Abstract While the need to provide appropriate

mental health services to children in foster care is well

recognized, there is little information on administrative

barriers to assuring that such services are provided.

This article presents results from a national survey of

mental health agencies to profile their awareness of

currently available practice standards, the roles these

standards play in guiding practice of mental health

agencies, common reimbursement strategies in use for

mental health services, and collaborations between

mental health and child welfare agencies that enhance

children’s access to appropriate mental health care.

Implications and recommendations for mental health

policymakers are discussed.

Keywords Children � Mental health � Foster care �Quality � Child welfare

Background

The need to improve child and adolescent mental

health services has been a policy priority for the past

several decades. Following the articulation of this need

by the Joint Commission on Mental Health of Children

(1969), numerous reports, meetings, and initiatives

have called for improved access to appropriate mental

health care (Institute of Medicine, 2001; President’s

Commission on Mental Health, 1978; President’s New

Freedom Commission on Mental Health, 2003; U.S.

Congress, 1986; U.S. Department of Health and

Human Services, 2005; U.S. Department of Health

and Human Services, 1999). The bulk of efforts to

improve access and quality of mental health services

have focused on the adoption and implementation of

specific evidence-based practices at the provider level

(Carpinello, Rosenberg, Stone, Schwager, & Felton,

2002; Hoagwood, Burns, Kiser, Ringeisen, & Schoen-

wald, 2001; LeBel et al., 2004; Sackett, Rosenberg,

Muir-Gray, Haynes, & Richardson, 1996; Tanenbaum,

2003; Torrey, Finnerty, Evans, & Wyzik, 2003). These

high-quality interventions are often packaged within

implementation ‘‘toolkits’’ or manuals suitable for

adoption by providers (Drake et al., 2001; Ganju,

2003; NASMHPD Research Institute, 2005; Substance

Abuse and Mental Health Services Administration,

R. Raghavan (&)George Warren Brown School of Social Work, Departmentof Psychiatry, Washington University in St. Louis, CampusBox 1196, One Brookings Drive, St. Louis, MO 63130, USAe-mail: raghavan@wustl.edu

M. InkelasUCLA Center for Healthier Children, Families, andCommunities; Department of Health Services, University ofCalifornia, Los Angeles, 1100 Glendon Ave Suite 850, LosAngeles, CA 90095, USAe-mail: minkelas@ucla.edu

T. FrankeUCLA Center for Healthier Children, Families, andCommunities; Department of Social Welfare, University ofCalifornia, Los Angeles, 1100 Glendon Ave Suite 850, LosAngeles, CA 90095, USAe-mail: tfranke@ucla.edu

N. HalfonUCLA Center for Healthier Children, Families, andCommunities; Department of Pediatrics; Department ofPublic Policy; Department of Health Services, University ofCalifornia, Los Angeles, 1100 Glendon Ave Suite 850, LosAngeles, CA 90095, USAe-mail: nhalfon@ucla.edu

Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201

DOI 10.1007/s10488-006-0095-6

123

ORIGINAL PAPER

Administrative Barriers to the Adoption of High-Quality MentalHealth Services for Children in Foster Care: A National Study

Ramesh Raghavan Æ Moira Inkelas ÆTodd Franke Æ Neal Halfon

Published online: 9 January 2007� Springer Science+Business Media, LLC 2007

2005; Torrey et al., 2001). However, there has been less

focus on how good practices can be adopted at the

organizational level, and on the development of

procedures and policies among public child-serving

agencies that are necessary for the support of good

practices. A range of state and national studies show

that children in foster care are consuming a dispropor-

tionate share of publicly funded mental health services

given their level of need, and for these children there

is a great need to focus on the role of financial,

organizational, and administrative procedures that can

promote better access (Halfon, Berkowiz, & Klee,

1992; Halfon & Klee, 1987; Takayama, Bergman, &

Connel, 1994).

