1. Pregnant and Parenting Women and Substance Abuse Treatment
Raquel Mazon Jeffers
Division of Addiction Services Director

2. Overview
DAS is the Single State Agency for substance abuse in New Jersey, and as such, plans, licenses, monitors and regulates New Jersey substance abuse treatment and prevention efforts
DAS provides funding for services through both federal and state funding streams, with our primary funding source of the Substance Abuse Prevention and Treatment Block Grant, which totals approximately $47 million annually
Total budget of $167 million for SFY 2010
As of September 2009, there are 279 outpatient and 60 residential facilities licensed by DAS
DAS has 308 Contracts and 217 Letters of Agreement for treatment and prevention services, including contracts with the counties

3. DAS Mission Statement
The Division of Addiction Services (DAS) promotes the prevention and treatment of substance abuse and supports the recovery of individuals affected by the chronic disease of addiction. As the Single State Agency for substance abuse, DAS is responsible for regulating, licensing, monitoring, planning and funding substance abuse prevention, treatment and recovery support services in New Jersey.
To achieve its mission, DAS provides leadership and collaborates with providers, consumers, and other stakeholders to develop and sustain a system of client-centered care that is accessible, culturally competent, accountable to the public, and grounded in best practices that yield measurable results.

4. DAS Vision
Addiction is situated within a public health paradigm where:
Early detection and assessment protocols begin with client engagement
Prompt and effective treatment is provided meeting a standard of care
All substance abuse and mental health programs are competent to screen, assess and address co-occurring mental health and substance abuse disorders
Prevention measures are employed throughout the life cycle and continuum
Consumers are active, informed and educated participants in their own recovery
Collaboration occurs regularly with mental health and primary health care systems
The use of best practices is widespread, including the latest pharmacotherapeutic responses
The financing of system promotes client outcomes 4

5. Addiction: A Chronic Illness
Addiction is a chronic, relapsing brain disease characterized by compulsive drug craving, seeking and use that persist even in the face of extremely negative consequences.
Addiction can cause permanent changes in brain structure and chemistry. It’s a brain disorder with the requisite characteristics of a medical illness.
There are effective medical and public health approaches to the problem of addiction.
Just as with diabetes, hypertension or asthma, for a person suffering with addiction, ongoing disease management is essential

6. Prevalence and Scope of Substance Abuse
Substance use disorders are a chronic disease identified in about 9.5% of the general population (about 24 million Americans over the age of 12), approximately the same number that suffers from Type II Diabetes
Substance use disorders are associated with over 110,000 deaths annually and are the second leading cause of disability

7. Substance Abuse Treatment Need and Demand
6,589,930 Million Adult NJ Residents
No need for treatment – 5,772,779
Need for treatment – 817,151 (12.3%)
Demand treatment – 86,866 (10.6%)
Met demand – 53,586 (62%)
Unmet demand – 33,280 (38%)

10. Treatment Outcomes in Comparison to Other Chronic Medical Conditions
Alcoholism % abstinent
Opioid Dependence % abstinent
Cocaine Dependence % abstinent
Nicotine Dependence % abstinent
Diabetes (relapse) % stable
Hypertension (poor control) %
Asthma (multiple ER visits) %
(Source: Gaber, Davidson, 1992; McLellan 2002)
The message is TREATMENT WORKS!

11. Addiction Treatment Outcomes in NJ
FY09 data on outcome measures at discharge for individuals completing publicly funded addiction treatment in New Jersey are:
Intensive Outpatient (12,808 discharges)
Abstinence from alcohol in past 30 days 31.5% increase
Abstinence from other drugs in past 30 days 38.5% increase
Change in being employed % increase
Arrests in past 30 days % decrease
Homelessness % decrease
Short term Residential (6,406 discharges)
Abstinence from alcohol in past 30 days 46.9% increase
Abstinence from other drugs in past 30 days 72.6% increase
Change in being employed % increase
Arrests in past 30 days % decrease
Homelessness % decrease

12. Pregnant and Parenting Women
SAMHSA’s Office of Applied Studies:
5.5% of women ages 18 – 49 who have one or more children living with them are substance abusers
70% of women entering treatment report having children
30% of the more than 13,000 treatment programs in US offer specialty programs for women; 14% offer programs for pregnant women

