Jean Blankenship: Good afternoon everyone.
Thank you for joining today's webinar, "Partnering to Treat Women with Opioid Use Disorders,
Lessons Learned from a Six Site Initiative." My name is Jean Blankenship. I am with the
Office on Child Abuse and Neglect at the Children's Bureau, within the Administration for Children
and Families. We are so pleased to have so many of you with us today, to take part in
this webinar. The second part of the webinar series started
on September 19th, with an overview and introduction to the newly released SAMHSA document, "A
Collaborative Approach to Treatment of Pregnant Women with Opioid Use Disorders, Practice
and Policy Considerations for Child Welfare, Collaborating Medical, and Service Providers."
We are happy to welcome you to today's presentation and to continue the conversation around this
very important issue. This webinar series and the document is a collaborative effort
between SAMHSA, the Children's Bureau at the Administration for Children and Families,
and the National Center on Substance Abuse and Child Welfare.
Today, we will feature six sites who have participated in the In Depth Technical Assistance
Program for Substance-Exposed Infants through the National Center. The six sites include
Connecticut, Kentucky, Minnesota, New Jersey, Virginia, and West Virginia.
The National Center provided In Depth technical assistance to these sites as they worked to
develop a comprehensive service array across systems in working with pregnant and postpartum
women with opioid and other substance use disorders, their infants, and their families.
At this time, I'd like to introduce Linda Carpenter, who will be leading us through
the next part of the webinar. Linda is the In Depth Technical Assistance program director
with the National Center on Substance Abuse and Child Welfare and has worked closely with
many of the states who will be sharing their experiences, key findings, and lessons learned
in the webinar, today. Linda Carpenter: Thank you, Jean. Thanks for
this introduction. Thanks, also, to Sharon Amatetti. I know she's not on the call, today,
from SAMHSA and, also, to Elaine Stedt from Children's Bureau for not only their continued
support for the National Center but, in particular, their support and guidance on this particular
issue. We're going to touch on a number of things,
today, that these sites have done and learned over the last two years. I want to point out
the one bullet that says, "Understanding Current Practice." I can't underscore enough the importance
of the amount of time that these sites spent on this particular issue, not just in understanding
practice in their own system but in their partner systems, as well.
There was a tendency with these sites, as there oftentimes is, to want to jump in to
implement new programs, to jump right ahead to fix something, without always understanding
what really needs to be fixed. The findings and the lessons learned from
these sites have really helped to inform their next steps. It's really helped to inform their
work across the collaborative systems, to understand each other, to understand the gaps
and barriers that these women are often facing, and then to help them begin to look at policies
and practices and even, sometimes, legislation that needed to be changed.
Last week, we hope that most of you or all of you turned into the first webinar, part
one of this two part series. If so, you would have heard Sharon Amatetti and Dr. Nancy Young
talking about the opioid epidemic, the impact on families, the impact on states and tribes
and communities and systems, and especially on the child welfare system, the treatment
systems and medical systems. They discussed the work that went into the
development of this guidance document and the expertise they relied on from multiple
individuals. This document really set the stage for the
work that we've done with these states over the course of the last two years. We hope
you've had a chance to download it and to really look and review this work. It's probably
been one of the most critical pieces of information and guidance that we had on working with these
communities. The purpose of the substance-exposed infants
in depth technical systems initiative, and I want to point out, even the title with this,
it's a substance-exposed infant, and yet, you're going to hear from all of us. You'll
hear, certainly, from each of the sites themselves. The importance of the mother-infant dyad,
even the mother-father-infant dyad, triad, and the work with families themselves, this
is not just about the babies. It's not just about pregnant women. It's about
the work that we need to do to address the needs of pregnant and post partum women, their
infants, and their families. The work that's been done over the last couple of years, you're
going to hear us talk about the knowledge gained with this, the lessons learned from
sites. The focus was really on strengthening the capacity of these sites to serve these
women and children, and to improve outcomes for what we consider one of the most vulnerable
populations. A little bit about our approach. You'll hear
us talk about the site application. We're going to talk at the end a little bit about
some new opportunities coming up. Sites were selected. One of the first things that we
did was to assign a senior level consultant, something that we call a change leader, to
work with each of these sites. This change leader has years of experience
either in child welfare, in the treatment system, early education, and sometimes, one
or more than one of those different systems. We used a wide range of tools to help them
identify issues and concerns. We focused on bringing together the right mix of partners.
We help them identify who those partners are and should be.
We talked about where partners were aligned, and where they experienced the greatest differences
in approaches and values and perceptions in serving this population of women and their
families. That was a really…it helped them form that
collaborative to get started, and look at who critical partners were and who missing
partners were to do this work. When we start to look at the individual states themselves,
I would really encourage you to pay attention to the depth and the breadth of the preparations
that were needed, and are needed, to do this work.
Talk about a phased approach. I said they applied for this, and again, I can't underscore
enough the importance of that needs assessment and that strategic planning piece. If you
speak to individuals in each of these sites, they'll tell you that they're just now getting
into that implementation phase. Working with our change leaders, they developed
some marvelous tools for conducting these need assessments across multiple systems,
and then engaging in this planning process. This is the time consuming process. I said
they wanted to jump right in sometimes to fixing the problem, but they spend…it really
does take time. It was really important for them to understand
not only how their systems work, and how their systems were operating, and the barriers and
challenges that that created for families, but it was also important to understand that
sometimes how their systems worked could impede something that would be happening in another
system. For example, if hospitals are not routinely
notifying Child Protective Services when an infant is born prenatally exposed, then Child
Protective Services can't respond to the needs of those infants and families, and they can't
then report these infants on to the Children's Bureau as they're required to do through CAPTA.
We needed to know that. They needed to know that. We spend a great deal of time trying
to uncover those practices in these various systems, and looking at the way these systems
are working in order to change practice and to work more collaboratively together.
Took a lot the time, it certainly took collaboration, and in many cases it took a great deal of
patience. Annabelle talked about these sites already Connecticut, Kentucky, Minnesota,
New Jersey, Virginia and West Virginia. It's important to note and again I'll go back to
the webinar last week when Dr. Young was talking about opioid epidemic across the country if
you look at where most of these states are clustered, they're along the east coast or
in the southeast region with Kentucky. Then the Minnesota site really focused on
the needs in the tribal communities and primarily the north western part of the state and tribes.
SAMHSA held a policy academy in August 2014. They convened 10 states, and it wasn't just
to look at the issue of pregnant women and substance-exposed infants. It was to look
at any number of different things that states needed to address, related to the opioid epidemic.
One of the opportunities that came out of that policy academy was really to focus then
on this particular issue. With the support through the National Center,
and with the additional support from SAMHSA, funding was allocated to select up to six
sites. We solicited applications, we picked the six sites, they were awarded late October,
started working with them in November. The original funding was supposed to be for
18 months. We would have finished up in about March 2016. We asked them to submit information
to us in terms of progress that they've made, their additional goals, additional technical
assistance that they needed. Then five of those sites moved on to continue with us through
September of 2016. I'll say again, we're wrapping up with them
right now in terms of this two year initiative, and they're really at the implementation phase.
When you look at long term systemic change, they've done a great job with forming these
partnerships, identifying who all their partners are, expanding those relationships, understanding
needs and doing that strategic planning. They're just now entering into the implementation.
All of them will tell you the importance of having some ongoing technical systems and
needs check ins periodically would be really helpful at this point.
They've made some tremendous gains. They started with their applications with a range of different
goals, and even though they may have been framed, each one of them a little bit differently,
there are great deal of commonalities and key issues across each of these sites. They're
all in some way, shape, or form are working on a statewide action plan to address the
needs of pregnant and post partum women, their infants and families.
You'll see where in a couple of our sites. Again, I'll go back to the webinar. Last week,
we talked about medication assisted treatment as being an evidence based treatment. That
doesn't mean it's necessarily accepted in every state across the country. Some of them
really focused on building in medication assisted treatment and having that accepted as an evidence
based practice. They may have started wanting to focus on
the infant or starting wanting to focus on the mother, the pregnant woman, but they really
ended up understanding that what they needed was a statewide system of care that extended
in pre pregnancy in a couple of cases, and certainly pregnancy through childhood.
You'll hear this from everybody who talks. The development of consistent protocols for
early identification of both pregnant women and their infants became one of the most important
things they looked at. Again, they looked at current practice. They looked at whether
or not things were occurring and were they occurring consistently and found in most cases
that that was not case. And so, this became a really important focus for all of them.
