BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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                                    THIRD READING


          Bill No:  AB 1133
          Author:   Mitchell (D), et al.
          Amended:  6/27/13 in Senate
          Vote:     21

           
           SENATE HUMAN SERVICES COMMITTEE  :  6-0, 6/25/13
          AYES:  Yee, Berryhill, Emmerson, Evans, Liu, Wright
           
          ASSEMBLY FLOOR  :  74-0, 5/9/13 - See last page for vote


           SUBJECT  :    Foster children:  special health care needs

           SOURCE  :     Angels In Waiting


           DIGEST  :    This bill requires that when determining the  
          placement of a foster child who is medically fragile, priority  
          consideration be given to placement with a foster parent who is  
          an individual nurse provider (INP), and who provides health  
          services under the federal Early and Periodic Screening,  
          Diagnosis and Treatment (EPSDT) program, unless the child has  
          the option of placement with a relative, as specified.

           ANALYSIS  :    

          Existing law:

          1. Establishes within state law a system of care for children  
             who have been removed from their homes and made dependent  
             wards of the juvenile court because the child has suffered,  
             or there is a substantial risk that the child will suffer,  
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             serious physical harm inflicted non-accidentally upon the  
             child by the child's parent or guardian, or because the child  
             has suffered, or there is a substantial risk that the child  
             will suffer, serious physical harm or illness, as a result of  
             the failure or inability of his/her parent or guardian to  
             adequately supervise or protect the child, as defined.  

          2. Provides for the licensure and regulation of various  
             out-of-home settings for children who need residential care,  
             including establishing licensing standards, and requires that  
             a placing agency consider the individual child's needs, the  
             ability of the facility to meet those needs, the needs of  
             other children in the facility, the licensing requirements of  
             the facility as determined by the licensing agency, and the  
             impact of the placement on the family reunification plan. 

          3. Defines a "medically fragile child" as having an acute or  
             chronic health problem which requires therapeutic  
             intervention and skilled nursing care during all or part of  
             the day. 

          4. Establishes in federal law payment for services to patients  
             who are younger than 21 and who qualify for EPSDT services as  
             Medicaid beneficiaries. 

          5. Establishes the role of INP as those providers authorized  
             under certain Medicaid home- and community-based waivers and  
             under the Medicaid state plan to provide nursing services to  
             Medi-Cal recipients in the recipients' own homes rather than  
             in institutional settings. 

          6. Requires in federal law that for states to receive funding,  
             they must consider giving preference to an adult relative  
             over a non-related caregiver when determining a placement for  
             a child, provided that the relative caregiver meets all  
             relevant state child protection standards. 

          7. Requires in state law that when a child is removed from the  
             physical custody of his/her parents and made a dependent of  
             the court, that preferential consideration be given to a  
             request by a relative of the child for placement of the child  
             with the relative, regardless of the relative's immigration  
             status. Existing statute defines what factors should be used  
             to determine if a placement is appropriate.  

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          8. Defines "preferential consideration" to mean that the  
             relative seeking placement shall be the first placement to be  
             considered and investigated. 

          9. Defines "relative" as an adult who is related to the child by  
             blood, adoption, or affinity within the fifth degree of  
             kinship, including stepparents, stepsiblings, and all  
             relatives whose status is preceded by the words "great,"  
             "great-great," or "grand," or the spouse of any of these  
             persons even if the marriage was terminated by death or  
             dissolution.  However, statute establishes that only the  
             following relatives shall be given preferential consideration  
             for the placement of the child:  an adult who is a  
             grandparent, aunt, uncle, or sibling. 

          This bill:
           
          1. Makes the following legislative findings and declarations:

              A.    There are growing numbers of medically fragile infants  
                entering the foster care system. 

              B.    Local resources have been, and continue to be,  
                strained to the limit in providing services to the  
                expanding number of these and other medically fragile  
                foster children.

              C.    These children are harder to place with the typical  
                foster parent because of their special needs, and they  
                become forgotten members of our society.

              D.    Encouraging trained nurses to be foster parents for  
                medically fragile infants and children results in more  
                positive outcomes for these placements.  The children  
                placed with trained nurses receive consistent medical  
                care, and benefit from the home environment and the  
                relationship with the foster family.

          2. Requires that when determining the placement of a foster  
             child who is medically fragile, priority consideration be  
             given to placement with a foster parent who is an INP, and  
             who provides health services under the federal EPSDT program.  


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          3. Specifies that this priority consideration be subordinate to  
             the preference granted to a relative of the child. 

          4. Establishes that a child welfare agency or a juvenile court  
             may place a medically fragile child in a specialized foster  
             care home with appropriate support services or another  
             appropriate placement if it is deemed to be in the best  
             interest of the child.

           Background
           
           Medically fragile children  .  According to California statute,  
          "medically fragile" means having an acute or chronic health  
          problem which requires therapeutic intervention and skilled  
          nursing care during all or part of the day.  Medically fragile  
          problems include, but are not limited to, HIV disease, severe  
          lung disease requiring oxygen, severe lung disease requiring  
          ventilator or tracheostomy care, complicated spina bifida, heart  
          disease, malignancy, asthmatic exacerbations, cystic fibrosis  
          exacerbations, neuromuscular disease, encephalopathy, and  
          seizure disorders. 

