The Mommies Program An Integrated Model of Care Karen Palombo, LCSW, LCDC Texas Women s SUD Intervention Specialist
Objectives Discuss the effects of opioid epidemic on pregnant women Recognize the importance of using an integrated model of care for pregnant and parenting women with substance use disorders Explain ways to reduce stigma associated with pregnant and parenting women with substance use disorders 2
Objectives Identify the key components of a successful integrated model of care for pregnant and parenting women receiving substance use disorder treatment or intervention services Provide an overview of the Obstetric Care for Women recommendations from a hospital and community perspective 3
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Source: Case, & Deaton, 2015; PNAS. 5
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Source: National Survey on Drug Use and Health, 2002-2013 8
Source: Perinatal Quality Collaborative of North Carolina, 2013 9
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Source: CDC, Pregnancy Mortality Surveillance System, 2015 12
Percent of All Maternal Death Texas Maternal Mortality 25 20 15 10 5 0 Maternal Cause of Death Source: Texas DSHS, Office of Program Decision Support, CHS Death File 2011-2011, Published 2016 13
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Journeys of Hope Video Texas NAS Website 15
Substance Use Among Women More Complex Correlated to Co-Morbid Conditions (Mental Health) Lower Socio-Economic Status Intimate Partner Violence History of Trauma 16
Trauma & Substance Use Pregnancy Mothering Substance use Stigma Reduce Access to Healthcare for Women 17
Mothers in Treatment Most feel a strong connection with their children Want to be good mothers Want to regain custody of their children 18
Culture Change Create a culture change within the healthcare system toward a more accepting and judgment-free environment. Address barriers to substance use treatment for pregnant women 19
Trauma-Informed Healthcare Examples: Asking before touching a patient Talking to the person rather than about them Asking if patient has questions, concerns Taking time to explain 20
What is NAS? Neonatal abstinence syndrome (NAS) is the constellation of signs in newborn due to substance or medication withdrawals. 21
NAS National Trends Parallel rising trends in prescription opioid misuse and incidences of NAS U.S. rates of NAS have increased fivefold 22
Texas NAS Trends 1350 1300 1250 1200 1150 1100 1050 2011 2012 2013 2014 2015 23
Cost of NAS Nationally, cost of NAS has risen from $190M/year in 2000 to $1.5B in 2012 Average hospital expenses are $53,400 when compared to $9,500 for all other births 81% of these costs are paid for by state Medicaid dollars 24
Texas Medicaid NAS NICU Data 25
Screening for NAS Maternal History and Prenatal Screening SBIRT Screening, Brief Intervention & Referral to Treatment The 4 P s Plus-Dr. Chasnoff Parents Partner Past Pregnancy *ntiupstream 26
Diagnosing NAS Instrument Year Published Number of Assessment Items Training Materials Available Finnegan Neonatal Abstinence Scoring Tool (FNAST) The Lipsitz Neonatal Drug- Withdrawal Scoring System Neonatal Drug Withdrawal Scoring System Neonatal Narcotic Withdrawal Index 1975 21 Video/DVD Manual 1975 11 No 1975 11 No 1981 7 No Neonatal Withdrawal Inventory 1998 7 No Neonatal Network Neurobehavioral Scale Part II: Stress Abstinence Scale MOTHER (Maternal Opioid Treatment: Human Experimental Research) NAS Score 2004 50 5 days of formal training and certification required 2010 19 Video developed for multi-center research staff training only
Diagnosing NAS Finnegan Neonatal Abstinence Scoring Tool (F-NAST) 21-item Good reliability (α=.82) when clinicians are trained Score q 3-4 hrs; reflects the entire time period Diagnosis of NAS varies Scores of 8 are high and typically indicative of NAS 28
ESC NAS Care Tool 1. Eating 2. Sleeping 3. Consoling 29
ESC NAS Care Tool 1. Eating a. Does the infant have poor eating due to NAS? Yes / No 2. Sleeping 3. Consoling 30
ESC NAS Care Tool 1. Eating 2. Sleeping a. Did the infant sleep less than 1 hour after feeding due to NAS? Yes / No 3. Consoling 31
ESC NAS Care Tool 1. Eating 2. Sleeping 3. Consoling a. Is the infant unable to be consoled within 10 minutes due to NAS? Yes / No 32
Parental Role 1. Diary 2. Presence 33
What we have done in Texas NAS Exceptional Item Coordinated Opioid Treatment Services (NAS-OTS) Statewide Pregnancy Stabilization Center Targeted Outreach to High Risk Women Mommies Programs NAS Trainings NAS Special Projects 34
Hospital Initiatives Assess all pregnant women for SUD Provide staff-wide education on SUDs Establish specific prenatal, intrapartum and postpartum clinical pathways for women with OUD Develop pain management protocols Know state reporting guidelines Know your referral sources and resources 35
Hospital Protocol Kangaroo Care Skin to Skin NAS Competencies Rooming In Visitor Rules Increasing NAS Scoring Abused Women Order Sets Review ED Patients Triage Patients Social Services Team Treatment Team 36
Hospital Educational Needs Community Resources ED Pregnant Women Developmental Education Harm Reduction Zoned Out Mothers Central Line Insertion NAS Competencies Rooming-In Koala Care Trauma Training Addiction Role Playing EAP Kangaroo Care New Admission Guidelines Soothing Techniques Screening/UDS 37
Hospital Internal Stakeholders NICU RN Couples Care Labor and Delivery Dietary Maintenance Central Supplies Biomedical Marketing Pediatric Therapy Team Social Workers Directors Physicians Administration Growth Media Lactation 38
Hospital Internal Needs Dietary Drinking, Meals Maintenance Lights, Windows, Privacy Environmental Services Noise, Manual vs. Automatic Supplies Central Supplies At Bedside Items: Tables, Recliner, Sanitizer, Lights In Unit Items: Quiet Trash, Quiet Linen, Bili Blanket Biomedical Central Monitoring, Line Drops, UV Light 39
Available Services in Hospital to Mother Methadone prescribing obstetrician Social Services (L&D, PP, NICU, ED) Counseling Methadone administration Cardiology Nephrology Internal Medicine Echo s EKG Central Lines In House/Out of House Phone Line established 40
NAS EI Funded- Services Patient navigator Outreach specialist Recovery coaches Credential staff Case manager Benefits coordinator 41
Available Services in Hospital to Baby Volunteers Developmental Clinic Social Services Child Welfare Liaison Home Health Early Childhood Intervention 42
External Stakeholders Local Mental Health Authority Local/Regional Treatment Center Child Welfare Early Intervention Programs Drug Court State Agency University 43
Community Initiatives Education about SUDs Education about NAS Establish a plan of safe care Identify and partner with nonmedical partners/stakeholders Develop continuing education for community members 44
Qualitative Data Data collection and analysis are ongoing: KMC is very meaningful to the mothers Photo courtesy of UT Health Science Center San Antonio, Mission magazine 45
Thank you Karen Palombo, LCSW, LCDC Texas Health and Human Services Texas Women s SUD Intervention Specialist 512-838-4381 Karen.Palombo@hhsc.state.tx.us 46