Understanding their financial resources, looking at financial mapping and where could they
leverage resources across existing programs and where were the gaps and barriers that
may need to ask for additional funding for. Data was a particular problem for all of them,
and continues to be a challenge in not only data across systems but data within their
own system. The importance of having some good baseline data on how many infants are
born prenatally exposed? Can we tell the difference between infants that are identified as being
neonatal abstinence syndrome as opposed to infants that are born with Fetal Alcohol Spectrum
disorder? Do we have those numbers? Are those numbers
consistently reported by hospitals and then on to child protective services? Do we know
how many pregnant women in our state with substance use disorders? Those were problems
across most of the sites in terms of being able to have that accurate, timely, and consistent
data. They're all looking at this. Then you're going to hear a couple of examples
of where state legislation, and possibly existing policies and legislation may possibly impede
this work. The work that people are doing to examine our current legislation and examine
their current policies and look at, proposed any changes that need to be made.
With this particular site, I'll just say that our Change Leaders are become critically important
in helping take sites through each of these phases. The facilitators guide the use of
it using a framework that I'm going to show you in just a minute, helping them build and
sustain that team in the midst of multiple challenges, whether it's fiscal challenges.
A lot of the states are going through massive turnover of not just front line workers but
also key administrators and state leaders. How do you keep this work going when you have
that kind of turnover? Again, how do you identify missing data elements? How are going to measure
progress over time? What tools did they have, that they developed and did we bring to this
to help them do all of this? We strongly recommend this structure. We strongly
recommend building this structure with any of this work that you're doing, that includes
an oversight committee that's composed of your policymakers, your senior leaders that
help you address barriers, help you look at fiscal challenges, help you move things forward.
Then a core team and this is really your worker base. Your core team of various senior managers,
mid managers that really are working across multiple systems to identify and address these
issues and then to work on them. You're going to see a list of partners from each of these
communities. It still amazes all of us at the depth and
breadth of partners that were needed to really address the comprehensive needs of these moms,
babies and families. In addition to that core team amassing that both at a state and local
level, all the partners that are needed to really address these issues.
Then they broke into work groups. Some of the workgroups focused on data, some of them
focused on legislation, some of them focused on actual programmatic practice changes. But
it takes that kind of a structure to really do this work.
The support of the Change Leader working about 20 percent with these sites and really helping
them with maintaining these teams and helping them with protocols, resources, research,
and any number of different things. Most recently, we've also started to look
at the role of the State Governor's task forces. Almost all states now have taskforces that
were formed to address the opioid epidemic. Usually those taskforces are focused on addressing
prescription pain medication, certainly focusing on the challenges with all of the overdoses
and all the other things that are associated with that.
Rarely do we hear state taskforces that are really focused on this population of women
and children. We've seen however the opportunity in this
initiative, these folks oftentimes someone might sit on that taskforce. There's been
an opportunity to form a subcommittee that really is addressing the needs of infants
that are born prenatally exposed, pregnant and postpartum women with substance use disorders
and how do you highlight that issue to the level of the Governor's task force and keep
that issue in front of the Governor, policymakers and all the other state leaders.
It's another level of engagement and oversight and connection that we have found really,
really important in this particular issue. We are going to do our first polling question.
We want to know, are pregnant women in your state or community routinely screened for
substance use during pregnancy? Some interesting results and not surprising.
Are pregnant women in your state community routinely screened for substance use during
pregnancy? We have about 31 percent of you who said yes. We didn't go so far as to say
are you using universal screening or are you selectively screening? Is it all women that
you're screening? A third of you are saying yes, 29 percent,
no. Then about 41 percent of you, uncertain. I think that uncertain becomes as important
as looking that yes or no. Those responses are pretty consistent with what we've found
when we were first looking at this issue with states too.
It's a good lead in. That question is a good lead in for me to talk about the importance
of the five point framework. We use this framework a lot. We use it all the time with these sites.
This is really the basis of the work that we do.
Not that every site was focusing on every single one of these intervention points, but
they realized that wherever they were starting, whether they were starting at the birth of
the baby, or the pregnancy period, the prenatal period, that ultimately they were going to
need to address the intervention points across this continuum.
Pre pregnancy, the opportunity to really increase community awareness about substance use effects,
and in this particular case it was really helping the community better understand the
effects of opioid use. The prenatal period, the screening and assessment period, this
becomes one of the most important aspects of this work.
As we just asked, are we screening pregnant women for substance use disorders and getting
her, when positive, into treatment that she needs? Appropriate kind of treatment? Because
that's going to improve outcomes, both for mom and for the baby.
Most often, that identification comes at the birth event, with the baby. At that point
in time it's critical to ensure that and this is what plan and state care should do address
the needs of both the child and the parent. We're going to talk a little bit more about
the postpartum period because it's a period where we're extremely concerned about women
and their infants and children falling through the cracks at this point in time. It's a period
that we all need to be paying particular attention to.
Then certainly that last and ongoing intervention piece, that infancy and beyond. Are we continuing
to address the needs of that baby, that child, that family from there on out? This became
really the framework for our work in helping sites really identify where they are, where
they can start, where they could work with our partners.
I'd ask as we go on to the next slide, look at this from your own perspective, from your
own system and see where are you right now, and where might you partner with someone else
to intervene at other points. Next slide, please.
Do some existing policies inadvertently discourage pregnant and parenting women from seeking
care for opioid dependence or other substance use disorders? Do you have this in your state?
Look at interesting, not surprising results. Do you have policies that inadvertently discourage
pregnant and parenting women from seeking care? About 46 percent of you said yes. This
could be any number of different, either legislation policies, practices that would…
One of the things we identified was the stigma and the shame and the fear associated with
using during pregnancy is much greater, I think, than any of us ever expected. We knew
it was there, it's certainly much greater than we thought.
Oftentimes what we put in place in our systems may not be supporting those women. They may
be doing just the opposite and driving them away from care, driving them out of your state,
driving them to other counties. One of things we saw that was probably the
most disturbing, was even discouraging them, not only from not seeking treatment for substance
use disorders but not even seeking prenatal care, because they were afraid of what would
happen with that. Again, the number of you uncertain. This is
one of the discussions within the collaboratives. This was one of the most important first critical
discussions around what are the policies and practices we have in place and are they supporting
these women or are they inadvertently driving them away?
This same question from one of our sites, and it really depends on who's answering the
question to begin with. You saw here the yeses, the fewer yeses, a little more nos. A lot
of folks from the treatment system more answering this particular question. But a lot of don't
knows, and this was in the very early stages of our work.
It's why these questions became so critical. These are part of our guidance questions,
at the end of that document that Dr. Young talked about last week.
Next slide. Now we're going to talk a little bit about
the sites themselves. We'd like to take you through some of the lessons learned from these
sites and the strategies and tools that they employ to address them.
Again, many of the issues were common, we've picked out several key issues that we want
to touch on within each of the sites, and we will give you examples of how they address
them. We've asked to change leaders to talk about the findings and what the sites did.
One of the things I'd ask you to pay attention to as we go through these sites is to pay
attention to the depth and the breath of the partnerships that were formed. Look at all
of the different partners that needed to be involved in this to really do this work. The
array of the partners and one of the challenges for these sites was constantly going back…
The good news was they kept bringing on new partners, the bad news with that was they
found themselves often stepping back and having to reorient or orient people all over again.
The depth and breadth of the partnerships with this has really been quite impressive,
and it's been one of the most important aspects of this work.
We're going to start with Kentucky. Actually Kentucky was one of my sites along with Annabelle.
You heard of Annabelle already on the phone. Annabelle and I had Kentucky. One of the biggest
issues that Kentucky was facing when we first went there was…
The treatment system in Kentucky was typically an abstinence based system and they did not
embrace, did not agree with and didn't provide medication assisted treatment as an evidence
based program. You heard Dr. Young, last week, talked about
the importance of medication assisted treatment as an evidence based program for opioid use
disorders and particularly for pregnant women. The importance of getting women into medication
assisted treatment to support her health, mother's health, as well as the health of
the baby is absolutely essential. That doesn't mean it's not controversial.
It doesn't mean that everybody agrees with it. It doesn't mean that even within treatment
systems, you have an agreement about medication assisted treatment being an evidence based
practice or one that people want to use. Certainly was controversial with the Child
Welfare System, the courts, some of the other even some medical providers. And so, this
is an issue that Kentucky has been working on over the last two years.
They've made some monumental change. They were awarded a couple of MAT expansion grants.
They've got about three communities now that are developing these really strong partnerships,
providing medication assisted treatment, providing residential care for moms and babies.
Then transitioning those moms and babies back home to communities once the baby's born and
moms and babies are stable. They have a ways to go, but I think it's been one of the things
they've made the greatest progress with. The array of partners in Kentucky, again you
can see they've got Substance Use, Mental Health. Department of Public Health was in
Kentucky as well as all these sites, an absolutely essential partner in this as is the Child
Welfare System. Medicaid, having Medicaid at the table and
being able to talk about, does mom have the appropriate coverage that she needs? When
does that coverage end or change? In Kentucky, they also have the Office of
Drug Control Policy, which ended up being a really interesting partnership because they
were able to provide some data that maybe the other partners would not have had before.
And then they had their programs and their community partners as well.
