Medical Fragility Research Articles

A quality improvement evaluation of a standardized intervention for children with medical complexity transitioning to adult care.

Children with medical complexity have medical fragility, chronic disease, technology dependence, and high healthcare use. Their transition to adult health care at age 18 involves medical and social elements and follows no standardized process. Our goal was to improve transition readiness in children with medical complexity using a transition intervention within a Complex Care program. All children with medical complexity aged 14 to 18 were included in this quality improvement (QI) project (n = 54). We conducted a pre- and post-intervention chart review to assess transition outcomes and implemented a transition intervention for 6 months, which included an age-stratified checklist, charting template, and transition rounds. Before the intervention, 72% of 17- to 18-year-old patients had documented transition discussions, which increased to 86%. Patients with a family physician increased as well (61% to 73% for 17- to 18-year-olds). Three transition education rounds were held. The intervention increased transition readiness, provided tools to facilitate transition, and created a forum for conversation.

Risk and protective factors associated with child welfare involvement among maternal-infant dyads affected by prenatal substance use

A 5-year retrospective cohort study (n = 4,178) was conducted to identify trends and outcomes associated with child welfare-involved maternal-infant dyads affected by perinatal substance use in Colorado. Two linked data sources were used: (1) vital records birth and death certificate data on live births between 2013 and 2019 and (2) child welfare data from the Statewide Automated Child Welfare Information System. Data integration and de-identification work was accomplished by the Linked Information Network of Colorado and authorized by state legislation. Two tools were available for identity resolution: (1) the Senzing identity resolution application and (2) SQL queries. Binary logistic regression was used to explore how a birthing person’s demographic characteristics, use of prenatal care, Special Nutrition Program for Woman, Infants, and Children (WIC) enrollment during pregnancy, health of birthing person during pregnancy and delivery, and the newborn’s health at the time of birth related to child welfare removal within the first 60 days. Factors associated with an increased risk of infant removal includeless than adequate prenatal care, lower household income, low participation in WIC, andgreater medical fragility of the newborn. For infants removed from the home, the rate of placement with relatives while in foster care decreased by 15 % (2016–2019). This is a concern as placing children with relatives is shown to promote healthy child development. Findings bring into focus opportunities for prevention, treatment, and support of maternal-infant dyads affected by substance use during the perinatal period and offers insight into early entry points for preventing the need for family separation by child welfare.

Inpatient Rehabilitation of Hematopoietic Stem Cell Transplant Patients: Managing Challenging Impairments and Medical Fragility.

Hematopoietic stem cell transplants play an important role in the treatment of cancer, particularly hematologic malignancies. These patients can encounter functional impairments unique to hematopoietic stem cell transplant, including deconditioning, cancer-related fatigue, steroid myopathy, graft versus host disease, and capillary leak syndrome. Medical fragility and increased risk of infection may make rehabilitation challenging on the acute care and postacute care settings. Patients admitted to acute inpatient rehabilitation experience a high rate of transfer to the primary acute service and high rate of mortality after transfer back. Physical medicine and rehabilitation physicians can use a number of strategies to mitigate these patients' risk of medical complications including evidence-based predictive models to assist with postacute rehabilitation triage, physiatry-led consult-based rehabilitation, and oncology hospitalist comanagement on inpatient rehabilitation.

An mHealth Design to Promote Medication Safety in Children with Medical Complexity.

Children with medical complexity (CMC) are uniquely vulnerable to medication errors and preventable adverse drug events because of their extreme polypharmacy, medical fragility, and reliance on complicated medication schedules and routes managed by undersupported family caregivers. There is an opportunity to improve CMC outcomes by designing health information technologies that support medication administration accuracy, timeliness, and communication within CMC caregiving networks. The present study engaged family caregivers, secondary caregivers, and clinicians who work with CMC in a codesign process to identify: (1) medication safety challenges experienced by CMC caregivers and (2) design requirements for a mobile health application to improve medication safety for CMC in the home. Study staff recruited family caregivers, secondary caregivers, and clinicians from a children's hospital-based pediatric complex care program to participate in virtual codesign sessions. During sessions, the facilitator-guided codesigners in generating and converging upon medication safety challenges and design requirements. Between sessions, the research team reviewed notes from the session to identify design specifications and modify the prototype. After design sessions concluded, each session recording was reviewed to confirm that all designer comments had been captured. A total of N = 16 codesigners participated. Analyses yielded 11 challenges to medication safety and 11 corresponding design requirements that fit into three broader challenges: giving the right medication at the right time; communicating with others about medications; and accommodating complex medical routines. Supporting quotations from codesigners and prototype features associated with each design requirement are presented. This study generated design requirements for a tool that may improve medication safety by creating distributed situation awareness within the caregiving network. The next steps are to pilot test tools that integrate these design requirements for usability and feasibility, and to conduct a randomized control trial to determine if use of these tools reduces medication errors.

