The Mommies Program Training
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Comprehensive Care for Women Using Substances
Karen Palombo, LCSW, LCDCWomen’s Substance Use Disorder Specialist
Objectives
• Describe Neonatal Abstinence Syndrome (NAS) to include management recommendations.
• Recognize the importance of using an integrated model of care for pregnant and parenting women with substance use disorders.
• Identify the key components of a successful integrated model of care for pregnant and parenting women receiving substance use disorder treatment or intervention services.
Objectives
• Outline a plan for implementing a successful 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.
• Request technical assistance for implementing an integrated model of care like the Mommies Program.
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The Changing Face of Substance Use
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Substance Use is a Public Health Issue
• National increase in opioid pain reliever use• CDC findings• National overdose death rates
05/06/2023 8
U.S. Cause of Pregnancy-Related Deaths
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isease
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Infect
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9
Texas Maternal Mortality Task Force
Cardiac Event Drug Overdose Hyptertension/Eclampsia
Hemorrhage Sepsis Homicide Suicide0
5
10
15
20
25
20.6
11.6 11.1
9 97.4
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Chart Title
Maternal Cause of Death
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ll M
ater
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eath
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Stigma• “Drug-Dependent Infants Detox at Tenn.
NICU”• “Mothers were hooked on painkillers” • “Born addicted: Heroin's innocent victims” • “Children Born Addicted To Drugs”• “Addicted At Birth: The Babies Hooked On
Heroin”
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Substance Use Among Women
• More complex• Correlated to co-morbid conditions (mental
health)• Lower socio-economic status• Intimate partner violence (IPV)• History of trauma (IPV or sexual abuse)
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Trauma and Substance Use• Pregnancy• Mothering• Substance use • Stigma
•Reduced access to healthcare for women
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Trauma-Informed Healthcare
• Examples:• Asking before touching a patient• Talking to the person rather than about
them• Asking if woman has questions/concerns• Taking time to explain
Mothers in Treatment• Most feel a strong connection with their
children• Want to be good mothers• Want to regain custody of their children
Neonatal Abstinence
Syndrome (NAS) Lisa Cleveland PhD, RN, CPNP, IBCLC
Assistant ProfessorThe University of Texas Health Science Center at San
Antonio
What is NAS?
NAS National Trends• Parallel rising trends in
prescription opioid misuse and incidences of NAS
• U.S. rates of NAS have increased fivefold
Texas NAS Trends
2011 2012 2013 2014 20151050
1100
1150
1200
1250
1300
1350
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Texas Medicaid NAS by County
2011 2012 2013 2014 2015Bexar 32% 33% 30% 26% 29%Dallas 9% 12% 14% 14% 13%Tarrant 9% 10% 10% 9% 10%Harris 12% 13% 9% 7% 6%Nueces 5% 4% 5% 7% 5%
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
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Texas Medicaid NAS NICU Data
Screening for NAS• Maternal History and Prenatal Screening
• SBIRT• The 4 P’s Plus-Dr. Chasnoff
• Parents• Partner• Past• *Pregnancy
*ntiupstream
Diagnosing NASInstrument Year Published Number of Assessment
ItemsTraining Materials
Available
Finnegan Neonatal Abstinence Scoring Tool (FNAST) 1975 21 Video/DVD Manual
The Lipsitz Neonatal Drug-Withdrawal Scoring System 1975 11 No
Neonatal Drug Withdrawal Scoring System 1975 11 No
Neonatal Narcotic Withdrawal Index 1981 7 No
Neonatal Withdrawal Inventory 1998 7 No
Neonatal Network Neurobehavioral Scale Part II: Stress Abstinence Scale
2004 50 5 days of formal training and certification required
MOTHER (Maternal Opioid Treatment: Human Experimental Research) NAS Score
2010 19 Video developed for multi-center research staff training only
Diagnosing NASModified 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
FNAST Training• Training and inter-
observer (90%) reliability
• Demonstration frequency of every shift to once yearly
Management of NAS• Non-pharmacological
interventions• Breastfeeding• Quiet environment• Dimmed lighting• Skin-to-skin• Swaddling• Rocking
Photo courtesy of UT Health Science Center San Antonio, Mission magazine
Management of NAS2nd Line=Pharmacologic management
• Most clinicians use some form of opioid• Morphine Neonatal Oral Solution
(0.4mg/ml)• Adjunct medications
• Clonidine and phenobarbital• Adherence to a standardized protocol is
recommended
Initiation of MNOS (0.4mg/ml)
Category Score Morphine
0 0-7 none
I 8-12 0.10ml
II 13-16 0.20ml
III 17-20 0.30ml
IV 21-24 0.40ml
V ≥25 0.50ml* Initial treatment dosing category should correspond with the highest score.* Initial treatment dosing category should correspond with the
highest score.