Children in foster care are a particularly vulnerable

group needing high-quality mental health interven-

tions. These children have disproportionately high

rates of emotional and behavioral problems (Clausen,

Landsverk, Ganger, Chadwick, & Litrownik, 1998;

Glisson, 1996; Halfon, Mendonca, & Berkowitz,

1995; Landsverk, Garland, & Leslie, 2002; Pilowsky,

1995; Zima et al., 2000) and mental health service use

(Halfon, Berkowiz, & Klee, 1992; Harman, Childs, &

Kelleher, 2000; Raghavan et al., 2005; Takayama,

Bergman, & Connel, 1994). Despite a high level of

need, only a quarter of children in foster care are

receiving services at any given time (Halfon, Berkowiz,

& Klee, 1992). Prior work documenting access barriers

to health services (Simms, Dubowitz, & Szilagyi, 2000)

shows that these barriers often have less to do with the

type and nature of emotional disturbances that affect

children in foster care, or with the absence of effective

treatment options, but instead derive from the unique

living situations of children in foster care, which pose

considerable challenges to the delivery, coordination,

and continuity of care. Even straightforward mental

health problems can be difficult to identify, assess, and

evaluate when placements are unstable, histories are

inadequate and incomplete, or clinicians are unable to

distinguish adaptive behaviors from underlying psy-

chopathology. Children enter foster care usually in

emergent circumstances, possess little or no health

histories at the time of their entry, and often experi-

ence multiple placements (Burns, Costello, & Angold,

1995; Halfon & Klee, 1987; Klee & Halfon, 1987;

Schor, 1981; U.S. General Accounting Office, 2003), all

of which pose considerable treatment challenges.

Therefore, assuring high-quality care for children in

foster care requires not only providing services appro-

priate to need or deploying evidence-based practices in

child settings, but also ensuring that service systems

and processes of care account for their changing

environments and relationships.

A recent national study found that by engaging in

coordinated service delivery, mental health and child

welfare systems can deliver mental health services

appropriate to need for children in child welfare

environments (Hurlburt et al., 2004). Recognizing the

challenges to delivering health interventions for such a

population, the Child Welfare League of America

(CWLA) issued standards for the provision of health

and mental health services for children in foster care

(Child Welfare League of America, 1988). Similar

standards have also been issued by the American

Academy of Pediatrics (AAP) in 1994 that were

re-affirmed in 2002 (American Academy of Pediatrics,

2002, 1994); the American Academy of Child and

Adolescent Psychiatry (AACAP) also issued compa-

rable standards (American Academy of Child and

Adolescent Psychiatry, 2001). The CWLA, AAP, and

AACAP recommendations suggest that all children

should receive a mental health screening when placed

into foster care, as well as a subsequent comprehensive

mental health assessment by a mental health profes-

sional within a month of being placed into foster care.

They also outline the need for a systematic, coordi-

nated approach to the delivery of mental health

services to meet children’s ongoing mental health

needs. The consistency and convergence of the stan-

dards from three different professional organizations,

representing purchasers and providers of care, is an

indication that there is the potential for developing

mutually agreeable service delivery pathways that

together operationalize high-quality care.

Despite their importance, the extent to which such

standards have been actually adopted within agencies

that serve children in foster care is unknown (Amer-

ican Academy of Pediatrics, 2002). While the barriers

to the deployment of specific high-quality interventions

can be examined at the provider level (Burns,

Hoagwood, & Mrazek, 1999; Weisz, Sandler, Durlak,

& Anton, 2005), identifying barriers to adopting

processes of care requires attention to organizational

and policy environments within which such delivery

occurs (Ganju, 2003; Glisson, 2002; Glisson &

Hemmelgarn, 1998; Goldman et al., 2001; Hoagwood,

2003; Rosenheck, 2001; Schoenwald & Hoagwood,

2001; Simpson, 2002; Torrey et al., 2001). Understand-

ing these environments is particularly important for

quality improvement in public mental health systems,

within which most children in foster care receive

services. However, little is known about the extent to

which the work of child-serving systems is consistent

with national standards. Consequently, the nature and

extent of administrative policies and procedures that

might support the standards for, and delivery of,

192 Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201

123

appropriate services for children in foster care is poorly

understood.

