This policy guide provides information on Medical Hubs (Hubs) including their locations, the wide array services they offer, and guidance on how to use them.

This policy guide was updated from the 05/24/16 version to update the roles and responsibilities of staff, and to update Hub locations, hours of operation, and services provided. Additionally, the following has been added: 1) Clarification of documenting medical information; what may be included, or shall be excluded from the Health Education Passport (HEP), the DCFS 561a, and/or other shared documentation; 2) Information on adolescent sensitive services that are confidential, including what to include/exclude from documentation; 3) Clarification on the purpose of the medical clearance exam; 4) Information related to Commercially Sexually Exploited Children (CSEC) and Sexual Assault Response Teams (SARTs); and 5) Links to resources (flyers) that may be used to explain the Medical Hubs (Hubs) program to external stakeholders.

Medical Hubs

The countywide Hub System is a Los Angeles County partnership between the Department of Health Services, the Department of Mental Health (DMH), the Department of Public Health (DPH),, the Department of Children and Family Services (DCFS), and Children's Hospital Los Angeles (CHLA) that provide services for DCFS-served children. Services are provided in a non-discriminatory manner that demonstrates sensitivity to differences in culture, ethnicity, sexual orientation, gender identity, physical and mental ability, language, religious beliefs, and other forms of human diversity.

• Staff are encouraged to use the two (2) Hub flyers (in the "Attachments" section below) when explaining the use and purpose of the Hub clinics to external stakeholders, including youth.

The table below provides contact information for the Hubs and highlights the DCFS offices that are geographically located to the nearest Medical:

**Although the DCFS offices listed are the closest geographically, the CSW may make a referral to any Hub and should take into consideration the location that makes the most sense for the caregiver.

Target Populations

The Medical Hub Program focuses on serving the following populations:

• Newly-detained children placed in out-of-home care. For newly detained children, the IME must be provided at a Hub.

• • Newly detained children placed outside of Los Angeles County are excluded.

• Children who are in need of a forensic evaluation to determine abuse and/or neglect have an open DCFS referral or case

• Children with special medication conditions (i.e. diabetes, hemophilia, etc.)

• All CSEC that are detained, taken into protective custody and/or for whom a non-detained petition is filed

Additional populations are served based on capacity at each Hub.

The caregiver who is most knowledgeable of the child’s health status should accompany the child to the Hub. The caregiver should be advised to take the child’s Health Education Passport(HEP) to each Hub appointment for review by a Hub physician.

If a child has severe or life-threatening injuries, they should be brought to an emergency care facility or trauma center and then be referred to the Hub after their injuries have been stabilized.

Confidentiality

It is important that team work together to ensure adolescent confidentiality laws are followed and that adolescent sensitive services are not disclosed to stakeholders in the HEP, the DCFS 561a, and/or any other shared documentation.

Out-Stationed Children's Social Workers (CSWs)

DCFS CSWs are out-stationed at each Hub. The out-stationed CSWs serve as liaisons between the Hubs and DCFS with the goal of sharing information related to children referred by DCFS to the Hubs. A list of CSWs out-stationed at the Hubs is available on LA Kids.

• Please note not to include information on an adolescent patient who has a right to confidentiality according to current California state law, unless the patient gives consent for it to be included.
  
  

DPH Co-located Public Health Nurses (PHNs)

The DPH PHNs co-located at the Hubs act as liaisons between the Hubs and regional CSWs and PHNs. Prior to the IME appointment, the co-located PHN reviews a case to confirm if the needed medical records were provided before the exam. If the records were not provided, the co-located Hub PHN will send a request to the regional CSW and PHN team to obtain the medical records. The regional CSWs, working together with the regional PHNs, obtain medical records, including but not limited to, birth records for newborns.

When a Hub medical provider flags an urgent/emergent need for immediate follow-up, the PHNs co-located at the Hubs will notify the regional CSW and/or regional PHN and provide the relevant medical, nutritional, developmental, and mental health information for follow-up.

The Hub Intermediate Typist Clerk (ITC), under the direction of the PHN Supervisor (PHNS) and in collaboration with the Hub PHNs, provides supportive clerical services within the Hub for children under the supervision of DCFS and in out-of-home care.

The Hub PHN/ITC team will also work with the regional CSW/PHN team to obtain prior medical records for DCFS children/youth referred to a Hub to aid in ensuring that Hub medical providers have adequate information to guide the IME and follow up Hub visits.

Regional CSWs, working together with the regional PHNs, maintain the primary responsibility for the child's health care coordination.

It is important that the team work together to ensure adolescent confidentiality laws are followed and that adolescent sensitive services are not disclosed to stakeholders in the HEP, the DCFS 561a, and/or any other shared documentation.

