Key Budget Assumptions

Key Budget Assumptions

One Hospitals Journey: Treatment of Opioid Dependence in Pregnancy, at Northwestern Medical Center Anna Gabaree, MSN, RNC-OB NMCs mission is to provide exceptional healthcare for our community. Conflicts of Interest Anna Gabaree MSN, RNC-OB has no conflicts of interest to disclose NMCs mission is to provide exceptional healthcare for our community.

Objectives Describe medication assisted therapy as delivered at Northwestern Medical Center during pregnancy. Discuss recommended prenatal guidelines for medication assisted therapy in pregnancy. Understand the significance of 42 CFR Part 2, as it affects communications within, and between, prescribers. Understand barriers, solutions, and outcomes as experienced by Northwestern Medical Center that could be replicated at other rural healthcare delivery systems. NMCs mission is to provide exceptional healthcare for our community. We Need To CHANGE !

Babies With NAS Maternal Opiate Use ~Patrick, 2015~ NMCs mission is to provide exceptional healthcare for our community. We Need To Change From 1999-2013 related to opiate overdose: Women - 4 fold increase in deaths Men 2 fold increase in deaths

~Gon, 2015~ NMCs mission is to provide exceptional healthcare for our community. We Need To Change Women Planning to Continue Treatment After Delivery Perhaps due to proximity to care? ~Gon, 2015~ NMCs mission is to provide exceptional healthcare for our community. Impacts Are Significant

My Community My School Systems My Playgrounds My Workplace My Family NMCs mission is to provide exceptional healthcare for our community.

Stark Reality I dont like thiswatching my kid withdrawal. I dont have a choice. I feel selfish. It is hard for me to agree to be on Subutex, but most of us are better off with it. If nobody was willing to treat us, we would be back on the street. This is hard I feel bad. Nobody could ever make me feel worse than I already make myself feel ~Quote from postpartum patient, 2016~ NMCs mission is to provide exceptional healthcare for our community. This Is Real

Our communities are important to us How do we help? NMCs mission is to provide exceptional healthcare for our community. Northwestern Medical Center NMCs mission is to provide exceptional healthcare for our community. Family Birth Center NMCs mission is to provide exceptional healthcare for our community.

Our Journey Where We Were Lack of Appropriate Services for This Population Lack of Relationship With These Families Care Out of Community

Patient Centered Care Insight Needed For Population We Were Caring For Still Showing Up for Delivery

Lack of Structured Nursing Education NMCs mission is to provide exceptional healthcare for our community. Our Journey First Steps To Change Nursing Education Provider Education ICON Improving Care of the

Opiate Exposed Newborn Administrative Support Tools NMCs mission is to provide exceptional healthcare for our community. Our Journey First Steps To Change Standardized order sets Standardized scoring tools Modified Finnegan Standardized education for

families NMCs mission is to provide exceptional healthcare for our community. Our Journey Continuing To Change 2012 - Maternal Medication Assisted Therapy (MAT) brought to community Active participation in ICON Intentional delivery at NMC NMCs mission is to provide exceptional healthcare for our community. Collaborative Education for Families Group Education Session patients of similar gestation receive education from birthing

center nurses. Neonatal Abstinence Scoring (NAS) Non-pharmacologic treatment methods Empower the family to help their child Communication Confidentiality NMCs mission is to provide exceptional healthcare for our community. Our Journey Staying The Course OBs providing MAT thy a p em

Relationsh ips with S ocial Serv ices and Care man agement h DCF t i w p i

nsh Relatio Collaborative prenatal education expectations for delivery NMCs mission is to provide exceptional healthcare for our community. ated c u d e

Literature: Opiate Abuse 4.3 million Americans engaged in non-medical use of prescription painkillers in the last month. (SAMSHA, 2014) Approximately 435,000 people were regular (past-month) users of heroin. (SAMSHA, 2014) NMCs mission is to provide exceptional healthcare for our community. Literature: Opiate Abuse Chronic Untreated Heroin Use Fetal growth restriction Abruption

Fetal death Preterm labor Intrauterine passage of meconium Why? Repeated fetal and placental exposure to opioid withdrawal ~ACOG, 2016~ NMCs mission is to provide exceptional healthcare for our community. Literature: MAT In Pregnancy Methadone vs. Buprenorphine? https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine-during-pre gnancy-reduces-neonate-distress NMCs mission is to provide exceptional healthcare for our community.