Rapid genome diagnosis of alveolar capillary dysplasia leading to treatment in a child with respiratory and cardiac failure.

Alveolar capillary dysplasia (ACD) is a fatal disorder that typically presents in the neonatal period with refractory hypoxemia and pulmonary hypertension. Lung biopsy is traditionally required to establish the diagnosis. We report a 22-mo-old male who presented with anemia, severe pulmonary hypertension, and right heart failure. He had a complicated hospital course resulting in cardiac arrest and requirement for extracorporeal membrane oxygenation. Computed tomography of the chest showed a heterogenous pattern of interlobular septal thickening and pulmonary edema. The etiology of his condition was unknown, lung biopsy was contraindicated because of his medical fragility, and discussions were held to move to palliative care. Rapid whole-genome sequencing (rWGS) was performed. In 2 d it resulted, revealing a novel FOXF1 gene pathogenic variant that led to the presumptive diagnosis of atypical ACD. Cases of atypical ACD have been reported with survival in patients using medical therapy or lung transplantation. Based on the rWGS diagnosis and more favorable potential of atypical ACD, aggressive medical treatment was pursued. The patient was discharged home after 67 d in the hospital; he is currently doing well more than 30 mo after his initial presentation with only one subsequent hospitalization and no requirement for lung transplantation. Our case reveals the potential for use of rWGS in a critically ill child in which the diagnosis is unknown. rWGS and other advanced genetic tests can guide clinical management and expand our understanding of atypical ACD and other conditions.

Drivers that decrease hospital-delivered care in children with medical complexity: Parental perspectives.

Children with medical complexity (CMC) have chronic and severe conditions leading to medical fragility. CMC represent less than 1% of children but account for one-third of paediatric healthcare expenditures. Enrollment to a complex care program (CCP) decreases health care resource utilization while improving parental satisfaction. An in-depth understanding of how these changes operate in real-world setting is needed to further support CMC and their families. This study aimed at assessing the possible reasons for a decrease in emergency department (ED) visits and hospitalization length of stay related to enrollment to a CCP, based on parental perspectives. Using a qualitative approach, data were collected using in-depth, semi-structured interviews with parents of CMC enrolled in a CCP from a university hospital centre in Montreal, Canada. The interview guide was co-constructed by an interdisciplinary team, including a parent partner and a clinical nurse coordinator. Themes have been identified inductively, using thematic analysis. Parents identified personalized care, family empowerment and guidance as enablers arising from the CCP that contributed to the decrease in hospital-delivered care utilization. Improvement in medical baseline condition was also identified as a contributing factor, while not necessarily related to program's support. In this study, we identified personalized care, parental empowerment, and guidance as three strategies for a CCP to potentially decrease ED visits and hospital length of stay, from the parents' perspective. Parents identified the clinical nurse coordinator as playing a central role in supporting the implementation of these strategies.

Point-of-Care Ultrasound in Children With Medical Complexity

Children with medical complexity (CMC) have significant chronic health conditions that involve congenital or acquired multisystem disease associated with medical fragility, functional limitations, dependence on technology, and high health care utilization. The objective of this study was to describe the indications, applications, and point-of-care ultrasound (POCUS) findings in this population. A descriptive study of POCUS scans performed for clinical purposes in CMC admitted to a single pediatric postacute care hospital. All children for whom a POCUS was requested by a medical team provider were eligible for inclusion. One hundred and four POCUS evaluations were performed for 33 patients. Diagnostic groups for the 33 patients included multiple congenital anomalies (41%), neurologic or neuromuscular (31%), prematurity (25%) and cardiac (3%). Lung, cardiac, and diaphragmatic ultrasound accounted for 57% of POCUS requested. POCUS was abnormal in 82% of diaphragmatic, 73% of lung, and 11% of cardiac ultrasounds. Twenty-three percent of POCUS studies were requested to answer a specific clinical question, 56% for follow-up information, and 21% for baseline evaluation. Lung, diaphragmatic, and cardiac ultrasound were the most prevalent POCUS studies requested in a postacute care hospital. POCUS may offer an expanded role in such patients and settings by answering clinical questions and by providing baseline and follow-up information.

