NC Department of Health and Human Services

Plan of Safe Care: Cross Systems

Response to Substance-Affected Infants

Kelly Kimple, MD, MPH, FAAP

Chief, Women’s and Children’s Health Section
NC Division of Public Health

Perinatal Quality Collaborative of North Carolina

March 1, 2018
Objectives
• Improve understanding of when notifications to child
welfare are appropriate by providers involved in
delivery and care of substance-affected infants
• Clarify how a notification differs from a report of
child abuse and/or neglect
• Learn about policies and procedures related to
substance-affected infants
• Understand the importance of a non-punitive
response to opioid use in pregnancy for maternal and
child health
 Unintentional Medication & Drug Deaths by Drug Type
700 North Carolina Residents, 1999-2015*
350% increase&in&deaths&since&1999
600

Commonly'Prescribed 549
500 Opioid'Medications
Other'Synthetic'Narcotics

400 Heroin
Heroin&deaths& 364
Cocaine
300 increase&800%+% 293
since&2010 254
200

100

0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

•Data&Source:&State&Center&for&Health&Statistics,&Death&Certificate&Data&(X40;X44&w/&T40.1,&T40.2,&T40.3,&T40.4)
•*&Number&of&times&mentioned; Cases&are&not&mutually&exclusive; Deaths&can&have&more&than&one&drug&involved.&
•Does&not&include&non;resident&or&out&of&state&resident&deaths.&

3
 Unintentional opioid deaths have increased more than 10 fold
Heroin or other synthetic narcotics are now involved in over 50% of deaths

~1300$
total(
deaths(in(
2016

~100$total(
deaths(in(
1999

Source:(N.C.(State(Center(for(Health(Statistics,(Vital(Statistics7Deaths,(199972015(((((((((((((((((((((((((((((
Unintentional(medication/drug((X407X44)(with(specific(T7codes(by(drug(type,(Commonly(Prescribed(Opioid(
Medications=T40.2(or(T40.3;(Heroin(and/or(Other(Synthetic(Narcotics=T40.1(or(T40.4.
Analysis(by(Injury(Epidemiology(and(Surveillance(Unit
 Number & Rate of Hospitalizations Associated with Drug
Withdrawal in Newborns, North&Carolina&Residents,&2004?2016
1400 12.0
From&2004&to&2016,& 10.7 10.7
1200 9.9
922% increase&in&number&
Number2of2Newborn2Hospitalizations

10.0

1000 of&hospitalizations

Rate2per21,0002Live2Births
7.4 8.0

800 6.5
6.0
4.8 1277 1278
600 1178
4.0
3.2 4.0
874
400 764
2.0 2.2
1.6 572
1.6 483 2.0
200 1.1 399
258 290
190 201
125
0 0.0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014* 2015† 2016†
Number2of2Newborn2Hospitalizations Rate2per21,0002Live2Births

*20142data2structure2changed2to2include2up2to2952diagnosis2codes.2Impact2on2surveillance2unclear.
†20152ICD292CM2coding2system2transitioned2to2ICD102CM.2Impact2on2surveillance2unclear.

Source:2N.C.2State2Center2for2Health2Statistics,2Hospital2Discharge2Dataset,22004M20162and2Birth2Certificate2records,22004M2016
Analysis2by2Injury2Epidemiology2and2Surveillance2Unit
 Hospitalizations Associated with Drug Withdrawal Syndrome in
Newborns per 1,000 Live Births, North&Carolina&Residents,&201242016

Statewide&hospitalization&rate&(201242016):&
9.0$per$1,000$live$births

NOTE:(2014(data(structure(changed(to(include(up(to(95(diagnosis(codes.(2015(ICD(9(CM(coding(
system(transitioned(to(ICD10(CM.(The(impact(of(these(changes(on(surveillance(is(unclear.