We talked about tools, we worked with them, certainly with the guidance questions. This
became particularly important for Kentucky, particularly with the discussion we just had
about medication assisted treatment and the resistance to that.
Babies being born with neonatal abstinence and whether or not they should go home with
moms and all of the kinds of differences and values and perceptions that were there when
we first went in. We did site visits. Then we used a process
called the "system walk through," where we really took them through every step of what
happens with mom, what happens when mom goes to an OB, is she screened, what happens when
she goes to the hospital to deliver, what happens with the baby.
Really trying to understand their current practices across multiple systems and how
they communicated and shared information with each other in order to start to then look
at changes in practice. Their goal, like all the sites was to develop
this system of care for pregnant and postpartum women. I think one of the things that made
the Kentucky site unique in the way that they're approaching this, is that they're really looking
critically at the case management of these women from the beginning.
They're looking at that critical postpartum piece, and said up front, that they were extremely
concerned about what happened after the birth of the baby, for both mom and baby both.
What one of our consultants calls the "fourth trimester," is where we have really started
to look at the fact that mom may lose coverage or her Medicaid coverage may reduce significantly
at a time where she's most vulnerable, and the baby's most vulnerable. Who's monitoring
them? Who's supporting them? Who's ensuring that they're still safe in care?
Kentucky's looking at this over from the pre pregnancy stage all the way, hopefully through
the first year of that infant's life. Really focusing their efforts on identification,
case management, and then developing that plan for mom and baby both.
In addition, they've done some great work with the hospitals led by their maternal child
and health director of identifying hospital protocols. Are the hospitals consistent in
the way that they're treating neonatal abstinence? They're working on a Plan of Safe Care for
infants and mothers right now. It's important to note with that, that they're
really looking at a multi disciplinary assessment process for developing that Plan of Safe Care.
Everybody that has a piece of information about that mom and baby in the beginning,
whether it's substance use treatment, whether it's the hospital's neonatologist, all of
those various folks coming together and providing that information to develop that plan, develop
a discharge plan and then working with Child Protective Services, who's doing an interesting
risk assessment process, will be doing an interesting risk assessment process with those
babies and pairing those two so that they have a comprehensive Plan of Safe Care that
focuses… Also on understanding protective factors as
well as risk factors, something they identified as never really having done before.
The timing of that, making certain that they have that prior to discharge from the hospital,
so that they're certain when babies go home that they're going home safely and the case
they can't then they go to out of home care. But mom's needs are still being addressed.
You'll see the range of things that they've been working on in Kentucky. We talked about
MAT expansion services. One of the things I want to point out with this is that they
looked at one of their current programs, called the "Kids Now Plus Program" how to leverage
that program to serve these moms and babies differently.
They're re tooling the program, they're retraining staff, and they're focusing much more on making
that a case management and linkage services. No new money in this. Same money, same program,
but re tooling and retraining staff to interface more with prenatal care providers and then
to be that case management function for those pregnant women and their infants.
I also want to say, the issue of changing culture which has a lot to do with that medication
assisted treatment. There are challenges, challenges is the same as most of these sites,
the early identification in screening, stigma, looking at whether or not moms had Medicaid
coverage through the postpartum period and then all of the collaboration challenges.
Ultimately, what they expect to walk out with, and I know they will and they will continue
to work on this, is developing a statewide protocol for a Plan of Safe Care. The guidelines
for the hospitals and then practice changes across multiple systems for moms and babies.
One more polling question. Think about your system and your partners. Are all staff supportive
and non judgmental about pregnant and parenting women with opioid use and other substance
use disorders? Be honest about that one. This is a really important question. It's
one of the questions that is asked very early on in these collaborative. It's incredibly
important for people to look at this from their own perspective of what they think about
women who are using during pregnancy. Again, I'm going to go back to the webinar
that was done last week when Sharon Amatetti and Dr. Young talked so eloquently about the
opioid epidemic and prescription pain medication, and how that's really helped people think
differently about this population of women and infants that we're seeing and this dramatic
increase across the country. Understanding where systems are when they
come to this work and what people think about this is absolutely essential. We talked about
the stigma associated with this and the fear that women feel and face. Whether it's fear
of being arrested or whether it's fear of having your child taken away, which is the
greater fear. It's really important that you have these
discussions and talk about what you bring to this and what you think and what the right
approaches are to this. It is one of the questions that we use that's in the back of the guidance
questions. It is one of the most important ones that
you can think about and reflect on with your partners. With that, I'm going to turn it
over to Kari Earle. Kari is one of our Change Leaders with the Minnesota site, and she's
going to talk about work in Minnesota.
Kari: Thanks, Linda. One thing, as we went through and discussed the lesson learned from
our site, we captured themes. One of the themes that sites can expect to have to address are
the barriers related to women and families accessing services that are appropriate for
their needs and culturally responsive. In Minnesota, the work we did there and continuing
to do there is a really powerful example of the state working in partnership with the
tribes with trying to look into what are some of the outreach engagement issues related
to engaging native families whether they live in rural areas or urban areas on reservation
or off reservation. They also had a lot of interesting challenges
related to the financing and reimbursement issues given that tribes don't get financing
for substance use disorders in the same way that non tribe populations do. There were
some focused areas to try to overcome the challenges that were part of the work we're
doing. Of course related to the regional and cultural
consideration looking at the differences that families experience whether they are in a
remote rural population, small community, sometimes those small communities have a lot
of stigma attached to seeking services. All of those barriers and additional ones
as well became part of the challenge the Minnesota team needed to look at addressing and finding
creative solutions too. We were really thrilled to see the growth of the partnership that
developed over the course of the two years of IDTA in Minnesota.
The leadership was at the state level a partnership between Minnesota Department of Human Services
or DHS and the Minnesota Department of Health. Those entities, underneath, that you will
see on the slide comprised the oversight committee and the leadership team for the project.
They in partnership with the tribe at government level and service level and community leadership
level became really the overall core team stakeholder group for the initiative and overtime
grew, in the background, to well over a hundred stakeholders that are continuing to provide
input into how do they address these issues and come up with better services.
The application originally came forth because the disparities for native women that are
opioid dependent during pregnancy and the number of births that have neonatal abscess
syndrome is almost nine times higher than the non native population in Minnesota.
The application came forward in really focusing on wanting to address that disparity. There
is a lot of data that they have around higher rates of prescriptions of opioids to pregnant
women for native women versus non native. There is significantly high health disparity
issues. Around those issues, they created three overarching
goals and all of them were grouped and action plans were organized around the goal of improving
screening and assessment so that pregnant women, their infants, and their families are
identified consistently across all the systems and all the communities.
The second goal that fell under the topic area the heading of the joint accountability
and shared outcome but looking specifically at how the state and Tribal partnership can
develop positive approach to serve the women and families that are at the intersection
of multiple systems. The third goal was improving capacity to deliver
quality culturally responsive services to pregnant women and their family. They used
that focused area to start developing a guidance that could be adapted across communities and
provide support in building up their service array.
Through that original developmental of those goals they developed an action plan and this
next couple of slides highlight some of the strategies that they identified for tackling
the issue. In addition to looking at the data, understanding
where the substance-exposed births were occurring in the state geographically and looking at
what was happening from one region to the next. What was some of the differences and
what was informing those differences. They also are developing outreach capacity
by doing more of an SBIRT approach and looking at different settings for implementing SBIRT.
Right now, the focus primarily up to this point around the prenatal care providers reviewing
SBIRT so now they will be on that then look on the other side.
We really want to engage law enforcement and understand how to educate and train community
law enforcement for referring in a supportive way to make sure that women are engaged in
services rather than in a punitive response. Same time we are looking at those resources
that can be responsive to specific needs that native families have.
I will talk a little bit about the financing issues. They are looking at what are the reimbursement
options for services like recovery support and case management beyond just direct treatment
services. Looking at how to develop strategic plans that increases availability in access
of the services, really looking at the collaborative capacity building strategies that they can
employ. Other challenges that they are continuing
to address very specifically are developing a better infrastructure for the tribes to
coordinate and collaborate with one another. Looking at how to improve communication mechanisms
and resource sharing so that across the state the multiple tribes in Minnesota are able
to partner where they can and also to borrow and share what they're doing that's working
well in their own communities. There is an ongoing and very rich argument
from one tribe to the next and from rural areas to urban areas about what is the best
approach for working with opioid dependent pregnant women. The ongoing work is to start
focusing on a strength based approach on what is working well versus focusing on the disagreements
about medication and treatment and some of the things that are deeply a part of their
culture. We are really focusing on plans that are outcome
driven because it does become challenging looking at the cross section of the multiple
governments that are represented in the tribal council as well as all the government agencies
at the state level. The key considerations that we have attended
to with Minnesota are really looking at ensuring the spirituality and culture are at the root
of all the programs are part of recommended as practices.
