Since its inception, the Colorado Hospitals Substance Exposed Newborns (CHoSEN) Collaborative has focused on and has made great strides in improvements to the birth hospitalization experience and outcomes of families impacted by perinatal substance use. With this ongoing work well underway, CHoSEN’s leadership decided to explore how they could begin proactively supporting families during the prenatal period and approached the Kempe Center to help develop a Perinatal Navigator Program that would take a collaborative approach to empowering and supporting families, beginning in the perinatal period.
We reached out to Jenny Koch-Zapfel, program manager at the Kempe Center, to learn more about the program and hear about successes and lessons learned so far:
What is the CHoSEN QIC Perinatal Navigator Program?
The Colorado Hospitals Substance Exposed Newborns Quality Improvement Collaborative (CHoSEN QIC) Perinatal Navigator Program is a program partnering the University of Colorado and Denver Health to improve the care and outcomes of families impacted by substance use. Believing that collaboration between systems serving affected infants and their families is best practice, the CHoSEN QIC Perinatal Navigator Program is focused on keeping families together by empowering them to identify and achieve personal goals, preparing them for the arrival of a new baby, and supporting them in accessing community resources. The Perinatal Navigator provides comprehensive and strength-based, client-centered navigation of goal setting, family education, and coordination of services. Learn more about each of the program’s elements here!
What have been some of the program’s greatest successes so far?
I think our greatest success has been the diversity and collaboration among our workgroup and other programs serving our target population. I think our program and our workflow represents the voices of each of our workgroup members. The collaboration has led to the creation of an informational flyer for providers and an implementation manual that is helping to track our workflow.
What have been some of the challenges you have experienced so far, and how have you approached them?
Identifying someone to fill the navigator role has been very challenging. At this time, the goal is for the navigator program to reside within the Nurse Family Wellness Program; however, staff availability is limited because the Nurse Educators are funded through the Denver Department of Human Services. We’ve been creative in thinking about how to staff this position given that the program is still in its pilot stage. Not knowing how it may grow and change, hiring staff is not feasible. In thinking about the scope of services we’d like to provide, as well as the experience we think would be most valuable, we’ve considered utilizing MSW students. However, due to the timing of the project and COVID restrictions on clinical time, student interest and availability has been limited. Currently, we’re piecing the navigator role together using one of the Nurse Educators within the Nurse Family Wellness Program, a social worker on the Mom/Baby unit at Denver Health, and the pilot’s Program Manager. Although each of these individuals has a wealth of knowledge and experience, they have other full-time clinical and administrative responsibilities, so we are continuing to brainstorm ideas for filling this role on a more permanent basis.
We have identified a process within the Denver Health electronic medical record system for notifying our temporary navigators of referrals. However, we anticipate that providers may forget to offer our program or may feel limited in discussing the program due to time constraints. We’ve approached this challenge by trying to anticipate what providers might consider barriers to the referral process and attempting to ease this burden. By creating an informational sheet with talking points for providers, we aim to educate them about the program, giving them confidence to discuss our program with patients and make referrals. Understanding that the time providers have in prenatal visits is limited, we are also working to educate the staff of Denver Health’s Integrated Behavioral Health program. This is a service which embeds mental health specialists within Denver Health’s clinics, providing additional support beyond the basic prenatal visits. We hope that knowledge of and familiarity with our navigator program amongst prenatal care providers, as well as the mental health specialists, will increase the chances that pregnant individuals may be offered a referral. I think we are heading in the right direction in terms of referrals. We haven’t had a chance to test out our method yet, but [we] hope to soon.”
What lessons would you share with others based on your experience?
Partnerships are key! We continue to reach out to other programs with similar aims in hopes of improving our processes and learning from what has and hasn’t worked for them. It’s also been invaluable to have a multi-disciplinary group working on the development of this program. Having perspectives of inpatient and outpatient pediatric providers, clinical and non-clinical social workers, non-profit program coordinators, nurse educators, and representatives from DDHS has fostered great relationships and rich discussions.
We are thrilled to see the work of CHoSEN expand beyond the birth hospitalization to begin supporting families prenatally! Please share information about this program with your colleagues, and if you have any questions or feedback about the program or ideas about filling the navigator role, please reach out to Jenny Koch-Zapfel at JENNIFER.KOCH-ZAPFEL@cuanschutz.edu.
