Drug Free Moms and Babies Project An analysis of a three-year pilot project Cassie Leonard, MD Alice Ruhnke, MA Christa Lilly, PhD WVU School of Medicine The Grant Advantage, LLC WVU School of Public Health

Learning Objectives Identify comprehensive services provided to pregnant and postpartum women with substance use disorders participating in the Drug Free Moms and Babies program in four pilot project sites. Describe the demographics of Drug Free Moms and Babies program participants. Identify effective strategies to meet the complex needs of pregnant and postpartum women with substance use disorders. Learn about obstacles to caring for this vulnerable and special needs population. Discuss outcome data of program participants.

DFMB Project Goal To develop, evaluate, document, and replicate programs that support healthy baby outcomes by providing prevention, early intervention, treatment, and recovery services for pregnant and postpartum women with substance use disorders.

Evaluation Design Qualitative Evaluation Quantitative Evaluation Program Design Organizational Characteristics SBIRT Process Staffing Services Partners Yearly Interviews Quarterly Check-Ins RedCap Database Demographic Information Medical and Substance Abuse Histories Quantity and Depth of Services Outcome Data Drug Screens Cord Tissue

DFMB Project History Began project development in 2011 Started awarding funds in 2012 Four pilot sites selected: Shenandoah Valley Medical Center Shenandoah Community Health Thomas Memorial Hospital Greenbrier Valley Medical Center Greenbrier Physicians Clinic WVU Medicine Obstetrics and Gynecology Department

Brief Design Overview SBIRT Model Screening Brief Intervention Referral Treatment Treatment Provided Case Management Counseling: Individual, Group, Family Peer Recovery Coaching Medication Assisted Treatment Educational Workshops/Coaching Drug Screens Incentive Programs

Shenandoah Community Health Located in Martinsburg, West Virginia Serves Berkeley, Jefferson, and Morgan Counties in WV and surrounding areas in MD and VA DFMB services began in May 2012 DFMB Staff: Clinical Director (10%) Licensed Professional Counselor (50%) Recovery Coach (75%) Grant Administrator (10%)

Shenandoah Community Health Treatment Unique Components Psychiatric Services and Medication Assisted Treatment Group Counseling Individual Counseling Peer Recovery Coaching Incentives Program One-stop-shop for medical and behavioral health services Onsite Peer Recovery Coach MAT with extensive monitoring and case management Collaborative treatment team

Thomas Memorial Hospital Located in South Charleston, West Virginia Serves 12 counties in southcentral and southwestern West Virginia DFMB services began in August 2012 (Pregnancy Connections) DFMB Staff: Patient Coordinator (100%)

Thomas Memorial Hospital Treatment Unique Components Individual Counseling Group Counseling Individualized Recovery Plans Recovery Support Community Resources Community and Hospital Education Incentives Program Extensive monitoring and case management MAT provided by Ob/Gyn Structured outpatient treatment program Mental health screenings and services Strong collaboration with hospital’s Mother-Baby unit

Greenbrier Physicians Clinic Located in Ronceverte, West Virginia Serves Greenbrier, Monroe, Pocahontas, Summers, Fayette, and Raleigh Counties in WV and Alleghany County, VA DFMB services began in December 2012 DFMB Staff: Care Manager (100%)

Greenbrier Physicians Clinic Treatment Unique Components Case Management Individual Counseling Group Counseling Extensive Brief Interventions and Education Sessions Community Resources Individualized Treatment Plans Incentives Program Universal urine drug screens on all new OB patients Care Manager meets with all OB patients regardless of substance use Extensive brief intervention sessions Extensive case management

Obstetrics and Gynecology Department WVU Medicine Obstetrics and Gynecology Department Located in Morgantown, West Virginia Serves statewide, as well as southwestern PA, western MD, and eastern OH DFMB services began in August 2015 (ACE Project: Assist, Connect, Encourage) DFMB Staff: Principal Investigator Licensed Clinical Social Worker Patient Liaison (50%) Peer Recovery Coach (50%)

Obstetrics and Gynecology Department WVU Medicine Obstetrics and Gynecology Department Treatment Unique Components Case Management Individual Counseling Group Counseling Community Resources and Referral Parenting and Health Education Incentives Program Peer Recovery Coaching Patient Liaison meets with participants at prenatal meetings or in the community ACE support group meetings address the unique needs of pregnant women with substance use disorders Extensive facilitation of treatment and access to education

Lessons Learned Takes more time than anticipated A dedicated staff position is critical to moving the project forward A collaborative treatment team needs to be developed and nurtured Flexibility to enhance/revise program is needed

Participants Data Received by June 30, 2017 Data Collected between 2012 - 2017 546 Entries from 4 Sites 36 Readmissions 510 Unduplicated

Participants 1 Regional representation consistent with site locations (N=487) 1% 30% 12% 24% 33% 4 2 3 5 6

Comparison Data Project WATCH/Birth Score Substance-exposed pregnancies October 2016-April 2017 Includes DFMB participants State of perinatal health in WV 2016 data (WV health statistics center/vital statistics) Comparison data highlighted through out

Demographics Race/Ethnicity consistent with Appalachian demographics: Valid percentages or means presented Number of unduplicated participants: 510 Race/Ethnicity consistent with Appalachian demographics: Race: 93.73% White Ethnicity: 99.6% Non-Hispanic