DMH Co-located Clinicians

DMH co-located clinicians are located at four (4) of the Hubs: HDRHC, OVMC, MLK, and Harbor. DMH clinicians collaborate with DCFS, DHS and DPH to ensure the provisions of mental health services to the child welfare population or children and youth at risk of entering the child welfare system are met. Mental health services require parent consent (i.e., form DCFS 179) or a court order. Mental health services may include screenings, assessments, crisis intervention, case management, case consultation and linkages.

DMH is available to intervene with children or youth who are disengaged from a mental health provider/facility, or require an appropriate level of mental health services. DMH provides affirming mental health services to the following targeted populations:

• Newly detained children and youth placed in out-of-home care that do not meet the eligibility for a Multidisciplinary Assessment Team (MAT)
  assessment or referred to Specialized Foster Care.
  
  
• Children and youth who receive a forensic medical evaluation while under DCFS investigation for child abuse and/or neglect and/or have an open DCFS case.
  
  
• Children with special medical conditions (i.e. diabetes, hemophilia, etc.) who may benefit from additional supports or services
  
  
• CSEC survivors who are in need of immediate crisis intervention and linkage to ongoing treatment.

Out-of-County Placements

The mandatory use of the Hubs does not apply to children placed outside of Los Angeles County. However, if a caregiver who resides out-of-county is willing to travel to a Hub, Hubs will service the DCFS-supervised child. If the child is subsequently placed in out-of-home care in Los Angeles County, the child should be taken for an IME at a Hub, if the child has not had a Hub exam during the course of the current open case.

Hub-Affiliated Hospitals

Children referred to a Hub for an exam after being discharged from a Hub-affiliated hospital should be referred to that hospital's affiliated Hub whenever possible.

Children previously served at a Hub-affiliated Emergency Room where the question of child abuse was raised, should be referred to that Hub whenever possible.

Core Services

Initial Medical Examination (IME)

The IME helps DCFS understand the baseline health needs when newly detained children enter out-of-home placements. The IME is a full medical assessment of a newly detained child/youth which helps determine the child/youth’s primary care needs, identifies acute and chronic medical conditions and provides direction for future health care. The child/youth’s caregiver is responsible for transporting the child/youth to this exam. The American Academy of Pediatrics (AAP)/Bright Future Periodicity Schedule should be adhered to when implementing future health examinations of the child.

The IME is not required when a child is being replaced from one placement to another in Los Angeles County.

Consultation should be sought by the CSW with the out-stationed Hub CSW regarding requests for IMEs for medically fragile children. Consideration should be given to the practicality of transporting a child who is too fragile for outpatient medical visits, or a child who was discharged from a hospitalization directly to placement. The Hub physician will determine if the medically fragile child should have a Hub examination.

The IME consists of the following components:

• Review of the child’s health history, when available
• Physical examination
• Measurements (e.g., height, weight, Body Mass Index (BMI), and blood pressure)
• Nutritional assessment
• Dental screening
• Developmental screening. This may be deferred to a follow-up appointment at the Hub.
• Screening for chronic diseases, which may include Fetal Alcohol Syndrome (FAS)
• Vision and hearing testing, if age appropriate
• Laboratory screening tests, if appropriate
• Immunizations, when due
• Appropriate health education
• Age-appropriate brief mental health screening
• LGBTQ+ friendly care
• Pending the above IME/assessment, referral to a subspeciality care may be made, as needed. This may include an on-site expert forensic evaluation on a case-by-cae basis.

Commercially Sexually Exploited Children (CSEC) Medical Clearance

CSEC survivors are often exposed to environments that pose significant health risks, including sleep deprivation, malnourishment, prolonged drug use and forced sexual activity. Due to the violent tactics often used by exploiters to control youth, youth require immediate medical services that address unhealed injuries and untreated infections, and medical attention to address reproductive health.

• CSEC survivors taken into protective custody shall receive a specialized CSEC medical clearance at the Hub as soon as possible, but no later than within the first 72 hours upon recovery so that they are given the opportunity to receive time sensitive portions of a medical evaluation, including:
  • Full reproductive health counseling, including education about safe sex practices, gender identity and healthy relationships
  • Comprehensive contraception counseling and same-day administration of most types of contraception
  • Education and emergency contraception offered
  • Sexually Transmitted Infections (STIs) screening and testing
  • Education and offers of pre-exposure prophylactics (PrEP) for HIV and for post-exposure prophylactics for HIV, if appropriate
  • SART examination, if appropriate
  • Medical caseworker evaluation with referrals to appropriate services (e.g., legal and medical services), if not already linked.
  • Screening for other physical health issues resulting from violence, trauma, abuse and/or neglect (e.g. injuries, pain, pelvic inflammatory disease, drug/alcohol dependency and pregnancy), as appropriate.