As rates of alcohol use are increasing nationwide and Coloradans of reproductive age continue to need accurate, tailored, and supportive information about alcohol and reproductive health, a dedicated group of Colorado experts developed a new patient education resource focused on alcohol and pregnancy. Developed by the Colorado Substance Exposed Newborns (SEN) Provider Education Work Group in collaboration with Peer Assistance Services, Inc., the new resource provides objective information to patients about the possible risks of substance use on health, including before, during, and after pregnancy.
The handout includes the following sections:
In initially searching for patient-facing resources about alcohol use and pregnancy for the Colorado Perinatal Substance Use Provider Toolkit (currently undergoing maintenance), members of the Work Group discovered that many existing resources lacked information about how to get connected to help or services, focused solely on the fetus rather than the pregnant individual, were very technical, and/or were potentially stigmatizing and shame-inducing. The Work Group discussed that while it is crucial to inform patients of the potential fetal impacts of prenatal alcohol exposure, such knowledge in and of itself does not address alcohol use, dependence, or interrelated factors. Reducing or quitting alcohol use can be difficult, and unintentionally instilling fear, guilt, or shame has the potential to trigger additional substance use.
The resource’s publication comes at a time when rates of alcohol use are increasing nationwide. A study comparing alcohol use before vs. during the pandemic revealed that the average amount of drinks per day consumed by an individual increased by 27% between February and April 2020, the number of consumers who exceeded drinking guidelines increased by 21%, and binge drinking increased by 26%. According to another study, women increased their heavy drinking days by 41% during the pandemic compared to before the pandemic.
Alcohol has had a long-standing role in culture over time in relation to social connectedness and relaxation, however is one of the teratogens with the most severe outcomes. Nationally, 45% of pregnancies are unintended. According to 2019 data from Colorado’s Pregnancy Risk Assessment Monitoring System (PRAMS), 67.2% of women drank alcohol during the 3 months before pregnancy, and 15.2% of women drank alcohol during the last trimester of pregnancy.
“Understanding the risks associated with alcohol use decreases
The SBIRT in Colorado team offered expertise throughout the resource’s creation. Bethany Pace-Danley, Program Manager of SBIRT in Colorado, shared that “Understanding the risks associated with alcohol use decreases the possibility of experiencing harmful health outcomes. We are glad to have had the opportunity to collaborate on this important resource. We hope that it will increase conversations between patients and their clinicians about substance use, especially alcohol.”
There is no known safe amount of alcohol use during pregnancy or when trying to get pregnant.
There is also no safe time to drink during pregnancy. If a person has consumed alcohol during pregnancy, reducing or stopping future use during the pregnancy minimizes further risk.
If you would like printed copies of this resource, contact Peer Assistance Services at SBIRTinfo@PeerAssistanceServices.org. Visit SBIRT Colorado to access additional clinical tools.
The Colorado Substance Exposed Newborns (SEN) Steering Committee envisions a Colorado that equitably serves all families through prevention and reduction of substance use during pregnancy and provides multigenerational support for families to thrive. Illuminate Colorado provides backbone support to the SEN Steering Committee. Illuminate Colorado additionally serves as the Colorado Chapter of the National Organization on Fetal Alcohol Spectrum Disorders.
Thank you to our partners at Peer Assistance Services, Inc. for their collaboration and leadership on the resource’s creation. As a program of Peer Assistance Services, Inc., the goal of SBIRT in Colorado is to promote Screening, Brief Intervention, and Referral to Treatment as a standard of care throughout Colorado healthcare systems.
Multidisciplinary healthcare and human services professionals currently engaged in or hoping to learn more about Colorado Hospital Substance Exposed Newborns (CHoSEN) Collaborative’s work convened virtually on April 15, 2021 to engage in shared learning and receive updates on work happening across the collaborative.
Intentions for the day were set by honoring Dr. Annie Hall’s legacy, reflecting on the ongoing impacts of structural and historical racism on maternal and infant health, and centering on the experiences of those directly impacted by perinatal substance use through recorded stories shared by two Substance Exposed Newborns Family Advisory Board members. Dr. Susan Hwang also shared a preview of CHoSEN’s current and upcoming efforts to expand its focus beyond the birth hospitalization to the prenatal and postnatal periods.
