Opioid Use in Pregnancy: Innovative Models to Improve Outcomes

Transcription

1 December 1, 2017 ML12 Opioid Use in Pregnancy: Innovative Models to Improve Outcomes Daisy Goodman, CNM, DNP, MPH Instructor, Dartmouth Medical School Tina Foster, MD, MPH Director of Education, Dartmouth Hitchcock Medical Center Michele Walsh, MD, FAAP Chief, Division of Neonatology and Perinatal Medicine, University Hospitals Jeff Rakover, MPP Sr. Research Associate, Institute for Healthcare Improvement

2 Objectives 1. Understand leading models of care to improve outcomes for women struggling with opioid addiction 2. Learn about innovative models for caring for babies experiencing neonatal abstinence syndrome 3. Brainstorm 2-5 small tests of change that can be introduced in your care environment to improve outcomes for women and babies impacted by opioid use

3 3 Quick Poll: In What Setting do You Work? 1.Hospital 2.Clinic 3.Payer 4.Government (e.g., public health agency) 5.Other

4 Icebreaker Activity Let s introduce ourselves! Name Where you re from Your role One reason you come to the IHI Forum

5 IHI s Perinatal Improvement Work in North America Innovation/R&D work: Toward a population health approach Ran from 2006 to 2015 Engaged scores of teams across the U.S. Aims included zero incidence of elective deliveries prior to confirmation of fetal maturity, improvement in nulliparous C- section rate to align with Health 2020 People goal Inpatient Continuum of Care

6 R&D Work to Develop a Population Approach Initiated in 2015 Context: High rates of prematurity and disparities in outcomes Desire to impact multiple factors contributing to prematurity Expert interviews Change package development Evidence scan Synthesis Expert interviews

7 Areas of Focus in Our Work Maternity Medical Homes: Bringing together resources and supports to provide holistic care that addresses social, health, and healthcare needs Reproductive life planning: Pilot work to develop an approach to improving family planning and contraceptive access to at-risk, low-income women (pilot in Detroit) Group prenatal care: Identifying and promoting emerging models of group care and peer support (including and going beyond Centering) Substance use in pregnancy: Especially focused on opioids, but also addiction more broadly; response to an emerging need nationally Forthcoming article in Population Health Management

8 Opioid Use in Pregnancy Public Health Emergency Incidence of neonatal abstinence syndrome rose 300 percent between 2000 and 2009, one thread of a broader nationwide opioid epidemic Incidence of NAS in newborns to opioiddependent women can be estimated as high as 70 to 95% The number of women receiving treatment for opioid abuse more than doubled between 2000 and 2012 Some states are reporting increases in overdose deaths among pregnant women and new mothers, making opioid addiction also a driver of pregnancy-related mortality, which has risen in the U.S. as a whole over the past years, in contrast to peer nations NAS incidence (per 1000 hospital births) NAS incidence (per 1000 hospital births)

9 A pressing need for policy change Need for more states to expand Medicaid, which helps fund treatment Need for more residential placements for pregnant women that can also accommodate their children Improved funding for case management in Medicaid and for treatment in particular Need for hospitals to stop building more NICU beds but invest instead in better treatment strategies for babies and moms (e.g., boarding together; non-pharmacological strategies) Need for child welfare policies that do not penalize women for seeking treatment (we will discuss throughout the day) Investment in social determinants of health of course housing, employment, job placement

10 Two interrelated delivery models: Mom and Baby Innovation happening in care for both mom and baby We will talk about both today Great case examples in both areas; practices being spread by many states through IHI-style collaboratives; we will also highlight this collaborative work Moms need integrated models of care bringing together addiction treatment, behavioral health integration, perinatal care, and case management Babies need change in approach to treating newborns Opioid-exposed newborns need to be treated less as being sick, and more as needing the things that newborns need time with mom, attention, quiet

11 Let s look at some testimonials: the difference that woman and baby-centered treatment makes Video clip(s) 1 Dartmouth: Link: Video clip(s) 2 Ohio: Link:

12 Agenda for today I. Introduction II. III. IV. Overview of the problem Overview of treatment models and key dimensions of care design Case study: Dartmouth-Hitchcock Perinatal Addiction Program V. Case study: Ohio Perinatal Quality Collaborative VI. VII. VIII. IX. Case study: Northern New England Perinatal Quality Improvement Network Exercise Discussion of tests of change you can try (if time) Closing

13 Intro to best practice care models for integrating perinatal care with addiction treatment IHI studied numerous programs across the country as part of research on population health approaches to perinatal care AMC Models Studied (examples) Dartmouth-Hitchcock Perinatal Addiction Treatment Program Toronto Center for Substance Use in Pregnancy Project RESPECT (Boston Medical Center) Community, non-amc Models Studied (examples) Kaiser Permanente, Early Start Project Nurture (Health Share of Oregon) Valley Health (Virginia)

14 Perinatal Care for Pregnant Women Key Dimensions Emerge Co-location of substance use treatment and perinatal care Models of peer support Differing levels of behavioral health care integration Numerous ways of working with child welfare services and conceiving of CW services as an asset and a challenge Varying care management approaches to ensure holistic models of care addressing, physical and mental health and social needs

