The Comprehensive Addiction & Recovery Act 2016 (CARA) CAPMIS TOT The Comprehensive Addiction & Recovery Act 2016 (CARA) Developed by: ODJFS-CPS Policy 10/14

The 6 pillars of focus: What is CARA????? CARA is the first major federal addiction legislation in 40 years, and the most comprehensive effort undertaken to address the opioid epidemic, encompassing the following six pillars necessary for such a coordinated response. The 6 pillars of focus: Prevention Law Enforcement Treatment Recovery Criminal Justice Reform Overdose Reversal

CARA’s Impact on CAPTA: Requires the Secretary of Health and Human Services, through the national clearinghouse established under CAPTA, to maintain and disseminate information about the CAPTA state plan and best practices related to safe care plans for infants born and identified as being affected by substance abuse or withdrawal symptoms or a Fetal Alcohol Spectrum Disorder. The state is required to apply policies and procedures to address infants affected by all substance abuse – not just illegal as was the requirement prior to this change. States additional requirements are to: Ensure the safety and well-being upon release from the care of health care providers (hospitals, clinics, maternal wards, etc.) Address the health and substance use disorder treatment needs of the infant and affected family or caregiver. Monitor plans to determine whether and how local entities are making referrals and delivering appropriate services to the infant and the family or caregiver. Develop the Plan of Safe Care for any infant affected by all substance abuse (illegal and legal).

CARA’s Impact On CAPTA Further clarified the population requiring a Plan of Safe Care “infants born with and identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder”. The word “illegal” was intentionally removed from this sentence – CARA addresses both the legal and illegal abuse of substances. Requires a Plan of Safe Care to include the needs of both the infant and the family/caregiver – CARA focuses on the family unit, specifically the treatment needs of the infant and the mother/caregiver of the identified infant. Requires state monitoring to ensure the Plans of Safe Care are implemented Referrals have been completed to the appropriate services Requires the following data to be reported to the National Child Abuse and Neglect Data System (NCANDS): The number of infants identified as being affected by substance abuse, withdrawal symptoms resulting from prenatal drug exposure or Fetal Alcohol Spectrum Disorder The number of infants for whom a Plan of Safe Care was developed The number of infants for whom referrals were made for appropriate services – including services for the affected family or caregiver

Definitions Within CARA A Plan of Safe Care is an arrangement that addresses the immediate safety of the affected infant, the treatment needs of the infant, and the health and substance use disorder treatment needs of the affected family or caregiver. The plan is developed with the parents or other caregivers, as well as the collaborating professional partners and agencies involved in caring for the infant and family. Information to be gathered to ensure adequate Plan of Safe Care is in place: Hospital or medical facility the infant is being treated Treating physician, nurse, social worker, etc. Toxicology results and symptoms Medical intervention to treat withdrawal symptoms Medical information on the infant (current diagnosis, prescription medication, therapies or treatment) Health and substance use history of the mother, father care caregiver(s) (their diagnosis, prescribed medications, AOD treatment provider(s), treatment plan, and contact information for these collaterals) Treatment plan at discharge for the infant, mother and/or caregiver(s)

Definitions Continued Substance Affected Infant: A child under the age of 12 months who has any detectable physical, developmental, cognitive, or emotional delay or harm which is associated with a parent, guardian or custodian’s abuse of a legal or illegal substance; excluding the use of a substance by the parent, guardian, or custodian as prescribed. Substance Exposed Infant: A child under the age of 12 months who has been subjected to legal or illegal substance abuse while in utero.

Expectations of Mandated Reporters The expectations for mandated reporters have not changed – required to make a referral to a PCSA when an infant is impacted by the abuse of legal or illegal substances. Per rule a referral needs to be made when: Infant is exhibiting signs of withdrawal Infant has a positive toxicology result Infant is diagnosed with Fetal Alcohol Syndrome Much of these referrals will come from hospitals at the time delivery: Mandated Reporter Guide for Plan of Safe Care Comprehensive Addiction Recovery Act Interagency Collaboration Handout Education & Interagency Communication is vital!!