Adapted from Jansson, L. (2009)
Escalation of Dose
Category Score New Morphine DoseI 8-12 Previous dose+0.05ml
II 13-16 Previous dose+0.10ml
III 17-20 Previous dose+0.15ml
IV 21-24 Previous dose+0.20ml
V ≥25 Previous dose+0.25ml
Two NAS scores in ≥Category 1, despite rescoring, warrants escalation of treatment:
*Escalation dose should correspond with the highest score*Consider NICU admission if infant requires greater than 0.20mg (0.5ml) of morphine (0.4mg/ml) every 3 hours to maintain scores in Category 0.
*Infants who appear somnolent and/or are difficult to arouse warrant transfer to the NICU.
On-Going Research Projects
Our Inter-Professional Team
Collaborators
Charles France, PhDProfessor and Director of the ARTT Center for
Addiction Research UTHSCSA
Douglas Granger, PhDFoundation Professor and
Director for the IISBR, UC-Irine
Ellen Yeung, PhDPostdoctoral Fellow
University of Missouri
Kangaroo Mother Care Study (KMC)
Funded by the Texas Health & Human Services Commission
Findings
Qualitative Data
Photo courtesy of UT Health Science Center San Antonio, Mission magazine
Today
Written consent obtained for use of photos
The Bexar County NAS Collaborative (BCNC)
Funded by the Patient Centered Outcomes Research Institute (PCORI)
Our Partners
Written consent obtained for use of photos
BCNC WebsiteKeeping Families Together.org
Maternal Opioid Mortality Study
(MOMS)
Funded by the Texas Health & Human Services Commission
Infant Feeding Decisions and MAT
Kelly McGlothen BSN, RN
Social Support & Stress
Cristina Cruz & Dr. Frank Puga
Stronger Together: Soothing Techniques for Moms and Babies soothing techniques for mommies
and ba
Mommies Training: An Overview
Briseida Courtois, LCDC, MSSWDirector of Addiction Treatment Services, Center for Healthcare
Services, San Antonio
Mommies Program History
2007-Project Carino2013-Mommies Program2017-Well over 1000 families have been helped
Population ServedEligible participants: Pregnant, CHCS consumers with any type of diagnosed SUD
Location of Services• Center for Healthcare Services (LMHA)
• Methadone Clinic• Outpatient Clinic• Residential and Ambulatory Detoxification• Intensive Residential• Recovery Residence• Substance Abuse Public Sobering Unit• Crisis Care Center
Support Services• Transportation• Childcare• Qualified and
Dedicated Staff• Outreach Staff• Case Manager• Patient Navigator
Integrated Model of Care
• Combines:• On-Site Pregnant,
Parenting and Child Services
• Addiction Services• Medication Assisted
Treatment for Pregnant Women
Restoration Center
Medication Assisted Treatment
Dose Response
0 hours 24 hours
high
comfort
withdrawal
MethadoneHeroin
Program Process• Enrollment begins at intake • Mental health concerns=LPC • Release of information document • Referral to Mommies Program• Meeting with Patient Navigator/Benefits
Coordinator• Need for services is determined• All services are voluntary
Credentialed Staff• Medical Director with
specialized training in substance abuse services
• Licensed Professional Counselors
• Licensed Chemical Dependency Counselors
• Access to benefits coordinator on location, 5 days a week
Outreach Specialist & Case Manager
• Two essential positions• Outreach Specialist
• Provides home visits• Extensive knowledge of the community
• Case Manager• Orchestrates staffing and resources across
agencies• Ensures presence of key individuals at
meetings• Provides family/consumer education about
MAT
Patient Navigator• Funded by University Health System• Degreed professional with applicable experience• Accessible 24/7 • Resolving issues and acts as coach/role model• Role:
• Advocacy• Communicate with healthcare systems • Updates Mommies’ progress to essential staff• Coordinate educational sessions
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Individualized Planning• Individualized Treatment Plans
• Substance Abuse Counseling• Crisis Intervention• Case Management• Therapy• Trauma Informed Services• Testing
Evidenced-Based Curricula
• Nurturing Parenting• Seeking Safety• Matrix Model• Life Skills Training
Changing the Culture of Care
Suzie Aldous BSN, RNDirector of the Neonatal Intensive Care Unit/Neonatal
Abstinence Syndrome Program, Baptist Medical Center-Downtown, San Antonio
Changes in Clinical Care
• Patient population seen at BMC• How care was traditionally provided• What care looks like today• What led to these changes
Making the Change• VON trainings• Staff “champions”• DFPS unit liaisons• Partnerships with Alpha Home and the
CHCS• Partnering with the BCNC to influence
change at the county level
Changing the Culture• Staff education
• Addiction as a disease• Stigma• Trauma informed care• Mother and infant are
a dyad• Offering no alternative
to change• May lead to some
staff turnover©Tyler Olson/Dollar Photo Club
NAS TeamVision- Create a non-judgmental welcoming environment that keeps mothers and babies together when medically able. Provide the support services moms need to be successful in their recovery as they partner with us in the healing of their newborn infant.
