Breaking Down Silos: Enhancing Foster Care Health with Proactive, Integrated Management

Foster children often face significant unmet medical, behavioral, and mental health needs, which can lead to long-term negative outcomes for those aging out of foster care. Information silos within the healthcare system hinder continuity of care, resulting in issues such as medication lapses, poor management of chronic conditions, and missed signs of distress. The Duke Foster Care Program (DFCP) and its affiliated Clinic (DFCC) have found that providing comprehensive, proactive, and coordinated care is essential for addressing the complex needs of children in foster care. Central to this approach is the role of a dedicated trauma-informed Population Health Nurse (PHN), whose responsibilities include care coordination to ensure preventative services and reduce unnecessary acute care, as well as collecting data to better understand this population and improve health outcomes. Drawing from this experience, we argue that the healthcare system must adopt a trauma-informed, proactive care management model to meet the unique needs of foster children and enhance their long-term health.