1. The Mommies Program – An Integrated Model of Care
Karen Palombo, LCSW, LCDC
Texas Women’s SUD Intervention Specialist

2. 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

3. 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

4. Overview of Substance Use Disorder
Misuse
Risky Use
Disorder (Mild, Moderate, Severe)
Recovery
DSHS/HHSC Maternal Morbidity & Mortality Workgroup Meeting Action Item

5. United States Mortality Rates from 1980 to 2014
United States Mortality Rates from 1980 to You may notice in 1999, drug overdoses killed more people than homicide and then in 2009, drug overdoses killed more people with motor vehicle accidents.

6. Source: Case, & Deaton, 2015; PNAS.

9. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, known as DSM-5, a distinction is no longer made between substance abuse and substance dependence. Moreover, the term “substance abuse” is no longer used. The term now used is Substance Use Disorders, or SUDs. A disorder occurs when the recurrent use of alcohol and or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.
The Opioid Epidemic has changed everything we know about substance use. Heroin use has increased among most demographic groups. Males has increased; Females has doubled; has doubled; White (Non-Hispanic) has doubled…all incomes and through health plans.
Source: National Survey on Drug Use and Health,

10. Source: Perinatal Quality Collaborative of North Carolina, 2013

12. Opioid Overdose Death has increased 237% for men and 400% for women (Washington Post article). About 18 women die every day of a prescription painkiller overdose in the US, more than 6,600 deaths in Prescription painkiller overdoses are an under-recognized and growing problem for women. Although men are still more likely to die of prescription painkiller overdoses (more than 10,000 deaths in 2010), the gap between men and women is closing. Deaths from prescription painkiller overdose among women have risen more sharply than among men; since 1999 the percentage increase in deaths was more than 400% among women compared to 265% in men. This rise relates closely to increased prescribing of these drugs during the past decade. Health care providers can help improve the way painkillers are prescribed while making sure women have access to safe, effective pain treatment. When prescribing painkillers, health care providers can
Recognize that women are at risk of prescription painkiller overdose. Follow guidelines for responsible prescribing, including screening and monitoring for substance abuse and mental health problems. Use prescription drug monitoring programs to identify patients who may be improperly obtaining or using prescription painkillers and other drugs.
Prescription painkiller overdoses are a serious and growing problem among women. More than 5 times as many women died from prescription painkiller overdoses in 2010 as in Women between the ages of 25 and 54 are more likely than other age groups to go to the emergency department from prescription painkiller misuse or abuse. Women ages 45 to 54 have the highest risk of dying from a prescription painkiller overdose.*
Non-Hispanic white and American Indian or Alaska Native women have the highest risk of dying from a prescription painkiller overdose. Prescription painkillers are involved in 1 in 10 suicides among women.
*Death data include unintentional, suicide, and other deaths. Emergency department visits only include suicide attempts if an illicit drug was involved in the attempt. The prescription painkiller problem affects women in different ways than men. Women are more likely to have chronic pain, be prescribed prescription painkillers, be given higher doses, and use them for longer time periods than men. Women may become dependent on prescription painkillers more quickly than men. Women may be more likely than men to engage in “doctor shopping” (obtaining prescriptions from multiple prescribers). Abuse of prescription painkillers by pregnant women can put an infant at risk. Cases of neonatal abstinence syndrome (NAS)—which is a group of problems that can occur in newborns exposed to prescription painkillers or other drugs while in the womb—grew by almost 300% in the US between 2000 and 2009.
Every three minutes a woman goes to the ED for prescription painkiller misuse or abuse.

13. Substance Use Among Women
SUDs in women tend to be complex and highly correlated with comorbid conditions such as depression and anxiety. Low socioeconomic status, domestic violence, and trauma are also common in women with SUDs. More specifically, having experienced personal violence and trauma is reported by 50-90% of persons with SUDs. Individuals may attempt to relieve distress related to past traumatic events through the use of substances, or they may be more at risk for experiencing traumatic events as a result of their substance use. Traumatic events occurring during childhood are strongly correlated with SUDs and severity of childhood trauma is a significant predictor of SUD relapse in women attempting to recover. Gender specific studies focused on illicit substance use show that there are distinct differences between men and women with SUDs. For example, when compared to men, women are more likely to have chronic pain and be prescribed prescription painkillers at higher doses and for longer periods of time. Women are also more likely to engage in “doctor shopping” (obtaining prescriptions from multiple prescribers)11 and more rapidly become dependent upon painkillers than men. Further, women may be reluctant to seek help for SUDs due to the social stigma and fear of losing their children to Child Protective Services.
More Complex
Correlated to Co-Morbid Conditions (Mental Health)
Lower Socio-Economic Status
Intimate Partner Violence
History of Trauma

14. Trauma-Informed Care
Non-judgmental
Confidential
Access
Safe

15. Trauma & Substance Use Pregnancy Reduce Access to Healthcare for Women
50-90% of women with substance use disorders report that they have experienced personal violence and trauma. Individuals may attempt to relieve distress-related to past traumatic events through the use of substances, or they may be more at risk for experiencing traumatic events as a result of their substance use.
Traumatic events occurring during childhood are strongly correlated with these disorders. Additionally, the severity of childhood trauma is a significant predictor of substance use disorder relapse in women attempting to recover.
Girls’ and women’s experiences of sexual abuse, interpersonal violence and other forms of gender-based violence can be central to substance use. Increasing attention is being brought to the interrelationships between historical trauma and substance. In order to address the substance use concern, violence, trauma, and trust can be seen as a system of care need. Pregnancy, mothering, substance use and social stigma interact to decrease accessibility of healthcare for women. Healthcare information such as contraceptive education and prenatal care opportunities are missed. Non-judgmental comprehensive outreach for pregnant women must be done. Women who inject drugs
Have significantly higher mortality rates
Increased likelihood of injecting related problems
Faster progression from first drug use to dependence
Higher rates of HIV
Higher levels of risky injecting and/or sexual risk behaviors
Greater overlap between sexual and injecting social networks
IPV is more commonly reported than the general population
Studies indicate 90% of individuals with substance use disorders have experienced one or more traumatic event and 33% have been diagnosed with PTSD. Survivors often use substances to manage the emotional distress that follows from trauma and they become more vulnerable to re-victimization through risks associated with addiction-related behavior. Stigma affects all opioid-dependent patients to some degree, but prejudice toward those who become pregnant is especially high.
Pregnant women are reluctant to seek prenatal care due to fear of losing custody of the infant or other children. Healthcare provider attitudes toward substance addicted mothers are often value laden with blame directed toward the mother.
Reduce Access to Healthcare for Women
Pregnancy
Mothering
Substance use
Stigma