15 Co-location of addiction treatment, behavioral health care, and perinatal care Bring addiction treatment and behavioral healthcare to perinatal care context Substance use counselor full-time in perinatal care context Behavioral health specialist onsite to help promote integrated care Onsite social worker provides case management and conducts in-depth mental health assessment Addiction-focused nurse-practitioner Bring perinatal care to addiction treatment context Family practice physician or OB provides pregnancy services onsite in substance use clinic Pregnancy group care anchored at addiction treatment site Onsite psychiatrist or addiction medicine physician to manage substance use treatment (e.g., medicationassisted treatment)

16 Emerging Models of Peer Support: Examples Dedicated CenteringPregnancy group for women with substance use challenges, integrating perinatal education and substance use treatment content Weekly education and support group for pregnant women with substance use challenges led by behavioral health specialist (social worker), with specially designed curriculum Hiring certified peer support specialists or doulas to work with pregnant women with substance use challenges in a mentorship role and provide a face for the integrated approach and build trust

17 Why is group care important? Major barrier to effective treatment is stigma; women feel alone and ashamed; providers sometimes contribute to this Peer support often provided by women who have successfully come out the other side had struggled with addiction during pregnancy, and are now clean, successfully raising families

18 Behavioral Health Integration High rates of co-morbidity addiction and mental health challenges In some cases, initial perceived symptoms of neonatal abstinence syndrome are really signs of withdrawal from SSRIs, or other psychoactive medications Best-in-class models integrate psychiatry and addiction medicine, and initial screening should always be whole-person centered not just for substance use, but also for depression and other mental health challenges, in addition to areas like social needs and domestic violence Examples of integration: The Dartmouth program employs two psychiatrists (not FTEs) who see patients for mental health treatment as necessary Part time psychiatrist in Project RESPECT (Boston Medical Center) manages medications for psychiatric comorbidities

19 Working with Child Welfare Services Women fear that CW involvement will mean their child will be taken; this can result in treatment avoidance, with worse downstream outcomes for both mom and baby Key principles of best practice partnership with CW: Have a clear institution-wide policy for when to involve child welfare to ensure all providers (in the hospital, in the community) have a common understanding Allow women the option of sitting in on calls made to child welfare, or tell them all the details to be shared in advance Establish strong working relationships with child welfare case workers to ensure trust and common approach to cases Most importantly, advocate against punitive child welfare policies like mandatory reporting even if the mom is making progress with treatment

20 Care Management Approaches Examples: Full-time or part-time social worker provides support to coordinate needs like employment, housing support, parenting education, transportation, and coordination with child welfare, as well as needs like identifying residential treatment placements Nurse care manager provides onsite care coordination Also consider the use of community health worker outreach models that can also support with care coordination (e.g., Breaking the Cycle program in Toronto employs a CHW model); IHI has observed the power of CHW models to support improved pregnancy care and especially care coordination for pregnant women (e.g., WIN model in Detroit)

21 In sum. Adopting all the best elements of a good maternity medical home model, but adapting it with tailored services for women struggling with addiction Payment has not caught up with the reality of the services needed; however, programs use a mix of grant funding to supplement low Medicaid reimbursement rates Ultimately, need to advocate for better Medicaid reimbursement Can make an argument for strong ROI for payers based on lower utilization of NICU, for example, especially when coupled with strong approach to treating opioid-exposed infants

22 Emerging best practices for opioid-exposed infants Less of a focus of IHI research Much of the work to date has focused on babies and not mothers, and so maybe more familiar to you Key areas: Rooming in Avoiding the use of pharmacotherapy where possible, and instead investing in non-pharmacological strategies Strong partnerships between OB, pediatrics, neonatology to ensure strong coordination of care and consistent expectations

23 Key principles of treatment for babies Providers tend to consider the opioid-exposed infant as sick ; rely on NICU Progressive programs (E.g., Yale, Dartmouth) have worked to dramatically lessen reliance on NICU, and focus on giving these babies what babies typically need, but perhaps more intensively calm, quiet, support, time with mom; includes a focus on rooming baby and mom together Rooming in keep babies in L&D with parents These centers have seen dramatic decreases in length of stay (down to 6 days at Dartmouth), lower NICU utilization, and lower numbers of referrals from regional centers to academic centers (via education on the common approach).

24 Yale Study 2017 Multidisciplinary team Standardization of nonpharmacologic care Morphine on as-needed basis Boarding in with mother Grossman et al. An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome. Pediatrics Results: ALOS decreased from 22.4 days to 5.9 days Proportion of methadoneexposed infants treated with methadone decreased from 98% to 14% Costs decreased from over $44,000 to just over $10,000 (reduction by 75%) No infants readmitted No adverse events

25 Other key ideas Correct identification of NAS in the first hours, what may look like NAS is actually normal newborn behavior or withdrawal from nicotine or SSRIs As needed doses of morphine to treat symptoms of NAS

26 Examples of key measures for improvement work NICU utilization Newborn length of stay Neonatal abstinence syndrome rates Maternal complications during childbirth Mother s length of stay Engagement with parenting support program Percentage of mothers with open child welfare cases Attendance in substance use treatment programs Rates of continued substance use by mother (e.g., abstinence at one year)