NH’s Plan of Safe and Supportive Care ( POSC) for Substance-exposed Infants

1. NH’s Plan of Safe and Supportive Care (POSC) for Substance-exposed Infants July 17, 2019 webinar

2. Agenda • NH Plan of Safe Care (POSC) Overview & Introduction to NH POSC Resources • Lucy C. Hodder JD, Director, Health Law and Policy; Professor of Law, UNH School of Law and Institute for Health Policy and Practice • Q&A period with: • Lucy C. Hodder JD • Joseph Ribsam Jr. JD, Director, NH Division for Children, Youth and Families • Patricia M TilleyMS Ed, Deputy Director, New Hampshire Division of Public Health Services, Department of Health and Human Services • NH hospital POSC Experience: • NH POSC Hospital Survey results • NH Birth Hospital POSC Implementation Processes • Dartmouth-Hitchcock: Bonny Whalen MD & Sandi Decato MSW • Wentworth Douglass: Lyndsey Wyma MSW • Brainstorming NH POSC Challenges & Strategies - Bonny • Additional POSC Resources/ Upcoming Events

3. https://jsi.webex.com/recordingservice/sites/jsi/recording/playback/47e0a90cbee1464d8b1bff2bcb378ed9https://jsi.webex.com/recordingservice/sites/jsi/recording/playback/47e0a90cbee1464d8b1bff2bcb378ed9 https://jsi.webex.com/recordingservice/sites/jsi/recording/playback/47e0a90cbee1464d8b1bff2bcb378ed9 What is A Plan of Safe Care?an introduction to best practices in new Hampshire Presented by: Lucy C. Hodder, JD Professor of Law and Director of Health Law and Policy UNH Franklin Pierce School of Law, IHPP July 17, 2019

4. Plans of Safe Care (POSC) NH Governor’s Commission on Alcohol and Other Drugs Perinatal Substance Exposure Task Force

5. Overview of POSC Process Is the infant affected by prenatal drug and/or alcohol exposure? Baby Born It is best practice to begin developing a POSC prenatally. No POSC is required by law No Yes It is best practice to develop POSC for all mothers and infants Notification of Birth* & POSC Developed POSC is sent to DCYF and sent home with mother upon discharge POSC is sent home with mother upon discharge. Is a mandatory report made? No Yes *Notification is captured through two situational surveillance questions on the birth certificate.

6. Framework to Support Mothers & Infants Clinical Teams • How can we engage mothers in a collaborative process to plan for healthy outcomes? • How can we work with existing supports and coordinate new services to help infants and families stay safe and connected? • How can Plans of Safe Care support mothers and infants during pregnancy, delivery, safe transition home and in parenting? State Community Mothers & Infants

7. What is a Plan of Safe Care? A Plan of Safe Care also referred to as “Plan of Supportive Care” for mothers and infants is developed by a health care provider collaboratively with the mother and coordinates existing supports and referrals to new services to help infants and families stay safe and connected when they leave the hospital.

8. When is the POSC developed with a mother? POSC must be developed when “an infant is born identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or fetal alcohol spectrum disorder.” See RSA 132:10-e. However, best practices support developing POSCs prenatally to serve as a living document throughout the pregnancy and after birth, especially when there is a risk of prenatal exposure to substance use.

9. Federal CAPTA/CARA Requirements

10. NH’s Plan of Safe Care Statutory Process SB 549: RSA 132:10-e and f

11. What is the purpose of a POSC? RSA 132:10-e and f The POSC must account for: Whether the infant’s prenatal exposure is due to prescribed medication Whether the mother is or will be actively engaged in treatment upon discharge Infant and Parent(s) • Safety and well-being of family • Address health and substance use treatment needs • Make appropriate referrals and deliver appropriate interdisciplinary health and social services

12. What is Notification? • New Hampshire has a federal data reporting requirement, which is referred to as “notification”. • The state reports annually to the federal Children’s Bureau the aggregate number of infants born affected by prenatal drug and/or alcohol exposure for whom a POSC was created and for whom services were referred. Notification ≠ Reporting

13. Notification Questions Exposure Was there documented opioid exposure at any time during the pregnancy? Aim: Determine the number of infants exposed to opioids in utero. Concern Was the infant monitored for signs of opioid withdrawal or neonatal abstinence syndrome (NAS)? Aim: Determine the number of infants considered to be at risk for withdrawal by the medical team. • Yes • No • Unknown

14. Best Practices: POSC Process *POSC must be developed when an infant is born with and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure or fetal alcohol spectrum disorder.

