Cross-System Collaborations

Behavioral healthcare services are a vital component in building true prevention supports for children who may be at risk of child welfare involvement. Unlike child welfare funding streams – including so-called prevention funding through Families First, Medi-Cal does not require that a youth be a candidate for foster care or even to be known to the child welfare system as all. Consequently, child welfare systems interested in building tertiary prevention programs can work with their local Children’s Behavioral Healthcare systems to expand and/or strategically deploy prevention services to help children stay at home with family and to remain in supported, successful informal or formal kinship care homes.

In California, these supports come from two main systems: the Specialty Mental Health System (delivered via County Mental Health Plans) and the Non-Specialty Mental Health System (delivered through managed care).

Specialty Mental Health Services (SMHS) for Kinship Care

CalAIM, an initiative through the Medi-Cal 1915b waiver and 1115 Demonstration Project, makes it easier than ever for children on Medi-Cal to access needed specialty mental health services. It adopts a trauma-based access criteria model, meaning that children who have experienced trauma are defacto eligible for medically necessary services through the specialty mental health system. Children may meet this eligibility criteria through trauma screenings through the local mental health agency. For foster children, including those with involvement in the juvenile justice system or homeless population no trauma screening is necessary; instead, they are considered presumptively to meet the trauma based access criteria because either of the situations that led to involvement in those systems or as a result of involvement in the systems themselves.

Practically, this means that children involved in the child welfare system should be immediately referred to the specialty mental health system and should receive a service.

Intensive Care Coordination (ICC) is a baseline Specialty Mental Health Service (SMHS) that was established as a result of the Katie A. settlement. While all children on Medicaid may receive it, it is especially applicable for foster youth who are being served by multiple agencies because of its coordinator function. Specifically, per the Medi-Cal manual at page 10:

• If a beneficiary is involved with two or more child-serving systems, the child should be getting ICC and the MHP should utilize ICC to facilitate cross system communication and planning.

Further, ICC is to be delivered according to the Integrated Core Practice Model (ICPM) (see DHCS’ own description) and as such is intended to be an important part of the Child and Family Team (CFT) to help coordinate all services across systems (ACIN I-21-18). The ICPM is aligned with the national wraparound standards and is really intended to build a team around the youth, to provide anything it takes to help meet a youth’s needs and not to require a child to fail up into services.

Importantly, ICC is not intended to only coordinate mental health care but to coordinate all services the child may need. See the Medi-Cal manual at page 10:

• ICC is intended to link beneficiaries to services provided by other child-serving systems; to facilitate teaming; and to coordinate mental health care.

For a list of examples of children who might benefit from ICC, see the Medi-Cal manual beginning at page 9. Please note that the manual has not been updated to include the new definition of access criteria that was
implemented by Behavioral Health Information Notice (BHIN) 21-073, making it clear that all youth in the child welfare system are categorically eligible for SMHS. Relatedly, the DCHS screening tool automatically refers a child in the foster care system to the MHP for a clinical assessment for what SMHS they should receive based on medical necessity.

Some children – especially those who do not presumptively meet the SMHS access criteria (e.g., not involved in the child welfare, juvenile justice or youth homelessness systems) may instead receive non-specialty services through the managed care system. Three benefits through the non-specialty system may be especially important for child welfare prevention, intervention and youth in informal kinship care homes.

Enhanced Case Management (ECM) is a new benefit which launched on July 1, 2023, for children and is only available to children through the managed care system. From DCHS’ description of ECM:

• [ECM] will address clinical and non-clinical needs of the highest-need enrollees through intensive coordination of health and health-related services. It will meet beneficiaries wherever they are – on the street, in a shelter, in their doctor’s office or at home. Beneficiaries will have a single Lead Care Manager who will coordinate care and services among the physical, behavioral, dental, developmental and social services delivery systems, making it easier for them to get the right care at the right time.

Youth can receive both ICC and ECM as appropriate. See DCHS’ instructions at slide 20.

Family Therapy through the non-specialty system focuses on improving relationships between family members (specifically between at least one adult in the household and the youth). Consequently, it can be a valuable resource for children to stay at home with family or to help support youth in informal or formal kinship care.

In 2021, DHCS clarified that young people under the age of 21 are eligible for family therapy, provided through the non-specialty system of managed care, based on a mental health diagnosis or any of the following:

• Separation from a parent due to incarceration or immigration.
• Death of a parent or guardian.
• Foster home placement.
• Food insecurity, housing instability.
• Exposure to domestic violence.
• Maltreatment.
• Bullying.
• Experience of discrimination based on race, ethnicity or gender.
• Identity, sexual orientation, religion or disability.

