The Power of Collaboration. Supporting Infants with Substance Exposure and their Families for Optimal Well-being

Transcription

1 The Power of Collaboration Supporting Infants with Substance Exposure and their Families for Optimal Well-being

2 Strengthening Partnerships Improving Family Outcomes An Initiative Funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Administration for Children, Youth and Families (ACYF), Children s Bureau ncsacw@cffutures.org

3 How do we get there? Understanding the Challenge Services that Support Families Roadmap to Collaboration Call to Action

4 Data: Understanding the Challenge Pregnant Women Entering Treatment Prevalence of Substance Exposed Infants Effects of Parental Substance Use on Removal Effects of Prenatal Substance Exposure

5 Estimated Number of Infants* Affected by Prenatal Exposure, by Type of Substance and Infant Disorder 700, , ,000 15% 500, ,000 Potentially Affected by Prenatal Exposure 360,000 9% 300, , ,000 0 Withdrawal 200,000 Syndrome 5% FASD 80,000 2% 16, % 24,000 (6 per 1,000 births) 28,000 (.2-7 per 1,000 births) Tobacco Alcohol Illicit Drugs Binge Drinking Heavy Drinking NAS FASD *Approximately 4 million (3,932,181) live births in 2013; National Vital Statistics Report, Vol. 64, No. 1 Estimates based on: National Survey on Drug Use and Health, 2013; Patrick, et al., (2015). Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to Journal of Perinatology, 35 (8), 667 May, P.A., and Gossage, J.P.(2001).Estimating the prevalence of fetal alcohol syndrome: A summary. Alcohol Research & Health 25(3): Retrieved October 21, 2012 from

6 AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT W WI W WY 16% 14% Percent of Women of Childbearing Age (Ages 15-44) Pregnant at Treatment Admission in the United States, 2014 National Average: 5.2% 12% Minnesota: 6.4% 10% 8% 6.4% 6% 4% 2% 0% Source: TEDS Data, 2014

7 Prevalence of Parental Alcohol or Other Drug Use as a Contributing Factor for Reason for Removal in the United States and Minnesota, 2000 to % 35% 30% 25% 20% 15% 10% 18.5% 19.6% 21.9% 12.3% 11.9% 13.8% 25.9% 26.5% 26.0% 26.2% 23.0% 23.9% 24.7% 20.2% 24.4% 22.3% 22.7% 17.2% 18.7% 19.5% 19.9% 28.5% 29.5% 30.7% 31.3% 23.4% 23.6% 28.7% 31.0% 35.4% 32.2% 34.4% 5% 0% National Minnesota Note: Estimates based on all children in out of home care at some point during Fiscal Year Source: AFCARS Data,

8 60% 50% 40% 30% 20% 31.1% 24.7% Percent of Children Under 1 Years old Removed with Parental Alcohol or Other Drug Use as a Reason for Removal in the United States and Minnesota, 2000 to % 35.0% 26.4% 29.4% 38.5% 30.9% 43.3% 32.3% 47.3% 46.3% 47.6% 33.6% 35.2% 43.6% 41.6% 41.5% 43.4% 42.9% 36.5% 37.0% 37.0% 38.3% 39.2% 47.6% 40.5% 41.4% 51.2% 42.4% 55.8% 44.9% 10% 0% National Minnesota Note: Estimates based on all children in out of home care at some point during Fiscal Year Source: AFCARS Data,

9 AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY 80.0% 70.0% Percent of Children Under 1 Years old Removed with Parental Alcohol or Other Drug Use as a Reason for Removal, 2015 National: 44.9% Minnesota: 55.8% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Note: Estimates based on all children in out of home care at some point during Fiscal Year Source: AFCARS Data, 2015

10 Percent of Children with Terminated Parental Rights by Reason for Removal in Minnesota, 2015 Neglect Parent Alcohol or Drug Use Parent Unable to Cope Physical Abuse Inadequate Housing 16.4% 13.5% 7.3% 41.2% 46.9% Child Behavior Abandonment Sexual Abuse Child Disability Relinquishment Parent Incarceration Child Alcohol or Drug Use Parent Death 7.2% 5.6% 4.7% 3.4% 3.3% 2.6% 1.4% 1.3% N= 2, % 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Note: Estimates based on all children in out of home care at some point during Fiscal Year Source: AFCARS Data, 2015

