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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Texas Journeys of Hope Video

Texas NAS Website

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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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Texas Maternal Mortality Task Force

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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: 512-838-4381karen.palombo@hhsc.state.tx.us

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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