nursing care during all or part of the day. This
measure should be amended to ensure that preference is being
given for the appropriately trained person who can provide for a
medically fragile foster youth.
Additionally, recognizing the great need for foster family
homes, this measure should be amended to ensure that it does not
inhibit the ability of child welfare agencies to place children
into small family homes with the appropriate and necessary
supportive services, such as wraparound, if it is determined to
be in the best interest of the child.
Specifically, staff recommends the following amendments:
Amendment #1
On page 2, lines 3 and 4, delete "foster child with special
health care needs" and insert:
medically fragile foster child as defined in subdivision (b) of
Section 1760.2 of the Health and Safety Code
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Amendment #2
On page 2, lines 8 and 9, delete "subdivision (m) of Section
14143.26" and replace with:
subdivision (m) of Section 14043.26
Amendment #3
On page 2, line 16 after "Code." insert:
(c) Nothing in this subdivision shall be construed to prohibit a
child welfare agency or the juvenile court from placing a
medically fragile foster youth in a specialized foster care home
with appropriate support services if it is deemed to be in the
best interest of the child.
REGISTERED SUPPORT / OPPOSITION :
Support
Angels-in-Waiting (sponsor)
California Black Health Network
Children Now
Lilliput Children's Services
National Association of Social Workers, California Chapter
(NASW-CA)
The Children's Partnership
Opposition
None on File
Analysis Prepared by : Chris Reefe / HUM. S. / (916) 319-2089