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Program/Project Name Health Care Access and Coordination for Children and Youth in Foster Care
Affiliation Name Medical College of Wisconsin
Website URL
Model Type Medical Home
City Milwaukee
State WI
State specific location Academic medical center-Child protection Center and primary care clinic
How is program/project funded?
Describe how it's funded

 AAP Chapter Grant from the AAP COFCAKC

What services does it provide Entry to care health assessment, Comprehensive health assessment, Subspecialty referrals, Ongoing primary care/medical home, Coordination and Communication of Health needs for children entering foster care
Where does it provide services County-based
Description of program/project

The goal of this project is to pilot the role of a health care coordinator for a select group of youth in foster care in Milwaukee County to assure their 30-day comprehensive health assessment (CHA) is being performed, to evaluate if health needs are being met in a timely fashion, and to assist in coordination and communication of these needs between providers during the child's first 90 days in foster care. The health care coordinator will ensure that all youth being seen by the Child Protection Center  for an initial screening exam (most children entering care in Milwaukee County) will establish care by a medical home provider for their 30 day CHA. In addition, there will be a smaller subset of youth who will be tracked more closely with care coordination services. These youth will be patients at the primary care clinics staffed by providers involved in the grant. The health care coordinator will provide care coordination services to facilitate completion of the 30 day CHA referrals in a timely fashion. Lastly, tracking of frequency of referrals, barriers to referral completion, and time required to do care coordination will be measured.

How are patients tracked? Commercial electronic medical record, EPIC
Provide special focus No special focus
Program/Project strengths

This project will build on existing resources and relationships previously established in Milwaukee County between child welfare agencies and PI's on the grant. Our EPIC record already has summary forms which are excellent communication tools which document health needs and referrals, making it straightforward for health care coordinator to abstract information. Full access to subspecialists, thru Children's Hospital of WIsconsin, is available. We hope that the health care coordinator will have acess to the child welfare database to facilitate care management. Child welfare agencies are being measured on the completion of 30 day CHA's in a timely fashion so they are motivated to partner with us to improve this outcome. Great interest and motivation exists between partners due to an upcoming pilot program which will manage the healthcare of children in foster care in 6 SE WI counties, including Milwaukee. THe grant's experience and data will be used to help build this pilot program.
One goal is to have the health plan integrated into permanency plan of the child.


Program/Project challenges

This project is in its early phases of establishment. We predict that barriers will include inability to obtain consent for referrals (especially mental health) in a timely fashion, and inadequate resources available to meet the needs of the youth (timely access to dental care).  Ongoing education of foster parents and child welfare professionals (to assure timely completion of referrals) will be an important  role of the health care coordinator.


Contact Name Lisa Zetley
Email Address
Phone Number 414 277-8900