11 Short-Term Effects of Prenatal Exposure by Substance Nicotine Alcohol Marijuana Opiates Cocaine Methamphetamine Fetal Growth Anomalies Withdrawal Neurobehavior Strong Effect Effect No Effect No Consensus? Not Enough Data Adapted from: Behnke, M., & Smith, V. C. (2013). Prenatal Substance Abuse: Long and short term effects on the exposed fetus. Pediatrics

12 Long-Term Effects of Prenatal Exposure by Substance Nicotine Alcohol Marijuana Opiates Cocaine Methamphetamine Growth Behavior Cognition Language Achievement Adapted from: Behnke, M., & Smith, V. C. (2013). Prenatal Substance Abuse: Long and short term effects on the exposed fetus. Pediatrics Strong Effect Effect No Effect No Consensus? Not Enough Data

13 SHORT-TERM EFFECTS OF PRENATAL EXPOSURE BY SUBSTANCE Nicotine Alcohol Marijuana Opiates Cocaine Methamphetamine Fetal Growth Anomalies Withdrawal Neurobehavior LONG-TERM EFFECTS OF PRENATAL EXPOSURE BY SUBSTANCE Growth Behavior Cognition Language Achievement Adapted from: Behnke, M., & Smith, V. C. (2013). Prenatal Substance Abuse: Long and short term effects on the exposed fetus. Pediatrics Strong Effect Effect No Effect No Consensus? Not Enough Data

14 Complex Interplay of Factors Interaction of various prenatal and environmental factors Family characteristics Prenatal care Exposure to multiple substances: alcohol and tobacco Other health and psychosocial factors have a significant impact The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), ; Emmalee, S. B. et al. (2010) Prenatal Drug Exposure: Infant and Toddler Outcomes. Journal of Addictive Diseases, 29(2), ; Baldacchino, A., et al. (2014). Neurobehavioral consequences of chronic intrauterine opioid exposure in infants and preschool children: a systematic review and meta-analysis. BMC Psychiatry, 14(104);

15 Services that Support Families Recognize the unique practice window of opportunity Screening, assessment and early engagement in Treatment Treatment that supports families Ongoing support for family recovery

16 Practice Windows of Opportunity Motivation to make health related changes is enhanced during pregnancy Prenatal care is a touch point with the system Edvardsson, K., Ivarsson, A., Eurenius, E., Garvare, R., Nyström, M. E., Small, R., & Mogren, I. (2011). Giving offspring a healthy start: parents' experiences of health promotion and lifestyle change du ring pregnancy and early parenthood. BMC public health, 11(1), 936. Crittenden, K. S., Manfredi, C., Lacey, L., Warnecke, R., & Parsons, J. (1994). Measuring readiness and motivation to quit smoking among women in public health clinics. Addictive behaviors, 19(5),

17 Supporting Families with Substance Use Disorders Identifying women during pregnancy Treatment during pregnancy Support at birth and beyond

18 Barriers to Screening Patient Fear of discrimination, judgment or CPS Previous bad experience with health care provider Don t consider use problematic Provider My patients don t use drugs I don t have time I won t get paid I don t know what to do if they screen positive

19 Assessment during Pregnancy Early identification can minimize potential harms to the mother and her pregnancy and maximize motivation for change Selective screening based on risk factors perpetuates discrimination and misses most women with problematic use Universal screening is recommended by ACOG But does CPS have a role?

20 Interventions focused on nonpharmacologic therapies, empowering messages to parents and simplified assessment led to substantial and sustained decreases in average length of stay, infants treated with morphine, and hospital costs. Interventions: Nonpharmacologic care coupled with empowering messages to parents Simplified assessment Administration of morphine on an as-needed basis Transfer of infants directly to the inpatient unit, bypassing the NICU. Outcomes: Average length of stay decreased from 22.4 to 5.9 days Methadone-exposed infants treated with morphine decreased from 98% to 14% Costs decreased from $44,824 to $10,289 No infants were readmitted for treatment of NAS and no adverse events were reported. Grossman MR, Berkwitt AK, Osborn RR, et al. An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome. Pediatrics. 2017;139(6):e

21 Treatment that upports Families Encourages maternal retention in treatment Increases family skills Enhances child well-being Werner, D., Young, N. K., Dennis, K., & Amatetti, S. (2007). Family-centered treatment for women with substance use disorders: History, key elements and challenges. Substance Abuse and Mental Health Services Administration Department of Health and Human Services.

