1. Preventing Pre-Natal Exposure: A Collaborative Effort Toward “Superior Babies”

2. Diane Torrel, PHN 218-749-0613torreld@co.st-louis.mn.us Carol Peterson, CD Counselor/LADC 218-749-2877 Julie Jagim, PHN Supervisor 218-725-5243jagimj@co.st-louis.mn.us Association of Maternal and Child Health Programs February 12-15, 2011

3. Program Goals 1. Reduce the incidence of Fetal Alcohol Spectrum Disorders (FASD) and other chemically related health effects by identifying and serving pregnant women suspected of or known to use or abuse alcohol and other drugs. 2. Promote healthy birth outcomes, normal growth and development and positive parenting.

4. Maternal – Child Health Teaching Sobriety Support Relapse Prevention LADC Public Health Nurse Home Visiting & Random UA’s Intensive Case Management

5. Program Components

6. Referral Sources Social Services Social Services Probation Probation Clinics Clinics WIC Program WIC Program Chemical Dependency Treatment Professionals Chemical Dependency Treatment Professionals Self/family Self/family

7. Participation Admission: As early in pregnancy as possible Admission: As early in pregnancy as possible Continued postpartum involvement Continued postpartum involvement with sobriety as a goal with sobriety as a goal Graduation: Baby’s 2 nd Birthday Graduation: Baby’s 2 nd Birthday

8. Activities Frequent Home Visits Frequent Home Visits Random UA’s Random UA’s Intensive Case Management Intensive Case Management Team Approach of PHN & LADC with regular communication Team Approach of PHN & LADC with regular communication Establish positive trusting relationship with client Establish positive trusting relationship with client Monthly team staffing with Supervisor Monthly team staffing with Supervisor Client Incentives Client Incentives Toxicology tests at birth Toxicology tests at birth

9. Interventions Collaborative case-management Collaborative case-management –Discipline specific visit protocols Multidisciplinary Approach Multidisciplinary Approach – Public Health Nurse – Licensed Alcohol and Drug Counselor Multiple types of contacts Multiple types of contacts –Home visits (primarily), office visits, telephone contacts, collateral contacts

10. Interventions Assessment and Education NCAST Tools & ScalesNCAST Tools & Scales Home Safety ChecklistHome Safety Checklist Developmental Screening ToolsDevelopmental Screening Tools Adult -Adolescent Parenting Inventory (AAPI-2)Adult -Adolescent Parenting Inventory (AAPI-2) Depression ScreeningDepression Screening Bonding/Attachment VideosBonding/Attachment Videos Toxicology at birthToxicology at birth Chemical Use Assessment and RecommendationsChemical Use Assessment and Recommendations Relapse Prevention EducationRelapse Prevention Education Random Drug ScreeningRandom Drug Screening Video of Parent-Child InteractionVideo of Parent-Child Interaction

11. Interventions Support and Advocacy Support and Advocacy Referrals to Community Resources Referrals to Community Resources Transportation Transportation Housing Housing Mental Health Mental Health Education and Employment Education and Employment Parenting ( Early Headstart and ECFE) Parenting ( Early Headstart and ECFE) CD Treatment and 12-step involvement CD Treatment and 12-step involvement

12. 2004 Evaluation

13. Participant Characteristics Generally young, 74% were < 30 years old Generally young, 74% were < 30 years old Half entered SB in the first trimester Half entered SB in the first trimester Almost half had previous chemical dependency treatment Almost half had previous chemical dependency treatment Nearly half have mental health issues Nearly half have mental health issues Over half had income below Federal Poverty Guidelines Over half had income below Federal Poverty Guidelines One-third of the women had previous criminal justice system involvement One-third of the women had previous criminal justice system involvement 2004

14. Program Strengths Serves appropriate clients Serves appropriate clients Effective interdisciplinary model Effective interdisciplinary model Consistent Staff Consistent Staff Frequent communication between team members; regular clinical staffing Frequent communication between team members; regular clinical staffing Regular random UA’s for toxicology Regular random UA’s for toxicology Extensive client contacts/case management Extensive client contacts/case management Good birth outcomes Good birth outcomes 2004

15. Weaknesses and Conclusions Conclusions Conclusions Significant advantage for PHN’s to partner with staff who have expertise in chemical dependency. Significant advantage for PHN’s to partner with staff who have expertise in chemical dependency. Gaining and maintaining the trust of participants is an integral part of the program. Gaining and maintaining the trust of participants is an integral part of the program. Flexibility and practical problem solving are key elements. Flexibility and practical problem solving are key elements. 2004 Weaknesses Weaknesses High drop-out rate postpartum High drop-out rate postpartum Large amount of data collection Large amount of data collection