CHoSEN was honored to be joined by attending neonatalogists Dr. Stephen Patrick, Director of the Center for Child Health Policy and Associate Professor of Pediatrics and Health Policy at Vanderbilt, and Dr. Elisha Wachman, Associate Professor of Pediatrics at Boston University School of Medicine, for the day’s keynote presentations. Dr. Patrick’s keynote presentation reflected on how public health systems improve and impede optimal outcomes for pregnant women and infants affected by the opioid crisis, with a focus on barriers to treatment, the role of communities, and recent changes to the child welfare system. Dr. Elisha Wachman’s keynote presentation gave an overview of Boston Medical Center’s innovative approaches to engaging families in the prenatal, birth hospitalization, and postnatal periods.
In addition to the keynote presentations, attendees heard updates from CHoSEN’s leadership and from participating entities who are implementing exciting work:
Missed the event or looking to refresh your memory of the day? Find the materials, recordings, and related opportunities to engage below.
Materials and Recordings:
Opportunities to Engage:
Please see below for a variety of resources recently shared by CHoSEN partners:
Nationwide Study Shows Continued Rise in Opioid Affected Births, January 2021
Postpartum Behavioral Health in Colorado, February 2021
Mothering and Opioids Toolkit: Addressing Stigma- Acting Collaboratively
Knowledge to Action: Care Equity for Black Moms: AWHONN - The Association of Women's Health, Obstetric and Neonatal Nurses is committed to bringing the truth about racial disparity in maternal care into the light. This video shares the journeys of two Black women whose lives were changed forever as they experienced bias, disrespectful care, and neglect during their hospital stay. The video also highlights the perspectives of a nurse and a nurse midwife who emphasize the need for change. Our hope is that this video will serve as a catalyst to challenge healthcare providers’ mindsets around racial disparity, and to transform knowledge into actions that will pave a pathway to equitable treatment for Black women and women of color.
Virtual Support Groups for Pregnant and Parenting Individuals:
Please see below for upcoming events and opportunities to engage recently shared by CHoSEN partners:
Don’t miss the spring CHoSEN Forum! CHoSEN Collaborative will host its spring Forum virtually from 9 am-1:30 pm on April 15, 2021. The virtual forum will include a focus on prenatal engagement and safe discharge of families and two keynote presentations. Visit this page to learn more, see the agenda, and register for the event!
Join a SEN Work/Advisory Group today! The Colorado SEN Steering Committee is recruiting participants for the work/advisory groups that will convene to advance its 2021-2022 priority areas. Visit this page to learn more about the Committee and its 2021-2022 priority areas and to sign up to join a work or advisory group.
Virtual Screening of "Community Voices": A Black Maternal Health Week in Colorado Event; Friday, April 16, 12 pm MT- In honor of Black Maternal Health Week 2021 (#BMHW21) occurring April 11-17, CPCQC invites you to attend a virtual documentary screening of "Community Voices." The infant mortality rate in Colorado is one of the lowest in the nation, so why is the death rate for Black babies over twice that of white babies? This short documentary depicts the experiences of the healthcare system by Black women in our community. The Addressing Infant and Maternal Mortality (AIMM) Medical Student Group at the CU School of Medicine will screen the film and facilitate a post-screening discussion about racism in the healthcare system. Register here.
Stigma, Equity and Trauma-Informed Care: Rebuilding Hospital Culture- Modeled on the CA Bridge implementation Blueprint, this “Boot Camp” series will provide specialized training and networking opportunities for hospital champions. Sessions will focus on changing the standard of care for substance use disorders, including clinical guidance for medication for addiction treatment (MAT), and health equity for underrepresented populations. You can join the webinars at any part in the series.
Colorado AIM: Substance Use Disorder Learning Collaborative Learning Opportunities- The Colorado AIM: Substance Use Disorder (CO AIM: SUD) Learning Collaborative, convened by CPCQC, focuses on establishing hospital guidelines and protocols for screening, brief intervention, and referral to treatment (SBIRT) for substance use disorder and perinatal mood and anxiety disorders at the time of admission for birth. Labor and Delivery units across the state are participating in the Collaborative, and CPCQC invites all who are interested to participate in related learning opportunities, even if their hospital is not participating in the Collaborative. For more information about the Collaborative and upcoming learning opportunities, visit CPCQC's project page or email email@example.com.
