TEAM SPOTLIGHT: FOSTERING WELL-BEING

Providing care coordination to our clients is central to helping them live with good health, independence and control over their decisions. Although most of HCS’s work involves older adults and adults with disabilities, the Fostering Well-Being team focuses on care coordination for children.

Fostering Well-Being, part of the Office of Well-Being, Improvement and Nursing (WIN), provides expert medical consultation for children in foster care who have significant medical, behavioral and/or mental health needs. Every year, the Fostering Well-Being team works with about 4000 kids – about 300 every month – with the goal of improving health outcomes through care coordination services.

“It’s such a unique body of work for ALTSA and HCS,” said Dawn Shuford-Pavlich, Office Chief for WIN. “The volume of work they do is off the charts. It has been for years and they just keep going steady. It’s really amazing. This is very challenging and compelling work with limited resources and this team has an unwavering commitment to these medically fragile children in foster care. I am so proud of this team and the work they do!”

This tiny team consists of Chani Hayes, the Fostering Well-Being Unit Manager, one Outcome Improvement Specialist, one Program Specialist, and two registered nurses and five pediatricians who serve as part-time Regional Medical Consultants. Chani has been with the program since its inception 11 years ago and has served as its Unit Manager since January 2020.

Originally part of Health Care Authority, the program migrated to ALTSA several years ago. Now, the program staff work in coordination with social workers and program management at the Department of Children, Youth and Families (DCYF) to support the care coordination needs of kids in foster care.

Through care coordination, the team aims to provide appropriate health care and timely and accessible services so that children don’t experience gaps in

health care when they move. The team also assists with coordination of wraparound services, including educational services, therapies, and behavioral health.

One of the biggest pieces of work is the development of comprehensive health overviews for children so that their new medical teams have a full picture of the child’s health history and can begin appropriate care immediately. This not only helps the kids with their transitions, but it provides risk mitigation for DCYF and provides social workers with a resource to answer Medicaid benefit questions or services such as durable medical equipment or pharmacy issues resolved.

“It’s difficult work. These aren’t fun stories that my team reviews,” Chani said. “But they’re so resilient and find ways to support each other. The dedication to continue to improve these kids’ lives is pretty amazing for this small team.”

In 2021, this tiny team handled more than 11,000 contacts and completed 131 comprehensive health overviews. Some of the children served are on the Fostering Well-Being caseload for a short period, while others may remain for longer, depending on their needs, such as high medically complex or medically fragile children.

Although the team is very busy with their current caseload, they do take time to support foster children in other ways too. Over the holidays, the team works with the DCYF office in Shelton to collect gifts for kids in foster care.

“The thing that really sticks out to me is the dedication of all the team members and how much they care deeply about the kids and ensuring they get all the care they need,” Dawn said. “I don’t know that I’ve seen a group work harder with the endless volume of work that just keeps coming. It’s not the kind of work that’s ever finished.”

Alexis’s Story

Alexis is a non-verbal, non-mobile client who lived in a medically fragile group home. She was going to age out at 21 years of age and needed to be transitioned to adult services before her birthday or the group home would lose funding every day that she remained. Not only did Alexis need to move to a home with the appropriate level of care, such as an adult family home, but she also had specialty equipment and a sand bed that had to be coordinated in this move. The coordination with Health Care Authority, Developmental Disabilities Administration and the vendor for the specialty equipment took months but she was successfully transitioned to her new home.

Naya’s Story

Naya was seen by a dermatologist in Washington due to a skin anomaly. Her biological parent thought that Naya had previously been seen by a dermatologist in Texas and that she had a biopsy with a diagnosis of skin cancer but couldn’t remember where she was seen. The Washington dermatologist tried to contact Texas providers but was not successful. The Fostering WellBeing nurse called every dermatologist in the area the child lived in previously in Texas and was able to find the provider, obtained records and connected the providers from each state for continuity of care.