16. 2010 Evaluation

17. 2010 Evaluation (covers 2007-2010) Examines client characteristics Examines client characteristics Summarizes outcomes Summarizes outcomes Identifies key components of program Identifies key components of program Suggests important program elements to replicate program Suggests important program elements to replicate program Provides example cost/benefit analysis Provides example cost/benefit analysis

18. Client Characteristics (N=40) CharacteristicNumberPercentage Below federal poverty level3690% Involved with child protection 1538% Mental health concerns2460% Mental health treatment at entry 1845% Criminal justice involvement1845% Prior substance abuse treatment 2152%

19. Client Use at Entry (N=40) DrugNoneDaily 3-6 times a week 1-2 times a week 1-3 times a monthUnknown Alcohol30%15%18%15% 7% Marijuana28% 20%8% Other reported use: 19 (48%) smoke 7 (18%) use methamphetamines 3 (8%) use inhalants 8 (20%) use other drugs

20. Outcomes Reported by Clients in Follow-Up Interviews (N=9 1 ) All reported good to outstanding relationship with Superior Babies staff (67% outstanding) All reported good to outstanding relationship with Superior Babies staff (67% outstanding) 89% reported reduced use of alcohol or drugs 89% reported reduced use of alcohol or drugs All reported that other families in similar situations could benefit from program All reported that other families in similar situations could benefit from program All reported their experience with Superior Babies program as very good or excellent All reported their experience with Superior Babies program as very good or excellent 89% reported SB program helped with parenting skills 89% reported SB program helped with parenting skills 89% reported that their lives were much better than they were before first contact with Superior Babies 89% reported that their lives were much better than they were before first contact with Superior Babies 1 Clients are often transient and difficult to contact after participation in the SB program

21. Birth Outcomes (N=31) Outcome# of positive outcomesResults Received 1 % positive results Birth Weight303197% Gestational Age283190% APGAR29 100% Mother Toxicology272896% Baby Toxicology242596% 1 Some APGAR and toxicology tests were not completed at hospital or not available

22. Discharge Outcomes (N=38) 58 % completed parenting training 58 % completed parenting training 21% ended involvement with child protection 21% ended involvement with child protection Of 26 known at discharge, 96% using birth control Of 26 known at discharge, 96% using birth control 50% are using mental health services 50% are using mental health services 42% are in 12-step program 42% are in 12-step program

23. Superior Babies is Administered by the St. Louis County Public Health and Human Services Department in Minnesota (supported by a grant from MOFAS)

24. Recommendations for Professionals Starting Programs for Women At-risk for FASD Focus on communication in creating PHN/LADC partnership Focus on communication in creating PHN/LADC partnership Network with other professionals (e.g., probation officers, social workers, physicians, WIC) for for referrals Network with other professionals (e.g., probation officers, social workers, physicians, WIC) for for referrals Lay out expectations for clients early in relationship Lay out expectations for clients early in relationship Incorporate intensive case management Incorporate intensive case management Work to develop trust with client through honoring who they are, visiting in home, being honest, providing support Work to develop trust with client through honoring who they are, visiting in home, being honest, providing support Incorporate regular, random urinalysis Incorporate regular, random urinalysis Meet with supervisor for regular staffing Meet with supervisor for regular staffing

25. Challenges for Program Clients are addressing multiple issues (CD, MH) Clients are addressing multiple issues (CD, MH) Many clients have transportation issues (rural) Many clients have transportation issues (rural) Difficult to facilitate group support Difficult to facilitate group support Client participation is usually voluntary Client participation is usually voluntary Funding is not secure after grant cycle Funding is not secure after grant cycle

26. Funding is a Good Investment! Mothers who are very highly at-risk are obtaining excellent birth outcomes Mothers who are very highly at-risk are obtaining excellent birth outcomes Cost of lifetime services for a child with FASD averages about $2 million (www.fasdcenter.samhsa.gov/publications/cost.cfm) Cost of lifetime services for a child with FASD averages about $2 million (www.fasdcenter.samhsa.gov/publications/cost.cfm) Cost to provide Superior Babies program for one year is less than $100,000 Cost to provide Superior Babies program for one year is less than $100,000 If only one FASD birth is prevented every 20 years, program pays for itself If only one FASD birth is prevented every 20 years, program pays for itself Very likely more FASD births and other negative birth outcomes are prevented Very likely more FASD births and other negative birth outcomes are prevented