Looking at what has been effective and well done that encompasses the entire family and
its approach and while aligning values across multiple systems so that their core values
for the tribes of respect, humility integrity, and sharing are reflected in the policies
and practices that are being adopted. There's a huge need for one of those values
to understand that interventions can't be global. That they need to be very targeted
and tailored. But because there are two major tribes in Minnesota, they do tend to be the
test point for interventions that are responsive and work well and could potentially be expanded.
Most powerful thing that they always remind me of is that no matter how dire the data
and no matter how frustrating sometimes the circumstances and the system barriers can
be their hope always transcends despair and they're always optimistic in their approach
for looking at what's going to work to improve the way that terms are delivered and the way
that outcomes are achieved. Linda: I will go ahead and do it, Kari. Thank
you. Thank you, Kari, for that. The last polling question, and it certainly lead us right into
discussion with one of the other states, is does your state have legislations and policies
that require a different notification process for infants affected by legal drugs? Whether
that's prescription pain medication, methadone, buprenorphine, as opposed to illicit drugs.
Take just a couple of minutes to think about that. 15 percent of you said yes, 29 percent
of you said no, and the vast majority of you said you're not sure. Again, the uncertain,
don't know, not sure answer is really…It's important to know that not everybody understands
this and to then find out about it. It's going to be really important as you are
doing this work to say do we have legislation, do we have policies or sometimes do we even
have informal or ad hoc practices that are causing us to respond differently to legal
drugs? Whether that's moms on methadone, moms on
buprenorphine, moms taking prescription pain meds. She is taking a prescription that was
given to her by her doctor without looking at that in the context of all of the other
safety issues and safety and wellbeing of both her and the baby.
What we found, and we found in these states and we found in conversations with other states
as well, is that most often the notifications were coming in around heroin, we would like
to they were coming in around alcohol but they're typically not.
They're coming in mostly around mom's use of illegal drugs and not often when she was
taking something that was prescribed. In some cases we're going to go to Jill. Jill is going
to talk about her work in Virginia and New Jersey there was actually legislation that
made this even harder for folks to know what to do.
As we uncover practices with hospital notification and their notifications CPS, it was easy to
see why a lot of times there was so much confusion around this issue.
I'm going to now turn it over to Jill Gresham. Jill Gresham is another one of our Change
Leaders, works for National Center. She worked with Virginia and she's also going to take
you through New Jersey. So, Jill… Jill Gresham: Thanks so much, Linda. Virginia
came to the In Depth Technical Assistance Effort with an intact work group that actually
predated IDTA. The work group was really assembled in response to recommendations that were provided
by the Virginia Child Fatality review team along with the Virginia maternal mortality
review team. The goal of the team was to identify maternal
use was a significant contributing factor in maternal and infant deaths and in response
to the findings a work group was implemented to handle its CARE initiative. CARE standing
for Coordinating Access and Responding Effectively. That working group became a jumping off point
for the IDTA. You can see a lot of the partners up there represented by the Virginia substance-exposed
core team. Many of those partners also inhabited the CARE team.
One of the stand outs during that initial phase, Linda has touched on this earlier with
Kentucky which is a high number of CARE who showed up because they wanted to be a part
of this effort as well staff from the local hospitals and hospital associations.
Virginia was focused early on the initiative on the practice of hospitals at the time of
discharge. This is in part due to a series of laws which we are going to get to in just
a moment. The laws in a nutshell called for infants who are identified as being substance-exposed
and their families be and their families to be referred to local community services boards
or CRB by the hospitals at the time of identification. The CSBs in Virginia are you can think of
them as a single point of entry system which provide blanket for substance use treatment,
mental health and early intervention services. Some CSBs directly offer treatment services.
If you really want to understand how hospitals identify those family and when and how they
were referred to the community service board. The first step for the team to develop this
pretty fantastic hospital survey is the intent of distributing it across the state. The survey
looked at what their screening and testing practices but also asked a lot of great questions
about familiarity with those local laws as well as some of the federal and capital laws
that are specific to Plan of Safe Care. It got into the nitty gritty of what hospitals
were doing at that discharge point in time and what the process look like. Unfortunately,
the survey met some resistance among some of the collaborative partners. It was ultimately
abandoned in favor of the survey that would directly target the community service board.
But not all bad news, because the survey went on to be the basis for us. New Jersey hospital
survey that we'll talk about in just a little while. But the Virginia law implementing community
service board survey they wanted to understand what was happening between the community service
board and hospitals but also what's happening between the hospitals and opioid treatment
programs, the medication and treatment providers. They started working on a survey as well to
target the OTPs across the states. At the beginning of the ITDA effort, Virginia
identified three goals. First one up there was to create a shared vision and coordinated
system effort to the treatment and identification of pregnant women and their infants. The survey
provided some baseline information about current on the ground practices with a plan to then
develop best practices guidelines for both systems for the CSBs and the OTPs.
Then, a longer term goal of how to institutionalize some of the best practices and integrated
them through standard of care contract language. The survey is allows the team to target outreach
for practice change. A good example of that comes at a community service board survey
and the survey identified the hospitals that routinely identified substance-exposed infants
versus some hospitals had never really referred infants.
The team now has a list to be able to outreach to hospitals who were infrequent referrers
to really target some practice change. Virginia also wanted to improve screening
practices across the state. This is also consistent with the laws I mentioned earlier that are
currently on the books in Virginia. One law mandates that all pregnant women are screen
but it doesn't go as far as identifying the tool. There is no system in place to really
track implementation. The team wanted to broaden the use of the
tool to identify pregnant women and ensure that they were referred to care. We often
wondered as a team because the law in Virginia state that screening needs to be happening.
What the screening actually look like on the ground, what were doctors using as a tool.
We joke, they ask clients, you aren't doing drugs now, right?
Understanding the vast difference between that approach and using the standardized tool.
They wanted to get clarity about how doctors were approaching this screening.
You can see on the screen the actual laws now in Virginia that I referenced earlier
to ensure that all pregnant women were receiving training for substance use and to determine
the need for substance use evaluation. Theoretically, the screening was happening and then positive
screenings were followed by a referral for an evaluation.
That second law says that medical providers have to file a report with CPS if an infant
is exposed to alcohol or other controlled substances. Thirdly, this law specifically
is the one that pertains to the Community Service Board, which is that hospitals must
develop a discharge plan for identified pregnant women and then refer them over to the CSB
to implement the plan. When we came into Virginia and heard that
these laws were on the books, there was a lot of excitement because it seemed really
just right on target and then also in some ways seemed to be a stepping stone for a lot
of the federal laws around plans of safe care. But we really struggled. The team struggled
in Virginia, because there wasn't a whole lot that mandated that these laws actually
happened. Nothing sort of checking up to ensure that
these screenings were happening that they were evidence based. That the referrals were
happenings. What we'll talk about in the challenges section,
but legislation isn't always the answer. How does that actually play out in the day to
day. The highlight slide now, the core team them developed huge surveys. As we talked
about the CSB survey, which really focused on the relationship between hospitals on the
referral process. The second survey went to the OTP providers,
really asked about their work specifically with pregnant women. How they were educating
pregnant women on neonatal abstinence syndrome, and then collaboration with the OBGYN the
medical partners as well on post partum practices. I'm thrilled to report that the Virginia was
actually able to get 100 percent response rate for both the OTP and the CSB surveys.
They learned quite a bit about current practices across the state and again even down to which
of those hospitals were actually referring those infants and families to the CSB and
which weren't. The third piece, actually the top of the slide
that you can see there, is work on guidelines, work specific to developing a plan of state
care. A lot of what Virginia learned about what was happening in the OTPs and CSBs again
filtered in to the development of guidelines for planning of state care within the state.
Part of the guidelines will include an actual discharge template that they're hoping to
send out to hospitals. That will be the discharge template that used to refer over to the CSB.
Really, it's in its early form, but could potentially be the base of planned day care
moving in the future. Challenges, the team concurrently has been
working on guidelines for both OTPs and the CSBs, even while the surveys were going out.
The guidelines focused on what information is critical to be shared.
It focuses on critical agency policies that support the work, and then partnerships with
the development on the continuum of care. Both of those have actually been drafted,
and the plan is now to have them reviewed by leaders of OTPs and CSBs.
This has been a pretty long and arduous process, but it sounds like the surveys will be reviewed
by the thought leadership over the next month or so.
The bigger piece of how do we then take the best practice guidelines and institutionalize
them? This is going to be a longer process, but again there's a lot of discussion about
how to take some of these pieces and put this into some regulations, so that they really
can start to create some practice change. The next slide, Key Considerations. We were
lucky in Virginia to have a site visit with all the community service boards, or at least
most of them. When the invitation went out, we requested that all the CSBs actually bring
their partners with them, so Child Welfare, substance treatment, their medical partners.