22 Rethinking Family Recovery Parents recovery must occur in the context of family relationships Services that strengthen families and support parent-child relationships helps keep children safe ~85% of children in substantiated abuse and neglect cases either stay home or go home

23 Recovery Support Matters A Randomized Control Trial Cook County, IL (n=3440) Comprehensive Screening & Assessment Early Access to Treatment Positive Outcomes Ryan, Perron, Moore, Victor & Park (2017) Timing matters: A randomized control trial of recovery coaches in foster care, Journal of Substance Abuse Treatment (77):

24 Recovery Support Matters A Randomized Control Trial Cook County, IL (n=3440) Comprehensive Screening & Assessment Early Access to Treatment Recovery Coach Positive Outcomes Ryan, Perron, Moore, Victor & Park (2017) Timing matters: A randomized control trial of recovery coaches in foster care, Journal of Substance Abuse Treatment (77):

25 Roadmap to Collaboration Recognizing the unique policy window of opportunity How Plans of Safe Care Encourage Collaboration SEI-IDTA Lessons: Developing Powerful Collaboration Tools for Developing a Powerful Collaborative

26 Policy Windows of Opportunity Attention on Opioid Epidemic CARA Legislation and Plans of Safe Care Cures Act Funding

27 A Collaborative Approach Women with opioid and other substance use disorders are identified during pregnancy Engaged into prenatal care, medical care, substance use treatment, and other needed services A Plan of Safe Care for baby and family is developed reducing the number of crises at birth for women, babies, and the systems!

28 CAPTA Focus Regarding Infants with Prenatal Exposure To identify infants at risk of child abuse and neglect as a result of prenatal substance exposure, so a range of appropriate services can be delivered to the infant and family/caregiver, ensuring the safety and well-being of infants and their families

29 21st Century Cures Act Opioid Crisis Grants (Opioid STR) HHS Secretary provide grants to states and territories to supplement opioid abuse prevention and treatment activities $500 million in award money available in each of FY17 and FY18 Funds awarded according to a formula based on the number of people with opioid use disorders with unmet treatment needs Eligibility is limited to Single State Agencies (SSAs) Outlines a non-exhaustive list of allowable uses of the opioid grant funds to states and territories Minnesota received a grant of $5,379,349 for FY 2017

30 Plans of Safe Care

31 CARA s Primary Changes to CAPTA Further clarified population to infants born with and affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder, specifically removing illegal 2. Required Plan of Safe Care to include needs of both infant and family/caregiver 3. Specified data to be reported by States 4. Specified increased monitoring and oversight by States to ensure that Plans of Safe Care are implemented and that families have access to appropriate services

32 CAPTA Plan of Safe Care Preparing for Baby s Arrival and Beyond Ideally, developed prior to birth of infant Comprehensive multi-disciplinary assessment Multiple intervention points: pregnancy, birth and beyond Addresses needs of infant and family/caregiver Structure in place to ensure coordination of, access to, and engagement in services

33 CAPTA Implementation Challenges Interaction between Statute and Current Practice Identifying Affected Infants Populations in Need of Plans of Safe Care Collaboration with New Partners Addressing Families in the Plan of Safe Care Plans of Safe Care vs. Safety Plan Implementation, Monitoring and Data Collection

34 SEI Statutes Affected by Definitions Hospital Protocols State Examples Notification Policy Plan of Safe Care Policy Plan of Safe Care Template SACWIS Changes & NAS Reporting

35 POSC is a unique opportunity for crosssystem collaboration No Single agency can do it alone

36 Substance Exposed Infants In-Depth Technical Assistance (SEI-IDTA, 2014-Present) To advance the capacity of State and local jurisdictions to improve the safety, health, permanency and well-being of infants exposed to maternal alcohol and drug use. Focuses on opioid use during pregnancy Recovery of pregnant and parenting women and their families

37 Substance-Exposed Infants, In Depth Technical Assistance 37 States Receiving In-Depth TA to Improve Practice and Policies Connecticut Delaware Kentucky Minnesota New Jersey New York Virginia West Virginia

38 Challenges Identified by Tribes and States Opportunities For women with opioid use disorders and their infants and families Prenatal Lack of Prenatal Care due to fear of prosecution or loss of custody Selective Screening Stigma of MAT Discrimination against PPW in treatment services

39 Opportunities Identified by Tribes and States For women with opioid use disorders and their infants and families Prenatal Birth Lack of Prenatal Care due to fear of prosecution or loss of custody Selective Screening Stigma of MAT Discrimination against PPW in treatment services Inconsistent identification and treatment of infants Unclear notification processes No Plan of Safe Care Discharge plans don t address parent/caregiver needs

