How are public health nurses assisting with child protection investigations?

On an initial visit with a family, a child protective services (CPS) caseworker notes that a young child in the home has asthma and asks whether the parents have medication on hand to treat it. They do. Upon review of the family’s medical records, however, a public health nurse (PHN) working with CPS notices an increasing frequency of urgent care visits for the child. The PHN accompanies the caseworker on a return visit. She assesses whether the medication on hand is the correct type and dosage, and asks the mother to demonstrate how it is administered. She explains that the medication being used for acute attacks is actually a preventive medicine that needs to be taken regularly to control the condition. The mother is grateful for the information, saying, “If you hadn’t told me, I never would have known! We would have landed in the E.R. again.”

On another day, the PHN and CPS caseworker visit a family with an infant who recently suffered a skull fracture. While the CPS caseworker checks on the other children in the home, the PHN reviews the scene of the accident. She notices that, despite the parent’s claim that the injury occurred when the infant fell off the bed, the bed is only 12 inches off the ground and the floor is carpeted. She shares these details with the CPS caseworker and together they communicate with the county’s child abuse pediatrician, who confirms that the parent’s explanation is not plausible and supports the recommendation to substantiate abuse and take steps to protect the child from future harm.

As these real-life examples illustrate, a CPS caseworker working alone may not have the expertise needed to accurately assess all aspects of child and family functioning, including normal child development and chronic medical conditions. The need for a multi-disciplinary approach is also particularly acute for children who are most vulnerable, including infants and those with special medical and developmental needs.

In some jurisdictions, public health nurses are utilized to provide this kind of teaming support to caseworkers during investigations. In addition to having medical training, nurses are highly trusted. Families often are more willing to open up about health and well-being challenges with a nurse than a CPS caseworker. The additional information they provide can be invaluable, both to ensure an accurate investigation and to promote the child’s future health and well-being.Beyond investigations, child welfare agencies partner with public health nurses and agencies to play a number of other roles, including monitoring special medical needs, providing care coordination for complex cases, supporting the well-being of children and youth in foster care, and supporting families to prevent out-of-home placement.

There’s something magical about being a nurse. Parents and children will share things with nurses that they won’t share with anyone else.

– Sherry Rumsey, Division Administrator for Medical Services, Texas Department of Family and Protective Services

Key considerations

The ways CPS agencies in different states and counties use PHNs vary greatly.1 However, officials from several agencies noted that the demand for nursing services, once made available, grows quickly so it is important to set clear parameters around the services that nurses are (and are not) able to provide. Some parameters may be determined by licensing restrictions (for example, PHNs may not be licensed to provide direct medical care to children, the types of care they can offer may be limited, or their role may be consultative in nature). Other parameters, such as a triage system, may be necessary due to high demand.

Engaging PHNs for investigations requires agencies to make a number of key decisions, including the following:

Which cases require PHN involvement? In some jurisdictions, consultation with a PHN is left to caseworker discretion. In others, caseworker staff are required to consult with a nurse under certain circumstances. These might include a child’s known or suspected serious medical condition (for example, asthma, diabetes, or seizures), failure to thrive, allegations of severe neglect, allegations of physical abuse, known or suspected developmental delays, hospitalization for any reason, or drug-exposed infants. Some jurisdictions also take the child’s age into account, prioritizing cases involving infants or children under 3, for example. 

Who is the focus of the PHN’s assessment? In some jurisdictions, the focus of the assessment is only on the child or children listed as the subject of a report; in others, PHNs assess the health and well-being of all children in the home (and sometimes the adults).