Source:(N.C.(State(Center(for(Health(Statistics,(Hospital(Discharge(Dataset,(2012<2016
Analysis(by(Injury(Epidemiology(and(Surveillance(Unit
 Primary Payment Type Associated with Drug Withdrawal
Syndrome in Newborns, North(Carolina(Residents,(2016

100%
88%
$63,604,033'" Total(charges*(in(2016
80%

60% $49,768'" Average(charge*(in(2016

40%

20%
6%
2% 1% 1% 1% <1% <1%
0%
Medicaid Self2pay BCBS HMO Commercial Champus PPO Other

*ChargesBdoBnotBreflectBwhatBtheBcareBactuallyBcostBtheBhospitalBorBwhatBtheBhospitalBreceivedBinBpayment.B
ChargesBareBtypicallyBnegotiatedBwithBinsuranceBproviders.
NOTE:B2014BdataBstructureBchangedBtoBincludeBupBtoB95BdiagnosisBcodes.B2015BICDB9BCMBcodingBsystemB
transitionedBtoBICD10BCM.BTheBimpactBofBtheseBchangesBonBsurveillanceBisBunclear.

Source:BN.C.BStateBCenterBforBHealthBStatistics,BHospitalBDischargeBDataset,B2016
AnalysisBbyBInjuryBEpidemiologyBandBSurveillanceBUnit
Effects on Families: Foster Care Placement
• In the last 5 years, NC has seen 25% increase in children in foster
care (10,500 children)
Comprehensive Addiction and Recovery Act of
2016 (CARA)
• Response to nation’s prescription drug and opioid
epidemic
• Addresses various aspects of substance use
disorders
• Section 503 (Infant Plan of Safe Care, POSC)
aims to help states address effects of substance
use disorders on infants and families
• Amended provisions of the Child Abuse
Prevention and Treatment Act (CAPTA) pertinent
to infants with prenatal substance exposure
 Amended Child Abuse Prevention and
Treatment Act (CAPTA)
States receiving CAPTA funding are required to assure the federal government
that they have a law or statewide program in effect and under operation that:
Addresses the needs of infants born and identified as being affected by illegal
substance abuse or withdrawal symptoms resulting from prenatal drug
exposure, or a Fetal Alcohol Spectrum Disorder (FASD) with
• A requirement that health care providers involved in the delivery or care of
such infants notify the child protective services system of the occurrence of
such condition of such infants
• The development of a plan of safe care for the infant…to ensure the safety
and well-being of such infant following release from the care of healthcare
providers, including through –
• Addressing the health and substance use disorder treatment needs of the
infant and affected family or caregiver; and
• Development and implementation by the State of monitoring systems
regarding the implementation of such plans to determine whether and in
what manner local entities are providing, in accordance with State
requirements, referrals to and delivery of appropriate services for the
infant and affected family or caregiver
NC Plan of Safe Care Interagency Collaborative
To create a state-specific policy agenda and action plan to address and
implement the provisions of CAPTA amended by CARA and to strengthen
the collaboration across systems to address the complex needs of
infants affected by substance use and their families.
• Division of Mental Health, Developmental Disabilities and Substance
Abuse Services
• Division of Public Health
• Division of Social Services
• Division of Medical Assistance
• North Carolina Association of County Directors of Social Services
• Community Care of North Carolina
• North Carolina Hospital Association
• North Carolina Obstetrics and Gynecological Society
• North Carolina Commission on Indian Affairs

• Additional ongoing input from other organizations/stakeholders

Local Collaboration to Support Plans of Safe Care
Build on existing local collaboratives or create
collaboratives that brings together stakeholders:
• CC4C, County Health Department
• Hospitals
• County Child Welfare Agency
• Pediatricians/Primary Care Providers
• Substance Use Disorder Treatment Programs
• Local Management Entity / Managed Care Organizations
• Home visiting programs
• Domestic Violence Shelters
• Child Development Services Agency (CDSA)
• OB Care Managers

