Dartmouth-Hitchcock’s Purple Pod Pediatrics Program
“See the strength in recovery first, the pride in parenting, and the transition from the shame of addiction in the past…. and really listening, engaging, partnering.” This is how pediatrician Dr Steven Chapman, MD, FAAP, described the keys to success for the Children’s Hospital at Dartmouth-Hitchcock's CHaD) Health’s Pediatric Purple Pod approach to supporting mothers receiving treatment for substance use disorders and caring for their newborns who may have neonatal abstinence syndrome (NAS), or neonatal opioid withdrawal syndrome (NOWS). Dartmouth-Hitchcock provides generalist and specialty practices to children and adults living in New Hampshire and Vermont. The Purple Pod is housed in the pediatric clinic at CHaD and is built on five key principles.
- Dyadic Approach
- Family-Centered Care
- Community Connections
- Stigma Reduction
- Strength-Based
Building a Therapeutic Alliance
Building support for mothers in recovery begins with the obstetricians and gynecologists (OB-GYNs) at the Purple Pod clinic and in the hospital nurseries. Using a strength-based approach, the team members focus on developing a plan of safe care and supporting the mother’s engagement into treatment. The collaborative process of developing the plan inherently builds a therapeutic alliance between mothers and the team early on. The planning document articulates the patients’ strengths and goals. It also serves as a reference document for the clinical care team, so they do not have to repeatedly ask mothers the same questions. The plan outlines support services available and a list of community resources to help mothers maintain their recovery after delivery.
Purple Pod team members treat mothers with respect and build trust and transparency from a place of care and concern. Purple Pod team members consider substance use as a chronic medical condition and they use language consistent with this approach. For example, use of plain language rather than scientific language that is difficult to understand. Trust is reinforced through transparent communication. Team members remind mothers how strong they are and tell mothers that they are proud of them. Also, if there are concerns, then staff engage the mother as part of the decision process— “they are the experts on their baby.”
Many mothers worry about their children being removed by child protective services. To build trust with mothers around reporting, Dartmouth Hitchcock makes every effort to talk with mothers before they make a report to the Department for Children Youth and Families (DCYF). Mothers are reassured that the Purple Pod team is on their side and that parents can be present when the social worker makes a report. When notifying the DCYF, the family’s strengths are emphasized before any concerns are shared. Mothers are coached to regard the DCYF as an additional resource that supports her and her infant’s well-being.
Staff reminds patients about their appointments via text and phone. In case a patient is missing an appointment, the team makes sure to not shame the mother, and regards this as an opportunity to build a trusting relationship. Sometimes families receive gas/fuel cards or are helped navigating the public transportation system. At the beginning of the program the no show rate for appointments was in the mid-twenties. After implementing this new approach, the no show rate dropped into the single digits.
A Multidisciplinary Approach to Patient Care
The Purple Pod uses a multidisciplinary team-based approach built on feedback from mothers. This approach helped the Purple Pod team understand that mothers need support throughout their recovery, and access to seamless care and health services for themselves and for their infants.
The multidisciplinary team includes physicians, medical residents, administrative staff, schedulers, nurses, medical assistants, social workers, community health workers, peer recovery coaches, and a resource center worker/specialist. An advisory group of mothers in recovery provides feedback to the Purple Pod team and supports mothers. The peer recovery coach is a critical team member focusing on advocating for mothers, helping them locate resources, providing advice about breastfeeding, and encouraging mothers to make positive changes.
The Purple Pod Medical Home
At the center of setting realistic goals for mothers and their infants the team takes in account the social determinants of health and the family’s individual needs. During the hospital stay, mothers can “room in” with a medical assistant who understands the challenges of pregnant and parenting women with opioid use disorder (OUD) and uses a trauma-informed approach to care. After delivery, the Purple Pod clinic becomes the dyad’s medical home, and the entire team continues to attend to each family’s individual needs. An important part of the medical home model is implementing empathetic care and viewing OUD as a chronic, treatable condition.
In mid-2020, the Purple Pod had a registry of about 130 mother-infant dyads. The team reviews the list of patients weekly and does pre-visit planning. This planning session involves calling mothers scheduled to visit the clinic the following week to get updates on how things are progressing at home and listen to their concerns and priorities for their visit. By focusing on mothers’ goals and needs, the pre-visit calls help maintaining a positive partnership between mothers and the Purple Pod team, and assure continuous supportive care between visits.
