Coordinated Care for Children in Foster Care: A Case Study From the Duke Foster Care Clinic

Abstract

Foster children’s unmet health needs have consequences that often lead to poor outcomes for children who age out of foster care. Information silos disrupt continuity of care resulting in inconsistent management of chronic conditions, medication lapses and missed signals of distress. The Duke Foster Care Program (FCP) and its affiliated Clinic (FCC) have found that delivering medical services to children in foster care requires a trauma-informed, unique approach. This model introduces care management tailored to the instability of foster care—addressing challenges such as system turnover and burnout. A key innovation is the use of a clinic-embedded Population Health Nurse (PHN), whose role focuses on coordination of care and the collection of actionable data to improve population outcomes. This health care-based solution bridges gaps in traditional medical case management. We posit that health care systems should consider this care management model to meet the needs of children in foster care.