86 Falling between the gaps, again, and again: the lack of coordination between health care and the child welfare system

Abstract

About 7% of youth in Ontario will have child welfare involvement at some point in their life. (Fallon, 2011) Up to 60% of children will meet criteria for a mental health diagnosis, and upon transition out of care 30% will have unaddressed health care needs. Following coroner recommendations from inquests into the deaths of Katelynn Sampson and Jeffrey Baldwin, last year another twelve youth died while in the care of the child welfare system. The 2018 coroner’s report again concluded there was lack of information sharing between societies and healthcare providers. (Cromarty, 2018) It has been established that social determinants of health contribute to the unaddressed health needs of these youth. In contrast, modifiable system level factors that can improve the collaboration and coordination between the healthcare system and Children’s Aid Societies has not been extensively analyzed. To use a policy analytic framework to outline the linkages between the healthcare system and the Children’s Aid Societies (CAS)s with the purpose of identifying factors that increase coordination, collaboration and information sharing within the child welfare system, and between the child welfare system and the healthcare system in Ontario. This paper will explore policy developments and choices that influence the information sharing structures between the child welfare and health care system using the policy analysis “3-i” conceptual framework – an analysis of the role of interests, ideas, and institutions. Interests refers to agendas of societal groups, civil servants, researchers etc. Ideas refers to knowledge and beliefs including research. Institutions refers to formal and informal rules (legislation) and organizational factors. Although some of the issues presented in this paper intersect with those of Indigenous child wellbeing societies, the health needs for this overrepresented population in the child welfare system necessitates a distinct analysis, and are not included in this paper. Institutions: Children are admitted to one of 49 CASs in Ontario. On admission or transfer to any CAS, legislation requires physician physical examinations within 48 hours. In Ontario these are most often completed at walk-in-clinics without medical history. No mental health screening or plan for healthcare follow-up is mandated. The current legislation does not does not track child health outcomes and the current funding formula for CASs does not include healthcare. See Figure 1.Ideas: Despite access to healthcare children did not use healthcare if a need was not identified by their CAS worker, or if workers were not equipped with resources to navigate the healthcare system. (Stiffman, 2004) In Ontario, only 1/3 of children in the child welfare system who were self-harming or voiced suicidality were referred to a mental health professional by their worker. (Baiden, 2018) The gateway providers for healthcare for children in care are their CAS workers. Interests: The Canadian Paediatric Society (CPS) is one of the governing medical bodies with interest in providing the primary health care to children and youth in care. A joint position statement by the CPS and family physicians could set the standard of medical care for children in the welfare system. The Ontario Association of CASs (OACAS) has the potential to systematically report upon performance indicators and outcomes without attributing results to specific CASs thereby providing a form of liability protection. Adverse childhood events and social determinants of health contribute to the health of children in the child welfare system. However, this analysis has identified modifiable system level factors that need to be targeted or else health advocacy initiatives will not have their expected impact. Importantly, we have identified child health workers as the gateway providers for the health of children in care, implying that future advocacy initiatives should include workers as key collaborators.