13. NJ Special Populations-Women
Pregnant/Postpartum Women (PPW)-Priority
Pregnant women need immediate access to prenatal care to meet admissions criteria for substance abuse treatment.
Women with dependent children (WDC)
Women with dependent children who are attempting to regain custody of their children

14. Women and Treatment
Historically, women were treated in men’s programs using male-dominated models
Women’s treatment changed through the years with the advent of gender specific approaches
Federal Substance Abuse Prevention and Treatment Block Grant Women’s Set Aside funding for Gender Specific Treatment
2004 – Department of Children and Families DYFS funding for child welfare reform

15. Personal Barriers for PPW/WDC
Fear of reprisal from significant others or family members
Confidentiality concerns
Linguistic or cultural barriers
Social stigma
Fear of child protection involvement (DYFS)
Financial (lack of money, insurance)

16. Systems Barriers for PPW/WDC
Lack of money or insurance
Waiting lists
Lack of treatment for pregnant women
Childcare
Employment
Housing
Need for time to address demands of other systems i.e., DYFS, TANF, Courts

17. Women and Trauma Treatment staff must be trained to:
Understand multiple and complex links among violence, trauma and addiction
Understand trauma related symptoms as attempts to cope
Understand that violence & victimization play large and complex roles for the women

18. SFY09 NJ Statewide Substance Abuse Admissions
Female,
19,512,
31%
Male,
42,879,
69%

19. 12% of funding for 20% of PPW admissions

20. Women Specific Outcome Data
Logistic Regression is a model used for prediction of the probability of an event occurring.
A logistic regression analysis indicated that women had significantly poor odds, i.e., poor outcomes, for not using drugs or being fully employed at discharge

25. Parent / pregnant women Primary Drug Using
Cocaine
13%
Alcohol
29%
Heroin/Other
Opiates
41%
Marijuana
77%
23%
Non Smoke
Smoke

26. IOP/OP makes up 50% of admissions but only 28% of funding
41% funding for LTR which makes up only 5% of admissions

27. NJ Funding - PPW & WDC Treatment
$6 million funding through Federal Substance Abuse Prevention and Treatment Block Grant Women’s Set Aside
$12 million State funding (Child Welfare)
Supports a statewide network of 48 licensed substance abuse treatment providers
Supports all modalities of care (IOP, IOP with Housing, Methadone IOP, LTR, HH)

28. Gender Specific Treatment
Gender specific therapies
Assessment and treatment for co-occurring disorders
Family centered treatment approach
Individual counseling sessions
Family counseling sessions
Trauma Informed/Trauma Specific treatment using “Seeking Safety Program”
Group and educational counseling sessions
Case management services including referrals and follow-up throughout continuum of care and recovery support

29. Gender Specific Treatment-Cont.
Childcare – to focus on developmental needs and age appropriate activities;
Children referred for medical (including immunization and/or psychological care as needed)
Primary medical care including referral for prenatal care
Evidence based Parenting Skills Curriculum
Strengthening Families Program
Life Skills Training (budgeting, nutrition, household, child safety)
Linkages and recovery management and supports
Housing support and assistance, helping women with children access permanent housing
Transportation

30. Moving Forward in NJ Recovery Zone Targeted Case Management
“Keeping Families Together” Pilot
In-Depth Technical Assistance – National Center of Substance Abuse and Child Welfare
National Association of Drug and Alcohol Directors (NASADAD) & CSAT Guidance to States: Treatment Standards for Women with Substance Use Disorders in NJ Regulations
NIATx
SBIRT
Medical Homes

31. Recovery Zone

32. Who Does Well in Current System of Care ?
The acute care model often works best for individuals with high “recovery capital” (internal and external resources)
The acute care model does not voluntarily attract the majority of individuals with low recovery capital, i.e., people who experience co-occurring issues of poverty, homelessness, unemployment, mental illness and poor physical health.
These are the very individuals the public sector dollars are targeted to serve.