Fragility and resilience: parental and family perspectives on the impacts of extreme prematurity

ObjectivesExtremely preterm babies have a significant risk of neurodevelopmental impairment (NDI). There has been little investigation regarding the impact of prematurity on families. The objective of this study was to...

Congruent Communication: Addressing Culture and Care for a Seriously Ill Rohingya Infant.

Pediatric palliative care teams seek to collaboratively promote the quality of life for children with serious medical illness in the context of the values expressed by the patient and family. Especially for infants with high medical fragility, shared decision making can be a complex task that often requires flexibility to respond to the clinical circumstances at hand, as well as contextualization within the family culture. In this paper, we present the case of an infant with a severe congenital brain malformation who was born in an American hospital to a Rohingya-speaking, Burmese family whose care preferences seemed to oscillate between comfort-focused and life-prolonging without clear acknowledgement of the consequences of shifting between treatment plans. Discussion of this case helps to illustrate the cultural factors, ethical challenges, and systems-level issues that can arise for medical teams in seeking to promote patient-centered care that respects family values while also honoring the principle of nonmaleficience.

Housing Need Among Children With Medical Complexity: A Cross-Sectional Descriptive Study of Three Populations.

Children with medical complexity (CMC) are hypothesized to have unique housing and accessibility needs due to their medical fragility and medical technology dependency; however, research on prevalence and types of housing need in CMC is limited. The objective was to describe housing need in families of CMC, and to compare housing need across CMC, children with one chronic condition (Type 1 diabetes; CT1D) and healthy children (HC). This cross-sectional descriptive study assessed housing suitability, adequacy, affordability, stress, stability, and accessibility using survey methodology. Participants were caregivers of CMC, CT1D and HC at a tertiary-care pediatric hospital. The association of housing need outcomes across groups was analyzed using logistic and ordinal logistic regression models, adjusting for income, educational attainment, employment status, community type, immigration status, child age, and number of people in household. Four hundred ninety caregivers participated. Caregivers of CMC reported increased risk of housing-related safety concerns (aOR 3.1 [1.3-7.5]), using a common area as a sleeping area (5.6 [2.0-16.8]), reducing spending (4.6 [2.3-9.5]) or borrowing money to afford rent (2.9 [1.2-6.7]), experiencing housing stress (3.3 [1.8-6.0]), and moving or considering moving to access health/community services (15.0 [6.4-37.6]) compared to HC. CMC were more likely to experience multiple indicators of housing need compared to CT1D and HC even after adjusting for sociodemographic factors, suggesting an association between complexity of child health conditions and housing need. Further research and practise should consider screening for and supporting housing need in CMC.

Progress, Persistence, and Hope: Building a System of Services for CYSHCN and Their Families.

Progress, Persistence, and Hope: Building a System of Services for CYSHCN and Their Families.

Pediatric Emergency Medicine Physicians' Perspectives on Emergency Care of Children With Medical Complexity: A Multi-institution Mixed-Methods Assessment.

Children with medical complexity (CMC) compose 1% of the pediatric population but account for 20% of pediatric emergency department (ED) visits. Previous descriptions of challenges and interventions to ensure quality of care are limited. Our objective was to elicit pediatric emergency medicine (PEM) physicians' perspectives on challenges and opportunities for improvement of emergency care of CMC, with a focus on emergency information forms (EIFs). We conducted a web-based survey of PEM physicians participating the American Academy of Pediatrics Section on Emergency Medicine Survey listserv. The survey was designed using an expert panel, and subsequently piloted and revised to an 18-item survey. Data were analyzed with descriptive statistics. One hundred fifty-one of 495 respondents (30%) completed the survey. Most respondents (62.9%) reported caring for >10 CMC per month. Whereas overall medical fragility and time constraints were major contributors to the challenges of caring for CMC in the ED, communication with known providers and shared care plans were identified as particularly helpful. Most respondents did not report routine use of EIFs. Anticipated emergencies/action plan was deemed the most important component of EIFs. Most PEM physicians view the care for CMC in the ED as challenging despite practicing in high-resource environments. Further research is needed to develop and implement strategies to improve care of CMC in the ED. Understanding experiences of providers in general ED settings is also an important next step given that 80% of CMC present for emergency care outside of major children's hospitals.

