Foster care youth have higher behavioral health needs and more ER visits leading up to entry, research finds

A critical step to improving the well-being of children and youth in foster care is understanding the complex health care needs they face. That's why a team of experts at the University of Colorado School of Medicine collaborated with state agencies to analyze health data and identify trends among those in the foster care system using Colorado's Medicaid program.

Mark Gritz, Ph.D., who is head of the CU Division of Health Care Policy and Research and the director of operations for the Adult and Child Center for Outcomes Research and Delivery Science, has been a leader in this analytics project, which is part of a larger collaboration between the CU School of Medicine and the Colorado Department of Health Care Policy and Financing (HCPF).

In 2017, the two entities formed an interagency agreement in which the CU School of Medicine agreed to provide data integration and analysis on projects that HCPF identified to improve health care access, outcomes, and value.

One of those initial projects focused on children and youth involved in foster care. Since 2019, the CU Eugene S. Farley, Jr. Health Policy Center has led this data work, and Gritz is the director of operations for the center.

"These last five years have been some of the most professionally rewarding that I've had over my almost 40-year career, and it's because we can truly be a partner with our state agencies," Gritz says.

"These agencies have been trying to improve the circumstances of our children, youth, and young adults with lived foster care experiences, but we need to strengthen these efforts through a better understanding of their health status and care experiences."

Documenting health complexities over time

As of May 2024, there are 3,448 children and youth living with Colorado's 2,471 certified kinship and foster families, according to the state Department of Human Services. These children and youth are eligible for Colorado's Medicaid program, called Health First Colorado.

When they are emancipated or "age out" of foster care, if they were already enrolled in Health First Colorado, then they remain eligible for coverage until they turn 26 years old. This is similar to the policy that permits young adults under the age of 26 to stay on their parents' health insurance.

When Gritz and his team began working on analyzing the health data of foster care children and youth, a primary goal was to document the health complexities these individuals face.

"The foster care population is very different from the average child or youth who is covered by Medicaid," Gritz says. "They have a lot more physical and particularly behavioral health complexities."

The team's initial reports looked at children and youth entering the foster care system for the first time, comparing them to other individuals who are covered by Medicaid but are not in the foster care system.

The findings, which were published in 2023 in the journal Academic Pediatrics, showed the overall presence of behavioral health conditions—such as anxiety/stress-related disorders, attention-deficit hyperactivity disorder, and major depressive disorders—was about three times higher for children and youth in foster care than for those who were not.

Those in foster care also had a higher presence of nearly all body system-specific physical health conditions and chronic conditions—such as pulmonary, respiratory, neurological, and progressive conditions—than peers who were not in foster care.

The team also investigated how physical and behavioral health complexities changed after these children and youth entered foster care, discovering that behavioral health conditions were higher at six months after entry compared to a comparison group that was matched on the presence of medical complexities.

Pulmonary, respiratory, and neurological conditions that were the most prevalent at the time of entry into the foster care system also increased six months later.

The findings suggest that these health complexities may have been undiagnosed before the individuals entered the foster care system. It may also mean these complexities were potentially exacerbated due to the trauma of transitioning into foster care.

Primary care and emergency department usage

Following those discoveries, Gritz and his team shifted their focus toward how frequently children and youth who entered foster care were receiving health care services.

In a 2022 article published in the International Journal on Child Maltreatment, Gritz and his co-authors described a seven-year retrospective study that examined primary care and behavioral health utilization patterns from 2014 to 2021.

The data showed that, relative to a matched comparison group, those in the foster cohort had lower primary care utilization but higher behavioral health utilization prior to entering the foster care system. However, both primary care and behavioral health utilization increased during and 12 months after entrance into the foster care system.

"The data suggests that as children and youth go into foster care, they are getting equal access to primary care services," Gritz says.

Further research found that, before entering the foster care system, children and youth in the foster care cohort were more likely to visit the emergency department than the comparison cohort. Emergency department use also tended to increase about four months before entry into the foster care system. This was particularly true for those aged 7 and up.

"If the state's child welfare agency could gain access to information on when children go to the emergency department, this could potentially be an early indicator of children who are at risk of entering foster care," Gritz says.

As part of their investigation, Gritz and his colleagues also assessed a claim made in previous literature that suggested foster care children and youth use the emergency department for primary care.

Data show that in the month after entry into the foster care system, there was a large decline in emergency department usage for these children and youth. Over time, the rates became more similar to the rate for peers who were not in foster care.

"It really isn't the case that foster care children and youth are using the emergency department any more so than those not in foster care, once we've accounted for their physical and behavioral health complexities," Gritz says.

Additional investigation found that children and youth in foster care had higher rates of emergency department visits associated with suicide, intentional self-injury, and fractures before entering foster care compared to their matched peers.

Particularly among older children and youth, emergency department visits related to suicide and self-harm occurred at higher rates leading up to entrance into the foster care system. For those ages 7 to 12, the rates continued to increase up to one year after entering the foster care system.

What happens after emancipation

After conducting several analyses around those entering foster care, the research team transitioned to looking at individuals who emancipate—or age out—of foster care, comparing them to a matched comparison group.

"We found that for those who emancipated out of foster care, their health care utilization drops much more dramatically than other people of the same age as they get older," Gritz says. "This is particularly true regarding psychotropic medications, which are medications used to treat mental illnesses like anxiety, depression, and schizophrenia. It's unbelievable how quickly they stop using primary care and they stop taking psychotropic medications once they're on their own."

Their research also found slight increases in emergency department usage for those who emancipated out of foster care. When compared to the control group, health care costs significantly increased among young adults who emancipated from foster care in the 12 months after their emancipation compared to the previous 12 months, especially for those with physical and behavioral health complexities.

"Primarily, that increase seemed to be driven by use of ancillary services, such as therapy," he says. "It indicates this is a population that has a lot of needs that probably were being met by the child welfare system while they were in foster care, but when they left, they had to find alternative sources for that support."

Reflecting on years of work

Over the past five years of this work, Gritz says one of the most rewarding moments was when the Department of Health Care Policy and Financing emphasized that children, youth, and young adults with lived foster care experiences are a priority population, as part of the state's Accountable Care Collaborative program.

Gritz feels the prioritization is necessary, given how the behavioral health complexities of foster care children and youth compound over time.

"The fact that the behavioral health complexities increased so much confirms the fact that these youth are undergoing very traumatic experiences, and it really is impacting their behavioral health," he says.

He explains that many of these individuals may struggle to achieve certain outcomes in life because of the challenges they encountered as a foster care child.

"This is not a choice they make. It's something that happens to them," he says.

"To me, these are the populations we really need, as a society, to focus on. Strengthening the behavioral health system in our state to better serve this population—and youth in general who have behavioral health issues—is what I would point to as the highest priority for addressing the needs of these children, as well as most others from historically underrepresented populations."