It is important to know if public mental health

agencies are aware of existing standards since aware-

ness is recognized as a necessary precursor to success-

ful adoption (Carpinello et al., 2002; Dixon et al., 2001;

Goldman, et al., 2001). Even when agencies are aware

of standards, it is unclear to what extent they have

adopted roles and responsibilities that promote ser-

vices consistent with prevailing standards. Service

delivery for children in foster care ostensibly requires

considerable coordination between mental health and

child welfare agencies, the nature and extent of which

are also largely unknown. The degree to which

Medicaid agencies align reimbursement policies to

outcomes (i.e., mandate quality through some type of

pay-for-performance mechanism) is also not well

understood in this population, though there is evi-

dence that this alignment does not always occur

(Blair-Hutchinson & Foster, 2003; Rosenbach, 2001).

This lack of knowledge about awareness of standards,

construction of roles and responsibilities that can

promote implementation of standards, and construc-

tion of fiscal mechanisms to promote their deployment

within state and county mental health and child welfare

agencies has adversely affected the ability of adminis-

trators and policymakers to design procedures and

implement processes that can adequately address the

many mental health needs of children in foster care.

To understand the extent to which public mental

health agencies are adopting roles and responsibilities

that are consistent with CWLA/AAP standards for

care, we conducted a national survey of state and

county mental health administrators on policies and

procedures relating to mental health services for

children in foster care. We first examine the extent to

which mental health agencies are aware of these

existing standards. Second, because mental health

agencies may construct systems and processes of care

in ways that approximate recommendations in these

standards even in the absence of formal knowledge

about these standards, we examine their roles in

implementing and enforcing standards of care. We

conclude with an analysis of specific barriers to mental

health service delivery to children in foster care, and

explore ways to improve service delivery for this highly

vulnerable group of children.

Methods

Administrators of mental health agencies were sur-

veyed between November 1999 and February 2000 as

part of a larger study of child welfare, child health, and

Medicaid agencies nationally. Self-administered ques-

tionnaires were sent to agency directors. Respondents

were sought from agencies in all 50 states and the

District of Columbia. In addition to state-level respon-

dents, purposive selection of respondents from mental

health agencies in counties with the largest numbers of

children in foster care was also performed. We selected

for participation the five largest counties in each of the 11

states that have county-administered child welfare

systems. We then selected an additional 10 counties

based upon size and child welfare population from the

remaining pool of counties, comprising child welfare

systems that were both state-administered and county-

administered. The overall goals of the sampling

approach were to identify mental health agencies within

counties that had large populations of children in foster

care, that were heterogeneous in terms of the level of

child welfare administration, and to identify systems and

processes at the level of service delivery (i.e., within

states for state-administered child welfare systems, and

counties for county-administered child welfare systems).

The full study targeted 204 state-level respondents and

260 county-level respondents, including 51 state and 65

county mental health agency participants.

Questionnaires were mailed out to agencies in

November 1999. Two weeks later a reminder postcard

was mailed to agencies not returning their question-

naire. A phone call was then placed two weeks later for

those agencies still not responding. Agencies were

called on a regular basis to maximize the response rate.

Mental health agency response rates were 82% for

states and 58% for counties. Further details regarding

the structure, organization, content, and design of this

survey are available elsewhere (Halfon et al., 2002).

The questionnaires included items about the provi-

sion of services representing standards of care for

children in foster care as identified by the CWLA,

AAP, and AACAP. Agencies were queried about the

provision, timing, and content of services to children in

foster care, policies and processes governing such care,

and the funding mechanisms for the provision of such

care.

Mental health agencies were first asked if they ‘‘...

directly participate in the mental, behavioral, or

developmental screening components of the initial

health screening exam...’’ at the time of entry into

foster care. They were then asked about their role in

‘‘... comprehensive health assessments... provided to

those children who will remain in out-of-home care for

a significant period of time...’’ Agencies were asked if

their agency played some role in determining who

performs the comprehensive mental health exam,

Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201 193

123

procedures that comprise this exam, tools or assess-

ment instruments used, duration of time following

removal from the home within which the exam is to be

conducted, the venue of the exam, reporting require-

ments, privacy requirements, standards for reassess-

ments, and policies governing such assessments.