16. Source: CDC, Pregnancy Mortality Surveillance System, 2015
There is a recent trend in treatment admissions for prescription opioid abuse during pregnancy. About 4% of women entering SUD treatment are pregnant. Of those 4%, 28% report current opioid use.
Source: CDC, Pregnancy Mortality Surveillance System, 2015

17. Texas Maternal Mortality
that all cases of maternal death in Texas must be reviewed, with the exception of motor accidents and non-pregnancy-related cancers. The task force uses the Centers for Disease Control and Prevention (CDC) definition of pregnancy-related death, which is defined as the death of a woman while pregnant or within one year of termination of pregnancy, 4 irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by her pregnancy or its management, including from: (a) a pregnancy complication; (b) a chain of events initiated by pregnancy; or (c) the aggravation of an unrelated condition by the physiologic effects of pregnancy. Based on analysis of maternal death data from calendar years , the task force found that 1) Black women bear the greatest risk for maternal death; 2) cardiac events, overdose by licit or illicit prescription drugs, and hypertensive disorders are the leading causes of maternal death; 3) a majority of maternal deaths occur more than 42 days after delivery; and 4) data quality issues related to the death certificate make it difficult to identify a maternal or “obstetric” death. The task force reviewed cases of maternal death and observed that mental health and substance use disorders play a significant role in maternal death, and also found repeated missed opportunities to screen for and refer women to treatment for mental health and substance use disorders. Office of Program Decision Support, FCHS, DSHS, 2016
Source: Texas DSHS, Office of Program Decision Support, CHS Death File , Published 2016

18. Percent of Patients who Relapse

19. Journeys of Hope Video http://www.dshs.texas.gov/sa/nas/
Texas NAS Website

20. Mothers in Treatment Most feel a strong connection with their children
Most mothers who are in substance use treatment feel a strong connection with their children and want to be good mothers. Most want to maintain or regain custody of their children and become “caring and competent parents” (Brudenell 2000, p. 86). Women who believe they have not cared for their children adequately or who believe that they are perceived as having neglected their children carry enormous guilt (Sun 2000). Unfortunately, they often have inadequate role models in their own lives or lack the information, skills, or economic resources that could make motherhood less difficult (Camp and Finkelstein 1997; Moore and Finkelstein 2001). They also have the challenge of balancing the work necessary for recovery with their tasks as mothers. Another challenge treatment providers may face is the mother who is developmentally disabled to the extent that her mothering is inadequate. Ensuring the safety of her children while respecting the mother’s choice to care for them requires careful case management to provide support for the mother (SAMHSA TIP 51, p151).
Women tend to develop their sense of self through relationships. A woman’s identity is also deepened when she becomes a mother(SAMHSA TIP 51, p151). Society places a high value on a woman’s ability to mother, and her own perceived success or failure in this endeavor forms an important aspect of her self-concept. For a mother with a substance use disorder, this concept can be paramount (Feinberg 1995).
Most feel a strong connection with their children
Want to be good mothers
Want to regain custody of their children

21. Women’s Barriers to Treatment
There are several reasons why women have a hard time getting to treatment:
Children are in the home; Women tend to be younger when they want to engage in treatment; They may have a lower income or not a reportable income because they are doing childcare or odd jobs; They could be unemployed; They are impacted by social stigma- shes pregnant she shouldn’t be using drugs; Lack of Childcare- outpatient.
Women often have a different pathway to using- they were using in the context of relationships. Suffer different consequences of using. (Child Endangerment)
There are also difference in which drugs women choose to use, difference relapse triggers and the frequency of why the use. -Lose weight; -relieve stress or boredom; -improve their mood
-increase their sexual drive; -self medicating. Women will accelerate to injecting faster and tend to have earlier patterns of dependence.
Opioids- DO NOT TELL A PREGNANT WOMAN TO STOP USING OPIOIDS. Very Dangerous to the fetus and mother- withdrawals.
Children in the home
Younger
Lower Income
Unemployed
Impacted by Social Stigma
Lack of Childcare
1/11/2019

22. Priority Populations
Individual are admitted to treatment in the following order:
Pregnant, Injecting Individuals;
Pregnant Individual;
Injecting Individual;
Individual referred by the Department of Family and Protective Services

23. Levels of Care Screening: OSAR Intervention: PPI/PADRE
Youth Residential and Outpatient
Adult Residential Detoxification
Adult Intensive/Support Residential
Adult Outpatient
Medication Assisted Treatment

24. Methadone: The Basics high comfort withdrawal
PREGNANT WOMEN RECOMMENDED TO BE ON MEDICATION ASSISTED TREATMENT
AND WHY
Reducing stigma, getting past abstinence dogma Medication Assisted Treatment, NOT DETOX
MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance use disorders.
Both ACOG and ASAM recommend against medically supervised withdrawal from heroin or other opioid drugs during pregnancy because of the high relapse rate and the increased risk of fetal distress and death.
Methadone protects the fetus from risk of repeated withdrawal. Medically unsupervised withdrawal is contraindicated.
As a result:
Prenatal care and nutrition is improved
Risk of exposure to infectious diseases that accompany IV drug use are minimized
Risk for accidental overdose is lower
Number of pre-term births are reduced
Incidences of pregnancy and delivery complications are lower
However, NAS resulting from methadone begins later and typically lasts longer when compared to heroin or other opioids
The severity of withdrawal for infant does not seem to be associated with maternal methadone dose or length of treatment. Onset is between hours after birth. Peak between 34 and 50 hours of life.
Dose Response
high
comfort
Heroin
Methadone
withdrawal
0 hours hours

