Baby Steps at East Tennessee State University Health Pediatrics
The vision for the Baby Steps Antenatal Drug Exposure Program to provide and coordinate care and services for families with infants and children exposed to opioids and other substances before birth emerged several years ago. Physicians and other clinicians at East Tennessee State University (ETSU) Health Pediatrics recognized the need for improved treatment for infants and continuous support and access to care for parents and caregivers. Over the past decade, the state of Tennessee (TN) has seen a dramatic increase in the number of newborns diagnosed with neonatal opioid withdrawal syndrome (NOWS) or neonatal abstinence syndrome (NAS), concomitant with the increased use of prescription opioid medications. Buprenorphine is the most common opiate used prenatally, and most common cause of NOWS/NAS in TN. Exposure or co-exposure to other substances, particularly methamphetamine and cannabinoids is common in the North-East TN. Potential strategies to prevent NOWS/NAS include increasing awareness of appropriate use of opioid prescription medications, improving access and utilization of services and treatments for opioid use disorder (OUD) and other substance use disorders (SUD), and increasing awareness and access to preventing unintended pregnancies and long-acting contraceptives.
Pediatricians, obstetricians, family physicians, childhood educators, and other health professionals who provide services to children, adolescents and pregnant women have a unique opportunity to intervene and prevent multigenerational risk of OUD and other SUDs, and implicitly incidence of NAS/NOWS. In the first 5 years of a child’s life, pediatricians typically interact with families over a dozen times during the health supervision visits; therefore, pediatric primary child health providers have frequent opportunities to engage parents and caregivers in discussion about parental substance and opioid use.
A Multidisciplinary Dyadic Approach to Care
Located in Johnson City, TN, the Baby Steps Clinic provides care and coordinates services for infants, children, and their families through the ETSU Health Pediatrics. The pediatric care team at the Baby Steps includes a pediatrician, an audiologist, a speech language pathologist, a physical therapist, an occupational therapist, a registered dietician, a care coordinator, and a nurse who also serves as a clinic administrator and lactation counselor. A multidisciplinary team provides care to pregnant patients with OUD at the ETSU Health OB-GYN clinic. The clinical team includes obstetricians who prescribe medication treatment for OUD based on the mother’s treatment goals, a perinatal care coordinator, as well as a behavioral health/psychology consultant and a lactation consultant, both recently added to the team. To bridge the care and services provided to the mother-infant dyad before and after delivery, the OB-GYN clinic and pediatric clinic share the same perinatal care coordinator. Pediatric residents and trainees from the other disciplines rotate through the clinic as part of their team-based care training.
The ETSU Health Pediatrics also has an integrated behavioral health care and resource team (BHART) that includes a licensed clinical psychologist, a social worker, and interns, who are also available for warm hand-offs during primary care and Baby Steps Clinic visits or see consults as needed. This model of integrated care offered through the ETSU Institute for Behavioral Health, is being expanded throughout all the ETSU Health clinics.
Building a Therapeutic Alliance
The perinatal care coordinator starts building a therapeutic alliance with mothers early on, during the OB clinic visits, or during the week of delivery. The care coordinator knows that mothers who use substances during pregnancy need continuous support and connections to access recovery services after delivery. The care coordinator aims to develop a trusting relationship with the mothers. After delivery she explains the benefits of the continuum of care and health services provided through ETSU and ensures mothers understand they have the option to stay with ETSU for their own care and their newborn’s, or they can pick a different practice. She ensures mothers have consistent access to a resource team, with which they can work with before and after delivery. Even if new mothers decide not to stay with ETSU, the care coordinator connects them with substance use recovery resources as needed. The program administrators have observed an increase in family engagement since the care coordinator joined the team.
The care team acknowledges the stress experienced by new mothers and imparts the idea that addiction and OUD is a chronic condition, not a choice. The entire clinical care team regards mothers as essential partners in their infants’ care and focuses on the dyads’ strengths. Mothers receive educational and anticipatory guidance handouts to take home including personalized recommendations detailing their strengths.
The care team members continuously seek to prove their truthfulness and loyalty when working with mothers in recovery. For example, they are consistent in following through with anything a mother needs. This is important in building the therapeutic alliance due to past experiences women may have had with other physicians and people in general.
Care Coordination for Infants and Mothers
The staff at the local birthing center, part of Niswonger Children’s Hospital and the Ballad Health System, are very knowledgeable about the care needs of this patient population. To confirm the dyad needs access and coordination for health services related to prenatal substance exposure, a maternal urine toxicology test, as well as a confirmatory newborn umbilical cord blood test, are performed at the hospital. ETSU pediatricians can access family health histories, including the hospital case manager notes, through the hospital electronic health system. Primary care pediatricians at ETSU encourage families to meet the Baby Steps perinatal care coordinator if they have not already done so. The therapeutic relationship and trust built between the primary care pediatricians and families has been a critical factor contributing to successful engagement with the Baby Steps program.
After delivery, and up until the child turns five, families can choose to be followed every three to six months in the Baby Steps Clinic, in addition to their primary care. In the Baby Steps Clinic, enhanced surveillance of child’s nutrition, developmental, behavioral, and social needs and assistance, above and beyond what is routinely provided through primary care, is available.