33. What is Recovery?
Recovery refers to the ways in which persons with or affected by addiction tap resources within and beyond the self to move beyond experiencing these disorders to managing them and their residual effects to build full, meaningful lives in the community.
It is regaining wholeness, connection to the community, and a purpose-filled life.
(White, W. and Davidson, L. Recovery: The bridge to integration? Part one. Behavioral Healthcare, November 2006)

34. What is Recovery Oriented Care?
Recovery-oriented care shifts the design of the addiction treatment system from an acute care model, focused on serial episodes of biophysical stabilization to a model of sustained recovery management.
Recovery-oriented care focuses on the acquisition and maintenance of recovery capital (internal and external assets required for recovery initiation and self-maintenance), global health (physical, emotional, relational, and spiritual), and community integration (meaningful roles, relationships, and activities).
(White, W. and Davidson, L. Recovery: The bridge to integration? Part one. Behavioral Healthcare, November 2006)

35. The Recovery Zone
The Recovery Zone is a term used to describe a state of sustained recovery characterized by long periods of abstinence, gainful employment, stable housing and supportive and rewarding social and spiritual connectedness
A client’s entry and stabilization in the Recovery Zone is accomplished by reducing service fragmentation, promoting service continuity, and increasing clients’ capacity to manage their chronic disease more effectively
Efforts to promote client movement into and ability to sustain the Recovery Zone is central to the work of DAS

37. Targeted Case Management

38. Targeted Case Management (TCM)
The goal of TCM is to facilitate a client’s entrance and stabilization in the Recovery Zone
The objectives of TCM are:
Reduce the need for intensive care
Experience less acute and frequent symptoms
Receive less costly and less restrictive levels of care
Free up capacity in the treatment system to meet demand in New Jersey
Improve outcomes

39. TCM Activities Assess and document eligibly
Comprehensive assessment and re-assessment using a recovery assessment tool
Development of recovery service plans
Revision of service plans
Convening team meetings with treatment and other service providers to support linkages, coordination of care and continuum of care planning
Referral to related needed services
Monitoring
Collateral contacts with family and services providers

40. Envisioned TCM Service Outcomes
Reduction in frequency of admissions to LTR, Detox, STR
Increase in frequency to OP levels of care
Decrease in duration of Detox, STR, LTR, episodes
Reduced cost per client
Increased Medicaid revenue

41. “Keeping Families Together” Pilot

42. What is the “Keeping Families Together” Project?
Demonstration Project: Illustrate through program evaluation that permanent supportive housing with child welfare preventive services can prevent family separation and child removal, increase housing stability, and improve family functioning among most vulnerable and high-risk families
Capacity Building Effort: Assist providers to: 1) better understand the complex needs of child-welfare involved families and 2) develop strategies to meet those needs
Systems Change Initiative: Establish permanent supportive housing as part of child welfare system and improve collaboration between multiple service systems

43. NJ “Keeping Families Together” (KFT) Pilot
NY Model (OASAS, NYC Child Protective Services and Corporation for Supportive Housing (CSH)
Permanent Supportive Housing Program
Implements a family focused approach with full array of services on and off site to substance abusing child welfare involved families
Services designed to prevent further child welfare involvement and enhance family functioning
Housing is barrier to treatment for women with children who enter residential facilities
Housing is part of early treatment planning as women face homelessness at discharge, variety of reasons
CSH developed model to demonstrate impact of supportive housing for chronically homeless and child welfare involved families

44. NJ “KFT” Pilot-Cont.
Department of Human Services (DHS) and Department of Children and Families (DCF) created:
Interagency workgroup (DCA, DMHS, DFD, DYFS, DAS, DLWD, Medicaid, NJHMFA)
Identify resources to create a NJ pilot of “KFT” model for homeless, substance abusing DYFS involved families

45. NJ “KFT” Pilot-Cont. KFT Model:
Integrates and enhances units of permanent supportive housing for homeless substance abusing child welfare involved families
Implements a family focused approach with full array of services on and off site
Services designed to prevent further child welfare involvement
Enhances family functioning

46. IDTA

47. IDTA Overview
Cross system collaboration to improve outcomes for children and families where substance abuse issues are involved in child welfare and the courts
Joint outcomes and data integration among DYFS, DAS and the Courts
Implementing best practice models across the systems
Professional training and staff development
Recovery support specialists

48. Guidance to the States

49. NASADAD/CSAT Guidance to the States
Treatment standards for women with substance use disorders
Addresses full continuum of treatment services
Includes 25 core elements recommended for best practice treatment for PPW/WDC
Help states develop women’s treatment standards to build on capabilities and strengths in our own system
Adopt into NJ Regulatory framework