25. What is NAS?
Neonatal abstinence syndrome (NAS) is the constellation of signs in newborn due to substance or medication withdrawals, typically opioids. Substance use during pregnancy is associated with significant adverse pregnancy outcomes such as prematurity, low birth weight, and neonatal abstinence syndrome (NAS). The term NAS is typically used to describe withdrawal that follows in-utero substance exposures, although NAS can also be iatrogenic in nature following the need for prolonged pain-management in critically ill infants.
Symptoms
Symptoms of NAS generally include: Irritability, An inconsolable, high-pitched cry, Fever, Feeding difficulties and poor weight gain, Vomiting and diarrhea, Skin breakdown, Sleep issues, A potential for seizures, And, in rare cases, death. For infants who are prenatally exposed to opioids, the severity of NAS symptoms may be intensified if the infant is also exposed to opioid agonists such as cigarette smoke, benzodiazepines, and antidepressants, such as SSRIs. Approximately percent of exposed newborns will experience NAS. Variability is explained by several factors: 1) Prenatal opioid exposure is a risk factor for but not a predictor of NAS; 2) Neither daily opioid dose nor total dose throughout the pregnancy predict incidences nor severity of NAS; 3) Wide variability exists among institutions in the diagnosis of NAS in opioid-exposed populations.
The severity of symptoms associated with Neonatal Abstinence Syndrome is not the same in all cases. Each case is unique based on what the infant is exposed to in-utero. For infants who are prenatally exposed to opioids, the severity of Neonatal Abstinence Syndrome symptoms may be intensified if the infant is also exposed to opioid agonists.
Neonatal Abstinence Syndrome (NAS) secondary to in-utero opioid exposure has increased 5-fold in the United States between 2000 and 2012 and now affects 5 per 1000 live births nationally.1-2 NAS typically refers to an opioid withdrawal syndrome characterized by behavioral dysregulation that occurs within 2-3 days of birth for infants exposed chronically to opioids in-utero.3 Signs and symptoms include altered sleep, high muscle tone, tremors, irritability, poor feeding, vomiting and diarrhea, sweating, tachypnea, fevers, and other autonomic nervous system disturbances.3 All opioids can cause withdrawal symptoms, including methadone, buprenorphine (Subutex, Suboxone), and short-acting agents such as oxycodone, heroin, and fentanyl, but the severity of these symptoms vary greatly. All infants should be treated first with non-pharmacologic (non-pharm) care. Some infants may also receive replacement opioids. All opioid-exposed infants should be monitored in the hospital for 4-7 days for signs of withdrawal that may require pharmacologic treatment according to the American Academy of Pediatrics.3 Without medication, symptoms typically resolve within 1-2 weeks. Withdrawal can also occur after in-utero exposure to non-opioid agents such as benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and nicotine. Prenatal exposure to cocaine can also cause infant symptoms of neurologic dysregulation.4 The ESC Care Tool may be used to assess these infants, however pharmacologic treatment with replacement opioids for these substances in the absence of opioid exposure is not recommended.
Neonatal abstinence syndrome (NAS) is the constellation of signs in newborn due to substance or medication withdrawals.

26. NAS National Trends
Over the past decade, there has been increased national attention focused on the parallel rising trends between prescription opioid misuse and incidences of NAS.
U.S. rates of NAS increased fivefold between 2000 and 2012; one child now being born every 25 minutes with NAS
Prenatal opioid exposure is a risk factor for but not a predictor of NAS
Neither daily opioid dose nor total dose throughout the pregnancy predicts incidences or severity of NAS
With the exception of alcohol (FASD), no good evidence exists to substantiate claims that infants who experience in-utero substance exposure will have poor long-term outcomes
NAS can occur following exposure to a wide range of substances such as certain antidepressants, barbiturates, and nicotine; however, the most severe symptoms are typically associated with in-utero opioid exposure.
It is estimated that 60%-94% of opioid exposed neonates will develop NAS.19-23
Still, prenatal opioid exposure is considered a risk factor for but not a predictor of NAS, and neither daily opioid dose nor total dose throughout the pregnancy predicts incidences or severity of NAS.24
With the exception of alcohol (FASD), no good evidence exists to substantiate claims that infants who experience in-utero substance exposure will have poor long-term outcomes.
Parallel rising trends in prescription opioid misuse and incidences of NAS
U.S. rates of NAS have increased fivefold

27. Texas NAS Trends
 Unfortunately, TX has experienced trends in NAS very similar to those observed at the national level. Rates of NAS in Texas have increased almost 60% over the past 5 years.
This chart represents the Texas Medicaid Newborns diagnosed with NAS by counties from The total numbers are: 1,152 (2011), 1272 (2012), 1239 (2013), 1296 (2014), 1315 (Incomplete)

28. Cost of NAS
Recently, it has become clear that in addition to the human cost of NAS, this issue is a very expensive one at the national level.
The associated healthcare costs for providing care for infants with NAS has risen from $190M per year in 2000 to $1.5B in 2012 as a result of these increasing rates.
Further, in 2009 the average hospital expenses for infants with NAS were estimated to be $53,400 per infant when compared to $9,500 for all other births
In addition to the human costs of NAS, the associated healthcare costs for providing care for infants with NAS has risen from $190M per year to $720M per year as a result of the increasing incidences.14
In 2009, average hospital expenses for infants with NAS were estimated at $53,400 when compared to $9,500 for all other births.14
The high cost of hospital care is primarily due to a lengthy hospital stay in a Neonatal Intensive Care Unit (NICU) and the need for extensive nursing care.14
Average hospital length of stay (LOS) for newborns with NAS is approximately 16 days when compared to 3 days for all other births.14
LOS for infants with NAS has not decreased during the past decade, leading experts to speculate that there may be more efficient and cost effective ways to provide care for infants with NAS.14
NAS also results in increased costs to the Child Welfare System through investigations, removals, and placement in foster care
The cost of providing foster care for one child is approximately $25,281 per year and kinship care for children placed with family is $1,500 per year
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

