Mothers and Babies Benefit From Cost-Saving Substance Use Disorder Program

社区卫生网络(CHNw)观察到的产妇物质使用障碍率高于全国水平，更多的孕妇对阿片类药物、可卡因、安非他明、巴比妥类药物和苯二氮卓类药物的筛查呈阳性。它制定了一个护理协调和药物使用项目，以帮助减少孕妇药物使用障碍的发生率。利用其数据平台和分析应用程序，世界杯厄瓜多尔vs塞内加尔波胆预测CHNw能够评估各种流程措施对患者结果的影响。

NEONATAL ABSTINENCE SYNDROME—A GROWING CRISIS

Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn when withdrawing from exposure to opiates. In the U.S., a baby is born with symptoms of NAS every 15 minutes. Between 2004 and 2014, inflation-adjusted hospital costs for NAS increased by $472M.¹

位于印第安纳波利斯的CHNw是美国最综合的医疗保健系统之一，是印第安纳中部地区提供优质医疗保健服务的领导者。每年有近8000名婴儿在中华民国医院出生。在印第安纳出生的婴儿中，有20%的人鸦片测试呈阳性。

Several state governments have responded to the increase in opioid use during pregnancy by prosecuting and incarcerating pregnant women with substance use disorders. That approach has no proven benefits and may decrease the willingness of women to engage in substance use disorder treatment programs.²CHNw opted to take matters into its own hands and find a way to improve outcomes for babies and mothers exposed to opiates

MATERNAL SUBSTANCE USE DISORDER RATES HIGHER THAN AVERAGE

CHNw observed rates of maternal substance use disorder in its patients that were higher than the national average. Many pregnant women screened at CHNw for drugs tested positive for opioids, cocaine, amphetamines, barbiturates, and benzodiazepines. At the Community Hospital East location, a total of 42 percent of babies were exposed to illicit substances, and the organization was losing an average of $12K for each NAS diagnosis, as the cost of care was substantially less than the reimbursement received.

更糟糕的是，被诊断为NAS的婴儿数量正在增加，反映了阿片类药物流行的增长。尽管有这种令人担忧的趋势，但患有药物使用障碍的妇女的治疗选择有限。CHNw不是继续通过治疗越来越多的NAS婴儿来应对这一挑战，而是需要站在问题的上游，进行干预以减少孕妇药物使用障碍的发生率。

MOTHERS AND BABIES SUPPORTED WITH COMPREHENSIVE INTERVENTIONS

In response to the growing concerns related to NAS, CHNw opted to develop, implement, and evolve a program for pregnant women struggling with substance use disorders. The organization started offering medication-assisted treatment (MAT), which involves the use of medications in combination with counseling and behavioral therapy to treat substance use disorders. An obstetrics and gynecology (OB/GYN) physician and nurse practitioner obtained licenses to prescribe buprenorphine for the treatment of opioid use disorder. Both are trained to address the unique needs of patients struggling with substance use disorders.

Over time, CHNw further developed the support available to women, offering patients the opportunity to participate in its CHOICE (Change, Hope, Overcome, Inspire, Compassion, Education) program—a program for pregnant women struggling with substance use disorders. The OB/GYN and nurse practitioner lead the CHOICE program, which has the flexibility to leverage various expert resources available either on-site or via telehealth that may help improve outcomes for patients. The goal is to help each patient get into a treatment program that works for her and to support her on the path to recovery.

Community Hospital East became a center of excellence in the care of mothers and babies that have been affected by substance use disorder. The labor and delivery (L&D) unit at Community East offers a team of registered nurses (RNs) trained in trauma-informed care, and specifically trained to provide care to these patients, who work with the CHOICE care team to provide exceptional care. From detoxification to delivery, patients are treated with dignity and respect.

Focusing on compassion, not punishment

为了确定哪些妇女可以从CHOICE计划中受益，CHNw在第一次产前检查和分娩时进行全面的产妇检查。临床医生对病人进行口头筛选，要求允许进行毒理学测试。一些患者在尝试在家排毒失败后到急诊科进行补水和处理呕吐后进入CHOICE计划;其他人则是被他们的社交网络中的人介绍到这个项目。

CHNw takes a non-punitive approach for toxicology testing and does not automatically report pregnant women with a positive drug screen to child protective services. Rather, the organization focuses on immediately providing these women the support required to help them to stop using substances.

Patients with a positive result are immediately offered:

• A referral for behavioral health consultant for on-going therapy and receive a referral to the CHOICE program.
  • One therapy option available to patients is a group-based program called MOMentum, a program for pregnant, or recently delivered, women that helps them work through the unique concerns of women struggling with substance use disorder.
• 产前咨询新生儿学，父母接受有关护理计划的教育，并了解接触物质婴儿的情况。
• 产前咨询注册护士麻醉师制定产后疼痛管理计划。
• 还提供与行为健康顾问一起的产后后续咨询，确保为这些有需要的妇女提供持续的支持。

Removing barriers in support of proactive treatment

Patients who could benefit from buprenorphine treatment meet with one of the buprenorphine subscribers. CHNw proactively removes barriers to program enrollment and participation, meaning its patients do not receive a referral and then wait weeks for an appointment. CHNw patients are not left to navigate the complex health system or coverage issues on their own. Maternity and postpartum patients in acute crisis are seen immediately, and the interdisciplinary team—including behavioral health coordinators, RNs, and social workers—provides care that supports the patient’s goals.

