CAP Pediatric Clinic at The John Hopkins Bayview Medical Center
The Center for Addiction and Pregnancy (CAP) is located in Baltimore, Maryland and part of The Johns Hopkins Bayview Medical Center. CAP is an outpatient program that provides multidisciplinary clinical care for pregnant and parenting women with substance use disorder (SUD)—principally opioid use disorder (OUD). The program offers adult clinical care treatment for SUD, behavioral and mental health conditions, obstetric care, as well as pediatric care that is administered through the CAP Pediatric clinic. Because all care and services are offered at one location, CAP operates as a truly collaborative medical home. CAP has been serving this population in its current location for over 30 years.
The clinic prioritizes parental treatment for SUD / OUD and mental health and emotional wellbeing, as an overarching consideration to ensure the wellbeing of the infants. To improve pediatric health and infant development that are specific to the needs of the family, the clinic provides services that are often extending outside of the boundaries of traditional pediatric care.
A Pediatric Medical Home and Multidisciplinary Care
The CAP Pediatric Clinic has a multidisciplinary team that cares for mothers, infants and children exposed to substances prenatally. The team includes a registered nurse, a developmental pediatrician, and a parenting coordinator. Since the patient population is largely referred from the larger CAP program, most of the mothers/caregivers are already receiving medication treatment for OUD when are transitioned to CAP Pediatric.
After delivery, mothers receive timely information with the type of care she and the infant will receive, and so the transition to CAP Pediatric is seamless. The parenting coordinator communicates with the clinic staff about the mother’s clinical care and recovery needs so that they too, are informed and prepared to assist her, as necessary. The clinical team has individual approaches for each family, so each dyad receives care specific to their needs and strengths.
In addition to caring for infants referred through the larger CAP program, the Pediatric clinic provides care to infants placed in foster and kindship care or referred by other providers and hospitals. The clinic strives to provide the same non-judgmental and empathetic care to all patients, regardless of referral avenue. The services provided at CAP start with prenatal care and continue throughout the child’s life up until the age of 21.
A Therapeutic Alliance Built on Trust
Many women with OUD and other SUDs have experienced a culture of discrimination, stigma, and shaming from clinicians and health care providers. As an established part of the community, patients are aware of the compassionate environment and non-judgmental care offered at CAP. This reputation is a source of pride to all CAP team members and contributes to positive health outcomes for the families they serve.
The parenting coordinator builds a therapeutic alliance with the mothers early on, during pregnancy. From the initial encounters, all the clinical staff works to establish a trusting relationship and carry open conversations about opioids and other substances use, recovery journey, relapse, mental health, or violence. The result of these discussions is crafted into a plan for recovery and treatment that addresses and acknowledges all aspects disclosed. The clinical staff reinforces that the mother and infant’s health, well-being, and safety are always their priorities.
The coordinator uses trauma-informed approaches to connect with and establish trust and transparency with the pregnant patients while they prepare for the birth of their child. It is essential to understand the mother’s health history and current environment, as well as her treatment and recovery status, to assess their capacity to successfully parent their child(ren).
The CAP Pediatric clinic strives to build a safe, accessible space—free from stigmatizing language or labels—where mothers and birth parents can speak openly about health concerns for their infants. Mothers seen at the clinic know they can discuss their own needs and can request support with parenting, without the fear of punitive consequences.
Individualized Anticipatory Guidance
Typical pediatric anticipatory guidance does not often fit the needs of pregnant and parenting mothers with OUD and other SUDs and infants affected by neonatal opioid withdrawal syndrome (NOWS). For example, breastfeeding recommendations are individualized based on the needs, recovery, and treatment progress of each family. The clinic steers away from providing written educational materials to mothers, as the NOWS symptoms can be so varied. Rather, the parenting coordinator connects with mothers during pregnancy and prepares them on what to expect related to caring for an infants with NOWS. The goal is to inform families about NOWS symptoms management and reassure parents the CAP clinic is available to help with comforting the newborn.
CAP Pediatrics developed a video titled Beyond Addiction to prepare and support families on what to expect related to NOWS symptoms and non-pharmacological care. The clinic does not specifically use the eat, sleep, console (ESC) method with their families, and rather helps caregivers understand the NOWS symptoms and how they are affecting their infant, and what are some individual non-pharmacologic care approaches to mitigate these symptoms. The non-pharmacologic interventions are integral to the CAP Pediatrics medical home model.
