Preventing Pre-Natal Exposure:

A Collaborative Effort Toward

“Superior Babies”

Diane Torrel, PHN Diane Torrel, PHN

218-749-0613218-749-0613torreld@co.st-louis.mn.ustorreld@co.st-louis.mn.us

Carol Peterson, CD Counselor/LADCCarol Peterson, CD Counselor/LADC218-749-2877218-749-2877

Julie Jagim,Julie Jagim, PHN SupervisorPHN Supervisor218-725-5243218-725-5243

jagimj@co.st-louis.mn.usjagimj@co.st-louis.mn.us

Association of Maternal and Child Health Association of Maternal and Child Health ProgramsPrograms

February 12-15, 2011February 12-15, 2011

Program GoalsProgram Goals1. Reduce the incidence of Fetal Alcohol 1. Reduce the incidence of Fetal Alcohol

Spectrum Disorders (FASD) and other Spectrum Disorders (FASD) and other chemically related health effects by chemically related health effects by identifying and serving pregnant women identifying and serving pregnant women suspected of or known to use or abuse alcohol suspected of or known to use or abuse alcohol and other drugs.and other drugs.

2. Promote healthy birth outcomes, normal 2. Promote healthy birth outcomes, normal growth and development and positive growth and development and positive parenting. parenting.

Maternal – Child HealthMaternal – Child HealthTeachingTeaching

Sobriety SupportSobriety SupportRelapse PreventionRelapse Prevention

LADCLADCPublic Health NursePublic Health Nurse

Home Visiting &Home Visiting &Random UA’sRandom UA’s

Intensive Intensive Case ManagementCase Management

Program Components

Referral SourcesReferral Sources• Social ServicesSocial Services• ProbationProbation• ClinicsClinics• WIC ProgramWIC Program• Chemical Dependency Treatment Chemical Dependency Treatment

ProfessionalsProfessionals• Self/familySelf/family

ParticipationParticipation

• Admission: As early in pregnancy as Admission: As early in pregnancy as possiblepossible• Continued postpartum involvement Continued postpartum involvement with sobriety as a goal with sobriety as a goal • Graduation: Baby’s 2Graduation: Baby’s 2ndnd Birthday Birthday

ActivitiesActivities• Frequent Home VisitsFrequent Home Visits• Random UA’sRandom UA’s• Intensive Case ManagementIntensive Case Management• Team Approach of PHN & LADC with regular Team Approach of PHN & LADC with regular

communicationcommunication• Establish positive trusting relationship with clientEstablish positive trusting relationship with client• Monthly team staffing with SupervisorMonthly team staffing with Supervisor• Client IncentivesClient Incentives• Toxicology tests at birthToxicology tests at birth

InterventionsInterventions• Collaborative case-managementCollaborative case-management

– Discipline specific visit protocolsDiscipline specific visit protocols

• Multidisciplinary Approach Multidisciplinary Approach – Public Health NursePublic Health Nurse– Licensed Alcohol and Drug CounselorLicensed Alcohol and Drug Counselor

• Multiple types of contacts Multiple types of contacts – Home visits (primarily), office visits, Home visits (primarily), office visits,

telephone contacts, collateral contactstelephone contacts, collateral contacts

InterventionsInterventions Assessment and EducationAssessment and Education

• NCAST Tools & ScalesNCAST Tools & Scales• Home Safety ChecklistHome Safety Checklist• Developmental Screening Tools Developmental 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 Recommendations Chemical Use Assessment and Recommendations

• Relapse Prevention EducationRelapse Prevention Education• Random Drug ScreeningRandom Drug Screening• Video of Parent-Child InteractionVideo of Parent-Child Interaction

InterventionsInterventions• Support and AdvocacySupport and Advocacy

• Referrals to Community ResourcesReferrals to Community Resources TransportationTransportation HousingHousing

Mental HealthMental Health Education and EmploymentEducation and Employment Parenting ( Early Headstart and ECFE)Parenting ( Early Headstart and ECFE) CD Treatment and 12-step involvementCD Treatment and 12-step involvement

2004 Evaluation

Participant CharacteristicsParticipant Characteristics• Generally young, 74% were < 30 years oldGenerally young, 74% were < 30 years old• Half entered SB in the first trimesterHalf entered SB in the first trimester• Almost half had previous chemical dependency Almost half had previous chemical dependency

treatmenttreatment• Nearly half have mental health issuesNearly half have mental health issues• Over half had income below Federal Poverty Over half had income below Federal Poverty

GuidelinesGuidelines• One-third of the women had previous criminal One-third of the women had previous criminal

justice system involvementjustice system involvement

20042004

Program StrengthsProgram Strengths• Serves appropriate clientsServes appropriate clients• Effective interdisciplinary modelEffective interdisciplinary model• Consistent StaffConsistent Staff• Frequent communication between team Frequent communication between team

members; regular clinical staffingmembers; regular clinical staffing• Regular random UA’s for toxicologyRegular random UA’s for toxicology• Extensive client contacts/case managementExtensive client contacts/case management• Good birth outcomesGood birth outcomes

20042004

Weaknesses and ConclusionsWeaknesses and Conclusions

• ConclusionsConclusionsSignificant advantage for PHN’s to partner with Significant advantage for PHN’s to partner with

staff who have expertise in chemical dependency.staff who have expertise in chemical dependency.Gaining and maintaining the trust of participants Gaining and maintaining the trust of participants

is an integral part of the program.is an integral part of the program.Flexibility and practical problem solving are key Flexibility and practical problem solving are key

elements.elements. 20042004

• WeaknessesWeaknesses• High drop-out rate postpartumHigh drop-out rate postpartum• Large amount of data collectionLarge amount of data collection

