Children in out-of-home care who meet the definition of medically fragile will be identified. Develop plans with caregivers of medically fragile children to identify necessary supports to meet the day-to-day needs of the child (including respite and emergency situations).
- Children who meet the following criteria are identified as medically fragile:
- Child has medical conditions that require the availability of 24-hour skilled care from a health care professional or specially trained family or foster family member.
- These conditions may be present all the time or frequently occurring.
- If the technology, support, and services provided to a medically fragile child are interrupted or denied, the child may, without immediate health care intervention, experience death.
- When there is an indication that a child is medically fragile, refer the child to the ADSA Fostering Well-Being Care Coordination Unit for consultation and determination of the child's need for services.
- All children identified as medically fragile and in out-of-home care must have an identified Primary Health Care Provider.
- Out-of-home caregivers must be provided a Caregiver Support Plan that addresses training and support needs related to caring for a medically fragile child.
- All children identified as medically fragile must be documented in the FamLink Special Needs page.
- Complete a referral by emailing the Fostering Well-Being Care Coordination Unit at: email@example.com.
- When a medically fragile child is discharged from a hospital:
- Participate in a discharge planning meeting with the identified caregiver
- Coordinate with hospital or Primary Health Care Provider about the discharge plan to:
- Assess appropriate placement,
- Identify resources and training to support the care of the child,
- Obtain a copy of the child's treatment plan or identify the on-going plan for treatment and examinations, and
- Refer the medically fragile child to the Fostering Well-Being Care Coordination Unit.
- When the assigned social worker has received confirmation from the Fostering Well-Being Care Coordination Unit that the child meets the medically fragile criteria:
- Ensure any recommendations made by medical providers and in the Care Coordination Summary are followed-up on to address the ongoing medical needs of the child.
- Document the child as "medically fragile" in the Special Needs page in FamLink.
- Develop a Caregiver Support Plan for initial and any subsequent placements with a caregiver. At a minimum, the plan must address:
- Caregiver training specific to the child's needs,
- Additional supports to meet the child's needs, e.g. Medicaid Personal Care,
- Support for the caregiver to have alternate care for the child if needed, e.g. planned and emergency respite care, and
- Steps to take in an emergency situation when a caregiver is unable to care for the child.
- NOTE: Children placed in Behavioral Rehabilitation Services group or foster homes, skilled nursing facilities, on a trial return home, or who receive case management services from a Child Placing Agency do not require Caregiver Support Plans.
- Determine any additional support and training needs during the initial Social Worker Monthly Health and Safety Visit within the first 7 days of placement.
- Review the Caregiver Support Plan with the caregiver at each Social Worker Monthly Health and Safety Visit to determine if any changes to the plan are needed.
- Upload the Caregiver Support Plan signed by the caregiver into FamLink. Document the following in FamLink within 10 calendar days of receiving information:
- Child's medically fragile status on the FamLink Special Needs page per Medically Fragile Documentation, and
- Child's medical conditions/information in the Health/Mental Health page per Health Care Services for Children in Out-of-Home Care policy
- Health Care Services for Children in Out-of-Home Care
- Social Worker Monthly Health and Safety Visit
- Medically Fragile Documentation
- Fostering Well-Being Care Coordinator Referral Form (located in the Forms repository on the DCYF intranet)