In 2022, over 500,000 youth were involved in foster care system nationwide (1). Youth in foster care experience unique health challenges, such as high mental health morbidity, foregone preventative care, and unmet sexual and reproductive health needs (2). These issues may be even greater for older youth (i.e., adolescents) in foster care, who face additional risks related to “aging out” of the system (3). Black youth and youth identifying as sexual and gender minorities are more likely to enter foster care (4, 5), disparities driven by disproportionate exposure to trauma, discrimination, and poverty (6–8). Thus, strategies to support youth in foster care must adopt healing-centered approaches that acknowledge these histories and provide holistic supports to buffer against negative health outcomes. Further, addressing these multi-layered health inequities requires models of care that are not only accessible, but integrative and developmentally attuned.

One potential model to better meet the health needs of this unique population is the patient-centered medical home (PCMH) (9). PCMHs, which integrate preventative and acute medical care, behavioral health, and case management services, can provide intensive medical and psychosocial supports within a unified setting (10). This strategy reduces key barriers in care access, such as transportation to and from appointments and coordinating visits across multiple providers, and the longitudinal nature of services facilitates trust-building with practitioners. In addition, PCMHs may decrease overutilization of healthcare resources, such as emergency department (ED) visits for non-emergent conditions (11), which can decrease associated healthcare costs. This is particularly relevant for youth in foster care, who, despite comprising less than 2% of Medicaid enrollees (12), incur a disproportionate burden of Medicaid costs (13).

Prior research has demonstrated that youth in foster care have higher rates of hospitalization and subspecialty care, as well as greater health service costs, compared to their peers without foster system involvement (14). This may be due, in part, to a greater number of visits for psychiatric concerns, which account for a large proportion of health service utilization in this population (15). Traumatic stress may also increase somatic symptoms (e.g., pain) due to overactivation of pro-inflammatory pathways and the glucocorticoid response (16, 17). In addition, foster youth may experience more foregone healthcare prior to entry into the system (18, 19). Factors such as placement instability and insurance discontinuity may also contribute (20–22). Data regarding ED utilization among foster youth is mixed. While past-year ED utilization may be as high as 31% among foster youth (23), some evidence suggests youth in foster care are less likely to seek care for preventable medical concerns (24). However, studies involving mental health diagnoses consistently demonstrate increased care utilization for foster youth, which reflects the complex psychosocial challenges they encounter (25–27). Although PCMHs may provide a mechanism to reduce healthcare costs in foster youth (28), studies evaluating impacts of the PCMH on ED utilization in foster youth is limited.

The goal of the present study was to evaluate trends in ED utilization among foster youth by leveraging electronic health record data from an academic-affiliated PCMH from 2018 to 2024. We specifically sought to examine whether 1) ED utilization decreased during the period adolescents received care through the PCMH and 2) ED utilization remained lower following their transition out of the PCMH. In doing so, we aimed to assess whether a PCMH specific to foster youth may reduce ED overutilization in this unique population.

In this retrospective study of foster youth engaged in a PCMH, we found significant reductions in ED utilization during involvement with the program. This aligns with prior work that has shown the benefits of PCMH for individuals with medical complexity and chronic disease. By offering integrated medical and behavioral health care with intensive case management support, PCMHs may serve as a critical touchpoint for preventing foregone care or disease progression in a particularly vulnerable subgroup. As such, resultant costs associated with higher levels of care may be avoided. Consistent with prior literature, we noted a high proportion of ED visits related to behavioral health concerns, and we found that some youth were high utilizers across all time periods of the study. However, we also observed that for the entire sample, rates of ED utilization increased after leaving the PCMH, even relative to rates prior to involvement in the program.

This pattern may be related to the unique challenges associated with entry into young adulthood. Youth transitioning out of foster care are at high risk of housing instability, unemployment, justice system involvement, and poverty (30, 31). All of these factors may contribute to greater health needs and create structural barriers to medical follow-up. Indeed, youth aging out of foster care have higher rates of mental health challenges and substance use (32, 33), yet are less likely to engage in outpatient mental health treatment (34). Given this especially vulnerable period, many states have implemented policies to allow extension of foster care beyond age 18 (35), and numerous agencies have developed multilevel interventions aimed at supporting this subgroup (36). Our findings reaffirm the critical importance of caring for youth beyond their involvement in the system. Although our PCMH is open to current or former foster youth, there may be opportunities to strengthen supports for patients entering young adulthood through dedicated transition planning, continued case management support, or integration and/or co-location of adult providers. In addition, it is essential to bolster known protective factors among foster youth transitioning out of the system, such as safe and caring relationships, nonfamilial mentoring, and setting goals for the future (37–39).

