HOPE Clinic at Massachusetts General Hospital
The HOPE Clinic (Harnessing support for Opioid and substance use disorder in Pregnancy and Early childhood) at Massachusetts General Hospital cares for mothers with opioid use disorder and infants affected by neonatal opioid withdrawal syndrome (NOWS) or neonatal abstinence syndrome (NAS), up to two years old. The HOPE clinic opened in April 2018 in response to a growing need to address the perinatal care of mothers with co-occurring mental health and opioid use disorder (OUD) and other substance use disorders (SUDs). Services and programs for infants and parents are co-located and address the entire perinatal care continuum using a multidisciplinary approach.
Building a Therapeutic Alliance
Pregnant women can access the services provided at the clinic before delivery. The clinical team members know that mothers affected by SUD and OUD during pregnancy and after delivery are generally distrustful of physicians and face numerous barriers to health care access and health care utilization. To build a trusting relationship with the families the clinic has implemented a patient- and family-centered approach to caring for mothers, her partner, and infants affected by parental substance use. The goal is that mothers will view the clinic as a supporting partner and trusted medical home.
During the first visit to the clinic, the team communicates openly with the family to identify and set health goals for both the mother and the infant. Physicians and other team members assure mothers that they will focus on having transparent communication and exchange of information, which builds parental trust to have the same honesty and transparency from families when they are struggling. The clinical care team understands the variety of challenges and needs mothers are facing and they emphasize that among their primary goals is to support and help mothers in their recovery and parenting. The team members are honest about their role as mandatory reporters to child protective services (CPS), and they encourage and facilitate that parents to be present in the room or on the phone if a call to CPS is required. This strategy demystifies the reporting process to CPS agencies and helps decrease anxiety about the interaction and reduce fear of negative consequence.
The team focuses on the mothers’ resilience and strengths and always uses non-stigmatizing language. Additionally, team members emphasize all of mothers’ small and big achievements such as her ability to care for and sooth their fussy child or keeping up with the appointments, which is feedback parents really thrive on. To develop a strong and positive relationship, the team hosts baby showers and celebrate special occasions with their patients such as the first birthday or Mother’s Day, even before delivery or if a mother is not currently in custody of her child.
A Multidisciplinary Approach to Care
The HOPE Clinic provides support to the families affected by opioid use through a multidisciplinary team that includes obstetricians, pediatricians, family physicians, family medicine trained addiction physicians, nurse midwives, psychiatrists, social workers, a maternal-fetal medicine specialist, perinatal psychiatrist, nurse care manager, patient services coordinator, and a care recovery coach. The team meets weekly to discuss the care and treatment status of each family. The multidisciplinary team at HOPE Clinic understands that successful care coordination is based on shared goals across professional training and disciplines. While it may be difficult to deviate from a specific discipline’s training and approach to caring for a patient, team members ultimately focus and work together to meet the family’s needs.
Pediatricians monitor the infant’s health including duration and severity of withdrawal symptoms, feeding difficulties, as well any referrals made outside the clinic. Referrals for developmental screenings and other specialties are provided on a case by case basis. This individualized approach to referrals was implemented after feedback received from mothers suggested too many external referrals make them feel as if their child is not “normal.” The overall care provided to infants exposed to opioids or diagnosed with NOWS/NAS is similar to the care provided to an average infant. The clinic allows and encourages family members to accompany mothers and infants to the visits, but problematic partners must receive care and services separate from the mother and the infant.
Mothers with OUD receive comprehensive medical care including general health care, reproductive health care, mental and behavioral health services, and substance use counseling services. Families are screened for adverse childhood experiences (ACE) including child maltreatment, intimate or domestic partner violence, community violence, and other traumatic events such as a past severe illness or accident. Mothers are also screened for depression several times, during their pregnancy and after delivery.