• All newly recovered CSEC survivors, regardless if a petition is filed, shall receive a CSEC medical clearance exam at a Hub as soon as possible, but no later than within the first 72 hours of recovery. The CSW, parent or legal guardian may take the youth to the Hub for the CSEC medical clearance.  The parent or legal guardian will not be billed for the exam.
  • There may be instances when the youth will not be in the mental space to have such an extensive exam, does not show up for their exam, and/or the parent does not consent to an exam, as such CSEC survivors will be provided an exam when they are willing to have the examination. Staff are encouraged to work with the youth on discussing the importance of the exam.
• CSEC survivors may be taken to a Hub on a walk-in basis for a CSEC medical clearance. The CSW needs to inform the Hub staff that the youth needs a “CSEC medical clearance” so that the youth receives all of
  the appropriate medical interventions included in this specialized exam.
  
  
• If the CSEC medical clearance is required after-hours, the youth needs to be taken to the LAC+USC Hub as it provides services 24/7, including weekends and holidays.

Medical Clearance

The medical clearance, also known as a medical screening is a brief exam that ensures there are no immediate medical conditions that require treatment before placement. It is important to note that the exam does not involve removal of clothing, rather, clothing may be moved around.

A medical clearance is mandatory for children entering transitional shelter care.

• If a child/youth/NMD is discharged from an emergency department or hospital (psychiatric or medical), the discharging care team may complete the DCFS 561a, thus satisfying the medical clearance requirement. When this occurs, the Hub medical clearance can be waived).

There may be a need for a medical clearance exam upon detention for children not entering shelter care.

The medical clearance may require follow up by DCFS, such as a referral to Regional Center if a child under the age of three (3) has a noted developmental delay. Medication prescriptions will be issued, if needed. A completed DCFS 561a will be provided to the individual accompanying the child to the medical clearance and similarly, to DCFS through the DHS E-mHub System if an electronic referral for the child was received from DCFS.

Timelines for IMEs and Medical Clearances

IMEs and medical clearances must be conducted according to the following timelines:

Forensic Evaluation

A forensic evaluation is comprised of a physical examination and clinical assessment to determine the presence and extent of injuries and/or signs of abuse and/or neglect (e.g. If there are marks, such as bites; fractures; burns; and/or bruises); and/or sexual abuse, and/or Commercial Sexual Exploitation. It includes the provision of clinical care for all injuries and effects of abuse and/or neglect. This may include old injuries that may not be clinically obvious and the initiation of treatment.

• Forensic evaluations interpret the physical findings regarding the likelihood that they are the result of abuse and/or neglect and may involve evidence collection, including evidence of sexual assault and STIs; and, may include photo documentation of injuries, including but not limited to, sexual assault injuries.

For every instance in which there are allegations of physical abuse or sexual abuse of a child come to the attention of DCFS, as soon as practically possible, the CSW shall submit a forensic referral. Consult with a Hub medical provider (aka, Specialist) who has specialized training in the detection and treatment of child abuse injuries and child neglect. It is the responsibility of the Specialist to determine if a forensic examination is appropriate.

• The CSW is to call 9-1-1 for life-threatening injuries or in instances when they are uncertain about the extent of the child's condition.

• The child may be taken to an emergency room if it seems that immediate medical services are needed and there do not appear to benon-life-threatening injuries, etc.

• A parent consent or there must be exigency or a court order for medical services. The parent/legal guardian has a right to be present and may not be excluded absent parent/legal guardian consent, a legitimate basis for exclusion, or an emergency requiring immediate medical attention (see the "Parent/Legal Guardian Rights in a Medical Examination” for more information.

• Consent also is needed for the CSW to take the child (and the family) to a medical facility (e.g., urgent care or emergency room) if the parent/legal guardian is unable to and/or unwilling to take the child to a medical facility. If consent is denied, the CSW should call 9-1-1 for medical transport (e.g., an ambulance).

For all Hub referrals, the Hub medical provider will determine the need for a forensic exam on a case-by-case basis. A forensic exam may be completed immediately, but no later than within 72 hours if there are concerns with detention, placement and/or the evidence could disappear quickly; or in a timeframe determined by the Hub medical provider.

A forensic evaluation may be authorized for a child when there are allegations of physical and/or sexual abuse, and/or Commercial Sexual Exploitation, and may occur either during an Emergency Response (ER)investigation /or when the child has been placed in protective custody. A forensic evaluation is not required for all DCFS children.

Forensic evaluations require:

• Parental consent or
• Exigent circumstances demonstrate either a medical emergency, or for preservation of physical evidence of a crime that is likely to dissipate before a court order can be obtained.
• In some circumstances, youth may consent to a sexual abuse exam, if deemed sufficiently mature to consent.