Dental care in children with medical complexity: A retrospective study.

Children with medical complexity (CMC) are defined by complex, chronic multi-system disease with significant medical fragility. Limited research exists on dental care in CMC, which is an important part of oral health and overall health. Objectives of this study were to (1) determine the frequency and type of dental visits at a tertiary paediatric hospital of all CMC between 2015 and 2020 and (2) identify the factors associated with dental visits. A retrospective chart review of the electronic records of CMC who were seen at a paediatric hospital from 2015 to 2020 was completed. The number and type of dental visits, demographic and clinical information were reviewed. Poisson regression models were used to test the association between the outcome (number of dental visits) and potential factors associated with receiving dental care. Four hundred and eighty-seven CMC (mean age=7.3±4.6 years, 43.7% female) were included in this study. CMC were seen by dentists at the hospital 4.4±3.8 times since 2015, which is approximately once per year over a 5-year period. Dental visits were mostly preventative (66.4% of all visits). CMC had more dental visits if they had dental care funding compared to no funding if they were living in a community with a population >100,000 people and if they were being followed by a greater number of sub-specialists. This study highlights the importance of funding, access to paediatric dental specialists, and care coordination support to improve access to dental care for CMC to optimize oral health.

Support for Community School Personnel Working with Pediatric Cancer Patients: A Quality Improvement Initiative.

Improved therapies and increased survival rates are sending more pediatric cancer patients and survivors back to their classrooms; however, most community school personnel lack training or experience in working with these students. The aim of this quality improvement project was twofold: (a) to evaluate community school personnel's perceptions of their preparedness to work with patients and childhood cancer survivors who have reentered the classroom; and (b) to standardize school reentry supports to improve community school personnel preparedness. Twenty community school personnel, prekindergarten through 12-grade teachers, guidance counselors, and administrators, who had previously worked with a pediatric cancer patient were surveyed regarding their experiences with the patient's school reentry. Responses were coded and analyzed, and a thematic map was created. School personnel reported concerns related to student functioning, such as academic readiness, cognitive impacts of treatment, social-emotional adjustment, physical ability to participate in school, and medical fragility. They also reported concerns related to their own ability to accommodate the student's needs. These results were used to design educational guides for community personnel consisting of information and resources to support them in managing the unique academic, social-emotional, physical, and medical needs of pediatric cancer patients and survivors in the classroom.

Parental perspective on important health outcomes of extremely preterm infants

Background and objectiveNeonatal outcome research and clinical follow-up principally focus on neurodevelopmental impairment (NDI) after extremely preterm birth, as defined by the scientific community, without parental input. This survey aimed...

22 Housing Need Amongst Children with Medical Complexity: A Cross-Sectional Descriptive Study of Three Populations

Abstract Primary Subject area Complex Care Background Children with medical complexity (CMC) have medical fragility, complex chronic disease necessitating specialized care, functional disability, and/or high technology dependence. Housing is an important social determinant of health, yet research on prevalence and types of housing need in CMC is limited. Housing need encompasses unstable (frequent moves), inaccessible (lack of ramps/lifts), inadequate (major repairs needed), unsuitable (not enough bedrooms), or unaffordable housing. Given the association between housing and health, housing need may be an important consideration when caring for CMC. Objectives The primary objective was to describe the prevalence of and factors related to housing need in CMC. The secondary objective was to compare housing need between CMC, children with one chronic condition (Type 1 diabetes; CT1D) and healthy children (HC) to understand the relationship between chronic conditions and housing need. Design/Methods This was a cross-sectional descriptive study. Housing affordability, adequacy, suitability, stability, and accessibility were evaluated through surveys administered to caregivers of CMC, CT1D, and HC at a tertiary-care paediatric hospital using convenience sampling. The association of binary outcomes of housing need between groups was analyzed using logistic regression models, adjusting for sociodemographic factors (income, education, employment, geography, immigration status). Results 453 caregivers participated (Table 1). Compared to caregivers of HC, caregivers of CMC had higher odds of reporting one or more moves in the last two years (1.3 times), having safety concerns (3 times), using a common area as a bedroom (5.2 times), and experiencing housing stress (3.2 times), after sociodemographic factors were adjusted for (Table 2). Families of CT1D also had elevated odds of some indicators of housing need compared to HC, although to a lesser extent than CMC. 62.2% of CMC indicated they had to reduce spending on basics in order to afford their rent/mortgage, compared to 35.9% of CT1D and 25.2% of HC. Nearly two-thirds of CMC (60.2%) reported a need for accessibility accommodations in their home. Of those who installed accommodations, 62.9% felt the installations were a financial burden (cost ranged from $800-$80,000). Conclusion Families of CMC had higher odds of reporting unstable, inadequate, unsuitable, and stressful housing compared to HC even after sociodemographic factors were accounted for, suggesting an association between complexity of child health conditions and housing need. Access to appropriate housing may improve the health of CMC. Health care providers can screen for housing need, become familiar with housing interventions, and advocate for improved resources to address housing need in CMC.

