Ve r monts CHARM (Childr e n and Re c ove r ing Mothe r s) T e - - PowerPoint PPT Presentation

Ve r mont’s CHARM (Childr e n and Re c ove r ing Mothe r s) T e am:

A c o llab o rative appro ac h to suppo rting pre g nant and pare nting wo me n with

• pio id use diso rde rs and the ir infants

Anne M. Johnston, MD, Ne o na to lo g ist

Unive rsity o f Ve rmo nt Childre n’ s Ho spita l

Sally Bor de n, M.E

d., E xe c utive Dire c to r K idSa fe Co lla b o ra tive OF A Pe e r T A We binar : Opio id Use Diso r de r , T r e atme nt, and Bar r ie r s to E mplo yme nt Amo ng T ANF Re c ipie nts

Marc h 29, 2018

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Ag e nda

• Opio id de pe nde nc e in

pre g na nc y

• Opio id-e xpo se d ne wb o rns
• T

he CHARM c o lla b o ra tive

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Neonatal Abstinence Syndrome (NAS) Incidence Rates – 25 States, 2012-2013

Maine 30.4 Vermont 33.3 W Virginia 33.4 Vermont had the highest annual rate increase of states surveyed

Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. MMWR Morb Mortal Wkly Rep 2016;65:799–802

INCREASE IN NAS IN VERMONT

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Represents:

• Increased access to safe treatment,

both prior to pregnancy and during pregnancy

• Increased identification

Myth #1: Opioids during pregnancy  “damaged baby”

• T

he re is no e vide nc e tha t o pio id e xpo sure , in a nd o f itse lf, re sults in de ve lo pme nta l de la y o r a ny o the r la sting e ffe c ts o n the e xpo se d c hild

• On the o the r ha nd, a lc o ho l e xpo sure c a n re sult in

pro fo und physic a l/ de ve lo pme nta l/ b e ha vio ra l e ffe c ts

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Myth #2: Every baby born to a mother on opioids is born “addicted”

• Opio id-e xpo se d: e xpo sure to o pio ids – e ithe r pre sc rib e d o r illic it
• Opio id-de pe nde nt: infa nt e xhib its sig ns o f withdra wa l se ve re

e no ug h to ne e d me dic a tio n

• Opio id-a ddic te d: infa nts c a nno t b e a ddic ts; the dise a se o f

a ddic tio n re q uire s o b se ssio n a nd c o mpulsio n, lo ss o f c o ntro l, “b re a king the rule s”

• Ve rmo nt da ta sho w tha t o nly 20% o f o pio id-e xpo se d infa nts

re q uire tre a tme nt

“Addicted newborns”

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Myth #3: If a baby needs treatment for opioid withdrawal, it must be because the mother “used” opioids during pregnancy

• T

he se ve rity o f withdra wa l is no t a sso c ia te d with the do se o f me dic a tio n during pre g na nc y

• E

xpo sure to to b a c c o c a n inc re a se the se ve rity o f withdra wa l

• Hig he r Ne o na ta l Ab stine nc e Sc o re s do no t indic a te tha t

a mo the r ha s “use d” during pre g na nc y

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Myth #4: Opioid abuse + pregnancy = child abuse

• >1500 b a b ie s b o rn to o pio id-de pe nde nt wo me n fo llo we d

thro ug h o ur c linic

• Ove r 80% o f the se b a b ie s we re disc ha rg e d in the c a re o f

the ir mo the r +/ - fa the r (2002 – 2016)

• T

he ma jo rity o f pa re nts we se e a re a c tive ly e ng a g e d in tre a tme nt a nd displa y g o o d pa re nting , ma ny ne e d suppo rt in o rde r to do so

• I

f a pa re nt is no t a dhe ring to tre a tme nt, do e s no t wa nt to re c e ive tre a tme nt, and is a c tive ly using – the y ma y NOT b e re a dy to pa re nt a c hild

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Why is me dic a tio n-a ssiste d tre a tme nt fo r pre g na nt wo me n with o pio id use diso rde r the sta nda rd o f c a re ?