40 Opportunities Identified by Tribes and States For women with opioid use disorders and their infants and families Prenatal Birth Beyond Lack of Prenatal Care due to fear of prosecution or loss of custody Inconsistent identification and treatment of infants Eligibility and Availability of essential services Selective Screening Unclear notification processes Infants not eligible for early intervention Stigma of MAT No Plan of Safe Care Challenges with engagement of PPW Discrimination against PPW in treatment services Discharge plans don t address parent/caregiver needs Lack of coverage for continuing care for mothers and infants Lack of appropriate family centered, trauma informed, gender responsive and evidence-informed services

41 Collaborative Lesson from SEI-IDTA Tribes and States Leadership Identifying champions from critical partner systems and a dedicated lead agency Engaging Critical Partners Ensuring that partners from multiple agencies and disciplines are meaningfully engaged Cross-system Collaboration Building a common foundation for systems change through share resources, relationships and results Data Collection, Reporting & Integration Developing systems, protocols and training to support shared data collection, analysis and reporting

42 Two communities No prenatal screening or assessment Stigma, no engagement specialist Late, inadequate or non-existent treatment No Postnatal Plan of Safe Care Outcomes? Early prenatal screening and assessment No stigma for engagement into treatment Quality treatment MAT, Family-Centered, Trauma-informed, Recovery Support Prenatal Plan of Safe Care Outcomes? Where do you live?

43 Purpose: Support the efforts of States, Tribes and local communities in addressing the needs of pregnant women with opioid use disorders and their infants and families Audience Child Welfare Substance Use Treatment Medication Assisted Treatment Providers OB/GYN Pediatricians Neonatologists National Workgroup 40 professionals across disciplines Provided promising and best practices; input and feedback over 24 months Available for download here:

44 Case Study: CHARM Collaborative What Makes it Work Shared Understanding Among Partners Regular Meetings Information Sharing Early Identification and Intervention MAT and substance use treatment services Prenatal Care Child Welfare 30-day pre-birth-assessment Intense Level of Support Pregnancy Birth Post-Partum

45 5 Next Steps & Resources

46 #1 Download the Cross-Systems Guide Use these system specific guides to help establish a baseline understanding of the practices and policies used across systems.

47 #2 Conduct an SEI Systems Walk-Through Screening Assessment Referral Monitoring Contact ncsacw@cffutures.org

48 #3 View and Discuss SEI-IDTA, Opioid Use and SEI Webinars A Collaborative Approach Addressing the needs of pregnant women with opioid use disorders, their infants and families. Partnering to Treat Pregnant Women Lessons Learned from a Six Site Initiative will provide an overview and share lessons from the SAMHSA-funded initiative, Substance Exposed Infants In-Depth Technical Assistance program. A Framework for Intervention for Infants with Prenatal Exposure and Their Families Identifies points of intervention for comprehensive reform to prevent prenatal exposure and respond to the needs of pregnant women, mothers, their families and infants.

49 #4 Contact the NCSACW TTA Program Connect you with programs that are developing tools and implementing practices and protocols to support their powerful collaborative Training and technical assistance to support collaboration and systems ncsacw@cffutures.org

50 #5 Get Engaged in Minnesota s Work Get involved with Minnesota s SEI-IDTA initiative focused on Native American families. Contact Don Moore, Supervisor Native American Section; Minnesota DHS, Alcohol & Drug Abuse Division: donald.w.moore@state.mn.us

51 Resources

52 NCSACW Resources Publications Online Resource Inventory Webinars Online Tutorials Toolkits Video Please visit:

53 NCSACW Online Tutorials Cross-Systems Learning Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers Resources Understanding Child Welfare and the Dependency Court: A Guide for Substance Abuse Treatment Professionals Understanding Substance Use Disorders, Treatment and Family Recovery: A Guide for Legal Professionals FREE

54 Resources to Help You Address the Opioid Crisis Substance-Exposed Infants, In-Depth Technical Assistance 18 months of technical assistance designed to strengthen collaboration and linkages across systems 8 sites: Connecticut, Delaware, Kentucky, Minnesota, New Jersey, New York. Virginia, West Virginia, Technical Assistance: Plan of Safe Care Implementation Clarifying key decisions for tribes & states Defining affected infants Understanding different populations of pregnant women Identifying components in plans of safe care Resource Directory Web-based Includes up to date research, training materials, videos, site examples and other resources Webinar Series: 8 recorded webinars

55 Contact Information Nancy K. Young, Ph.D Bringing Systems Together for Family Recovery, Safety and Stability