Oasis Center of the Rogue Valley, Medford – Oregon
Oasis Center of the Rogue Valley in Medford, Oregon was built to advocate for pregnant and postpartum people with opioid use disorder (OUD) and other substance use disorders (SUDs). The center reinforces the need for wrap-around services for addiction, prenatal, postpartum, and pediatric medical care. The Oasis Center functions as a family-centered medical home in alignment with Project Nurture Oregon, integrating maternity care and addiction treatment for pregnant people with SUDs. Oasis Center is well known throughout the community as a family medical home, and a safe clinic for pregnant and parenting people with OUD/SUD.
Multidisciplinary Team and Services
Services include individual pregnancy and pediatric care, group services, behavioral health, medication treatment for OUD (MOUD), referrals to residential treatment centers, and service coordination for women and birth parents with OUD/SUD. Oasis staff includes pediatric, family medicine and addiction medicine physicians, a pediatric family nurse practitioner, a child and family services coordinator, pediatric and adult behavioral health clinicians, a certified nurse midwife (CNM), a doula, and peer specialists with lived experience. Pregnant patients receive obstetric and prenatal care at Oasis Center. They deliver at Asante Rogue Regional Medical Center (ARRMC), Family Birth Center in Medford, and can access the Asante Neonatal Intensive Care Unit (NICU) if needed. The doulas and peer specialists support patients in labor, and the midwife assists with deliveries at ARRMC. After discharge from the hospital, families return to Oasis Center for pediatric care and for addiction and recovery services. The pediatrician at ARRMC can provide further referrals for postpartum care. Oasis Center also provides care to pregnant patients who are in acute withdrawal at delivery and did not receive prenatal care, and who might need a referral to a residential treatment center.
Therapeutic Alliances
Taking their first step towards recovery, pregnant people walk through the Oasis door knowing they can receive the best care and treatment for addiction and recovery. The guiding tenet at Oasis Center is on building an authentic one-on-one trusting relationships based on open and honest communication with patients. The team members are Oasis are quick to say their work is not a program and rather a continuum of meaningful relationships that empower pregnant and parenting people to seek care and to continue treatment for addiction recovery.
All personnel at Oasis Center are trained to use medically accurate non-stigmatizing language to alleviate the shame and guilt many patients with OUD/SUD experience. The prenatal visits can last 1 to 1.5 hours so the clinical team have meaningful conversations, get to know the families, and have time to discuss the health and recovery goals. Acknowledging the fear families have about the Child Welfare system, the clinical team explains the role of Child Welfare, and what birth parents and families can do to prevent separation. Clinicians offer verbal support, genuine hugs, and praises to patients for being brave in acknowledging addiction and seeking treatment.
Contributors to Accessible Care
Oasis is intentional about coordinating access to as many health services as possible. Peer specialists with lived experiences are brought in to offer support and encouragement and discuss with new patients the basic levels of need, such as, housing food security, a diaper pantry, infant nutrition, and clothing. A state worker from a self-sufficiency program is present at the center twice per week to help families register for the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and medical insurance.
Transportation services are offered through State resources and Medicaid Coordinated Care Organizations (CCOs). Patients receive city bus passes, fuel cards, or they can call in advance and arrange pick-ups with a peer specialist. The clinical team at Oasis wants to make sure they patients return for care, and they don’t miss appointments due to transportation challenges. As a result, the center offers flexible scheduling, so missed visits can be arranged for later in a day or during another day.
To ensure the visits are not rushed, the center offers childcare in an on-site playroom. Parents and caregivers are invited in the playroom and play with the children while waiting for their visits. To build community nurturance, the clinic staff often join parents in the playroom, converse with them, model positive play behavior, and provide emotional support.
Anticipatory Guidance
Families receive anticipatory guidance regarding the infant’ development starting with the first patient visit. Pregnant patients typically want answers to questions such as, how is the baby being affected by OUD/SUD? What is withdrawal going to look like? What will the hospital experience be like? The midwife who previously worked at ARRMC, helped with developing a training video about Eat, Sleep, Console (ESC) the non-pharmacological care strategy used at the hospital.
Patients delivering at Asante use ESC and learn about the importance of skin-to-skin contact and non-stimulating environments. During the hospital stay, the midwife works closely with the family and discusses in detail what they can expect at home after hospital discharge. These conversations emphasize safe sleep practices, the need for having a home visiting nurse and follow-up care with Early Intervention (EI) services. Discussions also center around the importance of a safe sleep environment for the mother-infant dyad.
The pediatric visits reinforce education on managing infant’s symptoms of withdrawal such as, crying and irritability, infant weight gain, fever, breastfeeding and preventing mastitis. Oasis reports measurable success with people in recovery who actively breastfeed for 6 months and up to 1 year after delivery. The clinic offers onsite resources including thermometers and breast pumps, and often patients can loan a scale for a weekend to monitor infant weight and breastmilk intake.
Coordination of Postpartum/Pediatric care
In conjunction with ARRMC, Oasis Center is piloting a communication folder given to each birth parent at hospital discharge, to bring at the infant’s pediatric follow-up. The folder includes the hospital discharge summary, the family infectious disease history, and educational materials about breastfeeding.
The folder lists community resources such as Women Infants and Children (WIC), EI, home visiting nurse programs, and other social services. The aim for this folder is to include all the supports available for the dyad, which is essential especially if the infant is placed with a foster caregiver. Part of the discharge bundle for parents, the ARRMC has a best practice protocol for providing referrals to EI, home visiting nurse and an order for the hospital Pediatric Assessment Team (PAT). Through PAT, families can access speech, physical, and occupational therapies for the infants and children up to 2 years old. To assess for developmental growth such as gross motor, fine motor, communication, and social interaction skills pediatric patients are screened with the Ages and Stages Questionnaire at the child supervision visits from 0 to 3 years of age.