29. Texas Medicaid NAS NICU Data
This slide represents the Texas Medicaid Newborn Medical Cost and Length of Stay for Total Average Length of Stay is going down in Texas. This is not the case in most places. The total cost of hospitalization is about the same for the past 5 years. The average is going down because there are more babies. All medical costs includes inpatient hospitalization, outpatient hospitalization, professional, and vendor drugs.
81% of NAS claims are filed in the NICU.
2012
2013
2014
2015
2016
# Patients
674
771
799
865
977
Total LOS
20,989
21,317
19,122
20,147
20,774
Average LOS
27.2
26.7
22.1
20.6
20.1
Total Cost
$27,754,286
$29,277,317
$28,189,276
$27,427,573
$25,991,366
Average Cost
$35,998
$36,642
$32,589
$28,073.26
$25,185
All Medical Care for 1st Year of Life
$45,436,583
$43,286,768
$48,161,891
$48,116,909
$48,448,255

30. Partner vs. Non-Partner Hospitals
This slide represents the Texas Medicaid Newborn Medical Cost and Length of Stay for Total Average Length of Stay is going down in Texas. This is not the case in most places. The total cost of hospitalization is about the same for the past 5 years. The average is going down because there are more babies. All medical costs includes inpatient hospitalization, outpatient hospitalization, professional, and vendor drugs.
81% of NAS claims are filed in the NICU.
2014
2015
2016
Partner
Non-Partner
Patients
239
1019
203
956
180
831
Total LOS
5897
14966
4767
17039
4805
16095
Average LOS
24.7
14.7
23.5
17.8
26.7
20.3
Average Cost
$17,831
$24,191
$18,238
$25,856
$23,651
$27,452
All Medical Care for 1st Year of Life
24.8
16.0
23.8
18.6
26.8
21.0
$18,027
$27,534
$18,383
$28,109
$23,693
$29,089

31. Screening for NAS *Maternal history and prenatal screening
SBIRT (Screening, Brief Intervention and Referral to Treatment)- Substance Abuse and Mental Health Services Administration [SAMHSA]
The 4 P’s Plus © Dr. Chasnoff
Parents-Did either of your parents have a problem with alcohol (beer, wine, liquor) or drugs?
Partner-Does your partner have a problem with alcohol or drugs?
Past- Have you ever drunk alcohol?
*Pregnancy
In the month before you knew you were pregnant, how many cigarettes did you smoke?
In the month before you knew you were pregnant, how much beer/wine/liqu or did you drink?
In the month before…mariju ana, medication, etc.
Screening:
Interview/screening should be conducted in a careful, empathetic and nonjudgmental interview.
Screening should be conducted in a clinically appropriate, private, and therapeutic manner
Formal SBIRT protocol may be used
Instrument (examples)
4P’s Plus (or integrated 5Ps), SURP-P (Substance Use Risk Profile-Pregnancy), T-ACE (Tolerance, Annoyed, Cut-Down, Eye Opener), TWEAK (Tolerance, Worried, Eye Opened, Amnesia, K © ut Down
Other Considerations:
Prescription Drug Monitoring Program (PDMP) should be reviewed
Medical, Social and Legal Consequences should be considered
WHO recommends that all pregnant women be screened for substance use as early as possible in pregnancy and at every follow up visit
A pregnant woman should give informed consent for urine, blood and saliva screening for substance use
Pregnant women should be given accurate information regarding the risks of discontinuing of opioids during pregnancy (Tx developed an informed consent document)
Screen for high risk infections
Maternal History and Prenatal Screening
SBIRT
Screening, Brief Intervention & Referral to Treatment
The 4 P’s Plus-Dr. Chasnoff
Parents
Partner
Past
Pregnancy
*ntiupstream

32. Number of Assessment Items Training Materials Available
Diagnosing NAS
Urine, blood, meconium
Assessment
Using a standardized assessment instrument
Several published instruments are available
Management of NAS begins with making an accurate diagnosis. The first step in doing this is the careful screening of all pregnant women for SUDs.
Following birth of the infant, diagnosing NAS may be aided through the use of blood and or urine sample screening from the mother and infant. But, this is only true if the substance exposure is recent. If the exposure is not recent, these tests may not be sensitive enough to detect substances.26
In this case, screening of the infant’s first meconium stools is more sensitive since meconium accumulates substances during the last five months of pregnancy.27
Assessment of the infant for signs and symptoms and severity of withdrawal is also essential in providing care for infants with NAS.
The American Academy of Pediatrics Committee on Drugs guidelines recommends that a reliable assessment tool be used to monitor for symptoms of withdrawal, a maternal history and urine drug screening be completed, as well as screening of the infant’s urine and meconium.17
A variety of NAS assessment instruments are available for use by practitioners. These include the Lipsitz Neonatal Drug-Withdrawal Scoring System, the Finnegan Neonatal Abstinence Scoring Tool (FNAST), the Neonatal Withdrawal Inventory, and the Neonatal Network Neurobehavioral Scale Part II: Stress Abstinence Scale.28
The FNAST is likely the most widely used instrument and has good measures of reliability (α=.82).29 Assessment of NAS symptoms using the FNAST should occur every 3-4 hours with treatment of symptoms generally recommended for infants with a score of 8 or greater during 3 consecutive assessment periods or 2 consecutive scores of 12 or higher.28 Inter-observer reliability is essential for practitioners who use the FNAST; therefore, the instrument’s author recommends thorough and regular training of staff.
Instrument
Year Published
Number of Assessment Items
Training Materials Available
Finnegan Neonatal Abstinence Scoring Tool (FNAST)
1975 21
Video/DVD Manual
The Lipsitz Neonatal Drug-Withdrawal Scoring System 11 No
Neonatal Drug Withdrawal Scoring System
Neonatal Narcotic Withdrawal Index
1981 7
Neonatal Withdrawal Inventory
1998
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

33. Diagnosing NAS Finnegan Neonatal Abstinence Scoring Tool (F-NAST)
A variety of NAS assessment instruments are available for use by practitioners. These include the Lipsitz Neonatal Drug-Withdrawal Scoring System, the Finnegan Neonatal Abstinence Scoring Tool (FNAST), the Neonatal Withdrawal Inventory, and the Neonatal Network Neurobehavioral Scale Part II: Stress Abstinence Scale.28
The FNAST is likely the most widely used instrument and has good measures of reliability (α=.82).29 Assessment of NAS symptoms using the FNAST should occur every 3-4 hours with treatment of symptoms generally recommended for infants with a score of 8 or greater during 3 consecutive assessment periods or 2 consecutive scores of 12 or higher.28 Inter-observer reliability is essential for practitioners who use the FNAST; therefore, the instrument’s author recommends thorough and regular training of staff.
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