Agencies were asked similar questions about policies

and procedures governing ongoing mental health ser-

vices, and transitional health services, defined as ‘‘...

those exams and treatments that occur at any transi-

tional point in out-of-home care e.g., change of place-

ment, prior to adoption, pre-termination).’’ Agencies

were also asked about their adoption of AAP/CWLA

standards, and for a description of any other standards

the agency might have adopted. Questions on policy

and procedures included the existence and benefit

structures of all contractual agreements governing

mental health care for children in foster care (including

initial health screening, comprehensive health assess-

ments, diagnostic services, transitional services, devel-

opmental services, and other services); details on a

variety of collaborative functions between mental

health and child welfare agencies (including capacity

assessment, monitoring service adequacy, utilization

review, monitoring adherence to standards, data col-

lection tools, management information systems, and

quality improvement); and a variety of mechanisms

through which such collaboration was conducted (reg-

ular meetings, interagency task forces, specific program

assistance, joint staffings, and other similar mecha-

nisms). Agencies also reported their perceptions of

current barriers to mental health service delivery.

Questions on health financing elicited details on

types of funding (Non-EPSDT Medicaid, EPSDT,

Title IV, Title V, Children’s Health Insurance Pro-

gram, other state funds, other local funds, and other

funds) used to pay for screenings and assessments.

Data were entered and analyzed using Microsoft

Excel (Microsoft Corporation, 2003).

Results

Awareness of Standards of Care

One third (33%) of mental health agencies reported

being aware of whether existing standards of care

governing services for children in the child welfare

system had been adopted in their state or county.

Roles and Responsibilities

About half of mental health agencies reported involve-

ment in determining policies and procedures at the

‘front-end’ of the service delivery pathway (Table 1).

Over half of mental health agencies (54%) play a role

in defining the procedures that are part of a compre-

hensive mental health exam as defined by the CWLA,

AAP, and AACAP standards. Somewhat fewer mental

health agencies are involved in identifying the specific

instruments used for these assessments, or in setting

standards for mental health reassessments. Few mental

health agencies report being involved with service

delivery when children transition from one placement

to another, or when they leave foster care altogether.

Most mental health agencies (71% of state agencies

and 94% of county agencies) report considerable

formal communication with child welfare agencies

(Table 2). State and county mental health agencies

report collaborating with child welfare agencies around

capacity assessment, monitoring the adequacy and

utilization of mental health services by children in

foster care, and use of standards and protocols for

service delivery. A smaller proportion of collabora-

tions are organized around quality improvement. The

mechanisms through which this collaboration occurs

include regular meetings (72% of state and 89% of

county agencies), interagency task forces (59% and

72%, respectively), and assistance around specific

programs (31% and 56%, respectively).

Table 1 Role of child mental health agencies in determiningpolicies and procedures regarding mental health exams forchildren in foster care

Any role of mental health agency indetermining policy/procedure

Stateagencies*

Countyagencies**

Initial health screening examProcedures that comprise exam 13 8

36.10% 23.50%Comprehensive mental health examTiming of when exam is conducted 12 6

34.30% 18.20%Procedures that comprise exam 19 18

54.30% 54.50%Specific tools or assessment instruments

used for the exam16 1545.70% 45.50%

Ongoing servicesStandards for mental health reassessment 17 15

48.60% 45.50%Transitional health servicesRequiring a post-transition mental health

exam4 2

11.40% 6.10%Requiring exit-point mental health exam 5 2

14.30% 6.10%

* 35 responding state mental health agencies. 7 agencies did notrespond to this series of items

** 33 responding county mental health agencies. 4 agencies didnot respond to this series of items

194 Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201

123

Reimbursement for Services Associated with

Standards

A variety of funding streams are used to deliver mental

health services for children in foster care (Table 3),

with Medicaid being the predominant mode of financ-

ing. About three-quarters of state mental health

agencies report use of non-Medicaid funds for basic

mental health assessments, ongoing services, and case

management. About 15% use Title IV for mental

health assessment and the provision ongoing services.

Approximately 46% of responding county mental

health agencies reported that insufficient Medicaid

payments necessitated the use of child welfare funds to

pay for mental health services for children in foster

care. Nearly half (49%) of state mental health agencies

reported not knowing whether or not child welfare

funds are used to support service delivery. Overall, few

agencies reported that financial mechanisms were

structured in ways that promoted quality of care for

children in foster care, reporting instead that down-

ward pressures on reimbursement adversely affected

quality of care.