Absent either of the above requirements, a request for an investigative / evidentiary medical examination, such as a forensic evaluation, should be made via:

• A warrant , or
• A court order

When completing a warrant consultation, specify the need for a forensic evaluation.

If a child has received a forensic evaluation at another facility other than a Hub, the CSW should consult with the Hub to determine whether an additional Hub examination is needed.

For siblings or other children who live in the same home and/or have contact with the alleged perpetrator (companion referrals or cases), the Hubs will request the CSW to provide complete information at intake from the CSW’s interview of each child.

In circumstances where the alleged victim is under the age of five (5) or is non-verbal, the Hub may request that older siblings or children/youth identified in companion referrals/cases accompany the alleged victim to the Hub to assist in providing history. In some instances, the alleged victim may be examined first and the other child(ren) may not require a (complete) forensic evaluation.

Any child/youth with serious acute medical concerns may be referred to the Emergency Department or hospitalized, if needed to address these conditions. The Hub medical provider will attempt to contact the DCFS CSW by phone if urgent forensic concerns are identified, or in case of hospitalization. Hub clinics may provide follow-up care for identified forensic medical concerns if a child does not have a primary care physician that is able to adequately address these issues.

The results of the Hub forensic evaluation are documented in E-mHub and sent to the DCFS regional CSW within ten (10) business days of the appointment or ten (10) business days after the receipt of all requested medical records needed to complete the forensic assessment.

• If the medical records are not received by the Hub forensic medical provider within ten (10) business days, the Hub forensic medical provider will communicate with the DCFS Regional CSW regarding what is needed to complete the forensic assessment.

Sexual Assault Response Teams (SARTs)

SARTs are comprised of a team of health care professionals that are specifically trained in responding to victims of sexual assault/rape. SARTs combine law enforcement and victim advocacy to ensure that the sexual assault/rape survivors receive comprehensive medical attention and evidentiary examinations.

The following Hubs serve as SARTs:

• Olive View-UCLA Medical Center
• LAC+USC Medical Center
• MLK Jr. MACC
• Harbor-UCLA Medical Center

Mental Health Screening and Linkages to Services

DMH co-located clinicians at the Hubs to deliver affirming mental health services to children and youth within the target population. Services include screenings, mental health assessments, crisis intervention, case management, case consultation and linkage to services for referred children and youth who have not already been connected to mental health services.

For referred children and youth who are already receiving mental health services from a contracted provider, the DMH co-located clinician will contact the said provider to confer regarding appropriate next steps in treatment.

Mental health findings and recommendations will be indicated on the DCFS 561c and transmitted back to DCFS through the E-mHub System.

Other Services

When requesting any other services for a child or youth, including court-ordered services, CSWs are to contact the Hub to ensure the service is available and/or medically advisable before completing the Medical Hub Referral form.

Forensic Interview

A forensic interview is a developmentally sensitive and legally sound method of gathering factual information regarding allegations of abuse and/or exposure to violence. These interviews are conducted by a neutral professional who utilizes research and practice-informed techniques as part of a larger investigative process in partnership with law enforcement. A court order or consent is required by the adult holding medical rights before a youth can receive a forensic interview.

• At this time, forensic interviews are conducted at the Harbor-UCLA and MLK Jr. Hubs. These types of interviews can also be arranged in partnership with law enforcement in several non-Hub facilities within the county.

Specialty and Sub-specialty Services

• Specialty and Sub-specialty Services – The Hubs may provide services to address the needs of children, such as weight management issues, screening and treatment for FAS, and/or refer to sub-specialty services.
• All of the Hubs provide FAS screenings. LAC+USC and Harbor Medical Hubs provide evidence based FAS supports to resource parents.

Expert Opinion

• Expert opinions are typically requested when a previous examination for child physical or sexual abuse has been conducted by a local community hospital (including an emergency care facility or a community provider), and the examination was not completed by a child abuse specialist. Expert opinions cannot be completed without providing the Hub with full medical records, including X-rays.

Court-ordered Services

• The Juvenile Court may order a special examination or service to be completed by a Hub to address a health or health-related concern that has become known to the Court.
• Under most circumstances, the Court will order the results of the examination or service be provided to the Court.
• Any DCFS-served youth can be seen at any of the Medical Hubs for counseling and discussion of available birth control options

After-Hours Services

When seeking after-hours services, CSWs should be mindful of the following:

• There may be a delay in the immediate scheduling of an appointment.
• If the child has a medical emergency, the CSW should take the child to the closest emergency care facility.
• If a CSW is seeking and cannot get an immediate non-emergent medical appointment, they should not delay the process of detaining a child. The CSW should follow standard procedures for detention in these instances.
  