• De c re a se s pre ma turity a nd lo w b irth we ig ht
• I

mpro ve s the he a lth o f the pre g na nc y

• L
• we rs infa nt mo rta lity
• Pre g na nt wo ma n fe e ls we ll (no t “hig h”) a nd ha s no c ra ving s
• Suc c e ssful e ng a g e me nt in tre a tme nt inc re a se s the pro b a b ility o f

g o o d pa re nting

• De to xific a tio n during pre g na nc y is ra re ly suc c e ssful a nd

da ng e ro us to the fe tus

Conc e r n: a nything tha t drive s pre g na nt o pio id-de pe nde nt

wo me n fro m se e king tre a tme nt re sults in mo re pre ma turity, hig he r infa nt mo rta lity, le ss pro b a b ility o f suc c e ssful pa re nting

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• Ne o na ta l o pio id withdra wa l
• Ne o na ta l c o mplic a tio ns:
• Pre ma turity, lo w b irth we ig ht
• Me c o nium a spira tio n, tra nsie nt ta c hypne a
• F

e e ding diffic ulty, se izure s, ja undic e

• I

f re c o g nize d tha t mo the r is o pio id-de pe nde nt:

• Child pro te c tive se rvic e s invo lve me nt
• Cha lle ng e o f ta king c a re o f ne wb o rn a nd sta rting tre a tme nt fo r

a ddic tio n

T he untr

e ate d wo ma n with o pio id-use diso rde r

who de live rs a ne wb o rn

www.the fix.c o m

• I

f unre c o g nize d a nd infa nt e xhib its no withdra wa l:

• Afte r disc ha rg e infa nt ma y b e pa rtic ula rly irrita b le
• F

a mily’ s a b ility to c o pe a nd se e k he lp is impe de d b y fe a r o f disc o ve ry

• Mo the r will pro b a b ly re ma in a c tive in he r a ddic tio n
• I

nfa nt ma y b e e xpo se d to unsa fe situa tio ns

• Mo the r c o ntinuo usly “flying unde r the ra da r” a nd hiding he r a ddic tio n
• Mo the r o fte n unwilling to c o me fo rwa rd fo r fe a r o f lo sing he r c hild/ c hildre n

Opio id de pe nde nc e : T re a tme nt o ptio ns

• De to xific a tio n – g e ne ra lly no t sa fe no r a dvisa b le in pre g na nc y
• Me dic a tio n Assiste d T

re a tme nt (MAT ): the sta nda rd o f c a re in pre g na nc y

• Me tha do ne
• Bupre no rphine
• Ha rm Re duc tio n
• Ne e dle e xc ha ng e

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• Generational substance use
• Untreated mental health problems
• Limited parenting skills and

resources

• Exposure to trauma
• Legal involvement
• Unstable housing
• Unstable transportation
• Lack of positive and supportive

relationships

I ssue s fa c ing sub sta nc e -using pre g na nt wo me n a nd the ir c hildre n

Slide c o urte sy o f H Jo ne s

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F

• c us o n the mo the r’ s he a lth to ha ve b e tte r o utc o me s
• Build trust
• Focus on respect and strengths
• Decrease fear and shame
• Promote breastfeeding

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UVM CHI L DRE N’ S HOSPI T AL : E VAL UAT I ON AND MANAGE ME NT OF NAS

• NAS sc o ring using mo difie d F

inne g a n, tra nsitio ning to E SC; ma ximize no n-pha rma c o lo g ic c a re

• I

npa tie nt me tha do ne fo r ne wb o rns re q uiring me dic a tio n

• Onc e infa nts a re sta b le o n me tha do ne fo r 72 ho urs, the y a re

disc ha rg e d ho me

• I

mpo rta nc e o f a sse ssing ho me a nd sa fe ty c o nc e rns

• I

mpo rta nc e o f c a re g ive r e duc a tio n re g a rding me tha do ne

• Ne o Me d Clinic visits within 1 we e k a nd the n e ve ry 2 we e ks fo r

we a ning o f me tha do ne , mo nito ring o f g ro wth a nd de ve lo pme nt, mo nito ring o f pa re nt(s) re c o ve ry

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UVM Childre n’ s Ho spital:

I nfa nts b o rn (a t UVM) to o pio id de pe nde nt wo me n with sub sta nc e use diso rde r o n me tha done o r bupre norphine a t de live ry (N = 1,119)

UVM CHI L DRE N’ S HOSPI T AL

BAYL E Y I I I : ME AN PE RCE NT I L E RANK (N=277) 7-14 MONT HS OF AGE

K e y Po ints

• T

he inc ide nc e o f ne o na ta l a b stine nc e syndro me is inc re a sing – do e s this re pre se nt inc re a se d ide ntific a tio n o f c a se s, inc re a se d a c c e ss to c a re fo r pre g na nt o pio id-de pe nde nt wo me n?