Home Visiting Nurse
Oasis Center affirms the value of the home visiting programs and relies on visiting nurse to connect families to long-term individualized supports. The midwife at Oasis manages the Home Health referral program and pregnant patients can meet with the visiting nurse early on during the prenatal visit. This introduction enables building a trusting relationship early in pregnancy and continue up to 2 years of a child’s life, which allows supporting a family for almost 3 years through their journey. This underscores a fundamental tenet of Oasis Center and their community partners on building trusting relationships with their patients and families.
Early Intervention Collaboration
An important element in the communication folder for families is information about EI, the importance of follow-up and participation. The hospital team at ARRMC learned that in the past, many patients were not following up with the EI programs. When parents were returning to Oasis Center for pediatric care, they had many questions about the infant development. Many were expressing guilt and shame, while others thought something was wrong with their infants. As a result, the clinical teams at Oasis and ARRMC began a concerted protocol to frame and introduce EI as a supportive activity that ensures an infant has the best possible start, and to reduce the parents’ shame, guilt, and negative self-talk.
Oasis works closely and continues to build its relationship with the Jackson County EI, a program of Douglas Education Service District. Recognizing the complex needs families face, an EI specialist is available at Oasis Center for 3-4 hours per week. The purpose is to provide a direct connection and warm hand-off in a familiar environment to increase the likelihood of follow-up with these services.
When parents come in for the initial pediatric visits, they are invited into the playroom to experience an EI session, so they understand its role and how they can participate. The sessions comprise age-appropriate basic exercises from 0 to 6 months. Additionally, the clinic hosts a weekly playgroup for birth parents and infants with an EI teacher present. Encounters with the EI specialists are informal and are seen as an opportunity to know the families and deepen relationships. This situation also gives parents the opportunity to socialize together, learn from each other, and build a community.
Since the partnership between the clinic and EI started, there has been a marked increase of follow-up with the EI services. From October 2020 to October 2021, only 25% of patients referred from Oasis Clinic received EI services. While varying reasons contributed to this low percentage, the primary reason was because EI lost contact with families or did not have contact with families at all. From October 2021 to October 2022, 40% of patients referred from Oasis received EI service. The goal is to increase this number even more by having an in-person presence at the clinic and a dedicated collaborative approach.
Clinical Services for Addiction Treatment
Oasis Center is using a model of care for the whole family, providing services for both pediatric and adult patients. When a family comes in for a visit, the family medicine and addiction medicine physicians can prescribe medication treatment for OUD for the birth parent, and the pediatrician is seeing the child for the health supervision visit. Oasis Center is well-integrated with residential treatment services and outpatient treatment facilities within the community. The clinical team can refer a patient to move into a residential facility or receive appropriate outpatient treatment services as needed.
Financial Considerations for Integrated Services
Oasis Center is 60% grant funded and recently there has been a surge of grant-funded opportunities. However, many program activities are not sustainable without continuous funding, or they are not reimbursable, creating barriers to providing integrated care. While ancillary services, such as EI playtime has positive impact and is beneficial, it is not easily quantified in metrics. Also, many childhood and family development services do not have clear metrics, and there are not clear guidelines on the cost savings that occurs through preventative procedures and services.
Since the medical care for addiction and OUD/SUD services fall into different billing mechanism, Oasis Center is in negotiations with state and local Oregon coordinated care organizations. The objective is to overcome some of the systemic and structural issues that create barriers to billing for the integrated services they are providing. Due to the low reimbursement for prenatal care, and inability to bill many integrated services Oasis Center is emphasizing value-based payments for integrated addiction and prenatal care, similar to the Project Nurture model. The center is actively advocating to receive a different per member/per month payment (PM/PM) to manage the increasing number of pregnant people with OUD/SUD to whom they offer care.
The Physiology of Addiction - Advice Around a Complex Issue
In addition to trauma-informed care approaches, the clinicians at Oasis Center emphasize the importance of training and the understanding of the physiologic basis and social impact of OUD/SUD in establishing trusting relationships with patients. From the moment families walk in, the personnel strive to be attuned and connect to the patients and their children. The clinical team at Oasis understands addiction and how it affects pregnant people, how they think and how parents engage with staff during the pediatric visit. Individuals with OUD/SUD experience a lot of shame and guilt and often misinterpret neutral facial expressions, body language or verbal statements as judgmental and negative. Clinicians can reflect on the lens the individuals with OUD/SUD view the world and be aware of transference trauma, given that patients with OUD/SUD almost always experienced trauma. Every interaction matters and all personnel that meets the patients, from front desk staff to providers, need to be warm and engaging. The Oregon Child Welfare Division is rolling out the Vision for Transformation an initiative that outlines many elements of the plan of safe care. The team at Oasis Center acknowledges and supports the guiding principles of the Vision for Transformation that women with OUD/SUD require individualized care that meets them where they are in the recovery journey. The team at Oasis suggests that practices that work with many patients with OUD/SUD, should have dedicated staff to work with this patient population, such as, a peer addiction specialist, or a case manager can work with patients individually, and build relationships. The team stress that it takes time to build trusting relationships and these relationships are more likely to happen through extended visits. Peers in recovery and case workers can be intentional in reminding parents about appointments to keep the communication ongoing and ensure families return for care.