Care Accessibility
Most mothers receiving care at the Hope Clinic do not have much social support such as from a partner or other family member, to help them get to appointments or with child care. For this reason, the clinical team views missed appointments as a barrier to care rather than a failure or refusal to receive care and treatment. To overcome this challenge, the HOPE Clinic has instituted a system where they take late and walk-in appointments to accommodate patients’ needs. This approach can make the practice chaotic, but the goal is to meet patients where they are. Parents also receive assistance with developing an emergency plan for their child’s care should the mother get sick and be unable to care for her child.
The residential treatment programs generally last 6 to 12 months after delivery. After leaving a program some families may stop showing up for appointments either because they have relocated, or because they do not have access to transportation. While the clinic offers telehealth services as an opportunity to continue treatment after discharge, many women do not have access to technology.
During the 2020 COVID-19 pandemic and lockdown families encountered additional challenges to accessing treatment and health services. To assure that infants will be seen for their pediatric health supervision visits, and parents can continue treatment for OUD, the clinic provided increased telehealth visits, including virtual group sessions.
Supporting Parents in Recovery
The HOPE Clinic believes OUD during pregnancy must be treated using a public health approach. Mothers in recovery receive access to the Journey Recovery Project , an online resource that includes information for each step through the treatment and recovery journey, as well as information on how to care for an infant with NOWS/NAS. While some patients may return to opioid use during the recovery process, these situations are anticipated in the treatment course. The clinical team reassures mothers that they are partners and will support them through the recovery process. A recovery coach, also called the “glue” of the clinic by team members, keeps track of patients’ missed appointments, and follows up with them regularly to make sure they are ok.
The clinic acknowledges that being connected to and contributing as an individual to a community plays a key role in mothers’ recovery. As a result, the HOPE Clinic team seeks to build a strong and positive community between patients and team members. Parents can be linked to outside programs such as residential treatment, family day programs for women with OUD and other SUDs, and home visiting programs. The HOPE clinic team works with community partners to identify the right balance of individualized clinical and community supports for each family.
Trauma-Informed Care
All HOPE clinic team members receive training in trauma-informed care where they learn how to focus on and emphasize the family’s strengths and resilience during recovery. Staff also receive training on conflict resolution and de-escalation strategies and skills which are essential in communicating with mothers who may experience distress or display difficult behaviors due to withdrawal or mental health conditions.
Financing
The program is entirely grant funded, which generates ongoing conversations about the clinic’s long-term sustainability. Some services are reimbursed through Medicaid, but services provided by the peer recovery coaches are not reimbursable. A reimbursement platform is moving forward in Massachusetts for coaches, which is considered a step forward. The clinic is looking to integrate bundled care to assure service continuity for both mothers and infants for the first year after delivery.
To provide evidence for the effectiveness of care provided, and to receive reimbursement for services, the clinic continually reviews which outcomes should be measured. Aside from individual outcomes for the infants and for the mothers, the clinic seeks to measure dyadic outcomes, such as health utilization outcomes, (i.e. flexible appointments), bonding, attachment, and parenting skills. Since these outcomes are heavily based on qualitative data, they take time to measure.
Advice for Other Practices
In Massachusetts more than half of the mothers who experienced an opioid overdose within a year of giving birth had no indication of opioid use disorder in their charts. This data highlights how pediatricians have a unique opportunity to identify this vulnerable population during frequent visits for their infant in the first year of life and learn how to support them through recovery. Pediatric practices can start by evaluating their potential to providing multidisciplinary care. A solution adopted by the HOPE Clinic was to communicate, collaborate and partner with providers operating in different “silos”.
The team understands that caring for this vulnerable patient population is trauma work. The stress placed on providers themselves when caring for these families must be considered when building strong clinical teams. Each team member needs support to strengthen their own resiliency and manage secondary traumatic stress and compassion fatigue. A multidisciplinary team needs departmental champion a person who will support and lead the work across various departments. Additionally, it is also important to examine whether there are disparities in the care provided to patients from diverse ethnic and racial groups and minorities.