Similar to clinical and medical care, CAP Pediatrics offers anticipatory guidance and preventive measures based on the unique needs of each mother-infant dyad, as well as based on the and the psychological capacity of the mother. The clinic noticed that adherence to the recommended visit schedule is challenging as these dyads require more frequent clinical observation and intervention than typical families. Recently, the clinic started conversations about families in recovery having naloxone (Narcan) available at home in a lock box as a preventive measure in case of opioid overdose. This was suggested after several patients seen at the clinic were lost to fentanyl overdose in the past year.
Care Accessibility
During the COVID-19 pandemic and social distancing recommendations, CAP Pediatrics found it challenging to see patients for regular appointments. However, the clinic was able to pivot to virtual visits quickly and continue to provide care to their patients. Much to the clinicians’ surprise, the virtual/telehealth visits worked very well for their patient population. Practitioners were able to see mothers and children in their natural environment, which offered a more realistic picture of child development, parenting styles, and their needs. Virtual visits offered the opportunity to quickly connect with patients and families on a needs basis and eliminated other common complications, such as finding transportation, or child care for other children. While in-person visits have resumed, the CAP Pediatrics would like to keep virtual visits as an option for emergent situations or for patients who have difficulty keeping in-person appointments. Important to note, although virtual visits helped maintaining connections with some families, many patients who needed urgent or intensive therapy services could not benefit from telehealth. Many patients and families that needed physical therapy or other developmental therapies, have been greatly affected as those in-person services were unavailable to them during critical points in their development.
Care Coordination and Community Partners
As an established presence in the community, as well as due to the tenure of its clinicians, CAP Pediatrics make for a strong network of external resources and sources of care. However, as previously noted, the pediatric patients seen at the clinic have specific care needs, outside the typical pediatric treatment paths. The clinic assesses each mother-child dyad individually to determine which services are needed. Early Intervention is not routinely suggested for an infant with NOWS based solely on this diagnosis. If physical and/or occupational therapies are needed, the clinic staff provide those services. CAP Pediatrics does not recommend home visiting care for their patients as they have found that these services sometimes confound the mother’s ability to remain engaged in CAP comprehensive care. Community resources that the clinic regularly partners with include, Early Head Start, child welfare services, domestic violence centers, and other adult SUD treatment programs.
Sustainability
Services provided through CAP Pediatrics are billed as part of the routine pediatric patient care. However, since CAP Pediatrics prioritizes comprehensive care and services to the mother-infant dyad, and not just the pediatric patient, they are unable to receive payment for care provided to the mother. Ideally, they would support developing a dyad model of care, where pediatric and non-pediatric clinicians can collaborate and work in tandem to coordinate care for both mother and child.
Evaluation
CAP Pediatrics has an open communication policy with their patients which allows for informal opportunities for improvement. The clinic does not currently evaluate their work in a formal way but welcomes an opportunity to explore aspects such as, maternal engagement and satisfaction in treatment, need for engagement in violence prevention services and how a mother’s engagement in SUD treatment affects the child’s development over time.
Advice for Other Practices
CAP Pediatrics recognizes that their model of care is unique. Providing comprehensive care for mothers in recovery and infants with NOWS is critically important. They encourage any other practices interested in taking on the responsibility to care for this population, to fully commit to non-stigmatizing methods, to strive for trusting relationships with the families, to think outside the boundaries of traditional pediatric care models, and to consider providing comprehensive care to the dyad.
The clinical team at CAP Pediatrics encourages other practices to share their knowledge and expertise about the needs of this population with their colleagues. For example, recent increase in fentanyl overdoses in the community have prompted CAP Pediatric clinicians to develop information for other physicians and social service agencies that are working with patients that experienced overdoses.
Ideally, other clinicians working this population can connect and discuss models of care where the needs of the mother-infant dyad, and payment for services provided can be addressed more effectively. Further, CAP Pediatrics would like to share with colleagues how their developmental theory-based non-pharmacologic model of care for infants exposed to opioids has been effective for their patients—both in the short- and long-term. The clinical team at CAP is also open to discussion with colleagues about how to approach documenting domestic violence and concerns about maternal relapse in the pediatric records.