Specific Barriers to Mental Health Service Delivery

Among a set of potential barriers to the delivery of

services for children in foster care (Fig. 1), frequency

of placement change was identified by both state and

county mental health agencies as the principal barrier

that affected delivery of high quality mental health

services. Underreporting of mental health problems by

foster parents, social workers, and providers were also

reported by one-third to one-half of state and county

agencies.

Discussion

This national survey of state and county mental health

agencies reveals a variety of administrative barriers to

the adoption of standards of mental health care for

children in foster care. The majority of mental health

agencies were unaware of the existence of CWLA/

AAP standards and the extent to which these were

being followed within their agencies. Despite this lack

of formal knowledge, most mental health agencies had

some role with at least the mental health assessment

standard, and collaborated in some of the ways that

these standards recommend. However, most activity

focuses on children entering the foster care system, and

few mental health agencies were involved with ongoing

assessments and intervention, or assessments con-

ducted at the time of transitions between placements

or before reunification. Because transitions are partic-

ularly disturbing for children in foster care (Newton,

Litrownik, & Landsverk, 2000) and are associated with

higher use of mental health services (James, Lands-

verk, Slymen, & Leslie, 2004), the lack of adoption of

these standards is likely to have adverse implications

for the quality of care received by children in foster

care.

Table 2 Areas of collaboration between mental health and child welfare agencies

Agency collaborates with child welfare agency to: State mental healthagencies

County mental healthagencies

Yes No N* Yes No N**

Assess capacity of mental health care system to respond to needsof children in OOHC

70.70% 29.30% 41 94.10% 5.90% 3429 12 32 2

Monitor adequacy of mental health care services provided to childrenin OOHC

65.00% 35.00% 40 82.90% 17.10% 3526 14 29 6

Monitor utilization of mental health care services provided to childrenin OOHC

61.00% 39.00% 41 82.90% 17.10% 3525 16 29 6

Monitor use of standards and protocols for delivery of mental health careservices to children in OOHC

59.50% 40.50% 37 72.70% 27.3% 3322 15 24 9

Develop specialized mental health data collection tools 52.50% 47.50% 40 34.30% 65.70% 3521 19 12 23

Share management information systems which link child welfare and childmental health systems

43.90% 56.10% 41 26.50% 73.50% 3418 23 9 25

Monitor quality of mental health services that children in OOHC receive 50.00% 50.00% 40 68.60% 31.40% 3520 20 24 11

Operate continuous quality improvement program for mental healthservices for children in OOHC

35.90% 64.10% 39 50.00% 50.00% 3414 25 17 17

* Responding state mental health agencies per each item

** Responding county mental health agencies per each item

Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201 195

123

Our findings also suggest that states and counties are

not able to adequately exploit potentially available

fiscal resources to support service delivery, and are

using flexible Title IV and other state funds to deliver

basic mental health services that Medicaid includes in

its benefit package. Mental health and child welfare

agencies seem to be struggling to deliver adequate care

within an overall environment of resource scarcity

(Smith, 2005; Szilagyi, 2004). While Medicaid should

be able to serve as the major payor of mental health

services, the fact that many jurisdictions report a heavy

reliance on their own child welfare funds indicates that

there is a significant gap between potential and actual

reimbursement. In many regions, local mental health

providers do not participate in Medicaid, requiring the

child welfare agency to purchase services with their

own funds. With looming Medicaid cutbacks affecting

the care of children in foster care (Rubin, Halfon,

Raghavan, & Rosenbaum, 2005), mental health and

child welfare agencies will likely face increasing

83.8%

43.2%

37.8%

45.9%

37.8%

8.1%

75.0%

56.3%

49.4%

12.5%

37.5%

40.6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Frequent change of placement

Underreporting of MH problemsby foster parents

Underreporting of MH problemsby social workers

Underreporting of MH problemsby physicians

Other

No barriers

Per

cen

t o

f M

enta

l Hea

lth

Ag

enci

es

State Mental Health Agencies (N=37) County Mental Health Agencies (N=32)

Fig. 1 Percent of mentalhealth agencies reportingbarrriers to the delivery ofMH services