12
 NC Current Policy
Health'Provider'
Involved'in'the'
Delivery'or'Care'of'
Infant
1.'Identifies'infant'as'
“substance;affected”'based'
on'DHHS'definitions'
2.'Makes'notification'to''
county'child'welfare'agency
County'Child'Welfare'
Agency
1.'Completes'CPS'
Structured'Intake'Form'with'
caller
2.'Develops'POSC/CC4C' Care'Coordination'for'
Referral'using'ONLY the' Children'(CC4C)
information'that'is'obtained'
during'the'intake'process 1.'Participation'is'voluntary'
3.'Refers'ALL infants'and' 2.'Services'based'on'needs'
families'to'CC4C'PRIOR to' of'the'child'and'family'and'
the'screening'decision'is' those'identified'in'POSC
made 3.''Progress'is'monitored'
4.'Collects'and'reports' based'on'monitoring'tools'
required'data' already'in'place'
5.'Screen'report'using'
Substance'Affected'Infant'
structured'decision'trees'
and'provide'services'for'
accepted'cases'''
Notifying Child Protective Services
In NC, a notification to the county child
welfare agency must occur upon identification
of an infant as “substance-affected,” as
Health(Care( defined by DHHS.
Provider(
Involved(in(the(
Delivery(or(
Care(of(Infant Notification requirement does NOT:
• Mean that prenatal substance use = child
maltreatment
• Establish a definition under Federal law of
what constitutes child abuse or neglect
• Change NC General Statutes
 Identifying a Substance-Affected Infant
Affected by Substance Abuse
Infants who have a positive urine, meconium or
cord segment drug screen with confirmatory
Health'Care' testing in the context of other clinical concerns as
Provider'
Involved'in'the'
identified by current evaluation and management
Delivery'or' standards.
Care'of'Infant
OR
Medical evaluation, including history and physical
of mother, or behavioral health assessment of
mother, indicative of an active substance use
disorder, during the pregnancy or at time of birth.
Identifying a Substance-Affected Infant

Affected by Withdrawal Symptoms

Health'Care'
Provider'
Involved'in'the'
Delivery'or' The infant manifests clinically
Care'of'Infant
relevant drug or alcohol
withdrawal.
 Identifying a Substance-Affected Infant
Affected by FASD
Infants diagnosed with one of the following:
• Fetal Alcohol Syndrome (FAS)
• Partial FAS (PFAS)
Health(Care(
Provider( • Neurobehavioral Disorder associated with
Prenatal Alcohol Exposure (NDPAE)
Involved(in(the(
Delivery(or( • Alcohol-Related Birth Defects (ARBD)
Care(of(Infant • Alcohol-Related Neurodevelopmental Disorder
(ARND)*
OR
Infants with known prenatal alcohol exposure when
there are clinical concerns for the infant according
to current evaluation and management standards.

*Hoyme, HE, Kalberg, WO, Elliot, AJ, et al. Updated Clinical Guidelines for Diagnosing Fetal Alcohol Spectrum
Disorders. Pediatrics, Volume 138, number 2, August 2016
CPS Structured Intake Form and Plan of Safe Care (POSC)
• DSS revised intake questions to include a
“Substance-Affected Infant” section
• CPS Intake Policy Substance Affected Infant
−Intake policy considers circumstances of exposure and
County( effect to infant
Child( −Prenatal Substance Use ≠ Abuse or Neglect
Welfare(
Agency( −Notification ≠ Screen-In
• POSC found on the CC4C referral
• POSC and Safety Assessment are NOT
duplicative
• POSC is voluntary even when CPS is involved
• Components of POSC are incorporated into
Family Service Agreements
 CC4C: Connecting Families to Services
• At-risk population management program for children
birth to age 5
• Referral criteria include:
−Children with adverse life events or toxic stress
Identification criteria include:
Care& • Children in foster care, other out of home
Coordination& placement
for&Children& • Neonatal exposure to substances, parental
(CC4C)& substance use
• Maternal depression, parental mental health
concerns
• Domestic violence, abuse and/or neglect
• Homelessness, food insecurity and/or extreme
poverty
• Exposure to violence in the community
−Children who have been discharged from the NICU
(includes prematurity and congenital conditions)
−Children with special health care needs
 CC4C: Supporting Substance-Affected Infants and Families
• Comprehensive assessment, includes Life
Skills Progression tool
• Goal setting with family
Care% • Linkage to resources and services
Coordination%
for%Children% • Parent education regarding needs of the
(CC4C)% infant
• Assistance and support to strengthen infant/
mother dyad
• Education regarding red flags
• Strengthen relationship to medical home,
promote quality care
• Emphasis on well and preventative care
• Developmental screening (inc. SWYC)
 Monitoring Implementation

