1. KIDS NOW Plus Substance Abuse and Pregnancy Initiative Kentucky Division of Behavioral Health Fran Belvin, MA, LPAT Funded in part by Tobacco Settlement dollars through the Kentucky Early Childhood Development Funding Authority

2. KIDS NOW Early Childhood Development Authority Other KIDS NOW Programs: Immunizations Newborn Hearing Screening Eye Examinations Folic Acid Public health home visitation (0-2) Early childhood mental health (0-5) Child care subsidy, quality rating system

3. Competitive Grants Awarded to 8 Community Mental Health Regions (36 counties served)

4. FUNDING $900,000 Tobacco Settlement 151, 890 KY Div. of Behavioral Health $ 951,890 Total FY 2011 PERSONNEL Case managers 13 FTE Prevention specialists 6.5 FTE State-level administrator 1 FTE

5. KIDS NOW Plus Substance Abuse and Pregnancy Program MISSION: to reduce harm to Kentucky children from maternal substance use during and after pregnancy.

6. Yes, and… Because pregnant women using alcohol and drugs often have complex challenges including mental health problems and victimization, and because these challenges also contribute to poor birth outcomes, the KIDS NOW Plus program includes assessment and linkage with other needed services.

7. Ambivalence about giving up substance – Substance abuse/dependence – Self-medicating a mental illness Shame/stigma Fear of losing custody Fear of prosecution Common Barriers to Seeking Help: Why Pregnant Women are a “Difficult Population to Reach”

8. More Barriers to Seeking Help During Pregnancy Influence of family & friends Coercion from boyfriend/husband Domestic violence Lack of readily available services Cost of treatment Transportation

9. Unintentional Barriers set up in the Health Care Setting We don’t ask, How we ask - “You don’t use alcohol or drugs, do you?” Fast pace of clinic Our own discomfort Our judgmental attitude Resistance (Lack of skill -- we have gotten “ahead of her” in the change process)

10. Referrals to KIDS NOW Plus – Health Departments – Local Physicians – High School Youth Service Centers – Department for Community Based Services – Drug Courts – Spouse Abuse Shelters – Pregnancy Crisis Centers – Internal Mental Health Center referrals

11. KIDS NOW Plus Substance Abuse and Pregnancy Initiative Pregnant women have varying levels of risk for ATOD use in combination with other risk factors, so a continuum of care is needed: OUTREACH SCREENING SUBSTANCE ABUSE PREVENTION CLASSES ASSESSMENT INTENSIVE CASE MANAGEMENT REFERRALS TO TREATMENT

12. Collaboration with Community Partners Health departments Private physicians Department for Community Based Services (child protection) Drug Courts Domestic violence shelters Pregnancy crisis centers High schools Etc.

13. Referrals Prevention Specialist participates in boards and advisory groups Provider incentives Training for referral sources on screening and brief intervention protocols Follow-up with referral sources Memoranda of Understanding (MOUs)

14. Screening Identifies Risk Self-report screening is effective Determines whether a referral is needed Should be universal Should be repeated multiple times during pregnancy May be integrated into health history Opportunity to educate all pregnant patients about the risks of substance use

15. Screening Tool: Level 1: Substance Use and Pregnancy Health Risk Questionnaire* Friends, family, partner SA problem Mental health symptoms Alcohol, drug, and tobacco use –“Before you knew you were pregnant” –“Past 30 days” Domestic violence * Completed by medical provider or KN+ worker

16. Negative screen (all “no” responses) Reinforce healthy decisions Provide brochure/fact sheet Invite to universal prevention class

17. Positive screen (any “yes” responses) BRIEF INTERVENTION: Ask permission to discuss her responses Review them with her State your concern Advise abstinence Ask if she is willing to accept help: If yes, refer to KN+ If not, what step is she willing to take? Follow up at every prenatal visit

18. Levels of Prevention Services Universal – For any pregnant woman Risks associated with alcohol, tobacco or another drug use during pregnancy and lactation, including risks to a fetus, such as low birth weight and fetal alcohol syndrome. Selective – For women who are not using ATOD during pregnancy but are at risk for substance abuse problems later in life Family AOD history Significant others w/AOD problems Mental health problems Victims of physical, sexual and emotional abuse

19. Levels of Prevention Services Indicated – For pregnant women who have received a substance abuse assessment, and assessment indicates: AOD use during pregnancy at a sub-clinical level or Have exhibited problems associated with AOD use prior to pregnancy

20.  Meet with woman at OB office, health department, home visit, office  Assist with housing, finances, baby items etc.  Complete Baseline screen to identify areas of risk: substance use, stress, victimization, mental health problems  Create individualized service plan based on Baseline screen  Appropriate level of contact  Use incentives to increase engagement  “Pretreatment” - to increase motivation for treatment  Support attendance at prenatal appointments  Follow woman through pregnancy and 6 weeks postpartum whether in treatment or not Outreach Case Management Services