Screening Expectations CPS agencies are required to collect the following information on all referrals involving an infant who has been identified as being substance exposed: Ensure a Plan of Safe Care has been established. Ensure the Plan of Safe Care addresses the safety needs of the infant. Ensure the Plan of Safe Care addresses the health and substance use disorder treatment needs of the affected family or caregiver(s). NOTE: The referral should be screened in for investigation if the above information is not available or not met.

What Steps We Need To Take Provide pregnant women access to comprehensive medication assisted treatment. Establish guidelines and standards for treatment which includes preparing mothers for the birth of their infant who may experience withdrawal syndrome and potential involvement with Child Protective Services (CPS). Beginning the development of a Plan of Safe Care prior to the birth event. Timely information sharing and monitoring of infants and families across multiple systems. Consistent hospital notifications to CPS. Develop a set of questions and responses that will help CPS hotline workers determine if a case should be opened in order to assess the risk and protective factors and safety concerns for the infant and mother. Provide comprehensive assessments of the infant’s physical health and the mother’s parenting capacity, physical, social and emotional health. Develop a thorough discharge plan that provides a multi-disciplinary Plan of Safe Care.

SACWIS Modifications CARA is required to be in production by May 1st . Cases involving an infant identified as meeting criteria for CARA will be flagged and followed for reporting purposes. Number of infants affected by substance abuse will be counted one time only. Identification of specific substance being abused. Questions required regarding Plan of Safe Care have been added. Questions have been added to include the number of referrals made to appropriate services for both the infant and the affected family member or caregiver. Questions required for NCANDS will be asked throughout case up to point of closure. Information will be pulled forward throughout case when able. Documentation of screening decision will be required if referral is screened out (if meets criteria for CARA). Documentation at time of closing of progress & Plan of Safe Care.

SACWIS Roll Out – Two Phases Intake Screening Safety Assessment Family Assessment Ongoing Case Plan Case Review SAR Case Closure

SACWIS Intake Enhancements What Is Currently in SACWIS??? Between October 28, 2016 & current date The SACWIS enhancements meet the requirements for data collection with the passing of CARA. Additional improvements to SACWIS are currently being addressed by ODJFS. Functionality of these additional enhancements are expected by January 2018. An infant was identified as affected by legal or illegal substance use An infant having withdrawal symptoms resulting from prenatal drug exposure An infant diagnosed with Fetal Alcohol Spectrum Disorder An infant affected by substance abuse/prenatal drug exposure AND Fetal Alcohol Spectrum Disorder Total intakes with documented fetal exposure

SACWIS Substance Abuse Screening Tool Functionality was released on December 12, 2016 As of September, 2017, 2,896 screening tool records have been created. 2,575 of the 2,957 records document that a screening tool was administered. Of those 2,575 records, 489 (19%) recommended that the case member receive additional diagnostic assessment.

SACWIS Intake Enhancements Leads to improved DATA “Intake Usability” enhancements were released into SACWIS production on October 27, 2016. The enhancements included the addition of a required question, “Is parent or caregiver substance abuse being reported by the referent?” If the screener answers “Yes” to this question, the screener is required to document how the reporter became aware of the substance abuse and to document the drug type(s) being abused.

SACWIS Intake Enhancements Leads to improved DATA Data for Intakes Received Between 10/28/16 to 9/10/17 73,035 CA/N intakes Screened In, of those: 22,234 had a “Yes” value for the new substance abuse question (30.44%) 50,800 had a “No” value for the new substance abuse question (69.56%) NOTE: This does not mean there isn’t substance abuse in 69% of referrals, it just mean if there is, the reporter is not aware of it. Multiple Drug Types can be selected per intake. Most commonly selected drug types for all intakes received: Marijuana – 8,144 Alcohol – 4,944 Heroin – 4,390 Opiates (other than Heroin) – 3,905 Cocaine – 3,407

What is Going On Around Ohio??? Neonatal Abstinence Syndrome Workgroup (NAS) Maternal Opiate Medical Supports Project (MOMS) Ohio START (Sobriety, Treatment, and Reducing Trauma) Brigid’s Path Pilot Women’s Prevention and Treatment Programs Statewide System Reform Program (SSRP)

Neonatal Abstinence Syndrome Interagency Workgroup Aim is to align state agency efforts to effectively address the screening, treatment and aftercare needs of families with infants at risk of withdrawal from exposure to opioids. The workgroup is comprised of the lead state agencies addressing Ohio’s opioid crisis and key community partners and stakeholders.