• Be hind e ve ry c a se o f ne o na ta l a b stine nc e syndro me , the re is a mo the r

suffe ring fro m the dise a se o f a ddic tio n – this is whe re e ffo rts ne e d to b e the g re a te st – ne e d to de c re a se judg e me nt, inc re a se a c c e ss to tra uma -info rme d tre a tme nt

• De ve lo pme nta l/ b e ha vio ra l o utc o me s a re o ve ra ll no t a ffe c te d b y
• pio id-e xpo sure in ute ro o n its o wn, unlike a lc o ho l e xpo sure
• Co mmunity stra te g ie s tha t fo c us o n punishme nt will re sult in inc re a se d

mo rb idity a nd mo rta lity fo r c hildre n a nd the ir fa milie s

• He a lthy c o lla b o ra tio n b e twe e n pa rtne rs wo rking with fa milie s is e sse ntia l

CHARM: Children and Recovering Mothers

CHARM is an inter-disciplinary and cross-agency team that coordinates care for pregnant and postpartum mothers with a history of opioid use disorder and their babies.

Model collaborative approach

(US Dept. of Health and Human Services, SAMHSA 2016)

s

CHARM Goal:

To improve the health and safety outcomes of babie born to women with a history of opioid use disorder by coordinating medical care, substance abuse treatment, child welfare, and social service supports

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Challenges for TANF Recipients

• Health Care: Prenatal and Postpartum Care

Substance Abuse Treatment: MAT; Counseling: Level of Care Services and Supports: Child Care, Housing, Transportation “Reach Up” Requirements

• CHARM: Promising Prevention Model

Pregnancy: Opportunity for Change Early Access to Prenatal Care and Substance Abuse Treatment

• Early child welfare involvement, assessment and develop

plans of safe care prior to birth

• Coordinated Services and Supports
• Systems for collaboration: information sharing to support

health/safety of moms and infants

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CHARM Beginnings

• 1998

̶ No MAT available in VT for pregnant woman with opioid use disorder ̶ Physician request: individual waivers from Opiate Treatment Authority

• 2002

̶ Substance abuse physician, OB, and Neonatologist meet, coordinate care for pregnant women needing treatment. ̶ First methadone clinic opens

• 2003

̶ Additional community-based health and social services join coordination – start of multi-disciplinary approach; these efforts lead to the CHARM Team

• 2004-2006

− KidSafe joins to facilitate team; empanelment as VT Multi-disciplinary Child Protection Team; development of MOU, release of Information; operating procedures

• Current

̶ Development of “Hub & Spoke” Substance Abuse Treatment/MAT system ̶ CHARM has operated continuously; MOU and ROI updated; SAMHSA recognition

CHARM Team – Partner Organizations

CHARM Team Facilitator – KidSafe Collaborative UVM Medical Center OBGYN – (COGS) Medical and Social Work

Child Welfare – DCF Family Services

VT Dept. of Healthcare Access – Moms Program (Medicaid)

VT Dept. of Corrections Healthcare (Centurion) Residential & Outpatient Tx – moms & babies (Lund) UVM Children's Hospital – Neonatal Medical and Social Work MAT (Methadone & Buprenorphene) – Howard Center Chittenden Clinic VT Health Dept. – ADAP, Hubs and Spokes VT Health Dept. – Maternal Child Health Children's Integrated Services – Home Visiting

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• Hub and Spoke:

Vermont’s Opioid Use Disorder Treatment System

Hub and Spoke is Vermont’s system of Medication-Assisted Treatment, supporting people in recovery from opioid use disorder

• Nine Regional Hubs offer daily support for patients with complex addictions
• Over 75 local Spokes: doctors, nurses, and counselors offer ongoing addiction

treatment fully integrated with general healthcare and wellness services

• Efficiently deploys

addictions expertise and expands access to opioid user disorder treatment for Vermonters

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Vermont’s Blueprint for Health uses claims and clinical data to evaluate program impact and program costs. A peer-reviewed article in Substance Abuse Treatment journal showed that health care costs for Vermonters in MAT were lower than for Vermonters with

• pioid addiction not in MAT, even

when including the substantial treatment costs.

Key Elements of CHARM Collaboration

• A Shared Philosophy: improving care and supports for

mothers is the most important factor in helping to ensure healthy and safe infants

• Shared Information improves

child safety and healthy outcomes

• Memorandum of Understanding: provides an important

framework for sharing information and coordinating services; consent to release information

• Vermont Law: “Empanelled” as a multi-disciplinary “child

protection” team under VSA Title 33 §4917

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CHARM Team Meetings: How it Works

• Team Members
• Average of 11 agencies/departments represented at

each CHARM team meeting

• Meet Monthly
• 12- 13 participants per month
• Systems Issues
• First 10-15 minutes of each meeting
• Case Reviews
• Average 15-20 case reviews per meeting

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CHARM: Case Review

At each monthly meeting the CHARM team reviews a list of current cases and prioritizes cases for discussion:

• All pregnant patients due in upcoming month
• Prioritized high-risk prenatal patients
• All new pregnant patients
• All new babies/post-partum patients
• Prioritized high-risk post-partum patients and their babies

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

Information Sharing at CHARM Meetings

Prenatal Care Initial: Confirm pregnancy , assess for opioid dependence Ongoing: compliance with prenatal visits and monitoring; referrals for specialty or community services

• Medication-Assisted Treatment: consistency, urine drug tests,

dose adjustment, substance abuse counseling Follow-up: post-partum MAT provider plan

• Residential program option for moms and babies
• Case Management and Referrals: WIC, breastfeeding,

nurse home visiting, social support services As available: gift cards, transportation passes, baby items  Post-partum and Neonatal Medical Follow-up

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

CHARM: Key Elements of Patient Success

S tart prenatal care early in pregnancy

 Pregnant women receive pharmacological treatment

for opioid dependence early in pregnancy

 Engaged in substance abuse counseling  Attend prenatal care appointments  Attend Neomed Clinic appointments  Family and social supports, stable housing  Plan of safe care

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,

• : (

'

' '

• - - -

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Vermont

CHARM Team Data - Calendar Year 2016 Number of Adult Patients 103 Number of babies

91

Total number of individuals served

194

# of Case Reviews

276

\ /

• r

Child Protection

DCF Policy: Assessment may begin one month before due date, where there is:

− Serious threat to a child’s health or safety − Mother’s substance abuse during third trimester

Innovative approach:

• Planning for safe environment for the infant
• Allows time for family engagement prior to birth
• Child maltreatment prevention: earlier indication of

risk/parent is unable to parent safely

• Avoid unnecessary placement crisis at birth

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CHARM "System Outcomes"

 More pregnant women are in treatment earlier with better prenatal care:

• Pregnancy: opportunity to engage in treatment
• Fewer premature births; fewer small birth weight infants

 Better care for infants:

• Support for moms, shorter hospital stay, attachment
• Plans of Safe Care

 Child safety: Safety assessed, support services accessed, and plans of safe care initiated prior to birth

• Fewer emergency custody orders at time of birth
• Decisions made based on better information from

project partners about safety and risks

• CHARM Process Outcomes

Time-saver

• Develop trust; minimize misunderstandings
• Improved understanding of patients/clients – more comprehensive view
• Improved understanding of each other’s roles and perspectives
• Development of expertise among project partners: health and safety

issues for opioid-exposed newborns

• Child Protection decisions made based on

better information about safety and risks

• Have a “go-to” contact

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Challenges for Collaboration

• Collaboration – requires ongoing attention
• Complex lives – need high level of ongoing support
• Assessing child safety with parents with a history of opioid

use disorder Balancing act – child welfare policies and practices: focus

• n child safety while not discouraging pregnant women

from seeking prenatal care and substance abuse treatment

• Privacy: confidentiality, limits to information sharing

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New: Expanding CHARM Family Supports

• Connection to New Moms Recovery program – peer support
• Gift cards, gas cards, diapers, baby needs
• 2016 CARA Notification requirements/Plans of Safe Care
• Teaming with parents/families beyond first year

– Collaborating with Reach Up (TANF)

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The health of the baby depends upon the mother’s health, the family’s health

Babyleavase.com

Adobe.com

 The Children and Recovering Mothers (CHARM)

Collaborative in Burlington, VT: A Case Study

National Center on Substance Abuse and Child Welfare

http://www.ncsacw.samhsa.gov/

 Vermont Health Department – Alcohol

and Drug Abuse Programs: Care Alliance for Opioid Addiction

http://www.healthvermont.gov/response/alcohol-drugs/treating-opioid-use- disorder

 University of VT – VCHIP: Improving Care

for Opioid-Exposed Newborns (ICON)

http://www.uvm.edu/medicine/vchip/?Page=ICON.html

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Vermont’s CHARM (Children and Recovering Mothers) Team: A collaborative approach to supporting pregnant and parenting women with opioid use disorders and their infants

Anne M. Johnston, Neonatologist Associate Professor, University of Vermont College of Medicine University of Vermont Children’s Hospital Smith 575, 111 Colchester Ave., Burlington, VT 05401 802.847.3993 Anne.johnston@uvmhealth.org www.uvmhealth.org Sally Borden, Executive Director KidSafe Collaborative 45 Kilburn Street, Burlington VT 05401 802.863.9626 sallyb@kidsafevt.org www.kidsafevt.org

Note: images in this presentation are used with permission; stock photos are licensed for use by KidSafe Collaborative 38