What services will the PHN provide? PHNs employed for investigative teaming are responsible for some or all of the following tasks, depending on the jurisdiction:

  • Assess children visually (for example, viewing bruises) and through the use of standardized assessment tools when possible. Formal/complete assessments may not be possible with families in crisis. Sometimes the PHN goes out with a caseworker on an initial (surprise) visit, but more frequently attends a scheduled follow-up visit with a family. 
  • Request, collect, and review family medical records, which they may summarize or interpret for caseworkers. 
  • Provide health education, either directly to families or to caseworkers (who convey the information to families). In some jurisdictions, in addition to casework, PHNs also provide trainings for child welfare staff. 
  • Support decision-making. Although final decisions about substantiation are the responsibility of the CPS caseworker and supervisor, PHNs offer vital observations and sometimes provide formal write-ups to support substantiation. 
  • Consult with physicians. PHNs do not replace child abuse pediatricians. However, they can help caseworkers determine when consultation with a physician is needed, and they provide a medically trained set of eyes on the child when that consultation takes place by phone.  
  • Encourage referrals to specialists when needed, either by requesting the referrals directly from a primary care physician or by coaching the family or caseworker on what language will be most effective in making such a request. 
  • Refer the family to additional community resources as needed, including health insurance and special medical equipment. 

In all jurisdictions consulted for this brief, PHN services stop short of providing a physical exam or any direct medical services, including taking vital signs, providing injections, bandaging wounds, or diagnosing conditions. 

Will PHNs be employed and supervised by the child protection agency or the public health agency? There are advantages to both approaches. Employing nurses directly within the child protection agency may provide a closer link between the nurses and child welfare caseworkers, including opportunities for joint training. Several jurisdictions have found that employing the child welfare PHNs within the public health agency provided a stronger support system for the nurses, including improved access to relevant training, clinical supervision, and opportunities for career advancement.

Will PHNs be co-located with child welfare staff? Regardless of which agency supervises the PHNs, co-location is generally viewed as beneficial, when feasible. In Los Angeles County, investigative caseworkers are encouraged to consult with their co-located PHN before submitting a formal consultation request; this allows for more cases to be triaged informally while reducing the administrative burden of official referrals.

Child welfare is complex and challenging. It can be overwhelming at times for caseworkers to be the only person meeting with the family and assessing health and developmental factors in a family system. We felt that public health nurses could be a support to them and to the families and children they serve — and that it should be a partnership.

– Margie Weaver, Assistant Director of Children’s Services, Hamilton County (Ohio) Job & Family Services

Addressing challenges

Certain challenges appear to be common when engaging PHNs in investigations. These may stem, at least in part, from the historical difference in emphasis between child protection and public health. While the primary focus of the child protection system has been safety, public health nursing focuses more broadly on child and family well-being, including physical, mental, emotional, and developmental health. Partnerships like these are a positive step toward bridging gaps between the two disciplines, but they may face initial hurdles. 

When starting a program, it may take time and effort to help CPS caseworkers understand how and why to consult with a PHN. Caseworkers need to understand how nurses can help make their jobs easier, rather than seeing the involvement of a PHN as an additional administrative burden. In Los Angeles County, for example, all new caseworkers are exposed to PHNs during their initial training academy. The nurses present a half-day session that covers how and when to consult with a PHN, in addition to some basic education on medical issues and proper infant care.

Staffing PHN positions can also be a significant challenge, exacerbated by nursing shortages in many parts of the country. Some nurses may be uncomfortable making home visits, particularly in the neighborhoods where they are needed most, or they may lack experience in the range of issues that are common in child welfare cases (for example, substance use, mental health, or domestic violence). Several program managers emphasized the importance of hiring nurses who have training or experience in public health (as opposed to someone who has exclusively worked in a hospital setting, for example). In Ventura County, California, all of the nurses in the RX for Kids and Families program have a certificate and interest in forensic nursing. 

Data collection and evaluation for PHN programs have proven particularly challenging. Most child welfare data collection systems capture minimal information about health (whether children in foster care receive regular medical and dental exams, for example). It can be difficult to share data between child protection and public health systems, despite the fact that the latter might have a greater capacity to capture medical information. Even when nurses are employed by the CPS agency, data about child safety are rarely captured or reported according to the PHN’s involvement or caseload. As a result, it has been difficult to demonstrate improvements in child safety resulting from these programs. While caseworkers in jurisdictions where PHNs are available highly value this kind of support, more research is still needed to assess the impact of PHN teaming on investigations, and to determine whether specific program models are more effective than others.