Table 3 Funding sources for mental health services to children in out-of-home care

Service Medicaidor EPSDTa

Non-EPSDTMedicaid

EPSDT TitleIVfunds

Title Vfunds

CHIP Otherstatefunds

Otherlocalfunds

Other N*

Mental health component ofInitial health screening

25 8 21 4 1 13 10 3 2 25100% 32.00% 84.00% 16.00% 4.00% 52.00% 40.00% 12.00% 8.00%12 7 9 3 0 3 3 3 1 1392.30% 53.80% 69.20% 23.10% 0.00% 23.10% 23.10% 23.10% 7.70%

Mental health component ofcomprehensive healthassessment

24 9 20 4 1 9 9 1 0 24100% 37.50% 83.30% 16.70% 4.20% 37.50% 37.50% 4.20% 0.00%10 9 5 3 0 3 4 3 1 1283.30% 75.00% 41.70% 25.00% 0.00% 25.00% 33.30% 25.00% 8.30%

Mental health assessment 31 23 17 5 1 17 24 10 4 3491.20% 67.60% 50.00% 14.70% 2.90% 50.00% 70.60% 29.40% 11.80%23 19 12 3 1 4 14 15 5 2785.20% 70.40% 44.40% 11.10% 3.40% 14.80% 51.90% 55.60% 18.50%

Ongoing mental health services 32 26 16 5 1 19 27 8 5 3494.10% 76.50% 47.10% 14.70% 2.90% 55.90% 79.40% 23.50% 14.70%26 23 13 5 1 4 15 16 7 2989.70% 79.30% 44.80% 17.20% 3.40% 13.80% 51.70% 55.20% 24.10%

Mental health component ofhealth care case management

22 12 16 5 2 8 19 5 4 2684.60% 46.20% 61.50% 19.20% 7.70% 30.80% 73.10% 19.20% 15.40%10 8 4 4 0 1 6 7 3 1283.30% 66.70% 33.30% 33.30% 0.00% 8.30% 50.00% 58.30% 25.00%

Note: From total of 42 responding state and 37 responding county mental health agencies. Bold numbers and percents represent stateresponse and the other numbers and percents represent county response. Respondents were asked to indicate all sources of fundingused to pay for each service. Thus, total percentages equal more than 100%. Respondents were not asked to report the level of fundingfrom each sourcea Denotes that either EPSDT, non-EPSDT Medicaid, or both are reported

* Total mental health agencies responding to each item. In calculating the percentages, the denominator is the total agencies indicatingat least one payer for the particular service. Agencies that did not indicate any payer are treated as ‘‘missing’’ and not included in thedenominator

196 Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201

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resource constraints to delivering the current level of

care much less an improved, more comprehensive set

of services.

The majority of agencies identified placement insta-

bility as an important barrier to service delivery. The

problem of unstable placements and its adverse con-

sequences for mental health service delivery have been

previously documented for children (James et al., 2004;

Rubin, Alessandrini, Feudtner, Localio, & Hadley,

2004; Webster, Barth, & Needell, 2000). Our findings

reveal that placement instability is a significant concern

at the agency level, and suggest the need for program-

matic and policy interventions. Support for interven-

tions that support foster families, and that provide

mental health care for the child, can improve stability

of placements. The barriers reported by these agencies

were, however, limited and largely attributed to those

factors that were external to their own policies and

procedures. Most of these identified barriers are issues

that existing health care standards address, suggesting

that adopting these standards may be a concrete first

step toward quality improvement within public mental

health agencies. And while considerable collaboration

reportedly occurs between mental health and child

welfare agencies, little of this communication seems

focused on quality improvement. However, we cannot

determine the instrumental value of this communica-

tion, and whether it results in the kinds of program-

matic, policy, and service delivery alignment and

coordination between mental health and child welfare

agencies that is necessary to deliver care to such a

cross-sector population.