34. ESC NAS Care Tool Eating Sleeping Consoling
The most commonly used NAS assessment tool in the U.S., often modified by individual institutions, is called the Neonatal Abstinence Syndrome Score (NASS).5-6 This tool, more commonly referred to as the Finnegan Scale, was developed in It contains a catalog of the most common neonatal opioid withdrawal symptoms with points assigned for each item based on its perceived severity. The Finnegan scale, or various modified versions of it, had an established inter-rater reliability coefficient of 0.82 when it was initially developed.5 Typically, Finnegan scores consecutively >8 are used to initiate and titrate medication treatment. However, the rationale for using a score of 8 for medication initiation and titration has never been scientifically established or validated.
Recent studies have questioned the validity of the Finnegan score and have demonstrated that it has poor psychometric properties.7 Newer research suggests that medication should not be titrated based on Finnegan scoring, but rather should be based on function-based assessments focused on how well the infant is eating, sleeping, and consoling.8-10 Data suggests that using a function-based assessment tool could result in reduced medication treatment rates and improved outcomes.9-10 While we believe the infant should still continue to be assessed for significant signs and symptoms of opioid withdrawal, the ESC method’s sole principle is that the treatment of the infant (both non-pharm and pharmacologic treatment) should be based on infant function and comfort, rather than reducing signs and symptoms of withdrawal. The ESC Care Tool only documents items key to the functioning of the infant – specifically, the infant’s ability to eat effectively, sleep, and be consoled within a reasonable amount of time. This method of assessing infants with NAS was developed by a collaborative effort between faculty at Yale, Children’s Hospital at Dartmouth-Hitchcock, and Boston Medical Center.
Staff should educate parents in use of the ESC Care Tool and its assessment items and their definitions. Staff should also educate parents in use of the Newborn Care Diary and to request infant assessments when infant finishes feeding. Staff should perform ESC care assessments every 3-4 hours at the time of other routine infant care, such as after feedings and with vital signs. Assessments should be initiated within 4-6 hours of birth, and should continue for 4-7 days for infants exposed to long-acting opioids3 (e.g., buprenorphine, methadone), and for a minimum of 48 hours for shorter acting opioids (e.g., oxycodone, codeine). Assessments should include all ESC behaviors that occurred since the infant’s last assessment as well as all non-pharm care interventions implemented including those used to and time required to console the infant. For pharmacologically treated infants, ESC assessments should continue for hours after stopping opioid replacement medications. Assessments should reflect the entire 3-4 hour interval since the last ESC assessment, and should incorporate input from all infant caregivers (e.g., mother/other parent, nurse, cuddler) who interacted with the infant during this time period. Infants should be assessed in their own room and do not need to be removed from their mother (or other caregiver) if being held. We recommend that parents use the Newborn Care Diary to keep track of their infant’s ESC behaviors and for staff to incorporate these observations into the ESC assessment. ESC assessments and care recommendations should be documented on the ESC flowsheet in the paper or electronic medical record, and shared with the parents.
Eating
Sleeping
Consoling

35. ESC NAS Care Tool Eating
Adequate eating depends on the gestational and postnatal age of the infant. “Eating well” is generally defined as breastfeeding 8-12 times per day with effective latch and milk transfer, or bottle feeding an expected volume for age when showing hunger cues.
Poor eating due to NAS: Baby is unable to coordinate feeding within 10 minutes of showing hunger AND/OR is unable to sustain feeding for 10 minutes at breast or with 10 mL of finger- or bottle-feeding due to NAS symptoms (e.g., fussiness, tremors, uncoordinated or excessive suck).
Special Note: Do not indicate “Yes” for poor eating if it is clearly due to non-NAS related factors (e.g., prematurity, transitional sleepiness or spittiness in the first 24 hours of life, or inability to latch due to infant / maternal anatomical factors). If it is not clear if the poor eating is due to NAS, indicate “Yes” on the flowsheet and continue to monitor the infant closely while optimizing all non-pharm care interventions.
OPTIMAL FEEDING:
Baby feeding when showing early feeding cues and until content without any limit placed on duration or volume of feeding.
Breastfeeding: Baby latching deeply with comfortable latch for mother, and sustained active suckling for baby with only brief pauses noted. Assist directly with breastfeeding to achieve more optimal latch/position and request lactation consultation if any concerns present.
Bottle feeding: Baby effectively coordinating suck and swallow without gagging or excessive spitting up; modify position of bottle or flow of nipple if any concerns present. Consult feeding specialist if feeding difficulties continue.
Eating
Does the infant have poor eating due to NAS? Yes / No
Sleeping
Consoling

36. ESC NAS Care Tool Eating Sleeping
Normal sleep patterns for gestational and postnatal age should be taken into account. Sleep < 1 hour may be normal in the first few days after birth, particularly in breastfed infants who are cluster feeding (i.e., feeding frequently in a short period of time especially during the night-time).
Sleep < 1 hour due to NAS: Baby unable to sleep for at least one hour after feeding due to NAS symptoms (e.g., fussiness, restlessness, increased startle, tremors).
Special Note: Do not indicate “Yes” if sleep < 1 hour is clearly due to non-NAS related factors (e.g., physiologic cluster feeding in first few days of life, interruptions in sleep for routine newborn testing, symptoms in first day likely due to nicotine or SSRI withdrawal). If it is not clear if sleep < 1 hour is due to NAS, indicate “Yes” on the flowsheet and continue to monitor the infant closely while optimizing all non-pharm interventions.
Eating
Sleeping
Did the infant sleep less than 1 hour after feeding due to NAS? Yes / No
Consoling