MAT In Pregnancy Currently Receiving MAT If stable on Methadone, not recommended to transition to Buprenorphine If stable on Buprenorphine, not recommended to transition to Methadone Not currently receiving MAT Consider for Buprenorphine Treatment If patient does not like or does not respond, consider transfer

to Methadone treatment Table adapted from (ACOG, 2016) and (MOTHER Study, 2012) NMCs mission is to provide exceptional healthcare for our community. Our Program - Diagnosis Consent Intake Assessment Howard Center Treatment agreement Residential Every other week

Must consider 42 CFR Part 2 visit Monthly visits Outpatient based opiate treatment Weekly visit with 2 With weekly UDS Bi-monthly UDS HUB UDS/week (with compliance to

(if stable and (1st 8 weeks) program compliant) requirements) NMC Monitoring Requirements Mandated Counseling Intensive outpatient program Individual

Group NMCs mission is to provide exceptional healthcare for our community. Outcomes At Northwestern Medical Center Overview Retrospective Chart Review September 1st, 2012 August 31, 2015 Neonatal and Maternal Outcomes Patterns of MAT care ~Gon, 2015~

NMCs mission is to provide exceptional healthcare for our community. Study Outcomes of Interest Infant Outcomes of Interest Birth Weight % Weight Loss Length of Stay APGAR Scores at 1 and 5 minutes Mode of Feeding First and Highest NAS Score Any Treatment Needed Maternal Outcomes of Interest Gestational Age at Delivery

Mode of Delivery Buprenorphine Dose Compliance with MAT Program Other Transfers Not Related to NAS ~Gon, 2015~ NMCs mission is to provide exceptional healthcare for our community. Program Compliance Very High Adherence to Program 76.3% (61 out of 80) of patients received prenatal care, MAT, and delivered at NMC. 23.7% did not deliver at NMC for various reasons

Non compliance with program (4) Elective delivery at tertiary care center Fetal demise Loss to follow up ~Gon, 2015~ NMCs mission is to provide exceptional healthcare for our community. Program Compliance Only 4 out on 80 patients in our program were

transferred for non-compliance 2 misuse of diverted oxycodone 1 misuse of diverted methadone 1 continuous cannabis use and elected to transfer care ~Gon, 2016~ NMCs mission is to provide exceptional healthcare for our community. Results Only 5% (n=3) Neonates were transferred directly related to NAS symptoms Only 7.5% (n=6) of moms receiving MAT had a

C/S 8/63 neonates were not scored ~Gon, 2016~ NMCs mission is to provide exceptional healthcare for our community. Not Scored? Limits to the 42 CFR part 2 law Known opiate addiction rate = 12% 8 out of 63 babies did not receive NAS scoring (Gon,

2015) 1 2 NMCs mission is to provide exceptional healthcare for our community. Privacy protection and 42 CFR, Part 2 Substance misuse disorders are subject to higher privacy standards than other diagnoses. This affects internal communication and emphasizes patient consent in internal communications.

NMCs mission is to provide exceptional healthcare for our community. HIPPA and 42 CFR Differ 42 CFR: http://www.samhsa.gov/about-us/who-we -are/laws/confidentiality-regulations-faqs These Frequently Asked Questions (FAQs) are for information purposes only and are not intended as legal advice. Specific questions regarding compliance with federal law should be referred to your legal counsel. State laws may NMCs mission is to provide exceptional healthcare for our community. also apply.

42 CFR FAQS QUESTION 10: Do all primary care providers who prescribe controlled substances to treat substance use disorders meet the definition of a program under Part 2? The answer is probably no in most cases NMCs mission is to provide exceptional healthcare for our community. 42 CFR FAQS Does a specific primary care provider meet the definition of a program under Part 2?