  

Parent/Legal Guardian Rights in a Medical Examination

Officials (CSWs, law enforcement, etc.) cannot completely exclude parents/legal guardians from the location of their child’s physical examination absent /legal guardian consent, a legitimate basis for exclusion, or an emergency requiring immediate medical attention.

• Depending o the age of the child/youth, for certain procedures, the child/youth may have a right to exclude anyone from the exam room including parents/legal guardians.

If there is a “valid reason” to exclude family members from the examination room during the medical procedure, a family’s right to be with each other during potentially traumatic medical examinations may be limited to being near the examination (e.g. in the waiting room or another nearby area). A "valid reason” may include authorities have reasonable evidence that a parent/legal guardian is abusive; cannot provide love and support to the child; or, will in some significant way interfere with the examination.

If a CSW determines that they need to exclude a parent/legal guardian from the medical examination, even if that medical examination was court-ordered, the CSW should consult with their SCSW for guidance. The SCSW will consult with the Warrant Liaison or County Counsel as needed.

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E-mHub System

The E-mHub is a web-based system used by the Hubs to track the health status of children in the child welfare system and facilitate the provision of quality medical care. It is a joint effort between DHS and DCFS. E-mHub accepts the electronic transmission of the DCFS Medical Hub Referral form and returns appointment status alerts and completed examination forms to DCFS via an email notification by using the SITE User ID (employee number) and Password (current password used by the employee). The link to the forms from the email notifications is only available to DCFS staff for ten (10) business days from the date of the email.

Once the Medical Hub Referral form has been electronically submitted through the E-mHub System and the Hub staff attempt to process the referral, an email notification will be sent to DCFS to alert the CSW and SCSW to any concerns with the referral or appointment.

When DCFS receives an appointment status notification or link to an examination form from E-mHub System, a CSW/CMS search is automatically conducted to obtain the currently assigned CSW and SCSW and an email is routed to staff as follows:

*Medical Hub Referral Forms Returned to DCFS
In some cases, the Hub staff may return a Medical Hub Referral form to the CSW to request additional information or report that they were unable to schedule the appointment. The Hub staff will select one (1) of the reasons below and may also write a message to the referring CSW with details and specific instructions. CSWs must carry out the instructions provided by the Hub in the email notification. The reasons for return are:

• Insufficient information. Please correct and resubmit
• Unable to schedule appointment
• Requested service not available at this Hub
• Phone consult; no appointment needed at this time
• Duplicate. An appointment for similar service(s) is already scheduled at the Hub
• No parent/legal guardian consent or court order
• Medical records not received
• Unable to establish contact with the CSW
  

When a Medical Hub Referral is returned to DCFS, the referral is removed from the Hub’s referral queue and the Hub staff will no longer work on the referral. To reinitiate the referral, the CSW should either re-submit the Medical Hub Referral form or call the Hub. If any information has changed since the time of the original Hub referral, a new Medical Hub Referral form should be submitted.

Rightfax Transmission of Medical Hub Referral Form to Children’s Hospital of Los Angeles (CHLA)

DCFS can submit the Medical Hub Referral Form automatically to CHLA through the Rightfax feature. Upon completion of a Medical Hub Referral form, the CSW should click the same “SUBMITtoEmHub” button currently used to submit the Medical Hub Referral form to the E-mHub System. The referral will automatically be faxed to the CHLA Hub.

The Rightfax feature does not provide electronic appointment status notifications to staff, and medical examination results will continue to be manually faxed to DCFS by the CHLA Hub.

Referring a Detained Child to a Medical Hub

ER CSW/CS CSW/ERCP CSW Responsibilities

The following procedures apply to the CSW who took the child into temporary custody.

1. Complete the Medical Hub Referral form.
   1. Consult with the PHN, as necessary, for completion of the Medical Hub Referral form.
   2. When referring a CSEC survivor, mark the "CSEC Referral" box on the referral form so that the referral is treated as a high-level referral and to ensure that the child receives the services of a specialized CSEC medical examination.
   3. Expert Opinions: When requesting a review of documentation on a child, after consultation with the SCSW, complete and submit the Medical Hub Referral Form through E-mHub/Rightfax to the Hub that is in closest proximity to the caregiver’s home. Examination or review of documentation is to be requested when the first forensic evaluation was received at a facility other than a Hub after consulting with a forensically trained medical specialist at a Hub.hese reviews are often requested when a previous examination for child physical or sexual abuse has been conducted by a local community hospital (including an emergency care facility or community provider.)
   4. When referring a child for an IME who is being served by the Medical Case Management Services (MCMS) section:
      • Submit the Medical Hub Referral form and check the box for an "Initial Medical Examination" in Section I, Reason for Referral.
      • In Section II, Child Status, document in capital letters, "THIS IS AN MCMS CASE", and note the Medical Hub Referral form is being submitted for consultation only.
        • This will initiate a dialogue between the MCMS CSW and the designated Hub provider regarding the care of the child. All information regarding the child’s medical condition and treatment should be submitted for review by the medical provider. On a case-by-case basis and after review of the medical records, the provider will determine when a child should be seen at the Hub; not necessarily meeting the current timeframe requirement for the IME. If deemed appropriate, the Hub provider will have the ability to waive the need for an IME for a child who is too fragile to attend.
2. Submit the Medical Hub Referral form based on the timeframes mandated in the table below electronically through the E-mHub System to all Hubs except CHLA that uses the Rightfax feature. The Hub selected should be identified through a discussion with the caregiver, with strong consideration given to caregiver preference.
   