37. ESC NAS Care Tool Eating Sleeping Consoling
Unable to console within 10 minutes due to NAS: Baby unable to be consoled within 10 minutes by infant caregiver effectively providing recommended Consoling Support Interventions.
Special Note: Do not indicate “Yes” if infant’s inconsolability is due to infant hunger, difficulty feeding or other non-NAS source of discomfort (e.g., circumcision pain) or non-opioid withdrawal. If it is not clear if the inability to console within 10 minutes is due to NAS, please indicate “Yes” and continue to monitor the infant closely while optimizing all non-pharm interventions.
Providers should perform these consoling support interventions in the following order to assess the level of support required for the infant to console. Parents and other caregivers are not expected to follow a specific order when consoling their infant, however they can be instructed on how to implement the CSIs to help calm their infant. This approach was adapted from the Newborn Behavioral Observations (NBO), Nugent et al.11
Caregiver/provider begins by softly and slowly talking to the infant, using his/her voice to calm the baby. 
Caregiver/provider looks for hand to mouth movements and facilitates as needed by gently bringing the baby's uncovered hand to his/her mouth.  Watch for signs of consoling (eye opening, stilling, calming, slowed breathing).
Caregiver/provider continues talking to infant while placing hand firmly but gently on baby's abdomen.
Caregiver/provider continues softly talking to baby while bringing baby’s arms and legs to the center of body.
Caregiver/provider picks up infant, holds skin-to-skin or swaddled in blanket, and gently rocks or sways infant.
Caregiver/provider offers a finger or pacifier for infant to suck, or a feeding if infant showing hunger cues.
SOOTHING SUPPORT USED TO CONSOLE INFANT
Providers are asked to rate the consolabilty of the infant on a scale of 1 to 3.
Soothes with little support: Consistently self-soothes or is easily soothed with one of first 4 CSIs above.
Soothes with some support: Does not soothe with one of first 4 CSIs but soothes fairly easily with additional CSIs (e.g., skin-to-skin contact, swaddling, feeding, sucking on a finger or pacifier).
Soothes with much support or does not soothe in 10 minutes: Has difficulty responding to all caregiver efforts to help infant stop crying OR does not soothe within 10 minutes .
 Removed “; never self-soothes”
A Team Huddle is recommended if the infant has a “Yes” response to any ESC item OR if the infant consistently receives “3s” for “Soothing Support Used to Console Infant”. Just one “Yes” is sufficient to consider a Team Huddle. At minimum, the Team Huddle should include the nurse and mother/other caregiver and includes a discussion of 1) ways to further optimize non-pharm care including ensuring the presence of a caregiver, 2) infant’s response to and efficacy of Consoling Support Interventions implemented, 3) efforts to improve feeding (when needed), and 4) assessment of the infant’s environment. All efforts should be made to encourage the parent or other caregiver to be present at all times to provide comfort measures for the infant. If the infant scores “Yes” on any ESC item more than once despite maximal non-pharm care OR other significant concerns are present, a full Team Huddle should be called including the mother/other caregiver, bedside nurse, AND physician or associate provider. A social worker should be included as needed to facilitate parental presence / engagement. If non-pharm care is maximized to its fullest and the infant continues to have poor eating, sleeping, or consoling due to NAS, then medication treatment should be considered.
Eating
Sleeping
Consoling
Is the infant unable to be consoled within 10 minutes due to NAS? Yes / No

38. Parental Role Diary Presence Parental / Caregiver Presence
We recommend documentation on the ESC flowsheet of the presence of a parent (biological or foster) or other caregiver (e.g., family support person) at the bedside when assessments are performed every 3-4 hours.12 Parental presence documentation should reflect time since the last ESC assessment. The ESC Care Tool includes a code from 0-4 with increasing code number indicating greater parental / caregiver presence. If the infant is having difficulties eating, sleeping, or consoling and parental/caregiver presence is less than the time since last assessment, the RN/provider should encourage ways to optimize presence further.
Non-pharmacologic Care
First-line treatment for infants with NAS is non-pharm care which significantly reduces an infant’s likelihood of needing pharmacologic treatment and reduces pharmacologic treatment duration when initiated.6,9-10,12-13 We encourage a consistent institutional approach to non-pharm care focusing on the parent as the primary caregiver. Staff should review recommended non-pharm care interventions with families prenatally, upon birth admission, and at time of newborn assessments. Staff should regularly educate parents in these interventions including when and how to increase their use, and reinforce interventions when they are implemented effectively. The infant’s care team should ensure that non-pharm interventions are maximized to their fullest prior to considering pharmacologic treatment when an infant is having difficulties eating, sleeping, or consoling due to NAS. Staff should also instruct parents in the CSIs noted above as additional ways they can console their infant.
Non-pharm Care Recommendations:
Rooming-in together throughout the hospital stay with additional help available
Parental presence at the bedside as often as possible during the hospital stay
Skin-to-skin contact
Holding / gentle rocking / swaying by a caregiver or cuddler
Swaddling / flexed positioning
Optimal feeding including breastfeeding for mothers without concerns for continued concerning substance use or other medical contraindication (e.g., HIV)
Quiet environment with low light stimulation in the room
Non-nutritive sucking with pacifier or finger (ensuring baby is well fed first)
Limiting visitors to one at a time (and to those that will be quiet and supportive)
Clustering infant’s care with uninterrupted periods of sleep
Ensuring that parent holding baby is fully awake; if sleepy, to allow other caregiver / cuddle to hold baby or place baby on back in bassinette for safe sleep and fall prevention
Inter-rater Reliability
We recommend that sites perform regular inter-rater reliability checks (checking the reliability of ESC responses between two providers) when using the ESC Care Tool. We recommend using the Eating, Sleeping, Consoling (with Soothing Support Used to Console Infant), and Team Huddle items for inter-rater reliability checks (total of five items). This means that one provider will perform the ESC assessment while a second provider simultaneously performs an independent assessment while directly observing the patient encounter. Providers then determine percent agreement between ESC items, with a goal of a minimum of 80% in agreement.16 “Gold star” nurses should be identified at your institution who consistently demonstrate 100% inter-rater reliability and can serve as a second nurse to assess the reliability of other providers on the unit on a regular basis. The ESC IRR Tool in Appendix C can be used to perform inter-rater reliability checks.
Diary
Presence

39. Priority Populations
Individual are admitted to treatment in the following order:
Pregnant, Injecting Individuals;
Pregnant Individual;
Injecting Individual;
Individual referred by the Department of Family and Protective Services

40. Levels of Care Screening: OSAR Intervention: PPI
Youth Residential and Outpatient
Adult Residential Detoxification
Adult Intensive/Support Residential
Adult Outpatient
Medication Assisted Treatment

