IHI Research Associate Jeff Rakover, and Helen Bellanca, MD, Associate Medical Director for Health Share of Oregon, describe the promising work of a program that integrates perinatal care with substance abuse management.
Increased rates of substance use and addiction have shaken many communities in the past decade, and pregnant women are no exception. For example, one study found that the incidence of neonatal abstinence syndrome (newborn opiate withdrawal) rose 300 percent between 2000 and 2009, and that antenatal maternal opiate use increased nearly five-fold.
Substance use during pregnancy has been linked to a number of adverse outcomes, including preterm birth and low birthweight. For example, one review found that prematurity complicates 25 percent of births among women struggling with substance use.
At the same time, pregnant women are often reluctant to seek treatment for substance use and addiction for various reasons, including fear of child welfare involvement and stigma regarding substance abuse during pregnancy.
Creating an Integrated Model of Perinatal Care
Health Share of Oregon, one of the state’s coordinated care organizations, has tackled the challenge of improving care and access for pregnant women struggling with substance use by creating a pilot program that seeks to both co-locate and truly integrate perinatal care and addiction treatment. (The state’s coordinated care organizations take full financial accountability for geographically defined populations of the state’s Medicaid population.) The program seeks to create welcoming, supportive environments for these women.
The program started seeing patients about one year ago and provides integrated care at two sites in Oregon. The first site — run by CODA, Inc., an addiction treatment provider with several sites in the greater Portland area — has started providing perinatal care under the leadership of a family physician affiliated with Oregon Health and Science University. The second site, a midwifery clinic owned by Legacy Health System, has started also offering addiction services by partnering with a local addiction and behavioral health provider who provides an addiction counselor and an administrator to help shape and manage the program.
Both sites use a similar model of care that privileges peer support. Women participate in weekly pregnancy groups based strongly on the CenteringPregnancy model, with the additional participation of an addiction counselor and including content focused on addiction treatment. Both sites also hired professional peer supports to model life skills and provide further support to pregnant women, as well as to serve as overall program champions. The CODA site hired a certified peer support counselor, and the Legacy site hired two doulas with extensive experience working with highly marginalized populations (such as homeless women and women involved with the criminal justice system).
Women also receive other services at both sites, including case management to link them to other social supports such as employment and housing resources — essential social and economic factors that often contribute to the life stress that complicates treatment for substance use.
The Motivation for Project Nurture
The impetus for Project Nurture was recognition by Health Share and others that there is a clear gap in care for pregnant women who need addiction treatment. Too often, pregnant women facing addiction who receive referrals for treatment do not follow through due to fear and stigma. Also, too many services focus predominantly on the wellbeing of the infant rather than on the wellbeing of the mother, failing to appreciate the link between the two.
Health Share convened several forums in the greater Portland area to identify the best solutions for engaging pregnant women struggling with addiction. In engaging a variety of stakeholders — including perinatal care providers, addiction treatment specialists, public health advocates and officials, and others — the integrated model of care became a clear imperative. CODA and Legacy volunteered to be the initial sites. CODA was already providing care for a significant population of pregnant women and had hired a nurse case manager to help coordinate their multiple needs. The Legacy site also was seeing an increasing population of pregnant women struggling with substance use and wanted a better way to meet their needs.
Overall, Project Nurture aligns clearly with Health Share’s overall care philosophy, which takes a “life course” perspective to caring for highly marginalized populations. Health Share, under the leadership of Dr. David Labby, has recognized that stressors and poor outcomes early in life have clear cascading, downstream effects later in life. Stress during pregnancy — whether due to addiction or other challenges — can jeopardize preparation for effective parenting, which in turn can jeopardize readiness for key milestones such as school engagement. In research informing the design of their approach to population health, Health Share found that many adult “super utilizers” (those who have the poorest health outcomes and incur the greatest costs) have a history of poor outcomes that lead back to health issues encountered early in life. Intervening during pregnancy can mean significant improvements in life prospects much later.
Ingredients for Success: Nurturing Trust
Leaders for Project Nurture cite strong peer support — whether from professionals or from others participating in group prenatal care — as crucial to the program’s success. Given the stigma associated with substance use during pregnancy, providing an opportunity for mothers to connect with others facing similar challenges or who have successfully overcome addiction can have a great impact.
Creating a transparent approach to interactions with the child welfare system serves as another essential ingredient to improving engagement and trust. Project Nurture’s approach to interacting with child welfare involves several key elements. Importantly, their approach aligns with the legal environment in their state. In Oregon, substance abuse during pregnancy, by law, does not require reporting. (On the other hand, if the woman has children at home during the pregnancy, this may result in mandatory reporting.) The Project cannot promise that they will not call child welfare services; in some cases, the law requires it. However, they provide education to the woman regarding the role of child welfare and the rules for mandatory reporting. They also make clear that engagement with treatment can help prevent child welfare involvement down the line.
Women who receive services from Project Nurture are more likely to engage with a number of other services that can better prepare a woman for safe and healthy parenting — of course, this includes addiction treatment, but also support to find stable housing, domestic violence counseling, and parenting classes. Engagement with these services can significantly reduce the prospect of child welfare intervention. When women realize this to be the case, through education by program staff, they become significantly more likely to engage with the program. Staff receive explicit training to ensure that women have a clear understanding of these potential benefits, and how accessing such services can reduce the likelihood of child welfare involvement.
If Project Nurture staff do need to call child welfare services at any point, they include the mother in this process and she has the option of being included in the call. Project Nurture staff clearly outline what will be discussed during the call, and the staff work with the mother to address the identified concerns.
One Example of an Integrated Model for Maternal and Infant Health
Project Nurture has a robust plan for collecting outcomes data, both for the mother and for the newborn, and with respect to issues like neonatal outcomes and child welfare involvement. At the same time, the project continues to receive requests for new sites. A third Project Nurture site, operating at a family practice clinic, is already in the works. They have received serious interest from other providers in Health Share’s catchment area.
Overall, Project Nurture demonstrates one path to addressing a clear need in maternal and child health care in the US: integrating traditional medical care with care that addresses the social determinants of health. Project Nurture offers a path to heal expectant mothers, setting them up for a better chance for success in creating healthy and nurturing homes for their young children.
IHI continues its work to develop a true Triple Aim approach to maternal and infant health, engaging numerous experts in this work and learning about the experiences of providers in many states, particularly those aggressively pursuing payment reform. Project Nurture provides one exceptional example of bringing together services that address the medical and social needs of pregnant women.
If you are a policymaker or provider interested in learning more about this work, of if you have a model of care to share, please contact Jeffrey Rakover at jrakover@IHI.org.
You may also be interested in:
Read the first (Designing a Population Approach to Maternal Health and Care) and second (The Maternity Medical Home: The Chassis for a More Holistic Model of Pregnancy Care?) in this series.
The IHI Virtual Expedition: Advancing Safer Maternal and Newborn Care, one of the benefits included in the Passport to IHI Training membership.