   

   Children's Age or Risk Level	Timeframe for Submitting IME Requests
   Children ages 0 - 3 Medically fragile children/youth	Complete and submit the Medical Hub Referral form through E-mHub/Rightfax within three (3) calendar days of the child's initial placement.
   All other children	Complete and submit the Medical Hub Referral Form through E-mHub/Rightfax within five (5) business days of the child’s initial placement
   CSEC survivors	When submitting a referral for a CSEC youth, mark the "CSEC referral" box to ensure priority attention and specialized CSEC services are offered. CSEC survivors taken into protective custody shall receive a specialized CSEC medical clearance at the Hub as soon as possible, but no later than the first 72 hours upon recovery. If needed, the Hub will also schedule an IME. Walk-ins are also accepted.

3. For e-mail notifications for the submission of the Medical Hub Referral form, an e-mail alert is sent to the CSW, SCSW and Assistant Regional Administrator (ARA) if the above timeframes have passed without the submission of the referral to a Medical Hub. E-mail alerts are sent regarding referrals for IMEs only (not for forensic evaluations or other Hub services). The intent of the e-mail is to remind staff of DCFS policy and to prompt staff to complete and submit a timely Medical Hub Referral.
   
   

   1. After the Medical Hub Referral form has been submitted, the referring CSW is to call the Hub and ask for the out-stationed CSW. The out-stationed CSW serves as an intermediary between the ER or CS CSW and the Hub for clarifying the information on Medical Hub Referral Form and/or requesting additional information along with completing a forensic intake.
      

      • The out-stationed CSW will provide the information on the Medical Hub Referral form and the forensic intake to the Hub provider who will then direct the Hub CSW on the appropriateness of a forensic evaluation and provide an appropriate timeframe for the child to be seen. Conversely, the Hub provider may determine an alternative to the child being seen for a forensic evaluation.
      • Upon the out-stationed CSW consulting with the medical provider, they will inform the CSW the directions received by the Hub provider on the appropriateness of the timeframe of the forensic evaluation
        
        
   2. CSW proceeds to implement the direction provided by the Medical Hub.

   3. Determine if it is appropriate for the parent/legal guardian to be present for the forensic exam, and if they should accompany the child/youth to the Hub. This decision should be made in consultation with the out-stationed CSW who will inform the Hub personnel if there is a “valid reason” to exclude the family members/parent(s)/legal guardian(s) from the exam room during a medical procedure.

      • If needed, inform the parent/legal guardian that they may not be present during the exam including any limitations.
4. For and IME, at the time of placement, inform the caregiver of the requirement to utilize a Hub.
   1. Identify and discuss with the caregiver:
      • The Hub that the caregiver is interested in taking the child to
      • The reason for the referral to the Hub
      • The timeframe for service delivery
   2. Review and complete the Medical Hub Notice to Caregivers with the caregiver
      • Have the caregiver initial and sign the form in the designated spaces.
   3. Inform the caregiver that the Hub will contact them to notify them of the appointment date and time.
   4. Remind caregivers to take the DCFS 4158, Authorization for General Medical Care for a Child Placed by an Order of the Juvenile Court, or the DCFS 179, Parental Consent and Authorization for Medical Care, with them to the Hub appointment along with proper identification.
   5. Notify the caregiver that examinations at Medical Hubs are comprehensive and therefore can be lengthier than routine exams conducted by a community health care provider.
   6. If the child is placed through a Foster Family Agency (FFA) or in an STRTP, contact the FFA social worker or STRTP representative.
      • Provide him/her with the instructions/requirements for making an appointment and utilizing the Hub selected by the agency
      • Inform the FFA social worker or STRTP representative of the time-frame in which the child is to be seen.
      • Send the Medical Hub Referral form to the FFA social worker or STRTP representative within one (1) business day of the submission of the referral through E-mHub/Rightfax
5. Inform Hub personnel if any other relative/individual aside from the primary caregiver (whose name appears on the DCFS 4158 or the DCFS 179) will be taking the child to the medical appointment.
6. Document all contacts with the FFA social worker or the STRTP representative, and all service providers in the CWS/CMS Contact Notebook.
7. When writing the Detention Report, under “Recommendations”, ask that the court order Medical Hub services for the newly-detained child as well as for those children who remain home when there is a recommendation pursuant to WIC 319.
8. Follow up with parent/legal guardian or out-of-home caregiver within three (3) calendar days regarding no-show notifications to ensure that the forensic evaluation or IME, or CSEC medical examination, or other medical appointment is rescheduled.