41. What we have done in Texas
The 84th Legislature appropriated $11.2 million in general revenue funds to Health and Human Services Commission (HHSC) to reduce the incidence and severity of neonatal abstinence syndrome (NAS) in Texas. Administered by Behavioral Health Services' Office of Program Services I, the funds created and expanded new and existing services aimed at reducing incidence, severity, and costs associated with NAS. This EI takes a multi-pronged approach to addressing NAS by:
increasing targeted outreach services to engage women earlier in care,
increasing the availability of intervention and treatment services to pregnant and postpartum women to improve birth outcomes, and
implementing specialized programs to reduce the severity of NAS.
Coordinated Opioid Substitution Therapy (OST)
This project expanded treatment slots designated for pregnant and post-partum women who have exhausted their pregnancy-related Medicaid coverage for a seamless transition to avoid any disruption in their opioid treatment. This new approach integrates Pregnant and Post-partum Intervention (PPI) program services into opioid treatment.  . There are 13 NAS-OTS providers in the state with four providers pending contract management approval. The 13 NAS-OTS providers have the funding to provide medication assisted treatment to 291 patients. During this fiscal year, 147 patients (51%) have been served. The NAS-OTS providers submit open enrollment applications but must be eligible for providing MAT services to Medicaid enrollees.
Statewide Pregnancy Stabilization Center
The Statewide Pregnancy Stabilization Center allows pregnant women to enter a single substance use disorder (SUD) treatment and recovery program that can address all their needs by providing them a full continuum of care for themselves and their children. This program serves families residing in areas of the state that may not be able to provide the care opioid dependent pregnant women require. The Center for Health Care Services in San Antonio is the site of the statewide pregnancy stabilization center, The Restoration Center, became operational in August 2016 allows pregnant women to enter a single substance use disorder (SUD) treatment and recovery program that can address all their needs by providing them a full continuum of care for themselves and their children.  This program serves families residing in areas of the state that may not be able to provide the care opioid dependent pregnant women require. This center served a monthly average of 14.5 women and served 57 unduplicated patients in 2017 fiscal year.
 Targeted Outreach to High Risk Women
The PPI providers conduct outreach to women with high risk behaviors that can lead to substance exposed pregnancies. The goal is to engage high risk women earlier in OB/GYN care, substance use disorder treatment, and to increase access to healthcare information such as pregnancy and HIV status. Harm Reduction Model. The PPI program have increased targeted outreach to over 1,000 high-risk women; provided over 1,000 at-risk and/or high-risk screening, provided high risk education in overdose prevention, tobacco cessation, and substance use and misuse and the effects on the family to more than 500 women.
Mommies Programs
The Mommies Program is an integrated and collaborative model of care that has shown to reduce expensive newborn hospital stays and supports family preservation. The model has been replicated in the most affected areas of the state and is supported by online training and intensive technical assistance. PPI programs were expanded to provide supportive services and care coordination as well as organize NAS response teams. The Mommies Program is an integrated model of care which collaborates and coordinates pregnant women who are using opioids care to better educate and inform them about their pregnancy and what to expect. Through an Exceptional Item in the 84th Legislative Session, HHSC, Behavioral Health Services was able to fund the replication of the Mommies Program in the five highest counties of NAS (Bexar, Dallas, Fort Worth, Houston, Nueces counties) to include targeted outreach and response teams to better address opioid use in the local community. In this fiscal year, the program has expanded to serve an additional five counties (Bell, Ector, El Paso, Hidalgo, Smith counties).
NAS Trainings
Trainings will be made available for community NAS response teams including contractors and other professionals working with pregnant and postpartum women with substance use disorders and their children. Another training opportunity that partnered University of Texas Health Science Center (not UT Health-San Antonio), University Health System, and The Center for Health Care Services funded by the Texas Department of State Health Services (now Health and Human Services) to develop and publish the Introduction to the Mommies Toolkit: Improving Outcomes for Families Impacted by Neonatal Abstinence Syndrome consisting of four modules hosted on the Centralized Training website which discusses Substance Use Disorders; reviewing national statistics and focusing specifically on substance use in women, specifically during pregnancy; describes NAS)and reviews the symptoms, incidence and costs of the syndrome; describes the Integrated Programs for treatment with a focus on both the components and benefits of treatment; and provides an overview of the Mommies Program. This module will present the Texas statistics on NAS, The Mommies Curriculum and the Outcomes of a 5-year study of the Mommies program in Texas. Introduction to the Mommies Toolkit: Improving Outcomes for Families Impacted by Neonatal Abstinence Syndrome
NAS Special Projects
Implementation, maintenance and expansion of efforts to increase provider awareness and proper diagnosis of NAS around the state. These funds may be used to provide support for research efforts to identify effective strategies related to the management of non-pharmacologic newborn care. HHSC, Behavioral Health Services has funded UT Science Center-San Antonio to study the non-pharmacological intervention of Kangaroo Care for infants diagnosed with NAS. This is the third year of funding and continued tracking of these mother-infant dyads up to six months.
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

42. Hospital Initiatives Assess all pregnant women for SUD
1. Assess all pregnant women for SUDs utilizing validate screening tools, incorporate SBIRT approach in the maternity care setting and ensure screening for all substances. Screen and evaluate all pregnant women with OUD for commonly occurring co-morbidities.
2. Provide staff-wide education on SUDs to clinical and non-clinical staff emphasizing SUDs are chronic medical conditions that can be treated and emphasize that bias, stigma and discrimination negatively impact pregnant women with OUD and their ability to receive high quality care. Provide training regarding trauma-informed care.
3. Establish specific prenatal, intrapartum and postpartum clinical pathways for women with OUD that incorporate care coordination among multiple providers
4. Develop pain management protocols that account for increasing pain sensitivity and avoidance of mixed agonist-antagonist opioid analgesics.
5. Know state reporting guidelines regarding the use of opioid pharmacotherapy and identification of illicit substance use during pregnancy by knowing CAPTA- Child Abuse Prevention & Treatment Act and understand plan of safe care requirement
6. Know state, legal and regulatory requirements for SUD care. Identify local SUD treatment facilitates that provide women-centered care. Ensure OUD treatment programs meet patient and family resource needs including wrap around services. Instigate partnerships with providers. Match treatment responses to each woman’s stage of recovery.
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