The teams came to the site visit and learned a whole lot about pregnancy, substance use,
and opioid use disorders. It was really apparent that the teams varied really widely in their
level of collaboration. Some teams came, they were super integrated
and had developed…and already really even implemented super strong systems of care,
while others were still getting to know their partners.
As we start to look at statewide implementation, it becomes really critical to understand the
capacity and standing of local collaboratives, and implementation may look different in different
communities. We had mentioned earlier, which is that legislation
isn't always the answer. Again, in Virginia they had some really fantastic laws, but the
laws weren't rigidly followed, and didn't bring quite the change they had intended to
bring. Sometimes it makes a little more sense to
focus on policy and practice implementation, before jumping right to legislation.
Finally, there's guidelines. Guidelines are great, but they're a stepping stone to institutionalization.
We heard from partners that guidelines might not likely produce that widespread change
that we were after, but then it really needed to be integrated into some concrete standards.
A good first step to be vetted and bought into and marketed to local organizations.
So far they can be implemented. New Jersey, I'm going to jump right into New
Jersey. One of the most notable features of the SEI-IDTA team in New Jersey was its partnership.
The team was led by Chris Luise out of the Department of Mental Health and Addiction
Services. Linda touched on the importance of this, but
they had a really extraordinary depth and breadth, not only with across the departments
and organizations who are participating, but also across the leadership level. We're going
up as high as deputy commissioner of the Department of Health.
The other thing is that New Jersey had a state opioid task force. This actually existed prior
to the policy academy. I wanted to mention that. If you participated in IDTA, you actually
participated in the policy academy. These New Jersey members went to this policy
academy, and then came back and actually expanded the state opioid task force.
Additionally there is communication between the opioid task force and the substance-exposed
infant In Depth technical assistance team. There was a lot of good communication that
was happening between those two so that initiatives can continue to be linked up.
Between that really marketability comes the available on these changes because of the
levels of leadership that we're able to engage. In the early days of the initiative, the team
recognized that they had really limited information about what hospital practices were ongoing,
in terms of identification of infants and pregnant women with substance use disorders.
When we talked directly with some hospital partners to try to delve in and understand
what those practices were, it became really clear that there was a wide variation across
different hospital systems. An initial goal was really set out to understand
how hospitals identified substance use, how they treated neonatal abstinence syndrome.
Specifically, where they're using pharmacological, non pharmacological methods, that type of
thing. Then, what kind of supports they built around the discharge planning process? They
ultimately wanted to understand the prevalence and the associated costs of neonatal abstinence
syndrome. We decided to tackle some of these issues.
One, by developing a white paper that was specific to cost and prevalence. They were
able to look at 2013 and 2014 data. Then, to launch a statewide survey of all the birthing
hospitals based on the initial Virginia survey that I referenced a while back.
You'll see, up on the screen, those initial goals that were identified by the New Jersey
team. That first one is really looking at increasing the prenatal screening for substance
use disorder and multiple intervention points. New Jersey does track quite a bit of their
prenatal screening through the Department of Health. We did have some pretty solid baseline
indicators for doctors who were using the Four P Plus along with information about referrals
that came in for the results of the screening. The goal is really intended to identify areas
in organizations who are maybe not using the tool, or are not using the tool consistently
in order to increase the prevalence of screening across the state.
Secondly, they wanted to increase the referral of pregnant women who screen positive over
to substance use treatment and evaluation and thirdly, to engage moms, and also care
about that initial engagement and care and early intervention services.
Action Plan highlights, you can see some of the highlights here. The survey itself was
actually implemented over several months with a large group of collaborators. The group
included multiple hospitals. There were state agencies. There were prenatal risk reduction
coordinators. Substance use treatment, medication assisted treatment among other organizations.
The team came together monthly. We were looking at a draft of the survey. We got a ton of
input. We were able to use beta testing at three participating hospitals before creating
a final draft. That final draft actually went over to partners
of the Department of Health who then worked with the more partners of the American Academy
of Pediatrics, along with some folks from the high intensity drug trafficking area,
including an epidemiologist who gave even more feedback.
Some of the survey is finally being reviewed by the institutional review board before distribution
to the hospitals. Actually, it's the reason it's been pushed back to October November,
and it's going to target the OB and nurse key manager chairs as well as pediatric chairs.
The survey will also go out to community pediatricians at all of the birthing hospitals across the
state of New Jersey. We want to take that information from the
hospital survey, one, to get a baseline, but then also to target hospitals and education
around best practices. Then also to start work on a statewide implementation of Plan
of Safe Care. Getting on to challenges, one of the biggest
challenges, even as we were developing the survey, was how the heck we were going to
distribute it and insure we got it to the right people at the hospitals. That really,
it was the AAP, the American Academy of Pediatrics, who came up with a fantastic solution.
They actually suggested breaking this survey up into sections with a lot of the policy
oriented questions going to the chairs of pediatrics and the chairs of obstetrics, and
then some of the more practice oriented questions going out to community pediatricians. We have
three different pieces that are going out. The second challenge was bringing together
such a broad cohort. It was really critical to have the eyes of our agency partners, also
the state partners, and quite frankly, some of the hospital chairs and administrators,
to really help us zero in on some of those questions. They just had a critical expertise
that just brought so much depth to the survey, as well.
The third challenge lies in wait for the team, which is really, and I think this gets back
to what I was saying earlier about Virginia, but how do we use this information that we've
gathered in the survey in order to really push practice change?
How do we institutionalize that change once we recognize and maybe develop some guidelines
for best practice, to not only change practice but also in terms of development of the Plan
of Safe Care? Next slide, key considerations. Again, in
New Jersey, having that cross with the oversight structure was critical to the work that they
were doing. That connection with the state level really helped us in terms of being able
to get that survey out and to create some change.
In New Jersey, we also had a really close working relationship with the medical community
and the Department of Health. It was invaluable. I cannot stress enough how having the partnerships
with local hospitals, the DOH, the DPH, has been, it's really invaluable.
It helped us, and I heard this several times in New Jersey, that working through the Department
of Health, it really helped to reframe addiction as a public health issue and maybe start to
move it away from that stigmatized view. Finally, it gets to the need to spend time
building that governance structure and I think again, we've been hearing about it this morning,
that we need to have that time to understand, to develop government structure before we
jump right into implementation. With that, I'm going to turn it back over to you, Linda.
Linda: Jill, thank you very much. The last state that we're going to talk about this
morning, our work with states, is the state of Connecticut. When Connecticut first came
to this, they really wanted to focus on understanding substance-exposed infants in their state.
They really wanted to look at the notifications that were coming from the hospitals, were
they getting the notifications that they needed, and if not, why? Ultimately to work on developing
a Plan of Safe Care. Also understanding the difference between Plan of Safe Care and safety
planning for those babies and moms. The partners in Connecticut, and I'm going
to go back to something that Jill said about New Jersey and Virginia. I'll use this as
second to say that the National Center has had some years of history with many of these
sites. We've worked extensively with New Jersey prior
to this, extensively with Connecticut, with Virginia and with Minnesota. There was a lot
of work done prior to this work on this particular initiative to help them build these collaboratives.
The Departments of Children and Families Child Welfare in Connecticut and the Department
of Mental Health and Addiction Services have both worked together for many, many years
and had some good relationships, some good partnerships. They've done some developing
of good models that they have jointly funded so they had that relationship already.
They were surprised, and later on pleasantly surprised, that they needed to bring so many
other people to the table to address this issue. Particularly when they started to look
at what's happening with notifications from the hospitals. The hospitals needed to be
at the table with that. One of the last site visits that we did with
them we had the gentleman who is the Connecticut Hospital Association Director, at the table,
spent the day with us, and talking about how to engage the hospitals.
We had a representative from the American College of Obstetricians and Gynecologists,
the American Academy of Pediatrics at the table. Somebody representing New Haven Children's
hospital, their Hartford Health Care System. Jill touched on in both New Jersey and Virginia,
the importance of having the managed care entities at the table so that when you're
talking about coverage for moms and case management services and all those critical pieces our
services pay for, can she get the services that she needs?
Those are the people that have control over those. Again, I don't think any of us can
underscore the importance of public health enough of being at the table and part of this
because, I think it was Dr. Brito in New Jersey who said, "This is a public health problem,
it's a public health epidemic. It's not just a child welfare issue, it's not just a treatment
issue, it is a public health problem across all of these states and unfortunately, across
the country." We also had the State Department of Education,
so early education, we had home visiting. They're absolutely critical partners whether
that's through the Maternal Child Health System or the Department of Education, having them
at the table, having the Early Intervention System.
One of the most interesting things in one of our last meetings in Connecticut was having
the IDEA Part C people at the table, the Early Intervention Providers system at the table.
The hospitals not even knowing, even though they feel they've done good outreach and education
around this, that babies that are diagnosed with neonatal abstinence, or FASD, become
automatically eligible for early identification services, or Early Intervention Services.