2010 Evaluation

2010 Evaluation 2010 Evaluation (covers 2007-2010)(covers 2007-2010)

• Examines client characteristicsExamines client characteristics• Summarizes outcomesSummarizes outcomes• Identifies key components of programIdentifies key components of program• Suggests important program elements Suggests important program elements

to replicate programto replicate program• Provides example cost/benefit analysisProvides example cost/benefit analysis

Client Characteristics Client Characteristics (N=40)(N=40)Characteristic Number Percentage

Below federal poverty level

36 90%

Involved with child protection

15 38%

Mental health concerns 24 60%

Mental health treatment at entry

18 45%

Criminal justice involvement

18 45%

Prior substance abuse treatment

21 52%

Client Use at Entry (N=40)Client Use at Entry (N=40)

Drug None Daily3-6

timesa week

1-2 times

a week

1-3 times a month

Unknown

Alcohol 30% 15% 18% 15% 15% 7%Marijuana

28% 28% 20% 8% 8% 8%

Other reported use:Other reported use:19 (48%) smoke19 (48%) smoke7 (18%) use methamphetamines7 (18%) use methamphetamines3 (8%) use inhalants3 (8%) use inhalants8 (20%) use other drugs8 (20%) use other drugs

Outcomes Reported by Outcomes Reported by Clients in Follow-Up Clients in Follow-Up Interviews (N=9Interviews (N=911))

• All reported good to outstanding relationship with Superior All reported good to outstanding relationship with Superior Babies staff (67% outstanding)Babies staff (67% outstanding)

• 89% reported reduced use of alcohol or drugs89% reported reduced use of alcohol or drugs• All reported that other families in similar situations could All reported that other families in similar situations could

benefit from programbenefit from program• All reported their experience with Superior Babies program All reported their experience with Superior Babies program

as very good or excellentas very good or excellent• 89% reported SB program helped with parenting skills89% reported SB program helped with parenting skills• 89% reported that their lives were much better than they 89% reported that their lives were much better than they

were before first contact with Superior Babieswere before first contact with Superior Babies

11Clients are often transient and difficult to contact after participation in the SB programClients are often transient and difficult to contact after participation in the SB program

Birth Outcomes (N=31)Birth Outcomes (N=31)

Outcome # of positive outcomes Results

Received1% positive

resultsBirth Weight 30 31 97%Gestational Age 28 31 90%APGAR 29 29 100%Mother Toxicology

27 28 96%

Baby Toxicology

24 25 96%

11Some APGAR and toxicology tests were not completed at hospital or not availableSome APGAR and toxicology tests were not completed at hospital or not available

Discharge Outcomes Discharge Outcomes (N=38)(N=38)

• 58 % completed parenting training58 % completed parenting training• 21% ended involvement with child 21% ended involvement with child

protectionprotection• Of 26 known at discharge, 96% using birth Of 26 known at discharge, 96% using birth

controlcontrol• 50% are using mental health services50% are using mental health services• 42% are in 12-step program42% are in 12-step program

Superior Babies is Administered by the Superior Babies is Administered by the

St. Louis County Public Health and St. Louis County Public Health and Human Services Department in Human Services Department in

MinnesotaMinnesota(supported by a grant from MOFAS)(supported by a grant from MOFAS)

Recommendations for Recommendations for Professionals Starting Programs Professionals Starting Programs

for Women for Women At-risk for FASDAt-risk for FASD

• Focus on communication in creating PHN/LADC Focus on communication in creating PHN/LADC partnershippartnership

• Network with other professionals (e.g., probation Network with other professionals (e.g., probation officers, social workers, physicians, WIC) for for officers, social workers, physicians, WIC) for for referralsreferrals

• Lay out expectations for clients early in relationshipLay out expectations for clients early in relationship• Incorporate intensive case managementIncorporate intensive case management• Work to develop trust with client through honoring Work to develop trust with client through honoring

who they are, visiting in home, being honest, who they are, visiting in home, being honest, providing supportproviding support

• Incorporate regular, random urinalysisIncorporate regular, random urinalysis• Meet with supervisor for regular staffingMeet with supervisor for regular staffing

Challenges for ProgramChallenges for Program• Clients are addressing multiple issues (CD, Clients are addressing multiple issues (CD,

MH)MH)• Many clients have transportation issues Many clients have transportation issues

(rural)(rural)• Difficult to facilitate group supportDifficult to facilitate group support• Client participation is usually voluntaryClient participation is usually voluntary• Funding is not secure after grant cycleFunding is not secure after grant cycle

Funding is a Good Funding is a Good Investment!Investment!

• Mothers who are very highly at-risk are obtaining Mothers who are very highly at-risk are obtaining excellent birth outcomesexcellent birth outcomes

• Cost of lifetime services for a child with FASD averages Cost of lifetime services for a child with FASD averages about $2 millionabout $2 million ((www.www.fasdfasdcenter.samhsa.gov/publications/center.samhsa.gov/publications/costcost.cfm.cfm))

• Cost to provide Superior Babies program for one year is Cost to provide Superior Babies program for one year is less than $100,000less than $100,000

• If only one FASD birth is prevented every 20 years, If only one FASD birth is prevented every 20 years, program pays for itselfprogram pays for itself

• Very likely more FASD births and other negative birth Very likely more FASD births and other negative birth outcomes are preventedoutcomes are prevented