Referring a Non-Detained Child to Medical Hub

The Hubs are available to provide forensic evaluations and CSEC Medical Clearances/IMEs for children who are not detained. Since the child is not under DCFS supervision, parental consent or exigent circumstances is required. 

ER CSW/CS CSW/ERCP CSW Responsibilities

The following procedures apply to the CSW conducting the ER investigation:

1. Complete the Medical Hub Referral Form for a forensic evaluation when there are allegations of physical abuse, sexual abuse, or severe neglect.

2. Follow the CSW/ER CSW/ERCP CSW Responsibilities (steps #1 through #8) under the section on “Referring a Detained Child to a Medical Hub”.
   
   

Referring a Newly-Transferred Case from Another County to a Medical Hub (Inter-county Case Assignment)

CS CSW/PHN Responsibilities

1. Within thirty (30) days of being assigned an inter-county case transfer (including FM, FR, APPLA cases), review the case record and, as needed/applicable, consult with the regional PHN to determine if there is a medical need to have the child seen by the nearest Hub for an IME.

2. On the Medical Hub Referral form, in the “Specify reason for DCFS current and prior involvement” field, note that this is an inter-county case transfer.

3. The CSW will provide copies of any medical records contained in the case file to Hub personnel on or before the date of the examination. 

4. Follow the CSW/ER CSW/ERCP CSW Responsibilities (steps #1 through #8) under the section on “Referring a Detained Child to a Medical Hub”.

Addressing Examination Results Received from Medical Hub

The results of the IME,forensic evaluation, updated medical examination, or medical clearance along with any mental health screening documents, if available/applicable, as well as any other available/applicable ancillary documentation shall be provided to the assigned CSW via the E-mHub System, or via fax from CHLA.

The results of the Hub forensic evaluation are documented in an electronic medical record and sent to the DCFS CSW via E-mHUB.

• Please note that the results of the examination will not include information on an adolescent patient who has a right to confidentiality according to current California state law, unless the patient gives consent for it to be included.

• It is important that the team work together to ensure adolescent confidentiality laws are followed and that adolescent sensitive services are not disclosed to stakeholders in the HEP, the DCFS 561a, and/or any other shared documentation.

• The forensic evaluation results are sent electronically to the designated DCFS CSW no later than ten (10) business days following the appointment; or no later than ten (10) business days after the receipt of all requested medical records needed to complete the forensic assessment.

• The Hub clinician will communicate with the DCFS CSW regarding what is needed to complete the forensic assessment.

CS CSW Responsibilities

1. Review the information on the DCFS 561(a), Medical Examination form, the CalEMA or forensic clinician note, and DCFS 561 (c),Psychological/Other Examination Form.
2. If there are any questions regarding the forensic exam results, contact the out-stationed CSW or the forensic provider who will take next steps necessary to resolve any concerns/address questions.
3. Consult with the Service Linkage Specialist (SLS), the PHN, co-located DMH staff, and co-located Educational Liaison (if applicable) to coordinate follow-up care.
4. Print out a copy of the DCFS 561(a), CalEMA or forensic clinician note, and DCFS 561 (c) and file them in the Psychological/Medical/Dental/School Report Folder.
5. Fax/Scan and email the completed DCFS 561(a) to the FFA or STRTP within five (5) business days of receipt.
6. Document all contacts with the caregiver, Hub staff, the SLS, PHN, DMH co-located staff, and the Educational Liaison (if applicable) in the CWS/CMS Contact Notebook.

• It is important that the team work together to ensure adolescent confidentiality laws are followed and that adolescent sensitive services are not disclosed to stakeholders in the HEP, or any other shared documentation.

Regional PHN Responsibilities

1. Review the DCFS 561(a), Medical Examination form, the CalEMA (if applicable), and DCFS 561 (c) Psychological/Other Examination form.
2. Enter the results of the 561 (a) and (c) into the CWS/CMS Health Notebook.

• In the event that a child/youth has immediate follow-up needs, the Hub medical team communicates with the Hub PHN to initiate coordination with the Regional team and/or begin addressing needs, as capacity allows.