          According to the Department of Health Care Services (DHCS),  
          there are approximately 3,600 children statewide who are  
          designated as medically fragile and receiving private duty  
          nursing services within the EPSDT program.  Los Angeles County  
          has approximately 600 children identified as medically fragile  
          at any given time. 

           Placement options for medically fragile children  .  In  
          California, there is a critical shortage of foster care  
          placements for children with special health care needs,  
          including, at the higher end of care, medically fragile  
          children.  Currently, counties use a variety of options for  
          placing these children. 

          Social workers can place a medically fragile child in the home  
          of a foster parent with specialized training related to the  
          individual needs of the child and provide additional services,  
          as needed.  There is much greater need for these homes than  
          there are parents able to take these children.

          A second choice is in an intermediate care facility, often for  

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          children with developmental disabilities.  Social workers have  
          said that these facilities can be difficult to place children  
          into because many facilities now require the child to be  
          assessed and entered into the Regional Center system prior to  
          placement to ensure that there is state funding to support the  
          child.  This process can take weeks or months.  Anecdotally,  
          social workers who place special needs children say they may  
          leave a child in the hospital for days or weeks longer than they  
          need to while trying to locate an appropriate placement. 

          An emerging third option is the INP.

          INPs  .  California law defines an INP as a nurse who is  
          authorized under certain home- and community-based waivers and  
          under the state plan to provide nursing services to Medi-Cal  
          recipients in the recipients' own homes, rather than in an  
          institutional setting.  Neither the DHCS, which approves  
          treatment authorizations for in-home care, nor Department of  
          Social Services, which oversees much of the state's home-based  
          social services programs, track the number of INPs as the  
          designation does not require a unique license.

           EPSDT  .  Federal law - including statutes, regulations, and  
          guidelines - requires that Medicaid cover a very comprehensive  
          set of benefits and services for children, different from adult  
          benefits.  Since one in three United States children under age  
          six is eligible for Medicaid, EPSDT offers a critical way to  
          ensure that young children receive appropriate health, mental  
          health, and developmental services.  
          In addition to the standard Medi-Cal benefits that other  
          qualifying beneficiaries receive, an EPSDT patient under age 21  
          may receive additional medically necessary services, typically  
          for a recognized mental disorder or a developmental disability  
          where interventions have been identified that are likely to help  
          the child to progress developmentally as appropriate.  Children  
          with special medical needs also would fall into the EPSDT  
          category.

           FISCAL EFFECT :    Appropriation:  No   Fiscal Com.:  No   Local:  
           No

           SUPPORT  :   (Verified 6/27/13)

          Angels In Waiting (source)

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          California Black Health Network
          California State PTA
          Children Now and The Children's Partnership
          National Association of Social Workers, California Chapter
          Special Discoveries Educational Services, Inc.
          The ARC and United Cerebral Palsy in California
          The Children's Partnership


           ARGUMENTS IN SUPPORT  :    According to the author's office, there  
          are growing numbers of medically fragile infants entering the  
          foster care system.  Some of these cases are attributable to  
          epidemic drug use by pregnant women, which have resulted in  
          premature births and children with medical and developmental  
          complications, the author states.  In other cases, the child may  
          have become medically fragile at the hands of their parents and  
          a return to their biological home is not in the child's best  
          interest.  The author's office states that the foster care  
          system is heavily burdened with an influx of medically fragile  
          infants and children who need help.  

          According to the author's office, creating preferential  
          placement for an INP, who is trained to care for complicated  
          pediatric medical cases, results in more positive outcomes for  
          medically fragile children in foster care.  The children have  
          consistent medical care, and they benefit from the home  
          environment and the relationship within the foster family, the  
          author states.


           ASSEMBLY FLOOR  :  74-0, 5/9/13
          AYES:  Achadjian, Alejo, Allen, Ammiano, Atkins, Bigelow, Bloom,  
            Blumenfield, Bocanegra, Bonilla, Bonta, Bradford, Brown,  
            Buchanan, Ian Calderon, Campos, Chau, Chávez, Chesbro, Conway,  
            Cooley, Dahle, Daly, Dickinson, Eggman, Fong, Fox, Frazier,  
            Beth Gaines, Garcia, Gatto, Gomez, Gordon, Gray, Grove,  
            Hagman, Hall, Harkey, Roger Hernández, Jones, Jones-Sawyer,  
            Levine, Linder, Lowenthal, Maienschein, Mansoor, Medina,  
            Melendez, Mitchell, Morrell, Mullin, Muratsuchi, Nazarian,  
            Nestande, Olsen, Pan, Patterson, Perea, V. Manuel Pérez,  
            Quirk, Quirk-Silva, Rendon, Salas, Skinner, Stone, Ting,  
            Torres, Wagner, Weber, Wieckowski, Wilk, Williams, Yamada,  
            John A. Pérez
          NO VOTE RECORDED:  Donnelly, Gorell, Holden, Logue, Waldron,  

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            Vacancy


          JL:k  6/27/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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