50. Federal Recommended Best Practice for PW/WDC
Screening:
Use standardized, brief, gender-specific protocol
Determine whether woman is pregnant, stage of pregnancy and link with appropriate medical service
Providers use screening process to educate women regarding effects of substance use on fetus, importance of using family-planning protection, and need to stop all use if they wish or think they may become pregnant

51. Best Practices-Cont Medical Care/Primary Health Care
PPW/WDC have co-occurring acute or chronic health problems neglected or exacerbated during substance use
Provide onsite or be referral to care providers who are sensitive to issues of gender, addiction, mental health, trauma

52. Best Practices-Cont. Family Centered Treatment Approach
Treatment that addresses full range of women’s needs with an array of:
Clinical Treatment Services – address medical and bio-psychosocial issues of addiction;
Clinical Support Services –assist clients to maintain recovery i.e., life skills, linkages, child development, employment readiness, housing support;
Community Support Services – services/resources outside treatment but within the community that is support system for recovering woman and her family

53. SBIRT

54. Integrating Substance Abuse into Primary Care
Primary care defined as “integrated and accessible health services provided by primary care clinicians” is the gateway for public health interventions
The early identification and treatment of alcohol and drug use problems is a public health imperative
Clinicians in the primary care setting have the unique opportunity to play a key role in detecting alcohol and other drug use problems, and in initiating prevention or treatment efforts
The federal government is calling generalist physicians the “first line of defense against substance abuse and addiction”

55. Screening, Brief Intervention and Referral to Treatment
The purpose of Screening, Brief Intervention, Referral and Treatment (SBIRT) is to expand the State’s continuum of care into general medical and other community settings
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.
Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.
This will support clinically appropriate services for persons at risk for or diagnosed with a substance use disorder (i.e., substance abuse or dependence) and identify systems and policy changes to increase access to treatment in generalist and specialist settings

56. Screening, Brief Intervention and Referral to Treatment (con’t)
Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment
Brief Intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change
Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care
A key aspect of SBIRT is the integration and coordination of screening and treatment components into a system of services.
This system links a community's specialized treatment programs with a network of early intervention and referral activities that are conducted in medical and social service settings.

57. Groundswell of National Support for Routine Screening of AOD
Beginning in 2003, the federal Substance Abuse and Mental Health Services Administration established a major initiative to support the development of screening, brief intervention and referral to treatment (SBIRT) programs
To date, fifteen cooperative agreements have been federally funded, implementing SBIRT in hospital emergency departments, trauma centers and primary care centers
American College of Surgeons, Committee on Trauma requires that Level 1 and Level 2 Trauma Centers provide SBI to meet accreditation standards
The Joint Commission (formerly JCAHO) has recently proposed SBIRT for all inpatients over the age of 12 as part of its core measures for hospital accreditation (review of public comments in progress, if approved these measures will bring addiction into mainstream medicine)

58. SBIRT Data
One State study of SBIRT among working-age, disabled Medicaid patients shows an estimated reduction in Medicaid costs per member per month of $366 for all patients, including those referred for treatment
For patients in the same study who received a brief intervention only, the estimated reduction in Medicaid per member per month costs was $542
The SBIRT program was also associated with decreased inpatient utilization (p=.04)
The same study concludes that SBIRT works especially well in hospital emergency departments given the large number of injured patients and other conditions related to substance abuse
SBIRT saves $$ 58

59. Medical Homes

60. Patient-Centered Medical Home
The patient-centered medical home (PCMH) concept is not new; it has its origins in pediatric care.
In recent years, the concept is expanding as the general healthcare system shifts focus from episodic care to managing the health of defined populations, especially those with chronic health conditions.
At the core of the patient-centered medical home is team based care that provides care management and supports individuals in their self management goals.
The medical home’s emphasis on self-care resonates with the behavioral health system’s movement towards a Recovery and Resilience orientation.

61. Conclusion
DAS continues to work with multiple systems and stakeholders at the local and State level on behalf of PPW/WDC to:
Improve coordination and collaboration among systems and stakeholders
Provide increased access to substance abuse treatment to ensure continuity of care