It was that kind of information sharing that occurred on a regular basis. What do you do
with that information? How do you then build this system that needs to be built for these
moms and babies? In Connecticut, I had said they had a strong
partnership between substance use and child welfare already. We used another tool with
them, the Collaborative Values Inventory, which asks a lot of the same questions.
But even more questions that really get at, do you have the capacity to collaborate across
systems, to work on these issues together? What are the challenges and differences in
values and perceptions that are occurring right now that we can highlight and uncover
and start to address with you to make this work?
We also use the cross systems guidance questions. We did site visits. As we did with the other
sites, we did system walkthroughs. We did this a couple times with them to really
try to understand what are the practices that are currently in place in Connecticut? It
uncovered some really interesting information, particularly about notifications, how hospitals
were dealing with babies and when those notifications were or were not made to child protective
services. Connecticut also took advantage of, and we
encouraged everybody to do this, not to try to reinvent the wheel, but to build on something
that somebody's already doing. They also took the original Virginia and then New Jersey
hospital survey. They've adapted it for their own needs and
have been in the process of disseminating that out to the hospitals in Connecticut with
the goal of trying to understand what happens from the time that mom shows up to deliver,
they're going to do a separate survey on the prenatal period and working with prenatal
care providers. This was really focused on, at that hospital,
point in time where mom shows up to deliver. Does screening take place? Do we have prenatal
history on mom in terms of any substance use? What are the practices around testing babies?
How is that information shared? What does it look like to make that notification and
develop both the discharge plan, as well as a Plan of Safe Care?
Like most of the other sites, their goal, it was to develop some guidance to hospitals
and practitioners. They adapted their goals a little bit as they went. As they did the
needs assessment, as they began to uncover information, they realized they needed to
adjust their goals a little bit to really address the gaps and barriers they were finding.
The need to have some guidance to hospitals and practitioners, one, so that everybody
was on the same page with CAPTA requirements and knew CAPTA requirements. Do they understand
what that means? Do they understand what a notification is as opposed to a child use
and neglect report? Do they understand that it means not just
infants exposed to illegal substances, but also legal substances, FASD, babies that are
presenting with withdrawal, and trying to get that out to all the hospitals in Connecticut.
They're really looking at developing this standard child welfare response, and, again,
working with the hospitals to understand the notification process, but really looking at
what would a different response in Connecticut look like? They're trying to be extremely
creative with this. They've looked at whether or not alternative response is the best pathway.
Is there another notification process that occurs between the hospital and child protective
services? They're gathering all the information and, somewhat like Virginia, and very much
like Kentucky, one of the things they're really taking a good, hard look at is what information
does child welfare need from the hospital when that notification is made?
This became this extensive conversation taking a long period of time in this state, along
with probably their first and maybe one of their most interesting questions, how are
they defining substance-exposed infants? They thought that was a relatively simple question
when they started. It ended up being a very complex question, taking a great deal of time
to reach some agreement across multiple systems. The hospital looked at that one way. Child
welfare looked at it a different way. The treatment system looked at it a different
way. They all came with a different understanding and perception about what a substance-exposed
infant was. It became really critical when they're sitting down and starting to think
about, what does that notification look like, and what information do we need from hospitals
to make that notification? What is the person on the other end at child
protective services asking, and what information are they getting, in order to ensure the best
response first at this step? A good example of that, and this was a fascinating
discussion among them, in much the same way that Jill talked about with Virginia, if the
hospital doesn't call because mom is already in treatment, or the hospital does call and
say, "I'm just letting you know that this baby is born. No need for you to do anything.
Mom's already in treatment," the response on the child welfare end has been, "OK."
Sometimes that notification doesn't happen at all. In working with them, we're saying,
"Do you know what kind of treatment she's receiving? Is she in a comprehensive medication
assisted treatment program? A comprehensive program that's addressing her therapeutic
needs as well as any medication needs? Is she only seeing a doctor for a prescription,
and maybe not connected to therapeutic services?" "Do we know? Is she in compliance with treatment?
Is she doing well? Do we know anything about the home environment?" All of the other things
that need to be taken into consideration when you're trying to decide what's the best next
course of action for both the baby's safety and the mom's safety, and the health of the
mom and the baby, both. You can see where the complexity of this conversation
has taken a very different turn from where they started with saying, "Are hospitals notifying?"
Their action plan, obviously, to focus on a Plan of Safe Care. The word "complexity"
has come up time and again in each of our sites, where they talk about, "This is so
much more complex than we originally thought it was going to be."
"It requires so many more partners than we originally thought." The work they're doing
around it and uncovering it and doing some very thoughtful thinking and planning about
this is going to result in a really good model. They did a really interesting what they call
the ABCs of MAT training, recognizing that there was a lot of misinformation in child
welfare, which led to some differences in perception about medication assisted treatment.
They worked with some treatment counselors in the state to develop this medication assisted
training called the ABCs of MAT training. It was just marvelous. They were gracious
enough to share it with us. We shared it with other sites. They talked a lot about not only
the training itself, but a discussion with workers around understanding and respecting
various roles and responsibilities. Really understanding MAT and who makes the decision
that mom needs to be on medication assisted treatment.
That's a decision with her treatment provider and her doctor. It's not anybody else's call
to make that decision. The same with breastfeeding. Understanding that, unless Contra-indicated,
it's OK to breastfeed under these conditions, that's a decision with her doctor, between
the mother and the doctor. That's not somebody else's decision to say, "No, she can't breastfeed."
By the same token, it's child welfare's decision around the safety of that child. It's not
the hospital's decision to say, "That baby's not going home," or, "That baby is going home."
It's recognizing that that's a child welfare decision in working with conjunction with
the hospital and all the partners and having that information on a timely basis.
It's required these In Depth conversations across systems to really make certain that
the right information is shared in a timely way, and that they're working together toward
the same end. They continue to work on the data collection issue. They've got a data
work group. They've been doing this data mapping process.
One of the things that they uncovered in the very beginning, and this is one more type
of a needs assessment, is when they looked at the numbers of babies born that were diagnosed
with neonatal abstinence and they had one set of numbers. They went back and looked
in that same time period at the numbers of babies that may have been reported to child
protective services as being prenatally exposed. Those numbers didn't line up at all. That
was just with the neonatal abstinence, not even taking into consideration were any babies
being notified in terms of Fetal Alcohol Spectrum Disorder or exposure to other substances.
They needed to know whether that was misunderstanding about notifications, whether it was a data
issue on their end. When the call was made, was it coded a different
way? It really was an eye opening experience for them. They didn't understand the depth
and breadth of the issue they were facing. They've also done some financial mapping.
Like other states, they're trying to look at what resources do they have that they can
leverage. What resources do they have that they can
share across systems and then go back and say, "Here's where we need some additional
funding to address this issue." Challenges in Connecticut, probably the same
challenges that we've talked about in most of the sites. Certainly collecting that baseline
data to understand what's happening in your own system, and then trying to share that
data across other systems. Do the numbers of women that entered treatment
this year, pregnant women that entered treatment with a substance use disorder, how does that
line up with the number of women that gave birth to a neonatal abstinence baby or another
baby that was prenatally exposed? Do they have numbers that they can even correlate
across systems? Do they have data that can talk to each other?
They've got a data workgroup that is making some fairly significant headway with this.
Using that data, as Jill described with New Jersey, now can they use that data to, one,
describe their current practice, and then start to inform practice changes from there?
They have a Governor's task force on opioids. They are now working to align the work around
pregnant and post partum women and their infants with other high priority goals on that Governor's
task force and making certain that they have a voice at that table. Connecticut's gone
through a number of some pretty significant budgetary constraints in the last couple of
years. Working on this and bringing partners to the
table and talking about how do they work together to make these changes in the midst of some
pretty dire budgetary constraints has been a challenge. What's happened is that they
are all on the same page with this issue. They're committed to addressing this issue.
They recognize that this is an extremely vulnerable population and they're committed to addressing
it and moving forward with it. Key considerations for them, they're another
one of our states where I think we're going to see an interesting model for what a Plan
of Safe Care looks like. They're in the process of working on that with our partners right
now. They're developing guidelines, as we've heard from most of the other sites right now,
for hospitals around the identification and treatment and management of neonatal abstinence
syndrome. One of the things we didn't touch on, that
we've heard from most of our sites, is the importance of managing these babies outside
of a NICU environment whenever possible. That's one of the things that's happened in Connecticut.
We've seen improved outcomes for both moms and babies when that happens.
They're looking at practices in hospitals like rooming in and all of the very important
non pharmacological supports for moms and babies that promote the infant mother bonding
at that point in time. Developing those practices, implementing and making certain they're implemented
consistently across the state, and working on that.
What does a multi disciplinary approach to a Plan of Safe Care look like? They're rolling
that out in a couple of sites before they try to go statewide with it.
That concludes our presentation portion of this webinar. What we wanted to do at this
point in time, we're going to take some questions and try to respond to a number of questions
that have come through. Before you get off the line, we'd ask you to at least make certain
that you do the evaluation at the end of the webinar.