3. Review the 561 (a) report and conduct follow up to address the needs and treatment plan for the child and enter the information into CWS/CMS.
4. Follow up on any health concerns indicated with appropriate parties and be cognizant of any mental health issues as stated on the DCFS 561(c) form.

• It is important that the team work together to ensure adolescent confidentiality laws are followed and that adolescent sensitive services are not disclosed to stakeholders in the HEP, or any other shared documentation.

CSAT Staff Responsibilities

1. Upon receipt, review the IME, DCFS 561(a) and (c),or any urgent mental health screening documents from the Hub.

2. Complete administrative activities associated with the Hub such as receiving the results of the IME, ensuring the Hub results are distributed to the MAT provider, and documenting the information in CWS/CMS.

• It is important that the team work together to ensure adolescent confidentiality laws are followed and that adolescent sensitive services are not disclosed to stakeholders in the HEP, or any other shared documentation.

Attachments

Medical Hubs for the Department of Children and Family Services, Initial Medical Examinations and Forensic Examinations

Know Your Rights for Sexual Health Services and Sexual Health Services Available at the Medical Hub Clinics

Medical Hub Services Recommendation

LA County Medical Hub Core Services - Escalation Decision Tree for CSWs

DHS-DCFS Medical Hub Operations - Contact Information

Forms

CWS/CMS

Detention Report

Medical Hub Referral Form

LA Kids

DCFS 174, Family Centered Referral and Services Form

DCFS 179, Parental Consent and Authorization for Medical Care and Release of Health and Education Records (also available in Spanish)

DCFS 179-MH, Parental Consent for Child’s Mental Health/Developmental Assessment and Participation in Mental Health/Developmental Services (also available in Spanish)

DCFS 179-PHI, Authorization for Disclosure of Child’s Protected Health Information (also available in Spanish)

DCFS 561(a), Medical Examination Form

DCFS 561(b), Dental Examination Form

DCFS 561(c), Psychological/Other Examination Form

DCFS 563, Medical Record Procedures for Foster Caregivers

DCFS 4158, Authorization for General Medical Care for a Child Placed by an Order of the Juvenile Court

Medical Hub Referral Form (with instructions)

Medical Hub Notice to Caregivers (also available in Spanish)

Referenced Policy Guides

0070-516.15, Screening and Assessing Children for Mental Health Services and Referring to the Coordinated Services Action Team (CSAT)

0070-526.10, Assessment of Fetal Alcohol Spectrum Disorder (FASD)

0070-529.10, Assessing Allegations of Physical Abuse

0070-532.10, Assessing Allegations of Child Sexual Abuse

0070-526.10, Assessment of Shaken Infant Syndrome

0070-548.20, Taking Children into Temporary Custody

0070-570.10, Obtaining Warrants and/or Removal Orders

0080-505.20, Health and Education Passport (HEP)

0300-301.05, Filing Petitions

0600-506.10, Child Health and Disability Prevention (CHDP) Program

1000-504.75, Inter-county Transfer (ICT)

1200-500.09, Model Case Format

Statutes

California Department of Social Services (CDSS), Manual of Policies and Procedures (MPP) Division 31-206.361 – States that each child in placement must receive a medical and dental examination within thirty (30) days of placement.

Welfare and Institutions Code (WIC) Section 324.5 – States that whenever allegations of physical or sexual abuse of a child come to the attention of DCFS, and the child is taken in to protective custody, DCFS must, as soon as practically possible, consult with a medical practitioner who is trained in detecting and treating child abuse injuries and child neglect, to determine whether a physical examination of the child is needed. If a physical exam is needed, DCFS must ensure the examination takes place within seventy-two (72) hours of the time the child was taken into protective custody. If the allegations are made while the child is in custody, the physical examination must be performed within seventy-two (72) hours of the time the allegations were made. In addition, DCFS must provide the results of the physical examination to the court, to any counsel for the minor, and any counsel for the parent/guardian of the minor. Failure to obtain the physical exam cannot be used as grounds for denying a petition.

The statutes also states that DCFS must, whenever possible, request that additional medical exams to determine child abuse injuries or neglect, be performed by the same medical practitioner who performed the initial exam. If this is not possible, DCFS must ensure that future medical practitioners to whom the child is referred for ongoing diagnosis and treatment have specialized training in detecting and treating child abuse injuries and neglect and have access to the child’s medical records covering the current and previous incidents of child abuse.

WIC Section 16010(c) – States that within thirty (30) days of initial placement of a child into foster care, DCFS must provide the caretaker with the child’s current health and education summary. For each subsequent placement, DCFS must provide the caretaker with a current summary within forty-eight (48) hours of the placement.