Child Maltreatment and Medical Fragility: Fatalities in the First Year of Life

In this month’s Pediatrics, Schneiderman et al examine infant deaths for medical causes among infants previously reported to child protective services.1 Using probabilistically linked birth records, child protective service records, and death records, the authors examined risk of death through the first year of life. Their analyses controlled for sex, race and ethnicity, maternal age, early prenatal care, insurance status, birth weight, and prematurity. Infants reported for maltreatment had an almost twofold increase in risk of for any medical cause of death.Are infants with serious medical conditions at higher risk for maltreatment or is maltreatment more likely to be detected among those with serious medical conditions? An increased risk for death would follow from prematurity, congenital abnormalities, or intrauterine exposure to infection.2 Children with these conditions likely require careful and more frequent medical encounters. Missed appointments and lack of follow-through on medications and treatment may be life-threatening. Medical teams caring for chronically ill infants are often sources of reports for neglect for infants whose caregivers fail to keep scheduled appointments, accept referrals, or take prescribed medications. Furthermore, the increased frequency of medical visits over the first year of life for ill children may also increase detection of sentinel injuries.3 Maltreatment may also be increased beyond failures in following medical care recommendations. Infants with chronic disease can contribute to financial and emotional stresses on their parents. Ill infants may be less capable of the responsiveness that helps create a strong bond between parent and child.4 Infants with chronic conditions may have high-pitched cries or disordered sleep patterns that add to parental stress. It therefore follows that infants with medical conditions are both at higher risk of maltreatment and more likely to be reported.The data from Schneiderman et al reveal that the outcome for infant medical conditions is dramatically altered by the family situation. Importantly, infants reported to child protective services and placed in foster care had the risk of mortality decreased by half. In the unadjusted analysis, the youngest mothers (<20 years old) had a 34% increase in the risk of infant mortality compared with older mothers. Poverty increases the risk for abuse and neglect.5 Young parents, with less schooling and fewer years in the workforce, are at an additional economic disadvantage. Poverty impacts survival of children with chronic medical conditions because poor families have increased exposure to risky environments and decreased access to health services.6Interventions to address this additional risk of mortality must be multifaceted.7 These interventions include paid parental leave, increased minimum wage, paid earned income tax credits, and access to long-acting reversible contraceptives for teenagers to prevent unwanted pregnancies.8 Many of these approaches address poverty directly. Community engagement programs such as Strong Communities9 reduce child maltreatment by giving visibility to the problem of child abuse and broadly engaging community members and medical practices in programs to support new parents. Home-visiting programs like the Nurse-Family Partnership10 for young first-time mothers enrolled prenatally and SafeCare11 for mothers of any parity with children enrolled in 20-week home-based educational program offer explicit and evidence-based support to new parents and have been shown to be successful.Additional strategies are needed after reports are made to child protective services. For example, child protective service agencies should include medical expertise in treatment planning and/or form partnerships with public health agencies to bring health expertise to judgements about the significance of missed appointments or undelivered medications.Forewarned is forearmed. Medical conditions represent a serious threat to the lives of infants reported to the child protection system. General and subspecialty pediatricians who have reported an infant for neglect or abuse or who have a reported infant in their practice must ensure continued care for the infants after a report. Child protective service professionals need to be aware of the elevated risk of death among their charges from disease and facilitate ongoing medical care.

Emergency department usage by adults with cerebral palsy: A retrospective cohort study.