21. 1. Medical provider completes Level 1 Screen Screen is Negative 2.Medical provider gives patient educational brochure & invitation to substance abuse universal prevention class 2.Medical provider delivers Brief Intervention & refers to KIDS NOW Plus 3. KIDS NOW Plus reviews Level 1 Screen and offers prevention and/or case management services Screen is Positive KIDS NOW Plus Services 4.KIDS NOW Plus case manager: Engages through traditional case management and incentives Completes in-depth screen Refers to SA, MH, DV, smoking cessation services Builds readiness for accepting referrals Encourages abstinence (MI) Supports attendance at prenatal appointments

22. Evidence-Based Practices Universal Screening Cannot tell who is using by appearances Brief Intervention Medical provider Intensive Case Management To address complexity of needs Motivational Interviewing Empathy, collaboration, autonomy Motivational Incentives Incentivize target behaviors

23. Gender Specific Treatment Trauma Informed Care Parenting education Family services Health services Educational and vocational services Case management Pregnant women are considered a priority population by the Federal SA Block Grant: requires that services are offered within 48 hours of initial contact.

24. FY 2009 DATA Women Served 1,366 – Received Universal prevention 171 – Received Selective or Indicated prevention 667 – Received case management services 360 – Received baseline assessments 195 – Received postnatal follow-up assessments 4,551 face-to-face case management contacts (average 3.33 visits per client)

25. Mental Health Problems Reported at Baseline (n=360)

26. DSM-IV Diagnoses (n = 360)

27. Partner Violence in the Past Year Reported at Baseline (n=360) Psychological abuse Physical abuse Extreme jealousy Harrassing behavior Forced sex

28. Percent of Clients Reporting Substance Use Prior to Knowledge of Pregnancy (n = 360)

29. Changes in mental health from baseline to postnatal and rate of change (n = 195) DepressionThoughts of hurting self IrritableOthers notice irritability Full of selfExcessively anxious ↓ 13.3%* ↓ 33.9% ↓ 42.9%** ↓ 31.7%*** ↓ 13.3% ↓ 27.5%*** *** p <.001, ** p <.01, * p <.05 a time frames used at baseline and follow-up are not necessarily the same b Significance established using z-test for proportions

30. Percent of clients reporting partner victimization from baseline to postnatal and rate of change (n = 195) Psychological abuse Physical abuse Extreme jealousy Harrassing behavior Forced sex ↓ 93.5%*** ↓ 73.5%*** ↓ 76.8%*** ↓ 89.1%*** ↓ 100.0%*

31. Percent of Follow-up Clients Reporting Substance Use: (1)Prior to Knowledge of Pregnancy; (2) at Baseline; and (3) at Postnatal and Rate of Change Between (1) and (2) (n = 195) ↓ 16.0%** During ↓ 86.0%*** During ↓ 49.2%* During ↓ 47.6%* During

32. Percent of Follow-up Clients Reporting Specific Illegal Drug Use Among Those Reporting Illegal Drug Use: (1) Prior to Knowledge of Pregnancy; (2) at Baseline; and (3) at Postnatal and Rate of Change between (1) and (2) (n = 51) Marijuana Cocaine Methamphetamine Amphetamine ↓48.9%*** During D ↓50.0% During ↓74.4% During ↓100% During

33. Percent of clients reporting specific prescription drug use prior to and during pregnancy among those reporting prescription drug use at prior and rate of change (n = 36) ↓100%*** During ↓66.3% During ↓100%** During ↓83.2%* During ↓100%*** During

34. Birth Outcomes Compared to Matched Group and General Population (n=189) Comparison group matched on: – Age – Race – Education – County of residence

35. Demographics Kids Now clients (n = 189) Comparison group (n = 189) General population (n = 189) Race* White94.2%95.2%87.8% Black4.2% 6.9% Other1.6%0.5%5.3% Education*** No high school degree33.7%33.9%16.9% High school graduate or GED43.9%43.4%27.0% College22.5%22.8%56.1% Avg. age***24.2 26.1 Married***35.6%52.4%55.0% Urban/rural status*** Metro35.3% 57.8% Non metro49.5%49.7%34.4% Very rural15.2%15.0%7.8%

36. Source of pay for birth of baby

37. Average birth weight (in grams)

38. Percent of babies with low birth weight (< 2500 grams)

39. Percent of premature births (less than 37 weeks gestation)

40. Gestational weeks for KIDS NOW Plus a comparison group, and the general population

41. Final APGAR scores

42. KIDS NOW Plus KY Division of Behavioral Health Fran Belvin fran.belvin@ky.gov