Problem Addressed

Substance use disorders (SUDs) can have a profound impact on pregnancy outcomes. Patients with substance use disorders may be unlikely to seek prenatal care due to fear of being reported to child welfare officials.  Further, data has demonstrated that patients with an SUD during their pregnancy have worse outcomes than patients without an SUD, including in rates of preterm births, C-sections, placental abruption, and hypertension.  Similarly, infants born to patients with SUDs are more likely to be born prematurely, have a low birthweight, be small for their gestational age, have respiratory distress syndrome, or have intrauterine growth restriction.² 

Patients who do seek prenatal care have a variety of complex needs. Unfortunately, maternal care providers typically have minimal experience with substance use disorder treatment, and addiction specialists have minimal experience with maternal care.¹ Therefore, the objective of this innovation is to address poor maternal and infant outcomes specifically among patients with an SUD diagnosis.
 

Description of the Innovative Activity

At the core of Project Nurture is the integration of maternity care, substance use disorder treatment, peer support, care management, and the referral of patients to social service resources. Maternity care includes services such as prenatal care, maternity stay, postpartum care, breastfeeding support, and family planning services. Substance use treatment includes services such as SUD assessment, individual and group counseling, MAT, and coordination between treatment and prenatal/postnatal care. In addition to these clinical services, peer support and social services coordination is a critical component of the innovation. This includes peer mentoring on topics such as pregnancy, SUD recovery, and parenting, as well as coordinating with welfare workers on activities such as navigating welfare services, assistance programs, and judicial services.³

All sites operate slightly differently based on the scope of the providers within the organization, but there are commonalities and core elements of the project. Core members of the team include a maternity clinician (which could be a family physician, obstetrician, or a midwife), a certified alcohol and drug counselor, a case manager, and a peer recovery mentor/doula.² Maternity care and Level 1 outpatient addiction treatment are provided weekly through treatment and maternity care groups. Counselors provide drug, alcohol, and mental health assessments, and trained peer recovery mentors or doulas are available as core members of the innovation team for a variety of peer mentoring needs.⁴ Critically, peer recovery mentors are not traditional community health workers, but rather must have lived SUD experience or be familiar with SUD care. The objective of this multidisciplinary provider team is to build trust and confidence in a nonjudgmental way to promote health and safety of both the mother and infant. By limiting strict programming requirements for patients, the program is able to move away from classifying patients as either compliant or noncompliant and instead focus on maximizing whatever levels of engagement are possible.

Context of the Innovation

Three original sites (Legacy/LifeWorks, Oregon Health & Science University (OHSU)/CODA, and Providence) received Affordable Care Act Transformation Fund grants in 2014 from the local Coordinated Care Organization. In 2019, Kaiser received a Transformation Fund grant and incentives from Medicaid to launch their program.

Project Nurture sites collaborate via a monthly Steering Committee. Steering Committee members consist of two representatives from each organization: one representing the administrative personnel and site requirements, and one the clinical side. The Steering Committee is an opportunity for the sites to share what they have learned in their work. It also serves as a forum to invite community stakeholders to participate in discussions, when appropriate. In addition to monthly Steering Committee meetings, quarterly meetings are held that allow for broader team inclusion. During these meetings, there are opportunities for cross-team collaboration as well as for educational sessions on topics of relevance to all sites.

Results

Data collection during the first couple of years of the program allowed for the identification of the following results. Results are based on an unmatched claims analysis of obstetrical and neonatal outcomes comparing patients with SUDs in Project Nurture to patients with SUDs in the rest of Medicaid (n = 114 and n = 507, respectively), a review of clinical data collected by the sites, and a qualitative study on the experience of care before and after Project Nurture.² Results include the following:

• A 70% reduction in the odds of preterm birth compared to patients with SUDs who are not in Project Nurture (p = 0.01)
• C-section rates in Project Nurture of 28%, compared to 36.5% in patients with SUDs who are not in Project Nurture (p = 0.01)
• Significantly greater likelihood that participants have seven or more prenatal care visits (p = 0.03)
• Significantly higher rates of engagement with MAT during pregnancy among patients with an opioid use disorder (adjusted odds ratio [AOR] 3.1, p < 0.001)
• Infants born to patients in Project Nurture half as likely to need additional care after birth (AOR 0.46, p = 0.01), including a decrease in infants given morphine (40% to 20%) and a decrease in the amount of morphine given (95.6% reduction)  

However, while the evidence and data collected have demonstrated that this is an effective intervention with improved outcomes among mothers and infants, it does not have a clear return on investment (ROI). In recent years, the program has focused resources on patient care rather than on data collection.