NAS Phases
Phase 1• Standardize
scoring to decrease LOS
Phase 2• Room-in
mothers on methadone
Phase 3• Room-in
babies with non-opoid exposure (cocaine/THC/Benzo/amphetamines)
Phase 4•Room-in mothers actively using heroin or other opoids without a prescription.
•Provide all the specialty services to the family to help preserve the family unit if possible.
Phase 5• Room-in
babies while on medications to help with withdrawal symptoms
Educational Needs
Kangaroo care
Ana/Jlo
Developmental education for mom’s and
support services
Soothing techniques
Addiction
Community Resources
NAS competencies
Rooming-in
EAPRole play
New Admission guidelines• Suzie/
Isaac• 6/13/16
Trauma training/
connect with respect
Jon/Michael
Zoned out mom’s…now
what???
Koala CareGinger/Daphne
Harm Reduction
ED pregnant women <20
weeksPat
Central line insertion
Kevin Christ
Breastfeeding•UDS• Isaac/Chen
Stakeholders1. NICU RN2. Couples Care3. Labor and Delivery4. Dietary5. Maintenance6. Central Supplies7. Biomedical8. Treatment Center9. Marketing10.Child Welfare11.Pediatric
1. Early Intervention Programs2. Therapy Team3. Social Workers4. Directors5. Physicians6. Administration7. Growth8. State Agency9. University10.Media11.Lactation
Needs1. Dietary
a. Drinking, Meals2. Maintenance
a. Lights, Windows, Privacy3. Environmental Services
a. Noise, Manual vs. Automatic Supplies4. Central Supplies
a. At Bedside Items: Tables, Recliner, Sanitizer, Lightsb. In Unit Items: Quiet Trash, Quiet Linen, Bili Blanket
5. Biomedicala. Central Monitoring, Line Drops, UV Light
Available Services to Mother
1. Methadone prescribing obstetrician2. Social Services (L&D, PP, NICU, ED)3. Counseling4. Methadone administration5. Cardiology6. Nephrology7. Internal Medicine8. Echo’s9. EKG10.Central Lines
Available Services to Baby
1. Volunteers2. Developmental Clinic3. Social Services4. Child Welfare5. Home Health6. Early Childhood Intervention
Centralized Tracking1. Disposition of Infant2. Length of Stay of Infant3. Days Rooming In4. Medication Days and Type of Medication5. Substance Use6. Discharge Plan
General Protocol 1. Kangaroo Care2. Skin to Skin3. NAS Competencies4. Rooming In5. Visitor Rules6. Increasing NAS Scoring7. Social Services Team
1. Abused Women2. Order Sets Review3. ED Patients4. Triage Patients5. Green Room6. Treatment Team
CASE STUDY EXAMPLE
Group Activities
©CG Inspiration/Dollar Photo Club
SWOT Analysis
Outlining a PlanWhere is this population (in your county) currently receiving the necessary services?
Who are potential partners?
Who at your agency would you need to get “buy-in” or approval from to develop and implement an integrated program to serve this population?
Outlining a PlanWho would be your referral source?
What resources does your agency currently have that can be leveraged?
Who can you name now as possible individuals to fill necessary roles for an integrated model (patient navigator, benefits coordinator, LPCs, LCDCs, psychiatrist, etc.)?
NAS Exceptional Item
Karen Palombo
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Year One: Texas Implementation
• Coordinated Opioid Treatment Services (OTS)
• Statewide Pregnancy Stabilization Center• Targeted Outreach to High Risk Women• Mommies Programs• NAS Trainings• NAS Special Projects
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Year Two: Texas Progress
• Coordinated Opioid Treatment Services (OTS)
• Statewide Pregnancy Stabilization Center• Targeted Outreach to High Risk Women• Mommies Program• NAS Trainings• NAS Special Projects
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Technical AssistanceKaren Palombo, LCSW, LCDC
Women SUD SpecialistSUD UnitIDD and Behavioral Health Services Section8317 Cross Park, Ste. 350 | Austin, Texas 78754 Office: 512-838-4381 Fax: [email protected]
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Texas NAS Website• http://www.dshs.texas.gov/sa/nas/ • Journeys of Hope: Mommies and Babies
Overcoming NAS• Stronger Together: NAS Soothing Techniques for
Mommies and Babies
Thank youKaren Palombo