MaineMOM at Mid Coast
In January 2020, the State of Maine was selected by the Centers for Medicare and Medicaid Services to receive federal funds to participate in the Maternal Opioid Misuse (MOM) Model. The MOM Model aims to address current fragmentation in the care of pregnant and postpartum Medicaid beneficiaries with opioid use disorder (OUD) and their infants. Additionally, it aims to improve the quality of care, reduce expenditures for parents with OUD, increase access to treatment, and create sustainable coverage and payment strategies that support ongoing coordination and integration of health services.
Located in Brunswick, Maine, Mid Coast Hospital began their MaineMOM Program (the Program), in collaboration with MaineCare, the state’s Medicaid program, in January 2020. The Program has a 5- year plan to first transition to a new model of integrated care, and then fully implement a plan to coordinate care for pregnant parents with substance use disorder (SUD) and their infants. The services available through MaineMOM Program are offered starting in the prenatal period, pregnancy, birth, and continued through the first year of the child’s life.
A Multidisciplinary Approach and A Safe Space
Mid Coast Hospital is part of a community health system that addresses a full continuum of health care, wellness, and prevention. This setting offers clinical services necessary to ensure a multidisciplinary foundation to support the Program. The services offered include, obstetrics and gynecology, pediatrics, mental health, and addiction and substance use recovery care through the Addiction Resource Center.
A nurse clinical coordinator (NCC) leads the MaineMOM Program team. Patients are primarily referred through the Addiction Resource Center or through women’s health services. Patients who are eligible to receive care through the MaineMOM Program either self-disclose they are using opioids or are identified through urinalysis. The patient is always informed of urine sample toxicology testing. If the test results are positive for opioids, the NCC will meet with the pregnant patient to discuss participation in the program and receive treatment for OUD at no cost.
Using trauma-informed care approaches, parents are assured a space without judgement, where they will be part of a team dedicated to their best health and health of their infants.
Pregnant patients are evaluated by a social worker who is also a clinical counselor at the Addiction Resource Center. An individualized treatment plan is developed for each patient, addressing substance addiction and mental health care. If needed, patients also meet with a psychiatrist or addiction medicine physician who prescribes and administers the medication treatment for OUD. Parents are provided peer support via group counseling sessions, both prenatally and postnatally. The NCC can visit a parent at home, if necessary. In a situation where a patient returns to use, the program staff makes sure to provide continuous support and avoid any punitive treatment, to ensure the parent can maintain a healthy trajectory. The Program team have worked concertedly to educate lactation consultants about OUD and neonatal opioid withdrawal syndrome (NOWS), especially around concerns and questions about the safety of medication treatment for OUD and breastfeeding.
At 30 weeks, parents meet with a perinatal coordinator, who is a labor and delivery nurse trained in addiction recovery and support. The perinatal coordinator gives the pregnant parent a better sense of what will occur during and after delivery and what services and care are available through the Program. The pregnant patient can tour the maternity unit and visit with a pediatrician who can care for the infant after delivery, and who understands the challenges mothers have through their recovery journey.
Care Continuity
Once the infant is born and under pediatric care, they are eligible for routine developmental and physical therapy evaluations, as well as speech evaluations from child development services. Additional needs of infant with NOWS are addressed, along with the typical Bright Futures anticipatory guidance.
Eat, Sleep, Console
Another important part of the MaineMOM Program is the focus on reducing stigma around SUD and prenatal substance use. Many parents with SUD have experienced a culture of discrimination, stigma, and shaming from health care providers. To address stigma and institutional bias, the Program offered a training for Mid Coast clinical staff to build awareness around negative language and provided strategies for using non-stigmatizing, person-first language. The pediatrician team member noted that the Program has been able to augment a positive, destigmatized shift starting in 2018, when the Mic Coast Hospital switched the primarily assessment for NOWS from the Finnegan scoring system to the nonpharmacologic, family-focused eat, sleep, console (ESC) method. This was the start of a significant culture shift to the use of positive language towards patients with OUD and OUD treatment.
