Pediatric Return Appointment Adherence for Child Welfare-Involved Children

Objective:  Child welfare-involved children, in foster care and at home, are one of the most medically vulnerable populations in the U.S. Thus, the local child protective service (CPS) agency established collaborations with health providers at medical clinics (HUBs) to provide expedited assessments and meet the health care needs of this population. HUBs only serve children in CPS. CPS social workers are co-located in these Medical HUBs to ensure that children receive appropriate referrals for needed medical services. The linkages involve the child’s caregiver, who acts as a gatekeeper to accessing and using pediatric health services. This mixed-method study of primarily Hispanic caregivers and Hispanic child welfare-involved children had the following aims: (1) explore the return appointment adherence patterns of children living with birth parents versus foster caregivers; (2) determine the relationship of adherence to return appointments and caregivers’ demographic and social variables; and (3) identify barriers to adherence to return appointments via qualitative interviews with caregivers.

Methods: The sample consisted of caregivers of child welfare-involved children who were asked to make a pediatric outpatient clinic return appointment at a medical HUB (N = 87). The sample only included children whose caregiver did not change between the first appointment and the return appointment. Data were collected from the clinic’s medical records, a questionnaire administered to caregivers at the clinic after they consented to participate, and a telephone interview with caregivers who did not return (N=22; 67%). Predictors including caregiver demographics, child medical diagnoses, and convenience factors were examined using χ² and ttests of significance. Content analysis was used to identify themes concerning why caregivers did not attend follow-up appointments.

Results: There were no significant differences in return appointment adherence for foster caregivers compared to birth parents, and 39% of all caregivers were nonadherent in returning for pediatric appointments. When return appointments were scheduled longer after the initial appointment, caregivers were less likely to bring children back for medical care. Five foster children, who were not included in the study sample, changed caregivers after the initial appointment and did not attend their return appointment. The primary reason caregivers reported for not returning was unawareness that their child had an appointment. Other common themes included forgetting about the appointment; difficulties with transportation; disliking the clinic environment/finding the hours inconvenient; and being too busy with other caregiving responsibilities.

Conclusions: This study found that the nonadherence rate for return appointments was greater for children in the child welfare system than in other studies with similar pediatric populations, in which nonadherence rates ranged from 16% to 35%. Better coordination between pediatricians and caregivers in partnership with child welfare case workers is needed to ensure consistent follow-up regarding health problems, especially when appointments are not scheduled soon after the initial appointment. Child welfare caseworkers need to consistently link new foster caregivers with the child’s previous medical provider when placements change, to assure consistent follow-up on health problems.  Reminders, possibly using text messaging, may increase caregivers’ attendance at return appointments.