The clinical team recognizes that social support is key to a mother’s recovery and that the immediate post-delivery period is particularly challenging for women with OUD. Mothers are screened for adverse childhood experiences (ACEs) in the clinic and the team has access to screening results for postpartum depression and current unmet social needs (such as substance use treatment among other individuals in the household, domestic violence, current financial challenges, and food and housing insecurity), as well as other previous assessments and referrals from prior primary care visits. Additional screening for developmental, behavioral, and nutritional issues, adverse childhood experiences (ACEs), and resource needs is performed during the visit. At the end of each Baby Steps Clinic visit, families are provided with a Family Note that summarizes the assessment and recommendations of the team in lists of Things That Are Going Well, Tips to Try at Home, and Next Steps. Contact information for the care team members and tailored community resources are also provided. A follow-up phone call from the perinatal care coordinator one month after each Baby Steps Clinic visit helps to assess the families’ questions, concerns, follow up on recommendations, and feedback on the clinic visit.
Community Resources
Counselors from a community-based, licensed substance abuse and mental health treatment provider, Families Free, are available to ETSU OB and Pediatrics Clinic patients in the clinic building two half days a week. Every Monday and Tuesday, families, including fathers, caregivers, and other family members, can participate in a “pop-up party” in the ETSU Health Pediatric Clinic. These parties are hosted by Families Free, and provide families with an opportunity to learn about parenting classes, social services, and treatment for drug use disorder. Parties are held in a decorated room in the clinic where families are offered snacks, drinks, personal care items and developmental toys, and free family photos. An ETSU Early Interventionist working with the Tennessee Early Intervention System (TEIS) is present as a warm handoff to educate families about Early Intervention services. These pop-up parties build a community around families and enhance trust and collaborations among families, external partners, and the clinical care team. ETSU has had a 75% success rate in connecting families to external services that they need through this model.
Although families can receive most behavioral health, recovery, and other professional services needed through ETSU and the Baby Steps Clinic, sometimes referrals do have to be made. Mothers with severe mental health conditions are referred to behavioral health services available in the community. Relationships with other community service providers, such as Strongwell/180 Health Partners, for assistance with transportation, coaching, and resources, and drug use treatment providers, like the Addiction Medicine Fellowship Program in ETSU Family Medicine, benefit patients as well.
Care Accessibility
During the 2020 COVID-19 pandemic, video-based health services were offered, and many families liked and took advantage of this option. After the pandemic, some components of appointments and guidance will continue to be offered through telehealth. The partnerships with Families Free and Strongwell/180 Health Partners provide families with additional resources if needed, including a phone, virtual counseling, transportation, and 24/7 access to a psychologist and nurse. Should a family miss any type of appointment, the care coordinator follows up with them and helps arrange transportation to the hospital or clinic as needed. Integration of a team from the Northeast Tennessee Regional Heath Office with the Baby Steps clinic was planned but is postponed until health department responsibilities for COVID-19 testing, contact tracing, and vaccination decrease.
Resources and Training for the Care Team
The clinical care team has regular opportunities to participate in training through the university. Training in ACEs and trauma-informed approaches are essential for helping team members understand circumstances that may have contributed to mothers developing opioid dependence and OUD. Ongoing training in team-based care, the science of addiction, health assessment screening tools, and behavioral health and community resources are provided. The nursing/administrative team also receive training on use of state databases and Title 10, including appropriate language to use with patients. All staff are consistently reminded that building trust with families takes time and that caring for families is a marathon – change does not happen overnight.
Funding and Evaluation
The clinic is funded through a fee-for-service model, but the administrative team is exploring other ideas for financial sustainability. Pediatrics currently has a CATCH Implementation Grant from the American Academic of Pediatrics to support resources for families in the Baby Steps Program as well as a program evaluation, but this funding does not pay for direct services. Substantial services and staff time, such as those offered through Families Free and Early Intervention, are in-kind services. The state’s Medicaid Upper Payment Limit (UPL) program also supports partial clinical staff funding. Conversations with state Medicaid directors are ongoing about future value-based reimbursement. Given that the fee for service model may not sustain the intensive level of services provided through the Baby Steps Program, the team is exploring value-based reimbursement and other avenues of support to ensure long-term sustainability.
To demonstrate success of the program and model to payers and funders, the clinic is continuously gathering and evaluating available data. Interns from the ETSU College of Public Health are helping to use available data to evaluate the program and analyze its return on investment. The program works with the corporate side of the healthcare organization to collect and analyze data with approval of the ETSU Institutional Review Board (IRB).
Advice for Other Practices
Other practices and hospitals that want to set up a similar model for working with mother-infant dyads affected by opioid use should be creative in thinking about finding and engaging community partners interested in working with this patient population. Additionally, it is important for practices to understand and be familiar with existent resources available in the community. Finally, practices can keep in mind that developing a “one stop shop” that includes as many services as possible under one roof is extremely beneficial, as this model has the potential to increase family engagement and the quality and diversity of care.