Natural Environments: Home Visits and Virtual Visits
Home visits became more frequent during the COVID-19 pandemic because the NCC was a maternal child home visiting nurse prior to joining the MaineMOM Program. She introduced home visits as viable therapeutic opportunities for families seen through MaineMOM in the winter of 2020. Not only did the in-home visit provide the NCC with a snapshot of the mother and infant in their natural environment, but it also served as an effective alternative for patients who were unable to attend in-person visits. Transportation options in Mid Coast’s service area are a barrier, especially for patients who live in rural communities. Important to note, prior to securing CMS funding, Mid Coast offered home visits to their patients through a voluntary, state-funded program. However, the program had limited funding, poor coordination, and a workforce shortage. The pediatrician member of the Program team described the current availability of home visits for patients, administered through the MaineMOM Program, as a “game changer.”
Care Accessibility
During the COVID-19 pandemic, when in-person appointments were a challenge, the clinical team found that the change to virtual visits did not affect care continuity. Virtual/telehealth visits worked very well for their patient population. Much like home visits, parents and children could be seen in their natural environment, which offered a more realistic picture of child development, parenting styles, and their needs.
The program team is committed to keeping both in-person and virtual visits as options for their patients. Telehealth visits are a strong alternative for emergent situations or for patients who have difficulty keeping in-person appointments. The team has found that more patients adhered to their visit schedule via telehealth. Telehealth visits have been especially productive and offered the opportunity for a quick connection for patients needing counseling. Further, peer recovery groups that were conducted in-person successfully switched to video platforms. The Program built a support community for their patients by connecting then with others on similar recovery journeys.
Care Coordination: An EPIC Hope
The care coordination services provided by the NCC is paramount to the success of the MaineMOM Program. The clinical team fears that the patients seen through the Program would be affected if the NCC position will no longer be funded. Care coordination works best when someone has an assigned role. This person is dedicated to serving as the central source of support for the patients, as well as leading the communication efforts among colleagues and the multidisciplinary teams.
To enhance clinical and patient care, the hospital system is transferring to a new single shared electronic health record system known as EPIC (Electronic Privacy Information Center). The Program team hopes that utilizing EPIC will secure greater connectedness across the hospital system and better access to subspecialty care. In turn, this will help systematize care coordination for their patients. The team also hopes EPIC will allow integration of trauma-informed practices – which are critical to the birth parents with OUD and infants with NOWS.
Sustainability and Finances
The MaineMOM Program is in the second year of the 5-Year funding from CMS and plans to sustain the Program beyond the funding period. Currently, the team bills MaineCare a set amount per month per patient. That amount covers only the care for the adult patient, such as, OUD treatment and care coordination services, but not adult reproductive care or pediatric services. The team would like to explore additional opportunities to fund infant services.
Pediatricians providing services to an infant with NOWS cannot ignore the health care needs of parents, as their well-being is integrally connected to the health of the child. However, pay for service options are not currently available for the services provided to parents. For example, a pediatrician can code for administering a maternal depression screen but there is no additional code available to pediatricians for finding an adequate mental health provider, making referrals, or for following-up with the mother. Prioritizing comprehensive care and services for the mother-infant dyad is critically important, but a payment model does not currently exist. The team would like to develop or have access to a dyadic model of care that better supports both, the birth parent and the child.
Evaluation
The MaineMOM Program team takes the concerns of their patients seriously and often makes changes or refinements based on the concerns elicited by patients. The Program recently learned which areas needed refinement through rich qualitative data generated by a focus group conducted with current and previous patients. Based on the success of that focus group, the team hopes to continue with additional, similar efforts.
As a recipient of the larger national MOM Model effort, the team employs The Patient Activation Measure® (PAM®) tool from Insignia Health. PAM is a survey that assesses a patient’s underlying knowledge, skills, and confidence integral to managing his or her own health and health care. PAM is administered to patients at specific times throughout the Program.