43. 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

44. 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

45. 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

46. 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

47. 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

48. NAS EI Funded-Services
Enrollment in the Mommies Program begins with the initial consumer intake assessment. If an assessment was already completed by an LCDC when the woman was enrolled in OATS, it is simply updated by the Mommies staff. At this time if the woman appears to have mental health concerns, an LPC completes a mental health assessment. Although there may be a waiting list for opioid dependent individuals hoping to begin Medication Assisted Treatment (MAT), it is a federal mandate that pregnant and parenting women have priority.
During the intake, women are given a referral to the Mommies Program. If they indicate that they are interested in the program, they may discuss this with the Benefits Coordinator (BC) or meet with the Patient Navigator (PN). Mommies are also told about the educational curriculum that is offered and on what days and times. Though a Mommy may have Child Protective Services (CPS) and probation mandates, all substance abuse and behavioral health services are voluntary. Also during the intake, Mommies sign a release of information document that allows members of the healthcare team to communicate about and coordinate their plan of care. At this time, a need for the various types of services already mentioned and their required frequencies are determined. Services are recommended, and, if accepted by the Mommy, she will receive assistance with making appointments and other arrangements.
A Medical Director with specialized training in SUDs oversees all SUD services at the CHCS.
The center is staffed by Licensed Professional Counselors (LPCs) and Licensed Chemical Dependency Counselors (LCDCs) with special training in the treatment of SUDs in women and during pregnancy. LPC’s focus on and provide services related to mental health issues, family and trauma while LCDC’s provide services related only to substance abuse and dependency.  Having this combination of credentials and training within one center is helpful in addressing the needs of consumers and their families in a cost-effective manner.
A benefits coordinator (BC) is on location five days a week through the OATS program and can assist women with enrollment in healthcare and other benefits, referrals for prenatal care, and scheduling appointments.
At one time, the Mommies Program was also staffed with an Outreach Specialist and a Case Manager; two positions that are considered essential to the success of the program. However, due to budget constraints, it became necessary to eliminate these positions and reallocate their responsibilities to other program staff.
The role of the Outreach Specialist was to provide home visits for Mommies who had “dropped-out” of treatment or had not been heard from for an extended period of time. This individual required extensive knowledge of the community and the population being served.
The role of the Case Manager was to provide intensive case management services that included orchestrating staffing and resources between multiple agencies to ensure that consumers received the services they needed. The Case Manager was also responsible for ensuring that key individuals were present during meetings about the Mommies as well as providing family and consumer education about Medication Assisted Treatment (MAT) and establishing “buy-in” from family members.
As participants in the Mommies program, women have access to a patient navigator (PN) who is provided through funding from University Health System. Some overlap exists between the role of the BC and the PN, but the PN’s primary role is to serve as an advocate for the Mommies as they interface with other services or referral agencies including the woman’s obstetrician and the hospital and Neonatal Intensive Care Unit (NICU) staff. The PN’s role is to
Communicate the Mommy’s history to University Health System obstetrical staff within the Labor & Delivery Unit prior to her arrival on the unit. This information includes number of previous pregnancies and deliveries, any illnesses that may have occurred during the pregnancy, dosage of methadone the Mommy is taking and any issues she may be experiencing.
Send out a brief overview of the Mommy’s progress within the program to all essential staff (social services, child health and safety staff, maternal/newborn nurses) who will be in contact with the Mommy during her stay at University Health System.
Act as the Mommy’s advocate and share information with other agencies following her consent.
Coordinate the educational sessions offered to the Mommies at CHCS.
The Mommies have access to the PN via her cellphone 24 hours a day 7 days a week.
Individualized treatment plan is developed which may include the following services:
Substance abuse counseling
Crisis intervention
Case management
Individual therapy
Family therapy
Group therapy
Urine Analyses conducted to monitor progress
Conducted weekly
Results discussed in therapeutic manner
HIV and STD
Monthly testing is available
Presentations on HIV and sexually transmitted infections are offered regularly
Evidence-based model
Focus is on trauma recovery
Gender-specific, closed sessions
Useful for women with history of abuse (physical and sexual)
Special training required for facilitator(s)
Seeking Safety: Evidence-based model
Appropriate for wide-range of participants
Focus is on seeking safety from trauma and/or substance addiction
Nurturing Parenting: Evidence-based model
Focus is on the prevention and treatment of child abuse and neglect
Recognized by the National Registry of Evidence-based Parenting Programs and Practices (SAMHSA)
Skills-focused and competency-based curriculum can be delivered in a home or group setting
Matrix Model: Evidence-based model
Focus is on helping participants’ cognitive-behavioral and clinical concepts
Optimal length of program is 16 weeks, but can be extended for 12 months to include aftercare
Life Skills Training: Focus is on the prevention of alcohol, tobacco, marijuana and violence
Addresses risk and protective factors and teaches skills that build resilience
Curriculum makes use of discussion, group activities and role playing
Patient navigator
Outreach specialist
Recovery coaches
Credential staff
Case manager
Benefits coordinator

49. Available Services in Hospital to Baby
Volunteers
Developmental Clinic
Social Services
Child Welfare Liaison
Home Health
Early Childhood Intervention

50. External Stakeholders
Local Mental Health Authority
Local/Regional Treatment Center
Child Welfare
Early Intervention Programs
Drug Court
State Agency
University

51. Community Initiatives
Provide education to promote understanding of SUDs and OUDs as medical, chronic disease. Emphasize SUDs are chronic medical conditions, treatment is available, family is necessary and recovery is possible. Emphasize opioid recommendations oftentimes includes medications.
Provide education about NAS and newborn care, awareness of signs and symptoms, and interventions to decrease NAS severity.
Engage appropriate partners to assist patients and families in the development of a plan of safe care for mom and baby
Identify ways to connect with non-medical local and community stakeholders with clinical providers and health systems to share outcomes and identify ways to improve systems of care/ engage child welfare services, public health agencies, court systems.
Develop continuing education and learning opportunities for external providers and staff regarding SUDs
Education about SUDs
Education about NAS
Establish a plan of safe care
Identify and partner with non- medical partners/stakeholders
Develop continuing education for community members

52. 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

53. Thank you Karen Palombo, LCSW, LCDC Texas Health and Human Services
Texas Women’s SUD Intervention Specialist