Based upon a memorandum of understanding (MOU) between DCBS and the Commission for Children with Special Health Care Needs (CCSHCN), CCSHCN may provide nursing consultation to DCBS staff and foster parents or biological parents for children in or at risk of entering out of home care (OOHC). CCSHCN is additionally available to provide nursing consultation to DCBS staff and foster parents for children and youth designated as medically fragile.
- The SSW begins the referral process to the local CCSHCN office by completing the M-002 CCSHCN Medically Fragile Referral Form, then forwarding the M-002 and the following information to the regional medically fragile liaison:
- A copy of the individual health plan (IHP) or relevant medical information about the child’s medical condition;
- A signed CCSHCN Notice of Privacy Practices form;
- A copy of the custody order granting DCBS custody;
- A copy of the child’s insurance or Medicaid card or other verification;
- The CCSHCN M-001 CCSHCN Verbal Release of Information;
- A copy of the DPP-106A Authorization for Medical Treatment; and
- Other pertinent medical information or medical records;
- The medically fragile liaison makes a referral to CCSHCN with the information requested in procedure #1 of this SOP;
- If all information is not available, the regional medically fragile liaison may make the referral to CCSHCN and request that the SSW provide the information to CCSHCN within thirty (30) calendar days of the initial referral.
For any child in OOHC or at risk of being placed in OOHC:
- May refer the child to the regional CCSHCN nurse consultant inspector (NCI) by:
- Written referral using the F-001CCSHCN Nurse Consultant Referral Form;
- Phone call;
- Email; or
- In person;
- Makes an initial joint home visit with the CCSHCN nurse, and utilizes nursing consultation.
- The CCSHCN nursing consultant may:
- Provide medical education and resources, as well as, nursing expertise related to the interpretation of medical records to DCBS staff, foster parents and biological parents when the permanency goal is reunification;
- Work in a consultative role to assist the SSW in determining accidental versus non-accidental trauma;
- Serve as consultant to the SSW, foster parents and biological parents and as an advocate for the foster child who may be placed in OOHC;
- Act as a resource, when reunification is the permanency goal, to the birth family and SSW as they identify and plan for the child’s health care needs;
- Assist with transportation arrangements as needed, but may not transport the child;
- Assist in the coordination of care with the child’s primary care provider and may consult with the DPP Medical Support Section, University of Louisville Living Forensics Unit, and other community resources as warranted by the situation;
- Review and assess the foster child’s medical passport upon entry into the foster care system to assure that it is up to date, and notifies the SSW if problems exist with the foster child’s preventative health care;
- Assist the SSW with the assessment and monitoring of the foster child’s medical needs after a referral is received;
- Offer fluoride varnish applications to foster children ages zero to six (0-6) years when on a foster home visit and any other child residing in the foster home with the eligible age range;
- Attend individualized educational plan (IEP) meetings and provide input for the individualized graduation plan (IGP) for foster children; and
- Assist with transition issues, which may include preparation for the transition from pediatric to adult health care, transition from one (1) foster care home to another or transition to another school district.
- For medically fragile foster care, CCSHCN nurses may:
- Provide medical education and resources to DCBS staff and the foster care family;
- Offer fluoride varnish applications to the medically fragile child ages zero to six (0-6) years, and any other children residing in the foster home that are within the eligible age range;
- Continue visiting the medically fragile child with the SSW if the child is returned to the birth family, if requested;
- Attend meetings for the IEP, and provide input for the IGP;
- Partner with DCBS to identify and recruit potential foster families; and
- Provide ongoing training and support to caregivers.
- The CCSHCN nurse visits a child designated as medically fragile at least one (1) time per calendar month in the placement setting, which includes a DCBS resource home, a private child placing foster home, PCC residential placement or a supports for community living (SCL) program.
- The face to face visit by the nurse, satisfies the agency’s requirement that the child be seen two times each calendar month.
- The CCSHCN nurse sends a copy of the contact note to the SSW, which is filed in the hard copy case.
The CCSHCN nurse:
- Schedules an initial individual health plan (IHP) meeting within thirty (30) calendar days of the child's placement or designation as medically fragile;
- Invites the members of the medically fragile service team including, but not limited to the following people, to assist with the child’s planning:
- Birth parents;
- Resource parents and either the R&C worker or private agency staff, as applicable;
- Medical providers;
- Service providers;
- Medically fragile liaison; and
- Any other appropriate family member;
- Requests written recommendations prior to the meeting and documents oral information provided by the team members in the child’s case record, all of which are considered at the IHP meeting if a team member is unable to attend;
- Completes the medically fragile child’s DPP-104B Individual Health Plan and distributes copies to all team members, including the Medical Support Section of Protection and Permanency (P&P) following the initial IHP meeting and every six (6) months thereafter;
- Schedules additional IHP meetings once every six (6) months for the team to review the child's ongoing needs and re-evaluates the child's continued medically fragile status;
- Contacts the Medical Support Section if the medically fragile service team determines that the child no longer requires a medically fragile designation.