Similar to other studies in this population, we demonstrated that most ED visits were related to behavioral health concerns, such as suicidality and aggression. Beyond having a higher burden of mental health morbidity (40), youth in foster care may also be impacted by the overall shortage of pediatric mental health services globally (41). Prior work has demonstrated that increased age, as well as delayed receipt of mental health treatment services, may contribute to ED utilization for this purpose (15, 42). Thus a PCMH, particularly one which includes psychiatric services and trauma-focused therapy, may be particularly well-suited to address this issue by decreasing time to entry into care. This aligns with qualitative research with foster youth and their families (43), where integrating mental health services with primary care was felt to be valuable. Furthermore, both longitudinal trust-building and provider continuity have been cited as key elements of ongoing service engagement, especially in preparing foster youth for the transition to adult mental health care (44). The PCMH offers an ideal setting for this occur when tailored to the unique developmental needs of adolescence.

Youth that were older, female, and non-Hispanic Black had higher ED utilization overall. However, among the 48 youth who were categorized as being high utilizers, we noted similarities in diagnostic categories, with the exception of pain. This may be due, in part, to known disparities in pain management according to racial identity, in which Black patients are less likely to receive analgesia (45). If pain control is inadequate, these individuals may return more frequently to seek care. Although some studies demonstrate increased ED utilization among individuals with functional pain disorders (i.e., in the setting of comorbid depression or anxiety) (46), Black women in particular are less likely to report these somatic symptoms than other identities (47, 48), making it essential for providers to combat structural racism and interpersonal bias when providing clinical care (49). This is of added importance for youth with foster system involvement, where experiences of discrimination may be even more common. PCMHs offer an ideal setting to incorporate healing-centered frameworks (50), which acknowledge these histories and cultivate well-being through relationship-building, hope, and empowerment.

There are several important limitations to this work which must be considered. First, as data was limited to information extracted from the electronic medical record, we were not able to account for important sources of confounding, such as placement changes and insurance discontinuity. In addition, we only examined data within one electronic medical interface, which may miss ED encounters occurring outside of a partnering health system, or care sought in other settings (e.g., urgent care). These variables may be inherently linked; youth with greater placement instability may be more likely to seek care outside of a single health system. Importantly, PCMH models have the potential to bridge care across multiple settings. This informed eligibility for COACH, which allows youth to remain in care through age 25, regardless of ongoing involvement in the foster care system.

That said, because our program focuses specifically on adolescents, our findings may not be generalizable to younger children in the foster system. Involvement in COACH was not randomized, so individuals engaged in the program may systematically differ from other youth in foster care. While the racial and ethnic makeup of our PCMH mirrors known disparities in the larger foster care system (51), the lack of reliable sexual orientation and gender identity data in our medical record prevents us from being able to assess all aspects of identity. This is a key gap in light of known systemic inequities for youth who identify as sexual or gender minority (4, 5). Applying an intersectional lens to future analyses is critical to better identify patterns of overutilization which can be addressed with tailored interventions (52, 53). We also noted a higher prevalence of females in our sample, suggesting additional structural barriers for males, such as crossover into the juvenile justice system (54).

We did not exclude non-preventable ED visits, and it is likely that some visits related to chronic medical illness were misclassified due to primary diagnostic code (e.g., “chest pain” rather than “status asthmaticus”). Greater research is needed to examine whether decreased ED utilization rates for preventable reasons are directly linked to PCMH visits. This has important implications regarding cost effectiveness analyses, as many health problems in this population may persist into adulthood. Despite these limitations, we were able to assess care utilization in a relatively large sample without reliance on self-report, which overcomes some of the gaps in prior literature. In addition, we observed youth over a relatively long follow-up period, enabling us to track utilization patterns after leaving the PCMH.

Together, our findings highlight the potential for PCMH to better support the unique medical, psychological, and social needs of youth in foster care. Rather than viewing the PCMH as a cost-saving strategy alone, our findings suggest it serves as a stabilizing institution that merits continued investment, particularly during transitions to adulthood. Future work should incorporate multilevel cost effectiveness analyses to understand broader implications for health services spending. This may involve identifying the “core components” of a successful PCMH intervention. In addition, describing care utilization across multiple settings (e.g., inpatient, residential, other outpatient) may provide a more comprehensive picture regarding use patterns in this population. Overall, our findings underscore the importance of minimizing barriers to care access, building longitudinal relationships, and creating trustworthy clinical environments for youth in foster care to better support well-being.