15. What is Reporting?

16. Considerations: Abuse and Neglect NH does not have a bright line rule

17. Does the POSC contain confidential information? YES! The POSC contains identifying information about the mother and infant that is private and is protected from disclosure by health privacy laws, and even substance use disorder record confidentiality laws if the developing provider is a SUD program (42 CFR Part 2)

18. Overview of POSC Process • For an additional 30 minute Overview of Plans of Safe Care in New Hampshire, go to: • https://jsi.webex.com/recordingservice/sites/jsi/recording/playback/47e0a90cbee1464d8b1bff2bcb378ed9 Is the infant affected by prenatal drug and/or alcohol exposure? Baby Born It is best practice to begin developing a POSC prenatally. No POSC is required by law No Yes It is best practice to develop POSC for all mothers and infants Notification of Birth* & POSC Developed POSC is sent to DCYF and sent home with mother upon discharge POSC is sent home with mother upon discharge. Is a mandatory report made? No Yes *Notification is captured through two situational surveillance questions on the birth certificate.

19. POSC Question and Answers Guidance Document: http://1viuw040k2mx3a7mwz1lwva5-wpengine.netdna-ssl.com/wp-content/uploads/2019/01/POSC_FAQ_v.6-1.pdf Additional Question and Answers: http://1viuw040k2mx3a7mwz1lwva5-wpengine.netdna-ssl.com/wp-content/uploads/2019/05/POSC_Questions_5.24.19.pdf Does the POSC contain information protected by 42 CFR Part 2 (Part 2)? What happens to the POSC when a report of child abuse and/or neglect is made? What if a mother declines to participate in developing a POSC? What is “Notification”? How is it different than a mandatory report?

20. Additional Resources POSC Website • Guidance Document • Q and A • Trainings • Pregnant & Parenting Services and Supports:List & Map • Questions about POSC, email: 2019POSC@gmail.com

21. Slides Developed and Modified by: Lucy C. Hodder, JD, Professor of Law, Director of Health Law and Policy, Institute for Health Policy and Practice at UNH School of Law David J. Laflamme, PhD, MPH, UNH Institute for Health Policy & Practice, NH DHHS Maternal & Child Health Epidemiologist  Kali Giovanditto, Community and Family Support Specialist, Division for Children, Youth and Families Rekha Sreedhara, MPH, JSI Research and Training, NH Center for Excellence Melissa Schoemmell, MPH, JSI Research and Training, NH Center for Excellence Developed in collaboration with the Perinatal Substance Exposure Task Force of the NH Governor’s Commission on Alcohol and Other Drugs with funding provided by the New Hampshire Charitable Foundation.

22. Q&A Time! • Lucy C. Hodder JD, Director, Health Law and Policy; Professor of Law, UNH School of Law and Institute for Health Policy and Practice • Joseph Ribsam Jr. JD, Director, NH Division for Children, Youth and Families • Patricia M TilleyMS Ed, Deputy Director, New Hampshire Division of Public Health Services, Department of Health and Human Services

23. What is the status of NH birth hospital POSC implementation?

24. NH Birth Hospital POSC SurveyMay 2019 12/17 NH birth hospitals responded: • 9 implementing POSCs • 3 in planning phase Hospitals willing to serve as a Peer Resource: Concord, Cheshire, DHMC, Frisbie, Speare, St. Joes, Wentworth Douglass

25. NH POSC Challenges General Challenges • Difficulties with how to start prenatally / operationalize (4) • Limited resources (3) • Bandwidth for all patients rather than just SUD (2) • POSC not accessible in the EMR due to transitioning to a new EMR Patient Challenges • Patient engagement/ownership (3) • No shows, drop ins, and unexpected use (2) • OB provider may never see mom again, or only for brief period of time • Many moms do not even have a PCP

26. NH POSC Challenges Provider Challenges • Workload and share-ability (2) • Inconsistency amongst staff members; who will be filling it out in a way that it is meaningful to the parents and the staff (2) • Difficult to cross train other social workers (2) • Lack of provider buy-in • Initiation of POSC tool with temporary staff and new staff • Pediatrician concern about revealing too much of mom's PHI

