The decades-old system Texas foster care officials use to track and monitor the health records of the nearly 20,000 children in their custody is both outdated and unreliable — so much so, advocates say, that children have been harmed or put at risk. And those deficiencies persist despite a 2015 order by a federal judge that state leaders fix the system’s deficiencies.

“The frustration with IMPACT is well known,” said Texas state Rep. Gene Wu, a Democrat from Houston, referring to the aging software.

That frustration, he added, is felt widely, from caseworkers to the court system, and boils down to a simple reality: IMPACT, Information Management Protecting Adults and Children in Texas, has been in place since 1996. It was designed to be a secure location for foster children’s records, including their health records and histories of neglect and abuse. But it doesn’t allow such information to be easily added by or shared among state and local health agencies, Medicaid, and even health care providers for the foster children in Texas’ care. Without that ability, children’s medical needs are getting lost in transit. After all, foster kids tend to move from place to place, home to home, and doctor to doctor.

A report released this year by court-appointed monitors is full of harrowing stories and frightening missteps. For instance, in January 2022, a residential treatment center lost track of a 16-year-old boy’s medications. The supply ran out but the center “didn’t realize it.” The boy, who had a history of suicidal ideation, had to undergo an emergency psychiatric consult.

The report also told the story of a foster child who had to stay in a Dallas hotel because caseworkers were unable to find her a family. But no one knew she had prescription drugs in her backpack. When she was left alone in her room, she swallowed a handful of pills. She was taken to a behavioral hospital. As of last September, she was in juvenile detention.

Such accounts, and the concerns they trigger about the state’s broken foster care system, have begun to find traction this legislative session.

The state’s Department of Family and Protective Services, for instance, which oversees the system, has been called in for a series of status hearings regarding its overall progress. Those involved say lasting improvement has to start with modernizing DFPS’ technological infrastructure, but whether their pleas will be met with action is unclear.

Making matters more frustrating for caseworkers is that the federal government in 2015 introduced a new set of regulatory requirements. States could use them to build a framework and become part of a national network that, from the federal view, would help states better track foster kids and their health care needs. Texas, however, is one of four states that has so far opted against using it.

The state now finds itself in the unprecedented situation of having a budget surplus of $32.7 billion, and DFPS is bidding to snag some of that windfall. During an appropriations meeting in February, commissioner Stephanie Muth said that priorities for any such allocation would include building community-based care teams and increasing pay to boost employee retention. The department isn’t planning to replace or make sweeping changes to IMPACT anytime soon.

That’s despite the fact that IMPACT is older than Google — and has had far fewer updates.

Marissa Gonzales, DFPS media relations director, said that when states were given the option to adopt the new federal standards — which incorporated modern technology to enable data to be shared between systems — the agency opted out because they found the requirements “quite restrictive.” On the table now, however, is a federal offer to cover half the cost of transitioning, she said, adding that the agency is “talking to other states about their experiences, and evaluating our own needs, before deciding next steps.”

According to a report by think tank Texas 2036 and the Texas Alliance of Child and Family Services, transitioning to the new program would cost the state $80 million. It said the state had already spent more than $80 million since 2015 to maintain its current system.

One of the biggest concerns of caseworkers is that IMPACT isn’t capable of supporting data-sharing, also known as interoperability, and flagging potential problems, such as when doctors separately prescribe medications that are dangerous when taken together. This is critical, because foster children are prescribed psychotropic drugs to treat mental health disorders at more than four times the rate of other children on Medicaid.

But without such a safety net, the responsibility falls to the caseworker.

“You wouldn’t really expect a CPS worker to have advanced knowledge of psychotropic medications” and which ones children can and cannot take together safely, said Tara Green, co-founder and executive director of the Foster Care Advocacy Center in Houston. But caseworkers have saved children’s lives by catching dangerous medication pairings, she said.

On several occasions, Green said, a caseworker has raised a concern about a child’s medications and a psychiatrist has confirmed that if the issue wasn’t caught then, “this kid would have had a heart attack in the next week or so.”

Scores of children in the past few years have died while in the state’s care, with most of the deaths attributed to preexisting medical conditions — disorders that, more often than not, require specialized care and treatments.

Asked during a House committee hearing about the timing of a modernization project, Muth seemed to suggest it would be a longer-range fix. “It would not be a process that takes a biennium or two, and you’d have to plan for that,” she said. “So, I still think we’re talking about down the road.”

But Wu told KFF Health News that putting off even starting such an upgrade will make things worse. The system will “probably already be out-of-date” by the time it’s ready, he said. That’s why “it always feels like we’re in a catch-up mode,” he added.

As it stands, caseworkers have heavy client loads and spend much of their day driving to visits with children who are scattered across counties. But IMPACT isn’t accessible on their mobile devices. That means they often end up transferring paper notes into the program when they return to the office. On top of that, it takes several steps to make a single entry, and the system is prone to freezing.

“All the data that we’re relying on to tell us about the lives of these kids, it has to be taken with a grain of salt,” said Meredith Parekh, the supervising attorney of Disability Rights Texas’ foster care team. “Your data is only as good as the ability of the caseworker to keep up with all of that, and they’re trying to juggle so many things.”

Texas’ foster system has been under intense pressure since a federal lawsuit was filed against it in 2011 for “leaving many thousands of children to be harmed while in the state’s care,” the complaint reads. U.S. District Judge Janis Graham Jack wrote in a scathing 260-page 2015 ruling that the system “shocks the conscience.” More recently, during a January status hearing, Jack scolded the foster care agency, saying children “come into your care with great needs. I just don’t want them going out of your care with even greater needs, which is what has been happening.”

As part of her ruling, Jack ordered a list of corrections the state agency must make, including hiring more caseworkers to reduce caseloads, stopping the placing of children in foster group homes that lack 24-hour supervision, and tracking child-on-child abuse.

In the eight years since, some progress has been made. For instance, according to the state, caseloads have been reduced, from a daily average of 17 children per caseworker in 2015 — which exceeded the national recommendation of 12 to 15 children per worker — to a daily average of 11 at the beginning of 2023.

But caseworkers say updating the foster care system’s technology would provide overall support for the care children receive, rather than placing band-aids on issues.

The new records system would “make it easier to track everything about that kid,” said Hope Osborn, the policy and advocacy manager at Texas 2036, since a variety of agencies would have access to that child’s data, and the “more eyes on that kid, the better.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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By Colleen DeGuzman
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.