To retrospectively profile the ED usage for a cohort of adults with cerebral palsy (CP). Five years of ED data from a Victorian hospital network was analysed to identify participants with CP using the Victorian Emergency Minimum Dataset supplemented with scrutiny of inpatient admission data to identify cases because of limited ED coding of CP. Presentation frequency, emergency diagnoses (International Classification of Diseases, 10th Revision codes) and presentation sequelae were calculated and described. An investigation into rates of low urgency presentations was conducted. Differences between adult and paediatric cohorts were described. Participants with CP constituted 1586 ED presentations. Adults represented 43% (n=689) of these. Thirty percent of adults presented more than five times over the study period, with respiratory (25%), gastrointestinal (17%) and epilepsy/convulsion diagnoses (11%) being the most common presentations. Rates of inpatient hospital admissions from the ED increased with age in adults (P < 0.001). Low urgency presentations made up 8.9% of total adult presentations. The high rates of respiratory diagnoses and epilepsy/convulsions, both ambulatory care-sensitive conditions, may be indicative of transitional challenges between paediatric and adult healthcare, potentially highlighting difficulties in accessing primary care services. Relatively low rates of 'low urgency' presentations may suggest perceived medical fragility in this vulnerable population. People with CP who present to ED and were not admitted may be underrepresented in this data. National expansion of this research will aid the development of an evidence-based model of care for CP in Australia.

Parents of Children With Medical Complexity Are Essential Health Care Personnel

* Abbreviations: CDC — : Centers for Disease Control and Prevention CMC — : children with medical complexity COVID-19 — : coronavirus disease 2019 The coronavirus disease 2019 (COVID-19) pandemic has created a national and global crisis. The United States has invested tremendous effort and resources to fast track severe acute respiratory syndrome coronavirus 2 vaccines from conception to market in 1 year, an amazing scientific achievement. Public health experts are now leading the distribution of COVID-19 vaccines. The Centers for Disease Control and Prevention (CDC) recommends that health care personnel be offered COVID-19 vaccination during the early phases of distribution. Health care personnel are broadly defined and include emergency medical service personnel, nurses and nursing assistants, physicians, technicians, therapists, dentists, dental hygienists and assistants, phlebotomists, pharmacists, students and trainees, contractual staff, dietary and food services staff, environmental services staff, and administrative staff. We strongly recommend that parents and family caregivers (collectively referred to as parents in this article) of children with medical complexity (CMC) be included in the early phases of vaccine distribution because they serve as essential frontline health care personnel. CMC have significant chronic health conditions that involve multiple organ systems, substantial health service needs, major functional limitations, and high health resource use. They have high levels of medical fragility, technology dependencies (tracheostomies, ventilators, feeding tubes, intrathecal baclofen infusion systems, and others), and psychosocial complexities. We identify CMC as those who have ≥3 organ systems affected (≥3 Feudtner … Address correspondence to Nancy A. Murphy, MD, FAAP, FAAPMR, Division of Pediatric Physical Medicine & Rehabilitation, Department of Pediatrics, School of Medicine, University of Utah, 81 North Mario Capecchi Dr, Salt Lake City, UT 84113. E-mail: nancy.murphy{at}hsc.utah.edu

CREATING NORMALCY: FOSTER CARE FOR CHILDREN AND YOUTH WITH DISABILITIES AND MEDICAL FRAGILITY IN GERMANY

In the area of foster care concerning children and youth with special needs due to disability or medical fragility, there is a paucity of knowledge and research. In Germany, these groups in foster care who have high special needs are an invisible and neglected population at risk. These children and youth are mostly cared for in residential homes; however, some are living in foster families and benefit from a familial setting. The purpose of the study was to understand how foster parents manage their lives with a child or youth who has special needs, and how they meet the challenges that arise. The qualitative research design used the method of narrative inquiry through in-depth interviews, which were conducted in the German state of Saxony-Anhalt with 19 foster parents from 15 families. Within the framework of grounded theory, the author developed a theoretical structure of the strategies foster parents use for coping. Results showed that foster parents dealt with this new and often unpredictable situation by applying one of three patterns of strategies — action-, resource-, or reflection-oriented — based on their personal experiences and worldview. Understanding these behavioral patterns gives administrative and supportive entities like child welfare systems and agencies a unique and tailored approach to recruit, retain, train, and counsel foster families adequately, and to strengthen their well-being and their ability to perform well for themselves and their children and youth.