C.A.R.E. WORKGROUP JANUARY 30, 2015 Virginia Laws Regarding Substance Use During Pregnancy 1

§ (1992) §63.2 – 1509 B (1998;2012) § (2012) Prenatal care providers must conduct a medical history to screen all pregnant women for substance use Providers must report substance exposed newborns to CPS Hospitals must refer postpartum substance using women to her CSB Virginia’s Substance Exposed Newborn (SEN) Laws 2

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Service Provided: SFY 2014  1071 SEN reports to CPS (§63.2 – 1509 B)  CSBs offered services to 335 hospital referred postpartum women (§ )  CSBs assessed 367 pregnant women for substance abuse 132 Self referrals 103 Criminal Justice referrals: Court/probation /correctional facility/ police/ parole/ A.S.A.P/ D.U.I. 29 DSS referrals: TANF/child welfare 15 Medical referrals: Hospital/physician/Health Dept Other SA or MH programs 41 other community/school/family/friend 24 unknown or not collected 4

All Ears?? 5

Prenatal Care: § All prenatal care providers shall routinely establish and implement a medical history protocol for screening pregnant women for substance abuse to determine the need for a specific substance abuse evaluation The protocol shall include, but need not be limited to, a description of the screening device and should address the abuse of both legal and i llegal substances The medical history screening may be followed, as necessary and appropriate, with a thorough substance abuse evaluation. 6

Confidentiality Results of the screening and substance abuse evaluation is confidential and protected by the federal confidentiality regulations, 42CFR. If 42CFR does not apply, these results may only be shared  with the woman/ her legally authorized representative  Any person designated in a written release by the woman/her legal representative  Health care providers for purpose of consultation and/or providing treatment 7

Expectations Results of the required screening or any specific substance abuse evaluation conducted as part of the prenatal care shall not be admissible in any criminal proceeding. Practitioners shall advise their patients of :  the results of the screening and substance abuse evaluation  appropriate treatment and the potential for poor birth outcomes from substance abuse if positive for use.  And provide such information to third-party payers for reimbursement of the costs of medical care. 8

Review: Prenatal Care: § EVERY prenatal care provider must: 1. Screen ALL pregnant women to determine her need for a substance use evaluation 2. Establish & implement a medical history protocol which addresses both legal and illegal substance use 3. If a woman’s history of use is positive, advise her regarding the potential for poor birth outcomes and refer her for appropriate services. ENSURES screening results are: 1. Confidential 2. Not admissible in any criminal proceedings

§ :Concerns Pre-dates advances in screening and development of the SBIRT model. Requires that providers take a medical history of substance use. It doesn’t require they use a “screening tool”. Requires that providers “advise” women regarding results of screening and possible negative birth outcomes. Doesn’t require that provider “refer” her to treatment 10

Postpartum Identification Code of Virginia § : medical providers must file a report with CPS whenever they suspect a newborn was exposed in utero to alcohol or a controlled substance Code of Virginia § : hospitals must develop a discharge plan for identified substance using postpartum women and refer them to their community service board (CSB) to implement the plan. Code of Virginia also mandated that DBHDS, DSS, VDH and Office of the Executive Secretary of the Supreme Court provide an annual study in 2000,2001 and 2002 regarding implementation of the legislation. 11

§63.2 – 1509 B: SEN Report to CPS 12

If, within 6 weeks of birth, they find that: 1. a toxicology study of the child indicates the presence of a controlled substance not prescribed for the mother by a physician or 2. the child was born dependent on a controlled substance which was not prescribed by a physician for the mother and has demonstrated withdrawal symptoms; Health Care Providers Must Report 13

And/Or If, at any time following a child's birth, they find 3. the child has an illness, disease or condition which, to a reasonable degree of medical certainty, is attributable to in utero exposure to a controlled substance which was not prescribed by a physician for the mother or the child or, 4. the child has a diagnosable fetal alcohol spectrum disorder attributable to in utero exposure to alcohol. 14

Penalties The reporter is immune from civil or criminal liability or administrative penalty or sanction unless they acted in bad faith or with malicious purpose. Providers who are required to file a report but fail to do so as soon as possible (but not longer than 24 hours after having reason to suspect a reportable offense of child abuse or neglect) shall be fined not more than $500 for the first failure and for any subsequent failures not less than $1,000 15

Exceptions Individuals are not required to make a report if they know that the same matter has already been reported to the local department or the Department's toll-free child abuse and neglect hotline. 16

§63.2 – 1509 B: Review Health care providers must file a CPS report,  within 6 weeks of birth, if a newborn has a positive toxicology for drug not prescribed for mom or displays signs of withdrawal or in utero drug exposure  if at any time following a child's birth, the child has an illness or condition that could be attributable to in utero drug exposure to a drug not prescribed for the mother 17