A child may also be eligible if their parent has a disability, a history of incarceration, job loss, domestic violence or is a teen parent. Foster youth are automatically eligible. See page 7 of APL 22-029.

Dyadic Benefits serve children and their parents together and leverage the periodicity of caregivers’ well child visits to support integrated behavioral health in a primary care setting. Dyadic benefits can include behavioral health screenings, tobacco and substance abuse supports and care coordination services. It can also fund community health workers, who can help connect the family to other resources like food banks, legal aid, parenting classes or therapy. Per the First 5 Center for Children’s Policy, dyadic services have been shown to improve immunization rates, coordination of care, child social – emotional health and safety, developmentally appropriate parenting and maternal mental health.

Community Supports is a new package of benefits provided through the managed care system. Community Supports can include funding for housing navigation supports and deposits, caregiver respite, sobering centers, asthma remediation, legal aid services and more. Not all community supports have to be offered by every managed care organization, and many MCOs are currently in discussion with counties and stakeholders about services and funding. Child Welfare agencies can and should be involved in these discussions to ensure that these supports can be leveraged to help with prevention as well as supporting informal and formal kinship placements.

Physical Healthcare and Consent

In California, youth can consent to many types of healthcare services as a minor under 18. For more information, see the fact sheet with legal citations provided by the National Center for Youth Law.

Additionally, relatives identifying as someone within five degrees of relatedness may consent to any healthcare service on behalf of a minor for whom they are providing care. They may need to complete and sign a caregiver’s affidavit like the one available through the Courts.

Any time a child transitions to a new home, there is a risk of school instability which can severely impact their academic outcomes. Youth in foster care have broad educational protections and rights in California under state and federal law. This includes supports and services through the Foster Youth Services Coordinating (FYSC) Programs through the California Department of Education and local County Offices of Education. Additionally, as soon as a child is removed, even temporarily pursuant to WIC 309 or is the subject of a petition via WIC 300 or WIC 602, youth have a right to continue attending their school of origin and the associated best interest determination (BID) process. Foster youth also have legal rights to the same access to extracurricular activities, including sports and all academics as youth not in care.

Additionally, relative caregivers may enroll a child in school regardless of if they are a formal placement or informally providing care. Pursuant to Education Code Section 48204(a)(5), they may need to complete and sign a caregiver’s affidavit like the one available through the Courts.

For more information on foster youth education rights:

• California Foster Youth Education Task Force.

• California Foster Youth Education Fact Sheets (2023).

   

There are a number of benefits programs that may be available to children in informal and formal kinship placements. Emergency funding for youth in formal kinship placements are discussed earlier in this policy guide.

Children in informal care with relatives may be eligible for CalWORKs – either as a part of the kin caregiver’s household or, if the relative is ineligible or does not want to apply for themselves, as a child-only household of one regardless of the relative caregiver’s income. The maximum a child may receive for CalWORKs is $779 in large counties or $771 in smaller counties. If the relative caregiver is taking care of additional children, the CalWORKs grant will only increase by approximately $200. In contrast, the basic AFDC-FC foster care rate is $1206, each additional child is eligible for a full AFDC-FC rate or at minimum the basic rate (i.e., so two children in foster care would receive basic rates totaling $2412), and a child who is eligible for foster funding may also be eligible for additional supplements based on needs.

Informal relative caregivers who are financially and otherwise eligible may receive SNAP/CalFRESH benefits. CalFresh benefits are issued on EBT cards and can be used to purchase most foods and are accepted at most farmers markets.

Informal kin caregivers may be eligible to receive expedited CalFRESH benefits within three days if they are otherwise eligible and meet one of the following:

• Cash resources of $100 or less and a gross monthly income less than $150.
• Combined cash resources and gross monthly income are less than your monthly expenses for rent/mortgage and utilities.
• The family includes a migrant or seasonal farmworker who has $100 or less in cash resources and very little income or income has been terminated.

Impact of Probate Court Guardianships

While many well-intended Social Services systems refer informal kin caregivers to probate court guardianships, those guardianships are frequently not needed (e.g., for school enrollment, to consent to healthcare or to be added to subsidized housing). Additionally, such referrals may be harmful down the road as a probate court guardianship may prevent the caregiver from accessing more supports and financial benefits later should it become necessary.

Probate Court guardianships generally do not provide additional financial eligibility to the caregiver or youth with one exception: youth with caregivers who are not considered relatives (i.e., are outside of the fifth degree of relatedness) may receive state AFDC-FC benefits at the basic rate through a probate court guardianship. Relatives within the fifth degree are only eligible for CalWORKs when guardianship was established through probate court.