BILL ANALYSIS                                                                                                                                                                                                    




                                                                  AB 1133
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          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