If a provider is not a general medical care facility, And it is an individual or entity that holds itself out as providing, and provides alcohol or drug abuse diagnosis, treatment or referral for treatment, then the provider meets Part 2s definition of a program NMCs mission is to provide exceptional healthcare for our 2016~ community. ~SAMSHA, 42 CFR FAQS

When does a specific facility meet the definition of a program "under Part 2? If a general medical care facility holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment or referral for treatment, it is a program under Part 2. ~SAMSHA, 2016~ NMCs mission is to provide exceptional healthcare for our community. What is the privacy issue for a general hospital like NMC? Hospitals or federally qualified health centers would generally be considered general medical care facilities.

Therefore, primary care providers who work in (or for) such facilities would only meet Part 2s definition of a program if: 1) they work in an identified unit within such general medical care facility that holds itself out as providing, and provides, alcohol or drug abuse diagnosis, treatment or referral for treatment, or 2) the primary function of the provider is alcohol or drug abuse diagnosis, treatment or referral for treatment and they are identified as providers of such services. ~SAMSHA, 2016~ NMCs mission is to provide exceptional healthcare for our community. So What Does This Mean For You? In order for a program in a general medical care

facility to share information with other parts or units within the general medical care facility, administrative controls must be in place to protect Part 2 information if it is shared. ~SAMSHA, 2016~ NMCs mission is to provide exceptional healthcare for our community. Compartmentalization of EMR Broken Glass features of EMR Closed segments of the EMR Separate EMRs *Most Important is the idea of Privacy above HIPPA*

NMCs mission is to provide exceptional healthcare for our community. Sharing of Information - CHARM CH ildren A nd R ecovering M others NMCs mission is to provide exceptional healthcare for our community. Provider/Patient Relationships

Confidentiality must be met Open and Honest Communication Trust Collaboration Education These are critical!! NMCs mission is to provide exceptional healthcare for our community.

Our Journey Where We Are NOW! Better Able To Care For Our Whole Community Relationships Are Being Built Care In Our Community

Patient Centered Care Opiate Addicted Patients Feel Welcome Intentional Delivery at NMC

Structured Nursing Education NMCs mission is to provide exceptional healthcare for our community. A Changing Approach Impacts Your Community

Your School systems Your playgrounds Your workplace Your family NMCs mission is to provide exceptional healthcare for our community. The Stark Reality I dont like thiswatching my kid withdrawal. I dont have a choice. I feel selfish. It is hard for me to agree to be on Subutex, but most of us are better off with it. If nobody was willing to treat us, we would be back on the street. This is hard I feel bad. Nobody could ever make

me feel worse than I already make myself feel ~Patient Quote, 2016~ NMCs mission is to provide exceptional healthcare for our community. This Is Real Your communities are important to you How can you help? NMCs mission is to provide exceptional healthcare for our community. Thank You! Questions?

NMCs mission is to provide exceptional healthcare for our community. References Bandstra, E. (2012). Maternal opioid treatment: Human experimental research (MOTHER) study: maternal, fetal and neonatal outcomes from secondary analyses. Addiction, 107(Suppl. 1). doi:10.1111/j.1360443.2012.04059.x Gon, K. L., Bernstein, P. S., Sullivan, L., and Roberts, W. Neonatal outcomes of buprenorphine MAT treatment for opiate misuse disorder in a rural setting. Manuscript, 2015. Hedden, S., Kennet, J., Lipari, R., Medley, G., Tice, P. (2014). Behavioral health trends in the United States: results from the 2014 national survey on drug use and health. Substance Abuse and Mental Health Services Administration (SAMSHA). Retrieved from :http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf Opioid abuse, dependence, and addiction in pregnancy. Committee Opinion No. 524. American College of

Obstetricians and Gynecologists. Obstet Gynecol 2012;119:10706 Patrick, S.W., Davis, M.M., Lehmann, C. U., Cooper, W. O. (2015) Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. Journal of Perinatology 35(8), 650-655. doi:10.1038/jp.2015.36 Substance Abuse and Mental Health (SAMSHA) (2016). Substance abuse confidentiality regulations. Retrieved from: http://www.samhsa.gov/about-us/who-we-are/laws/confidentiality-regulations-faqs Whitten, L. (2012). A multisite clinical trial lays groundwork for improving care for mother and babies affected by opioid dependence. National Institute on Drug Abuse. Retrieved from: https://www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine-during-pregnancyreduces-neonate-distress NMCs mission is to provide exceptional healthcare for our community.

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