Some patients may want to quit using the substances they have been abusing and want to be able to parent their child; others may have different goals, such as using fewer substances. Patients receiving buprenorphine are scheduled to attend weekly counseling sessions. Patients may also be offered inpatient detox on the labor and delivery unit.

CHNw提供全方位的服务，支持每一位病人实现她的特定目标。该组织帮助患者解决具有挑战性的日常问题，如缺乏住房或安全问题，同时也提供情感和医疗支持，以确保他们实现长期治疗目标。该团队为患者提供灵活的治疗选择、强化和宽恕。病人不会因为迟到、错过预约或其他与坚持治疗相关的问题而被“开除”。CHOICE项目认识到混杂因素影响患者的行为，并为患者提供必要的支持，使其能够有效地参与到项目中。

例如，病人缺乏交通工具的情况并不少见，这使得他们很难按时到达预约地点。一位病人想要完成住院治疗，但又担心要把她心爱的狗狗留给男友。社工协助病人为狗狗找到紧急寄养地点，以便病人完成住院戒毒。

Care coordination ensures continuity of care

The interdisciplinary team coordinates patient care, providing an effective hand-off to the L&D inpatient unit for delivery, and informing the special care nursery staff of the patient’s delivery plan and expected delivery date, ensuring the special care nursery is prepared to provide care to a baby who is likely to experience NAS. CHNw performs umbilical cord drug screens for babies born to mothers with a history of substance use and/or a positive tox screen upon admission. This screening is also conducted if the patient refused an ambulatory drug screening.

Babies identified as being exposed to opioids are monitored for signs of withdrawal for five days. Those who experience NAS receive pharmacological treatment to manage symptoms and prevent complications. Affected babies also receive non-pharmacologic care, including a low-stimulating environment, breastfeeding on demand, rooming in with their mother, and “cuddlers” who help snuggle the babies, decreasing uncomfortable stimulation, lessening crying time, and helping the babies to sleep peacefully.

After delivery, CHOICE program participants are connected with another provider to continue their long-term MAT.

Effectiveness of interventions monitored with analytics

CHNw leverages the Health Catalyst^®数据操作系统(DOS™)平台和一套强大的分析应用程序，包括世界杯厄瓜多尔vs塞内加尔波胆预测母体物质使用障碍分析应用程序，以了解其患者群体的需求，并评估各种流程措施对患者结果的影响。

使用分析应用程序，CHNw可以很容易地可视化接受丁丙诺啡的患者数量，以及服用美沙酮的患者数量，并评估各组的结果(见图1)。该组织可以很容易地比较各组之间的差异，包括孕产妇和新生儿LOS和可变成本。这使得提供人员可以很容易地可视化在产前期间阿片类药物检测呈阳性而在分娩时阿片类药物检测呈阴性的患者数量，因此可以适当地评估所有干预措施的有效性。CHNw能够回答有关患者群体的具体问题，并能够快速识别患者群体的变化，从而调整其项目提供，以更好地满足患者的需求。

RESULTS

CHNw’s CHOICE program meets the needs of women with maternal substance use disorder, and has positively impacted patient outcomes and financial performance. Results include:

• $764K in savings by reducing the variable cost per case across the CHNw system in just one year and a 39.9 percent relative reduction in neonatal LOS.
• Babies whose mothers took buprenorphine had a 25 percent lower incidence of NAS than babies whose mothers took methadone, and spent 15.5 fewer days in the hospital.
• 服用丁丙诺啡的病人比服用美沙酮的病人多20%的病人在分娩时的阿片类药物测试呈阴性。

“It is an incredible gift to have access to real-time data. We’re able to use the analytics platform to immediately demonstrate the clinical benefit of the universal drug screen, and our medication-assisted treatment program for both mom and baby.”

– Brooke Schaefer, MSN, FNP-C, RN, Director Perinatal Substance Use Disorder Program, Nurse Practitioner

WHAT’S NEXT

CHNw plans to continue to grow the CHOICE program to meet patient needs, also opting to continue to advance analytics within the organization to help facilitate outcomes improvement. The organization is also working to ensure the well-being of the CHOICE team care providers and is working to prevent burnout.

REFERENCES

1. 国家药物滥用研究所。(2019)。Indiana opioid summary – Drug overdose deaths.
2. 印第安纳州围产期质量改善协作(IPQIC)，围产期物质使用工作组。(2018)。Perinatal substance use practice bundle – A toolkit for Indiana hospitals.