Demographics Planned Pregnancy: 14% Maternal Age: 26.23 (Range 16-43) Number in Household: 3.13 (Range 1-8) Number of Living Children: 1.97 (Range 0-8) Marital Status: Never married: 68% Married: 18% Other: 14% Cohabitation (for those not married): Yes: 61% Planned Pregnancy: 14% Comparison WV 2016: Married: 54.4%

Demographics Income <$15,000: 70% $15,000-$24,999: 17% Education Some elementary: 1% Some high school: 34% High school diploma or GED: 49% Technical training: 6% Some college: 10% College or greater: 1% Income <$15,000: 70% $15,000-$24,999: 17% $25,000-$34,999: 9% >$35,000: 4% College or greater: 1%

Demographics Insurance Private: 5.6% Medicaid: 92.8% Other 1.6% Comparisons WATCH (all substance-exposed pregnancies): Medicaid: 80.9% Intention to Breastfeed: 31% All WV Births 2016: Breastfeeding at time of discharge: 65.2% All WV births 2015: Medicaid: 48% Insurance Private: 5.6% Medicaid: 92.8% Other 1.6% Intention to Breastfeed 63%

Substance Use Prior to Pregnancy During Pregnancy Alcohol: 61% Tobacco: 91% Cannabis: 83% Stimulant: 41% Hallucinogens: 10% Opioids (non- prescribed): 77% Other Substances: 40% Alcohol: 12% Tobacco: 80% Cannabis: 53% Stimulant: 16% Hallucinogens: <1% Opioids (non- prescribed): 67% Other Substances: 26% Comparisons Tobacco: WATCH: 68.5% WV 2016: 25.2% Drug use (illicit/ non-prescribed): WV 2016: 7.7%

Care and Treatment Drugs (95%) Alcohol (2%) Both (3%) First: 63% Trimester Entering Care Enrolled in Treatment (N=457) First: 63% Drugs (95%) Second: 29% Alcohol (2%) Third: 8% Both (3%) Treatment Types (can be more than one) Trimester Entering DFMB Medication Assisted Treatment: 275 (54%) First: 50% Counseling: 279 (55%) Second: 35% Intensive Outpatient: 62 (12%) Third:16% Brief Intervention: 348 (68%) Comparison First trimester entering care: WV 2016: 79.5%

Additional Top 10 Referrals Made Type/Source Number (Percent) WIC 292 (62%) AA/NA 285 (59%) Right From the Start 153 (35%) CPS 135 (29%) Transportation 130 (27%) Postpartum Medical 117 (25%) Public Assistance 100 (21%) Dental 80 (17%) Education/Vocation 76 (16%) Family Planning 68 (14%) Referred to other substance abuse treatment program? Yes: 141 Inpatient: 48 Outpatient: 43 Both: 50

Outcomes 354 Program Completers 510 participants 200 (38%) completed/ in program 310 (62%) left program 154 (50%) after delivery 156 (50%) prior to delivery 69 (45%) noncompliance 64 (42%) lost to follow-up 27 reasons included: Personal preference (67%) Moved (19%) Incarcerated (15%) 21 (14%) referred to higher level of care 2 N/A Outcomes 354 Program Completers

Outcomes Positive Urine Drug Screens For program completers (N=354) First Trimester 194 participants 156 (80%) positive Second Trimester 297 participants 142 (48%) positive Third Trimester 354 participants 86 (24%) positive At Delivery 73 (21%) positive Positive Urine Drug Screens For program completers (N=354) Does not include positive drug screens prior to program entry Positives generally defined as non-prescribed

Outcomes 46% 21% 20% 53% 19% 17% -- 26% Positive Urine Drug Screens Entering first trimester 46% 21% 20% Entering second trimester 53% 19% 17% Entering third trimester -- 26% Positive at second trimester Positive at third trimester Positive at delivery Outcomes Positive Urine Drug Screens Earlier trimester entering program associated with improved outcomes Improvements across all

Outcomes Live, term birth: 83% Live, preterm births: 8% 131 (47%) Birth Outcomes Live, term birth: 83% Live, preterm births: 8% Positive Cord Tissue 131 (47%) Of positives, for prescription drugs only? 33 (45%) NAS: Yes: 112 (44%) Comparison Preterm: WATCH: 14% WV 2016: 11.8% For program completers (N=354), positive cord numbers may be conservative due to data entry of the pilot Comparison NAS: WATCH: 38% WV 2016: 4.6%

Summary: Demographics DFMB Program is reaching high-risk, medically-underserved women, including high percentages of: Low education Low income Medicaid insurance Unplanned pregnancies

Summary: Demographics Comparisons with WATCH/Birth Score Intent to breastfeed actually an outcome: higher percentages than Birth Score data Otherwise, demographics consistently more high-risk DFMB has the potential to expand: Better regional medical coverage Efforts targeting smoking and cannabis use during pregnancy Expansion to include all substance-use pregnancies Expand demographic reach (e.g. WATCH)

Summary: Outcomes Positive urine drug screens decreased from 80% at first trimester to 21% at delivery Comparisons with WATCH/Birth Score Lower pre-term delivery percentage Higher percentage NAS diagnosis Perhaps due to definition and increased awareness of newborn need for treatment High percent on Medication Assisted Treatment

Summary: Outcomes DFMB has the potential to expand: Getting women into DFMB and prenatal care sooner Outcomes are among program completers, need to improve follow-up (especially post-delivery) Number of readmissions suggests increased opportunity for expanding birth control education and options Expansion of referral education and follow-up

Questions and Answers