Policy Implications

Repurposing Child Welfare-Mental Health

Collaborations toward Quality Improvement

Mental health and child welfare agencies may view the

CWLA/AAP standards as standards of practice. In

other words, they may represent ideal processes of

service delivery rather than practical service delivery

outcomes that agency practice and policy should

actually achieve, measure, and be held accountable

for improving. In contrast, outcomes-focused standards

such as those imposed by the Adoption and Safe

Families Act of 1997 (ASFA), when backed by federal

regulation and financial consequences for non-perfor-

mance, have been shown to have high visibility and

moderate effectiveness in changing practice among

child welfare agencies (Mitchell et al., 2005). ASFA

provisions not only focus attention on ongoing

improvement within states, but also articulate the goal

of child well-being in addition to traditional child

welfare goals of safety and permanency, and opera-

tionalize its indicators.

Attention to both process and outcome is necessary

for the adequate delivery of mental health services to

child welfare populations. Because foster care place-

ment has both secondary prevention and treatment

goals for a child, elaboration of specific processes that

are required to assure high quality care across both of

these types of services is necessary to inform child

welfare and health policymaking. Simultaneously,

adoption of indicators that can guide mental health

and child welfare agency practice toward improving

mental health outcomes for children in foster care is

also necessary. Adoption of the CWLA/AAP stan-

dards in addition to ASFA may offer a more solid

foundation for quality improvement that addresses the

essential components of prevention and treatment.

However, assuring the emotional well-being of

children in foster care requires the elaboration of

specific set of processes like the ones that are outlined

in the CWLA-AAP-guidelines that can produce

practice improvement, linkage of these steps with

outcomes monitoring, and an explicit orientation

toward achieving such performance outcomes, which

are all processes that few agencies may be currently

able to readily deploy. Mental and child welfare

agencies are each responsible for outcomes that are

influenced by the other agencies’ policy decisions.

Despite these challenges, models for quality improve-

ment initiatives exist at the state level (Daleiden &

Chorpita, 2005; Markus, Rosenbaum, Sonosky, Repa-

sch, & Mauery, 2005). The inclusion of the unique

needs of children in foster care within national quality

benchmarking efforts (Dougherty, Meikle, Owens,

Kelley, & Moy, 2005; Margolis, 2004) may further

accelerate the ‘uptake’ of standards into child welfare

and mental health agency practice.

Implementing Policy Within Programs

A policy focus on outcomes is necessary but insuffi-

cient for organizational change. Quality improvement

efforts require institutional templates, practical strate-

gies, well-defined procedures, and feasible mecha-

nisms, within which such efforts can occur; all of

these efforts need to be replicated over time and across

service settings (Burns, 2003; Carpinello, 2002; Grol,

2001; Torrey et al., 2001). Several model programs

exist that may suggest possible approaches to increas-

ing the quality of service delivery. One fiscal approach

might be the development of pay-for-performance

Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201 197

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plans for health care delivery to children in child

welfare environments, similar to those called for in

Medicare (Berwick et al., 2003). However, Medicaid

managed care plans have posed considerable chal-

lenges to states attempting to become prudent pur-

chasers of care, and greater rate-setting ability by states

may be necessary to institute such plans (Fossett et al.,

2000). An organizational approach may be the adop-

tion of foster care carve-outs preferably with risk-

adjusted capitation rates that allow adequate resources

to finance the complex health and mental health needs

of children in foster care. Colorado currently provides

higher capitation rates for children in foster care

(McCarthy, 2003), but few states have implemented

traditional features of a carve-out (i.e., specialized

managed systems for care of a designated population

such as those created in Medicaid behavioral health

carve-outs) (Frank, Huskamp, McGuire, & Newhouse,

1996).

One provider-directed approach is the Institute for

Healthcare Improvement’s Breakthrough Series

(Homer et al., 2005; Institute for Healthcare Improve-

ment, 2003; Kilo, 1998). This methodology has been

used by the National Initiative for Children’s Health-

care Quality (www.nichq.org/nichq) to improve quality

of care for children in foster care. This initiative

attempted to support multi-agency teams from several

states to develop improvement plans and measurement

strategies designed to improve health care evaluation

content, care coordination, and follow-up in services

received. These multi-agency teams were drawn from

child welfare, child health, mental health, and Medic-

aid agencies and also required participation by parents

and providers. Quality improvement efforts under-

taken by the National Child Traumatic Stress Network

(www.NCTSN.org) also follow a similar model. The

widespread use of such practical strategies directed

explicitly toward child health quality is necessary to

improve the delivery of mental health care to children

in foster care.