§63.2 – 1509 B: Review Providers will not be penalized so long as they report in good faith Providers who fail to report within 24 hours will be fined 18

§63.2 – 1509 B: Concerns No uniform expectations or procedures across hospitals for drug testing infants at birth. Legislation changed in Originally required delivering physicians to report within 7 days of birth. Reporting period extended; pediatricians and other health care providers now required to also report. Law clarifies that, if a report has been made to DSS, other medical providers do not need to file an additional report. Does this relate to why hospitals aren’t referring women to the CSB per § ? 19

§63.2 – 1509 B: Questions How have delivering physicians, pediatricians & other providers been informed regarding changes in the law? Does CPS have additional procedures for investigating reports made by other health providers post delivery? 20

Hospital Referral to CSB: §

Postpartum Hospital Referrals Each licensed hospital must have and implement a protocol requiring written discharge plans for substance abusing postpartum women and their newborns. The discharge should be discussed with the woman and appropriate referrals for the mother and the infant be made and documented. Referrals may include, but are not limited to treatment services; comprehensive early intervention services for infants and toddlers and family-oriented prevention services 22

Postpartum Hospital Referrals To the extent possible, hospitals shall involve the child’s father & other extended family members who may participate in the follow-up care for the mother and the infant. Immediately upon identification, pursuant to § , of any substance-abusing, postpartum woman, the hospital shall notify, subject to federal law restrictions, the community services board to appoint a discharge plan manager. The community services board shall implement and manage the discharge plan; 23

§ : Review All hospitals must have written procedures for developing discharge plans for identified postpartum SA women and their newborns. The discharge plan must be discussed with the woman, appropriate referrals made & documented. To extent possible, the father and other family members should be involved. HOSPITAL MUST REFER THE WOMAN TO HER CSB TO IMPLEMENT HER DISCHARGE PLAN 24

§ : Questions What does “pursuant to § ” actually mean? How is it interpreted? # of hospital CPS reports are significantly higher than their #CSB referrals? Why are they so different? Does this law need to specify that the woman is being referred to CSB to be “assessed” for a possible substance use disorder? 25

Starting to Feel Restless? 26

2002 Leg. Workgroup’s Findings Few women & infants identified. Misinformation cross systems re: legislation, 42CFR & mandates governing respective services. CSB staff had difficulty locating, engaging & retaining postpartum hospital referrals. Providers lacked necessary expertise. Little communication / collaboration within or between systems. Policies, procedures, expertise, awareness & willingness address problem varied across Commonwealth. Collaboration “personality driven”. Virginia’s locally administered, state supervised social & human services system posed “challenges” to effecting change. -> 27

Subsequent Collaboration Efforts DBHDS sponsored discipline specific & interdisciplinary trainings for substance abuse, child welfare and health care providers regarding perinatal substance use, 42CFR, Virginia’s SEI legislation, collaboration etc. In collaboration with DBHDS and VDH, DSS developed a brochure for medical providers regarding the legislation Perinatal Substance Use: Promoting Healthy Outcomes In 2004, DBHDS, DSS and the Office Executive Secretary of the Supreme Court (OES) applied for and received in-depth TA from NASACW to address substance affected families involved with child welfare system 28

SEN Workgroup In 2005, brought health, child welfare, early intervention, Medicaid, and SA together to identify how we might improve identification of SENs and services for their moms. Developed screening guidelines for pregnant and parenting women for  medical providers  other providers that serve women in their homes. Identified menu of preferred screening tools for pregnant women 29

SEN Workgroup/HVC 2006: SEN Workgroup merged into Home Visiting Consortium Worked with DBHDS & DMAS to approve pregnancy specific screening tools for Medicaid reimbursement Developed Virginia Behavioral Health Risks Screening Tool for pregnant women and women of child bearing Age. Developed screening and brief intervention resources for home visitors and other providers including HV 3 part series on Screening and Brief Intervention 30

What’s Different in 2015 ? Women & infants are still under identified. Misinformation cross systems re: legislation, 42CFR & mandates governing respective services still exists. CSB staff still have difficulty locating, engaging & retaining postpartum hospital referrals but are better & are working more with CPS. Many providers still lack necessary expertise &/ or referral information 31

Communication / collaboration within or between systems better but still lacking when it comes to developing policies regarding this population. Policies, procedures, expertise, awareness & willingness address problem has increased across Commonwealth. Collaboration remains “personality driven”. Virginia’s locally administered, state supervised social & human services system still poses “challenges” to effecting change. 32

Things to Consider 33 Where’s the problem? the laws, their implementation or both? What other information do we need before we can suggest solutions? Do the laws need to be updated or revised? Pro’s and cons of trying? Other initiatives/efforts we sh0uld interface with? Low hanging fruit?

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Done 35