Planning and Development Process

When planning for the implementation of this innovation, the Project Nurture teams identified the following as key to success: 

• Identifying a clinician champion, ideally an obstetrician/gynecologist (OB/GYN), family practitioner, or midwife, to lead the innovation at each site from the clinical side. 
• Creating an interdisciplinary team with clear role definitions of how each member’s skill set contributes to patient care.
• If care team members do not yet have experience or training in trauma-informed care, substance use disorder treatment, or harm reduction, provide time for education. 
• Establishing a small workgroup to ensure clear understanding of the workflow process, addressing key “how do we do it?” questions such as: 
  • Do we want to use an electronic health record (EHR) referral?
  • How do patients enter the program?
  • What questions are asked of the patient?
• Having a clear understanding of the data metrics that you would like to track and the data required so that expectations can be set with the implementation teams up front and information technology personnel can ensure that the necessary data collection forms are available. 

Interested sites should also be prepared to identify and make changes to their existing systems of care to accommodate the intervention, including rewriting or introducing new protocols or prescribing best practices.⁵

Resources Used and Skills Needed

The staffing composition for Project Nurture is critical. It is particularly important to ensure the availability of recovery mentors with lived experience as a person with a substance use disorder and/or a pregnant person with a substance use disorder or experienced with SUD care. However, finding providers who already have experience treating this nuanced patient population may be difficult. Therefore, program representatives emphasize that it is important to identify providers that are passionate and excited about working with this patient population and are eager to learn how to approach their specific needs.

In addition to staffing, ongoing funding support from the organization or from local/state agencies is likely required.

Funding Sources

While initial grant funding supported up-front costs associated with the intervention, the programs require ongoing financial support from their organizations, as activities are not financially self-sustaining.

Getting Started with This Innovation

When getting started with this innovation, there is a need for intentional outreach to staff in the organization not directly assigned to the initiative, but who will be interacting with the patients. The objective is to help them understand what the initiative is doing and why, because in order for the program to work, individuals who encounter these patients in the broader organization need to engage with them in a way that aligns with the messaging and intent of the program. Most notably this includes ensuring that patients feel supported and not shamed. Education within the organization can ensure that core elements are being reproduced across the board, not just within the initiative team.

Sustaining This Innovation

As mentioned, this innovation is unlikely to generate ROI or be financially self-sustaining. As such, ongoing buy-in, commitment, and willingness to provide funding at the organizational level are required. That said, the business case could be made that the system is likely going to be taking care of these patients at some point — it’s just a question of whether it is more upstream care, as is provided in this program, or in a more acute care setting. Additionally, interested organizations may be able to identify opportunities for enhanced reimbursement from payers. For example, some local Medicaid providers may offer enhanced reimbursement benefit designs for substance use disorder services under behavioral health services.⁵

References/Related Articles

McConnell KJ, Kaufman MK, Grunditz JI, et al. Project Nurture integrates care and services to improve outcomes for opioid-dependent mothers and their children. Health Aff (Millwood). 2020;39(4):595-602.

Footnotes

1. Health Share of Oregon. Project Nurture: A New Model of Care That Integrates Maternity Care and Substance Use Treatment. Accessed February 12, 2021. https://www.healthshareoregon.org/storage/app/media/documents/Health%20Equity/Ready_Resilient/ProjectNurture_Handout.pdf
2. Bellanca HK. Project Nurture. Health Share of Oregon; 2018. Accessed February 12, 2021. https://mthcf.org/wp-content/uploads/2018/09/Project-Nurture-Presentation_7.13.18.pdf 
3. McConnell KJ, Kaufman MR, Grunditz JI, et al. Project Nurture integrates care and services to improve outcomes for opioid-dependent mothers and their children. Health Aff (Millwood). 2020;39(4):595-602.
4. Legacy Health Systems; LifeWorks NW; CODA, Inc.; Oregon Health & Science University; Oregon Department of Human Services Child Welfare; Health Share of Oregon. Project Nurture: A Center of Excellence Model That Integrates Maternity Care and Addiction Treatment. Accessed February 12, 2021. https://www.healthshareoregon.org/storage/app/media/documents/Commitment%20to%20Health/Project%20Nurture%20-%20Learn%20More%20Flyer.pdf 
5. Risser A. Project Nurture. Oregon Health & Science University; 2019. Accessed February 12, 2021. https://www.ohsu.edu/sites/default/files/2019-11/CPD%20OB19-Thu-08-Risser.pdf

Date Verified by Innovator

February 18, 2020