In order to pique your interest in and encourage you to stay on through the question and answer
portion of this, we're going to talk a little bit about an opportunity that's coming up
for a number of states to participate in some technical assistance that we're going to be
providing on this issue. Hanh, questions that have come up during this presentation?
Hanh Dao: Thank you, Linda. We received several great questions throughout this discussion,
but first and foremost, we received several requests for the presentation and also several
requests for a recording for today's discussion. The PowerPoint will be sent to you today.
A webinar recording will be available shortly after the conclusion of this webinar. We'll
make sure to send out both of those things to everybody who has registered.
The first question that the audience posed to the speakers is, are there lessons learned
or experiences to share from any of the sites in implementing programs for medication assisted
treatment, particularly methadone, in rural communities? The person who is posing the
question is expecting challenges related to reaching a population that is widely dispersed
over a large geographic area. Linda: I'll take a first crack at this, Hanh.
I saw that Dr. Young is on as a panelist as well and may want to speak to this. I don't
know if Karri or Jill have anything to say as well. Certainly, whoever asked this question,
if you would send us an email, we can follow up with you in a different way, too.
One of the states, Kentucky, is a really good one to look at with this. I said not only
did they really not have much in the way of medication assisted treatment, there was a
lot of resistance about medication assisted treatment. They have a number of extremely
rural areas in Kentucky, so even just reaching their population was incredibly difficult.
They went for a couple of MAT expansion grants. One of them, they then placed in one of the
very, very rural areas down in Southeastern Kentucky.
They spent quite a bit of time pulling together all of the community, working through some
of the resistance with providers, certainly working through some of the uncertainties
about medication assisted treatment, and preparing the community to embrace that modality. They've
been relatively successful with that. One of the things that they realized was because
they have so many women, men as well, people with opioid use disorders in Kentucky that
live in rural regions, the idea would be to serve them in their own communities. That's
typically what you'd want to do. They realized they were going to be oftentimes
taking people out of their own community and taking them to a facility, a residential facility
where they could get this kind of treatment because they weren't going to be able to have
MAT everywhere throughout the state. The other piece of that then is, what is all
the work that needs to be done to reintegrate them back into their community, to provide
those additional supports and services that are needed to maintain their recovery, and
to continue to have them be successful with this?
They looked at a number of different challenges, but they're one of the best examples of the
work that needed to be done initially to even get it accepted there. We'd be more than happy
to make that connection with Maggie Schroeder in Kentucky for you to talk further about
it if you're interested. Anybody want to add to that?
Dr. Young or anybody else want to add to that? Dr. Nancy Young: Hi, Linda. Thanks so much.
The other thing that I would add is make sure if you're from the child welfare agency that
you have a partnership underway with your single state authority.
There are many initiatives out of SAMHSA in expanding access to medication assisted treatment,
particularly related to the recent expansion of a number of patients that a doctor can
have on his caseload, who is prescribing buprenorphine. If you don't have a partnership with your
substance use and treatment agency at the state level or at the county level, I would
encourage you to reach out and find out what initiatives they have underway to expanding
access and to make sure that that partnership includes this population of families that
need access to medication assisted treatment. Kari: This is Kari. I would just tag on to
that the experience in Minnesota, they were really looking at a lot of telehealth options
and working with the rural technical assistance providers related to that under the health
Linda: I'm sorry, Jill. Go ahead. Jill: I think you probably know what I'm going
to say, Linda, but also just remembering when we talk about medication assisted treatment,
it's not just the medication, the doses, buprenorphine or methadone, but really, what is that medication
paired with in terms of actual psychosocial treatment experience as well.
Linda: Thanks, Jill. That was exactly what I was going to say. It was one of the interesting
lessons learned coming out of these sites is that for a lot of these people who are
going for medication, those providers may not certainly be providing the therapeutic
services, may not be connecting them to therapeutic services.
It's certainly a way of expanding medication assisted treatment in rural areas but making
certain that they still have the connection to the therapeutic services as well, and mom
is prepared for the birth of the baby and all of those other issues. This is a team
response. Hanh? Hanh: Thank you for that. It's great that
all of these speakers and Dr. Young spoke to the importance of addressing stigma and
training, which is a great lead into the next audience question, which is that a lot of
tools and resources have been shared throughout this presentation.
Are some of these resources and tools available so that communities can use them within their
own communities? Some of the specific asks include that training from Connecticut on
the ABCs of training, as well as the New Jersey Hospital Survey. The question is, are those
resources available to communities? Linda: There are a range of National Center
resources that are available right now. The New Jersey survey is still in its final stages.
They're getting ready for distribution, Jill? Jill: That's correct. I have talked to the
New Jersey team and they are more than happy to share that survey after it has been distributed
in the state. Linda: We can certainly make that available
at that point in time. Hanh, what was the other one that you asked about?
Hanh: The ABCs of training? Linda: For MAT?
Hanh: Mm hmm. Linda: We have gotten that from the person
who works with this child welfare system in Connecticut. He was fine with us sharing that.
We've shared it with other folks as well. We will make that available, Hanh, through
you guys, through the National Center Resources. Hanh: Definitely. As part of the follow up
in today's webinar, when we send a PowerPoint, we'll send out the…We will send out the
PowerPoint as well as some of the resources that are currently available so that everybody
who has registered for the webinar will have access to that. For those…
[crosstalk] Linda: One more thing on that one, Hanh, one
of the things that we always encourage those, and I think Dr. Young said this when she talked
about going back to your single state authority and understanding the treatment systems within
your state, it's great to have this PowerPoint. It's a very good PowerPoint. We would strongly,
strongly urge you to partner with either your state or your local treatment system to do
that together. There will be questions that come up.
There are certain things in your own state that may be nuanced in your own state, that
might be a little bit…It's always good to have somebody who can speak to this from a
treatment perspective maybe doing this with you. It's one more reason and opportunity
to partner. Dr. Young: Let me just turn things back over
to Hanh. For those of you on the phone, if you haven't reached out to the National Center
on Substance Abuse and Child Welfare, Hanh Dao has all of the resources in the country
about this particular topic. Hanh, would you share a little bit about the resources that
are available on the National Center website? Hanh: Sure. Many of you who are attending
today's webinar may have attended the first webinar in the series. That first webinar
in the series was really a walkthrough of our most recently published and released document
on this issue. It's a document that helps communities, sites,
and states really try to develop a collaborative approach to working with pregnant women with
opioid and other substance use disorders and their infant.
That document contains a lot of great resources. Some of the resources that it includes include
best practices and evidence based practices in the treatment of opioid use disorders amongst
pregnant women. What are some of the best practices and evidence based practices for
infants who may have been prenatally exposed to opioid?
The other great thing about this resource is that there are a set of concrete tools
that communities can look to to start this process of collaborative process. Linda, Kari,
and Jill throughout this presentation really spoke to the need of conducting a needs assessment.
They shared several of the tools that have been developed and implemented throughout
the states. Some of those needs assessments that Linda talked about include a system walkthrough
as well as a New Jersey Hospital survey. There are certainly tools similar to that
available to you as part of this comprehensive collaborative guidance document. When I send
out the emails today, we're going to include the link to this comprehensive document.
That includes the tools as well as recorded link to the webinar that was facilitated just
about two weeks ago that really walkthrough the tools and resources. It even includes
some detailed guidance and explanation on how the tools can be used, including sequencing
as well as analysis of some of the results of the tools.
Some of the other tools that we have available through the National Center is a comprehensive
Web based resource directory that really focuses on these issues. The resource directory is
categorized into five or six different content areas at this point in time.
The content areas include best practices in the treatment of opioid use disorders, best
practices in the treatment of infants who may be diagnosed with neonatal abstinence
syndrome. We've included some examples from sites across the country that have started
to work on this issue. I did fail to highlight the CHARM Collaborative
Case Study, which is part of the collaborative guidance document that we're going to send
out today. Dr. Young: There is also a webinar that was
presented by many of the stakeholders in Burlington, Vermont, who for over a decade have been putting
practice in place that engages pregnant women in a way that reduces, if you will, the crisis
at birth for child welfare so that there is a plan of care prior to the infant's birth.
That the mother and the family are engaged in that assessment process and decision making
about where the baby will go after birth. Child Welfare has the opportunity to do family
assessment prior to the identification at birth. Many resources that are on the National
Center website. We look forward to also getting your questions about any specifics related
to that. Hanh: Thank you, Dr. Young. We received another
question. Did any of the states who were discussed during today's webinar develop memorandum
of understanding? Is it possible to get copies of some of those MOUs?
Linda: There are a range of memorandum of understanding that are in the process of being
developed and protocols that are being developed right now, certainly depending upon what that
piece of the system looks like. We've talked about the importance of the memorandum
of understanding. Also, I think when Jill and Ken DeCerchio were in New Jersey a couple
of weeks ago, they talked about the importance of even developing a charter between the various
agencies, with the commitment to address this population of infants and moms and babies.