When we get a referral, we don’t just address the focus child. We address the whole family’s needs. Many times when nurses go to the home, they find out there are a lot more issues than originally identified in the referral, or there are other children in the home with medical issues that need to be addressed.

– Maria Lieras, Nurse Manager, Los Angeles County Department of Public Health

Jurisdictional examples

Several counties in California offer PHN support for investigations:

  • In 2015-16, Los Angeles County implemented a pilot program requiring joint CPS/PHN visits on all child abuse and neglect investigations for children under age 2. While data analysis from the first year did not show improvements to specific child safety indicators as a result of the pilot, the program did identify a significant number of unmet health needs and children lacking access to health insurance. Although the program was ultimately discontinued, the co-located PHNs still continue to consult on investigations in Los Angeles County on caseworker request, and consultations are required on all cases of chronic or serious medical conditions.
  • Ventura County’s RX for Kids and Families program, started in 1997, now has four co-located nurses who respond to emergency response (ER) or immediate response (IR) cases during normal business hours. Nurses attend home visits, gather and review medical records, and consult with a child abuse physician. When cases are closed, PHNs attend multidisciplinary team meetings to support hand-off to community partners for additional family support. They also provide trainings for caseworkers on request. The Ventura County Human Services Agency provides funding for the program.
  • Orange County’s longstanding CPS/PHN program employs six co-located PHNs and one supervising nurse who go out on ER or IR visits, provide consultation, and serve as liaisons with the county’s child abuse physician on cases involving a medical issue or allegation of physical abuse. PHNs are available until midnight during the week and 10 p.m. on weekends. Their observations and review of medical records are formalized into the caseworker’s report as needed to support substantiation. The nurses are funded through a variety of sources, but all are supervised by the local health care agency. 

In Texas, PHNs are registered nurses and part of a statewide comprehensive medical services team that includes nurse-consultants, well-being specialists, a pediatrician, and a network of forensic assessment centers. There are six PHNs distributed throughout the state; they cannot attend all home visits due to distance, but they consult by phone as needed and help CPS staff navigate other available medical services. The team is funded through the Department of Family and Protective Services budget, and includes three positions funded with federal CAPTA dollars.

Hamilton County, Ohio first contracted with its public health department two years ago for on-site nurses to help caseworkers access and interpret health records. The county is now revising the scope of its program to focus more on field work in support of child protection investigators, particularly in cases involving younger children. The agency has entered into a contract with a local children’s hospital to reduce data-sharing barriers. The program will be staffed with an on-site nurse practitioner, one nurse, and a medical assistant to help obtain records and complete documentation. The nurses are funded through local county levy dollars. 

1 Information in this brief was informed by interviews with the following jurisdictional representatives: Berenice Gomez, Public Health Nurse, Los Angeles County Department of Public Health-Child Welfare Public Health Nurse Program, February 6, 2019; Maria Lieras, Nurse Manager, Los Angeles County Department of Public Health-Child Welfare Public Health Nurse Program, March 15, 2019; Margie Weaver, Assistant Director, Children’s Services, Hamilton County (Ohio) Job & Family Services, April 18, 2019; Megan Steffy, Director of Public Health Nursing, Ventura County, Calif., May 8, 2019; Laura Riley, Supervising Nurse Manager, RX for Kids and Families Program, Ventura County, Calif., May 8, 2019; Scott Burdick, Deputy Director, Intervention and Prevention Services, Orange County, Calif., May 8, 2019; Colleen Honch, Administrative Manager, Orange County, Calif., May 8, 2019; and Liz Kromrei, CPS Director of Services, Texas Department of Family and Protective Services (DFPS); Sherry Rumsey, Division Administrator for Medical Services, Texas DFPS; Cathye Bullitt, Regional Nurse Consultant, Texas DFPS, April 30, 2019.