Who is At The Table?? Ohio Department of Jobs & Families Services Ohio Department of Medicaid Ohio Department of Developmental Disabilities Ohio Department of Mental Health & Addiction Services Ohio Department of Health Nationwide Children’s Hospital Ohio State University Children’s Hospital of Akron Wheeling Hospital Will be adding PCSA representatives

Key Topics: NAS Workgroup Use of Plans of Safe Care – standardize and ensure delivery of cross- system service needed to promote child safety, recovery and family stability statewide Screening protocols for pregnant women and newborns Targeted efforts (recruitment, education, and practice support) to increase the number of MAT providers and the number of patients each provider may treat. Funding options to support early intervention & care coordination 21st Century CURES Act Expansion of MOMS Comp Drug (Franklin County) will serve as the mentor organization for six new MOMS site: ComQuest – Canton, East Liverpool and Massillon Crossroads – Cincinnati Health Recovery Services – Athens and SE Ohio Mercer – Youngstown and Warren Zepf Center – Toledo and NW Ohio Comp Drug – Expansion in Central Ohio

The 21st Century Cures Act Passed by Congress and signed into law in late 2016: Goal: to modernize health care through enhanced innovation, research and communication, leading to better patient outcomes New funding through the Substance Abuse and Mental Health Services Administration to combat the prescription opioid & heroin crisis Ohio will receive over $26 million in FY 2017 and is eligible for additional funding in FY 2018 Emphasize service integration between physical health care, emergency health care, behavioral health care, criminal justice, and child welfare

Maternal Opiate Medical Supports Projects (MOMS) Goals: Improve maternal and fetal health outcomes Improve family stability Reduce costs of NAS to Ohio’s Medicaid program by : Providing treatment to pregnant mothers with opiate issues during and after pregnancy through a Maternity Care Home (MCH) model of care Emphasize Care coordination Wrap-around services Combination of counseling, MAT, and case management

Ohio Start (Sobriety, Treatment, and Reducing Trauma) What: An intervention program created through the Ohio Attorney General’s office, providing specialized victim services; intensive trauma counseling to children who have suffered victimization with substance abuse of a parent being the primary risk factor. How: Assist parents with their path to recovery from addiction. Family Peer Mentors will play a key role to support family through processes. They will be paired with a child welfare caseworker to provide intensive case management services Who: PCSAs, behavioral health providers and juvenile/family courts. Currently 16 Ohio counties involved

Brigid’s Path Pilot Brigid’s Path is a facility in Montgomery County, designed to be a home-like facility with individual rooms for the babies to minimize the noise, lights and other irritants for babies going through withdrawal. Supportive environment for the families – creates a better environment for bonding, learning to care for their infants and be linked to services in the communities. Uses nurses and treatment guidelines developed by the Ohio Perinatal Quality Collaborative, with the Departments of Medicaid, Job and Family Services and Health.

Women’s Prevention & Treatment Programs Provides Maternal Depression Screening, training, education, and treatment support to women at high risk for Substance Use Disorder in collaboration with other state agencies, prevention providers, parents and caregivers. Goal is to reduce risk of neonatal exposure to alcohol, tobacco and other drugs Promotes prevention, intervention, screening, diagnosis and treatment for babies and children exhibiting Fetal Alcohol Spectrum Disorders

Statewide System Reform Program (SSRP) Expand and enhance Ohio’s efforts to implement effective Family Drug Courts in communities and in the larger state-level child welfare, substance abuse treatment, and court systems. Currently 11 counties are involved in this program (Ashtabula, Clermont, Coshocton, Hancock, Hardin, Henry, Lucas, Ross, Summit, Union and Wayne) Goal is to add expand efforts to other counties in Ohio.

Thank You!!