Leveraging Financial Resources

While Medicaid has an expansive medical necessity

definition for children through its Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT) pro-

gram, covered services vary considerably across states

(American Academy of Pediatrics, 2005; Blanchard,

2004; Fox & McManus, 2001; Lerner, Gesek, &

Adams, 2003). Nearly all children in foster care and

most services needed by children in foster care are

eligible for coverage under EPSDT. However, there

are differences across states between what EPSDT

covers and what the CWLA and AAP standards call

for (Horvath, 1997), and Medicaid benefits and pay-

ment provisions are complex and often poorly

addressed or accessed. Given the poor access to mental

health care documented in prior studies and the

relative lack of policies and procedures supporting

access that are documented in this study, Medicaid

programs should consider the establishment of disease

management programs for mental health care for

children in foster care, performance-based monitoring

of indicators of high-quality care that incorporates

existing standards, and outcomes-based reimbursement

of such care. The new provisions of the 2005 Deficit

Reduction Act (DRA) will force many states to

re-examine the scope of benefits available to children

in their state Medicaid plans, including those in foster

care, and also result in changes in how EPSDT services

can be deployed (Rubin, Halfon, Raghavan, Rosen-

baum, forthcoming).

Limitations

First, mental health and child welfare services in the

United States are organized at both the state and

county levels, with the bulk of child welfare services

organized at the state level. Hence, agencies are

heterogeneous in the extent to which they can influ-

ence specific aspects of service delivery for children in

foster care. Second, our focus was on institutional

policies and procedures governing adoption. It is not

known to what extent the existence of such agency-

level practices is associated with better child-level

outcomes, i.e., translates into implementation of high-

quality services throughout the agency and by individ-

ual providers. Third, the extent to which agencies

provided knowledgeable respondents determines the

extent to which our findings represent an accurate

assessment of administrative policies and procedure as

well as knowledge and attitudes. Although agency

heads were encouraged to solicit input from the most

knowledgeable staff, the extent to which this actually

happened is unknown. Finally, our respondents were

asked to report on highly complex and differentiated

systems, and may have been unable to adequately

capture their subtleties.

Conclusion

Mental health and child welfare agencies today face

considerable organizational and policy challenges in

their attempts to deliver care to children in foster care,

and the CWLA, AAP and AACAP have all issued

198 Adm Policy Ment Health & Ment Health Serv Res (2007) 34:191–201

123

standards to ostensibly improve the delivery of health

and mental health services to children in foster care.

However, our findings indicate that these standards are

not well known to the public mental health agencies

that provide care to child welfare populations. The

1997 ASFA legislation, and the emphasis on improving

mental health outcomes provides a unique opportunity

to revisit existing CWLA, AAP, and AACAP stan-

dards, and revise them in keeping with other similar

standards-driven performance improvement efforts

underway nationally. Attention is also necessary to

ensure that updated and upgraded standards can be

disseminated and implemented not just in child welfare

agencies but in all collaborating agencies, including

those in the mental health sector. Taking advantage of

these opportunities may allow child-serving agencies to

comprehensively promote the well-being of children in

our nation’s foster care system.

Acknowledgments This study was funded by the Maternal andChild Health Bureau (MCHB) through a partnership with theAdministration for Children and Families (ACF) with advisoryinput from the Public-Private Partnership Subcommittee of aTechnical Advisory Group convened by MCHB and ACF.Federal partners included the Centers for Medicare andMedicaid Services (CMS), and the Substance Abuse andMental Health Services Administration (SAMHSA). Thesurvey was developed and fielded by the National Center forInfant and Early Childhood Health Policy at the University ofCalifornia, Los Angeles with funding from the MCHB. Theauthors thank Alex Zepeda for work on a previous version ofthis manuscript, Alan Steinberg for helpful suggestions on aprevious version of this manuscript, and Preston Finley forassistance with the references. The opinions expressed in thisarticle are those of its authors, and do not necessarily reflectthose of MCHB, CMS, ACF, SAMHSA, or the National Centerfor Infant and Early Childhood Health Policy.

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