I know that Connecticut is in the very early stages of this, Hanh. Jill, I think with Virginia
and New Jersey, they're still working on their guidance portion of that. Do you have anything
to add to that? Jill: No. You're correct. I think that Virginia
is starting to finalize the guidance and start looking at standards, but just as you said,
New Jersey is starting to talk about really developing a charter that would be signed
by all the different system needs to maintain the work.
Hanh: Thank you, Jill and Linda. As part of the resource list that I ticked off, the CHARM
Collaborative Case Study in Burlington, Vermont, includes an example of their MOU that has
been developed between the collaborative partners involved in that partnership.
The next question that we've got is very timely to today's current environment, with the passage
of the CARA legislation specific to the cast of Plan of Safe Care.
The question is, how can state specific policies on some of these issues that we've discussed
today, including screening during pregnancy, access to medication assisted treatment, and
the instant notification to Child Protective Services, how can and are those types of state
specific policies and legislation…How can they be identified?
Linda: How can the policies be identified? How can the legislation be identified? Hanh,
is that the ask? Hanh: Yes. Basically, if somebody wanted to
figure out what are some of the specific legislation and policies within their state, what is the
best way, or is there any guidance on how they can start that process?
Linda: I think that's a lot of the work. I'm going to say in about two minutes, I'm going
to turn it over to Ken and talk about the policy epitome, but that's the gist of the
work that we've done with these sites, in terms of bringing all of those key stakeholders
to the table and everybody sharing those policies. You can certainly go back in your individual
states and find out what legislation is in place, if any legislation is in place, that
either impedes or supports women getting services. Is there legislation in place regarding women's
substance use during pregnancy? We can help make that available, too.
With regards to some of the internal policies and practices, that's the conversation at
either a state level across partners or a local level across partners of what are we
doing? That was part of our needs assessment. It was part of our walkthrough. It was part
of our work with the sites to really begin to uncover that.
I will say that in many of the sites when we first went in, even people within their
own systems, I'm not going to pick on any one of these systems individually, but you
could be from a child welfare system or a treatment system and not truly understand
your own policies and then what this practice looked like with regards to that.
We spend a great of time trying to uncover that and then understand it across the various
systems. Jill, Kari, either one of you want to add to that?
[crosstalk] Linda: Go ahead, Ken.
Ken DeCerchio: Hi. Good afternoon, everybody. Ken DeCerchio. I work with Linda in the National
Center on Substance Abuse and Child Welfare. The obvious place to go is into your state
that is around child welfare, but there are a couple other documents to look at.
The Children's Bureau just issued an information memorandum back in April and then a more recent
one coming out around CARA and the Plan of Safe Care. Each state is required to do a
child and services family plan, each state a child welfare agency.
This past June, they are required to do an annual services and progress review. Go into
those documents and look under how they respond to the capital legislation plans of safe care
in substance exposed infants in collaboration with substance abuse initiatives.
Under there, you may find additional language in the protocols and how states have organized
the responses to this issue and how states are responding to requirements in the capital
legislation. Also, in the Department of Health, the division is over the maternal and child
health lot grants would have procedures, protocols for requiring notification into the state
health department for infant births and the substance-exposed infants, etc. Other places,
you can look at your state plans and see what they say about responding and working around
these issues. Linda: Thanks, Ken. I know Jill has got an
answer. I'm going to say one thing with regards to that. When you're talking about the notifications
from hospitals, one of the things that we uncovered a couple of different times was
hospitals saying, "My risk assessment department, my risk department is not going to let me
do that," or, "It has to go through them. It has to be cleared by them."
Understanding hospital protocols as well, this was the thing. Everybody came with their
own policies and procedures with regards to this. It was really understanding not only
what the child welfare policy was but what was the hospital policy for even making that
notification to begin with, and then what needed to change in both of those systems.
Jill did you want to add to that? Jill: We got to this a little bit in Virginia
but sometimes the policy come out sideways. I think of it that way.
There was a law that we looked a whole lot at in Virginia around how investigations were
handled if an infant was born substance-exposed but mom had attempted to or was in treatment,
and how sometimes those moms really did need maybe an investigation or a couple more questions
asked but maybe it wasn't routine to jump into that investigation.
The law was having some longer term implications that would then affect the Plan of Safe Care
piece in terms of that recording mechanism. Sometimes it's not just about what is the
law but it's also how does it actually get implemented.
Linda: Exactly, and recognizing that what it looks like at the state level, and what
that policy or that legislation looks like, and whether or not that's Karid out consistently
at local levels across the state, could very well be two different things.
That's where a lot of understanding what practice comes into play. Hanh, I don't know if we
have any more questions. I want to make certain that we leave at least a couple of minutes
for Ken to talk about what's coming up next. Hanh: It's actually the perfect time to transition.
Linda: Then I'm going to turn it over to Ken DeCerchio, one of the program directors for
the Children and Family Futures and National Center on Substance Abuse, Child Welfare,
and will actually be taking the lead on this. Ken?
Ken: Thank you, Linda. Good afternoon everybody, again.
It's exciting for me to be able to announce, and perhaps this is the first time publicly,
we have announced the opportunity…to give you the opportunity to expand the work that
you're doing in this area, to expand our capacity to provide technical assistance around substance-exposed
infants, prenatal exposure, and the responses to both parents and children with these issues,
and developing plans of safe care. With the support of SAMHSA and the Children's
Bureau, and the Administration of Children, Youth, and Families, through the National
Center on Substance Abuse and Child Welfare, we'll be organizing a Policy Academy in February
of 2017, February seventh and eighth. The Policy Academy, you can see the title
here, "Improving Outcomes for Pregnant and Postpartum Women with Opioid Use Disorders
and Their Infants and Families." It will give states, tribal nations, state child welfare
agencies, substance abuse agencies even large local jurisdictions the opportunity to develop
an action plan to address the multiple needs and complex needs of this population.
Through that policy academy we give you the opportunity to think about what you want to
accomplish in developing those action plans and what systems change you're hoping to bring
about, you'd like to achieve as a result of participating in the policy academy.
Applications will be forthcoming hopefully in the next couple of days. We're scheduled
to release those on September 30th. It will be released to state child welfare directors
so the women's services coordinators within the substance use offices, the state substance
use directors. We hope to get these out, again, to state
public child welfare administrators, court improvement and administrative officers of
the courts administrators, state and territorial health officials as well as maternal and child
health director. If you're not on that list or don't know how
to connect to those offices, if you send us an email when that policy academy application
comes out, we will make sure that we make that available to you so that you can engage
on the leadership in your states, your interest in perhaps putting a team together for the
policy academy. There will be a selection of 8 to 10 teams
to participate in the academy with up to eight team members to bring to Baltimore with the
support of the National Center. The applications will be due on November 4th. The application
will be anywhere between three and five pages and what we send out on September 30th will
detail the content of that application. The notification to successful applicants,
the applicants that will be accepted, will be made in early December. Sometime after
that, probably before the end of the year, we'll have an orientation webinar for those
jurisdictions selected. At the policy academy you'll have an opportunity
to engage not only with those of us on the call today and the National Center technical
assistance teams but the subject matter experts and the consultants that have supported this
work through our first round of In Depth technical assistance on this important issue, as well
as the current In Depth assistance sites. They will be represented at the policy academy.
We'll give you an opportunity to engage and talk to them about their experiences in a
little bit more detail to what you learned about today.
As you can see, on the bottom part of this slide, funding and travel lodging for up to
18 members will be supported by the National Center. If you have any questions about anything
you heard today, you can contact me at this email address.
Also, we don't have it up here I don't think, but the National Center website is ncsacw.samhsa.org.
As Hanh mentioned just a few minutes ago, that's where you can access the technical
assistance resources that she highlighted, as well as all the resources available through
the National Center to improve outcomes for children and families affected by substance
disorders in the child welfare system. You can in addition to sending me an email
or in lieu of sending me an email send an email directly to the National Center with
any technical assistance requests, or additional information that you may like to have.
That would be again at N C S A C W at C F, Futures, C F F U T U R E S.org. We hope that
we encourage you to take a look at the application for the Policy Academy. We're excited for
the opportunity to expand our technical assistance support to you.
I forgot to mention that each of the teams will be assigned a Change Leader, and will
have an opportunity to engage with the National Center after the Policy Academy. In 2018,
they have an opportunity to apply to become an In Depth technical assistance site as well.
With that, I'll turn it back over to Hanh. Thank you.
Hanh: Thank you, Ken. That brings us to the end of our webinar. Thank you everybody so
much for joining today's webinar. We'll make sure that we send out the list of resources,
as well as today's PowerPoint. The other webinar that was facilitated in this series, so thank
you very much for your time, and we look forward to working with you in the future.