27. DHMC Plans of Safe Care POSC Workflow for Prenatal Providers, & Inpatient Social Workers and Infant Providers Sandy Decato MSW and Bonny Whalen MD – Birthing Pavilion/Newborn Nursery Notes from Daisy Goodman, DNP, MPH, CNM, CARN-AP – Purple Pod Prenatal Clinic

28. Prenatal Clinic POSC Workflow Community Health Worker (s) and OB Providers help complete POSC supports/services grid, where appropriate / needed, documenting needs present and any education provided, resources present, and any supports/services offered in pregnancy Maintained in a Care Coordination Note in mom’s Problem List

29. Prenatal POSC Process • All prenatal patients are screened for social determinants of health, depression, substance use (SUD), and intimate partner violence. • If positive for SUD, they are offered Purple Pod care (a dedicated prenatal clinic for women with SUD). Some women decline, but many accept. Those who decline are encouraged to to be seen in Purple Pod at least once per trimester for SUD-related education and services(including support of a Recovery Coach). • Discussion of the Plan of Safe Care is part of that education and we strive to do this for every Purple Pod patient (shared or not). • We have built two templates to help us standardize this process. These are depicted on the prior slide, the top one is a checklist for overall prenatal care for a woman with SUD which includes a reminder to introduce the Plan of Safe Care discussion early in pregnancy and then complete the POSC in the third trimester.

30. Prenatal POSC Process • The second is the portion of the NH POSC template most relevant to the prenatal setting, specifically targeting resource needs and services to ensure that when a woman has her baby she has as many things in place already as possible. • Both of these templates are designed as living documents, to be updated regularly; and also serve as handoff tools for the inpatient setting. • We also offer a copy of the POSC template to the pregnant woman, along with the CDC’s Safe Sleep brochure and the NNEPQIN ESC parent education pamphlet.

31. “POSC For Newborns Inpatient Social Work Procedure” In OCM shared drive for information about the process of developing POSCs with families

32. MSW e-DH Process: Use .poscpilot smart phrase to open POSC template & document within

33. POSC is placed in Multi-Disciplinary Discharge Instructions and auto-populates into the After Visit Summarywhich is printed and reviewed with mother/family.

34. BP/NBN Transitions to Home for ESC Babies At Time of Discharge, Infant Provider: • Requests 1-2 day appointments with VNA and 1-2 day and 2 week visits with PCP (and LC if available). • Places “.NBNNASDCINSTRUCT” smartphrase in Provider Instructions (includesESC/ NAS concerns to watch for, details of feeding plan if baby >=10% down from birthweight or if feeding difficulties present, and importance of no substance use in parenting/breastfeeding. • Signs VNA referral in the discharge order reconciliation. • Includes the“.POSCINSERT” smartlink in the newborn’s discharge summary (as found in “.NBNDCSUMM”) to pull in the: • POSC Multi Disciplinary Instructions • Discharge f/u appointments – newborn visit 1-2 d after d/c, paired w/ LC appt if available • VNA referral information – 1st visit 1-2 d after d/c (day opposite PCP newborn visit) • Provider discharge instructions

35. InfanT’s Discharge Summary

36. Overview of POSC Process Lindsey Wyma MSW; Inpatient Social Worker

37. Overview of POSC Process • POSC completed for all substance-exposed infants (including THC) – ideally initiated during prenatal Care Planning Session; otherwise started on birthing unit • Katie White, RNC-LRN; Perinatal NAS Care Coordinator • Allow parent(s)/caregiver to work on POSC on their own and then Inpatient SW assists in finishing/typing up • Original POSC given to parent(s)/caregiver & copy sent to pediatrician • Eventually will be placed into infant's medical chart • Copy given to DCYF as requested for mandated reports

38. Who are you developing a “Plan of Safe/Supportive Care” for? What are your Challenges?

39. Peer Brainstorming POSC challenges and strategies

40. General Challenges

41. General Challenges

42. General Challenges

43. General Challenges

44. Patient Challenges

45. Patient Challenges

46. Patient Challenges

47. Provider Challenges

48. Provider Challenges

49. Provider Challenges

50. NH POSC Resources https://nhcenterforexcellence.org/governors-commission/perinatal-substance-exposure-task-force/plans-of-safe-care-posc/