• Child Welfare data collection

DHHS
• CC4C data collection
Plan)of)Safe)
Care)
Interagency)
• Review of qualitative information
Collaborative)
• Technical assistance
• Continued outreach and education
Pregnant Women and Opioids
• Medication-assisted treatment (MAT) standard of care during
pregnancy for women with opioid use disorders and can improve
outcomes.
• Withdrawal from opioid use during pregnancy is associated with poor
neonatal outcomes, including early preterm birth, fetal distress or
fetal demise, as well as higher relapse rates among women.
• In addition to treatment of substance use disorders, counseling and
discussing on postpartum contraception to prevent unintended
pregnancies should occur with all pregnant women.
• Biggest concern with opioid agonist medication during pregnancy is
the potential for neonatal abstinence syndrome (NAS) – a treatable
condition.
• NAS is NOT addiction
Care of Infants Exposed to Substances
• Protocols for identifying, assessing, monitoring and intervening,
using non-pharmacological and pharmacological methods, for
neonates prenatally exposed to opioids
• AAP recommends observing all infants exposed to opioids for
minimum of 72 hours OR a minimum of 96 hours total if
methadone or buprenorphine exposure
• For infants at risk of or demonstrating withdrawal symptoms, non-
pharmacological measures (swaddling, dim lights, quiet room, skin-
to-skin, etc) should be initiated
• Neonatal Abstinence Scores or Finnegan scores provide objective
data to monitor infants at risk for withdrawal and assess severity
• For women in well-supervised maintenance treatment programs,
breastfeeding is encouraged. Breastfeeding is not contraindicated
for women without HIV who are not using additional substances
 AAP Policy Statement:
Public Health Response to Opioid Use in Pregnancy (2017)
• Coordinated, evidence -based, public health approach
• Punitive measures not in best interest of health of mother-infant dyad
• Primary prevention strategies to educate public about addictive
potential of prescription opioids and enhance access to reproductive
health services
• ACOG policy – universal substance use screening of all pregnant women
via validated screening tools, applied equally to all women, regardless of
age, race, ethnicity, or socioeconomic status
• Improved access to comprehensive prenatal care for pregnant women
with substance use disorders, including MAT and gender-specific
substance use treatment programs that provide nonjudgmental,
trauma-informed services
• Social support services and child welfare systems

http://pediatrics.aappublications.org/content/early/2017/02/16/peds.2016-4070
Ongoing Efforts
•Ongoing feedback from stakeholders
•Monthly monitoring meetings (policy
implementation, ongoing QI)
•Multiple presentations to varied audiences
•Monthly statewide conference calls for providers
•Reinforcing best practice around substance use in
pregnancy
•Increasing awareness of the Perinatal Substance
Use Project, NC Perinatal & Maternal Substance
Use Initiative, and other treatment and recovery
supports
Ongoing Efforts
•Developed email address for ongoing questions,
concerns, feedback:
SVC_NCPOSCIC@dhhs.nc.gov
•Developing NC Plan of Safe Care Interagency
Collaborative website
•Ongoing development of materials specific for
audiences
•Strengthening existing partnerships and forming
new ones – state and local level
Opportunities
•Educate and promote best practices around
substances during pregnancy and the care of
infants affected by substances
•Strengthen local partnerships and improve
communication with hospitals, health care
providers and child welfare agencies
•Care Coordination for Children (CC4C) program
continues to offer support to families affected by
substance use and work with health care
providers, addressing toxic stress
Summary
•Federal legislation requires notification to child
welfare for substance-affected infants
−Distinct from report of child abuse and neglect
•For infants affected by substances, NC has definitions
of substance abuse, withdrawal and FASD for
notifications
•Focused around hospitals and providers involved in
the care after birth, although may affect community
providers who work in birthing hospital/ newborn
nursery or if infant identified with NAS/ withdrawal
after discharge or FASD in first year of life
Questions?

SVC_NCPOSCIC@dhhs.nc.gov