While the focus of the pediatric clinical team is to care for, and treat infants and children, the mothers’ well-being is always at the forefront. Mothers are screened for postpartum depression, and the clinic schedules visits with a mental health clinician, an OB-GYN, or with a primary care physician, as needed. The Purple Pod team checks in with mothers regularly on the progress and status of their OUD treatment and recovery and follows up with referrals if any concerns arise.
Anticipatory Guidance and Maternal Education
The team partners with mothers in setting short- and long-term goals. Anticipatory guidance is provided to each mother based on her needs, interests, goals, and concerns. The team provides information on breastfeeding and lactation support, and they educate mothers on the details when breastfeeding is safe while taking medication treatment for OUD.
Before hospital discharge, new mothers are educated on the Eat, Sleep, Console (ESC) model of care for newborns affected by NOWS/NAS, skin to skin contact and cuddling, and attending to their infant’s needs and safety. Additionally, mothers are advised about their automatic eligibility for early intervention services, which is also noted in the plan for supportive care.
While the team communicates that symptoms of NOWS/NAS can occur, the team emphasizes that the care parents provide to their child is the most important determinant of future health and something that they can control. Mothers are motivated to do the best job they can, and the team partners with them to set realistic goals and expectations for themselves and their family.
During the first health supervision visit mothers receive information about the importance of child development. In addition to routine developmental surveillance and screening performed at the clinic the infants receive additional developmental screening and referrals. For example, the 2-month health supervision visit involves formal developmental screening, as well as an attachment-oriented discussion of developmental engagement and support. Referrals for Early Intervention services are offered to all infants seen at the clinic at the 2-months visit.
Families receive books, scales to monitor the infant’s weight at home, and some mothers receive bassinets for safe sleep. Along with anticipatory guidance provided during the first postnatal visit, families are screened for food insecurity and other social determinants of health.
Community Resources
The Purple Pod’s community health resource specialist connects families with community services and helps them enroll in government programs such as Medicaid. Staff meet with families anywhere that is convenient for them including at their home or even in the shopping mall parking lot. To build trust, referrals are never made without the family’s permission. A release of information form is signed prior to a referral being made.
Family resources centers located in the community and providing services such as, home visiting, child care, transportation assistance, support with enrolling in government benefit programs, are another important resource for families. While many resource centers are available, the team recognizes the need to continuously inform and educate families and staff about them. The team considers it is important to emphasize with families that these services are specifically created for them, therefore they can be utilized without the concern of being stigmatized and judged for the OUD diagnosis or specific treatment needs.
The Purple Pod team and staff from referral organizations maintain communication about challenges the families are facing. Continuous communication allows the clinical team to stay focused on daily medical care, while community partners and social workers direct their efforts towards other family needs.
A Trauma-Informed Approach to Care
Many mothers with SUD and OUD have experienced traumatic events in their lives. A three-part training on harm reduction is open to all staff members including the administrative staff. Training programs on the science of addiction, NOWS/NAS management, the stigmatization of poverty (Bridges Out of Poverty), and a session on destigmatizing language and practical tips on working with families in recovery are also offered. An evidence-based attachment-oriented parenting class (Circle of Security) involving Purple Pod staff is offered to families to help mothers and caregivers build parenting skills and their own community with other families affected by opioid use.
Conclusion
The Purple Pod team considers that the fractured approach to health care, and the silos in health care delivery, makes extremely challenging for pregnant and parenting women with OUD to navigate the health systems and feel supported. They advise other practices interested in adopting a similar model to start by providing as many services as possible in one location through a multidisciplinary team.
This type of integrated approach takes careful financial planning. The Purple Pod is supported by external grants and internal funding and they bill for care as usual. Bundled payments integrating care for both mothers and infants are suggested as a promising financial approach that should be considered by other practices.
The Purple Pod model is focused on building a trusting relationship with families and always approaching them with non-stigmatizing language and empathetic attitudes. “Uncontrolled addiction is part of the past… we can part of the present and help them shape their future in a strength-based way, as their partners” (Steven Chapman, MD, FAAP).