**Please note: While the learning opportunities are open to anyone who is interested, the last 30 minutes of each Monthly Coaching Call will be dedicated to sharing challenges, successes, and questions of participating hospital teams only. Additionally, portions of each quarterly Learning Session will be dedicated to group work for participating hospital teams only. Those who are not members of a participating hospital team can leave the call when this portion of each learning opportunity begins.**
Stigma of Addiction Summit: June 10, 2021 | 12 pm- 6pm ET: Join the National Academy of Medicine, Dell Medical School at The University of Texas at Austin, and Shatterproof on June 10, 2021 for the Stigma of Addiction Summit - a half-day, virtual, action-oriented summit entirely dedicated to understanding, addressing, and eliminating the harmful impacts of stigma on people who use drugs.
The Summit will endeavor to elevate current efforts at reducing stigma, identify successes and gaps in the evidence base, and prioritize and identify areas for future research and funding with an explicit focus on stigma, which is often touched upon only marginally in broader conversations about addiction.
The Summit is free to attend and will be recorded for viewing after the event concludes. Register to attend and/or submit an innovation abstract.
To further strengthen families impacted by perinatal substance use in Colorado, the Prenatal Substance Use and Improving Family Health study examined data at the intersection of health, public assistance, and child welfare. This research offers unique insights into how these systems can coordinate efforts to strengthen families, prevent family separation, and decrease foster care placement. Findings show several factors associated with an increased risk of infant removal from their family by child welfare due to prenatal substance use, including:
For infants removed from the home, the rate of placement with relatives while in foster care decreased by 15% (2016-2019). This is a concern as placing children with relatives has been shown to promote healthy child development.
Study findings inform prenatal opportunities for wrapping services around families impacted by prenatal substance use, beginning in pregnancy and using Plans of Safe Care, with the long-term goal of proactively preventing child welfare involvement and setting families who are involved in child welfare on a trajectory of safety and well-being.
The statewide perinatal substance use data linkage study was made possible by SB19-228 and the Linked Information Network of Colorado (LINC), which securely connects data across multiple systems. The study was designed in partnership with the Center for Prescription Drug Abuse Prevention, Illuminate Colorado, the Substance Exposed Newborns Steering Committee, and experts from state agencies, hospitals, non-profits, and the research community. Learn more about the project and access the report here.
For more information, contact Dr. Elysia Clemens at Elysia@ColoradoLab.org
The Challenge: Engaging Families during the Birth Hospitalization
Implementation of the Eat Sleep Console (ESC) tool and decreased use of pharmacologic therapy has contributed to great progress in reduction of the average length of stay for substance exposed infants within the CHoSEN Collaborative. While this care model has led to exciting outcomes, it requires significant support and time investment from both hospital providers and families, and we don’t yet fully understand how parents and caregivers are impacted by this new approach.
The Solution: Learning Directly from Families
To fill this gap, CHoSEN QIC has begun to engage birthing individuals in semi-structured qualitative interviews to better understand their birth hospitalization experience. By engaging directly with those involved, we aim to better understand the barriers and facilitators to implementing ESC and non-pharmacologic care during this time. These interviews focus on the following key areas:
Engaging in this process will allow us as a Collaborative to learn directly from those receiving this care with the goal of tailoring our interventions and approach to hospital care to best serve families.
While this work is ongoing, so far, three key areas have emerged as important for families during this time:
One participant emphasized the importance of education throughout this process by saying, “One thing has been consistent through both of my experiences, I was very surprised at how every staff member, specifically the RNs knew a significant amount about withdrawal, the adverse effects of medication vs. no medication. They were very non-biased and very informative, and they all were consistent on what they knew, you can tell the information was accurate.”
Looking to Understand the Experiences of Families at Your Hospital?
If your hospital is interested in having families who receive care at your site share their experiences, CHoSEN QIC is currently conducting interviews with birthing individuals affected by substance use. This allows us to learn directly from individuals and families who have experienced caring for an infant prenatally exposed to substances and how we can best care for them during their birth hospitalization. To learn more about this opportunity, contact Dr. Stephanie Bourque.
Dr. Bourque is a member of the CHoSEN QIC Steering Committee and is on faculty at the University of Colorado School of Medicine. Her clinical work as a neonatologist is primarily at Children’s Hospital Colorado and University Hospital. Within the CHoSEN Collaborative, Dr. Bourque’s focus is on optimizing family engagement, specifically during the birth hospitalization.
With the coronavirus (COVID-19) pandemic ongoing, multidisciplinary professionals from across the Rocky Mountain region who support families impacted by prenatal substance exposure convened virtually on October 13th to share updates and learn from each other’s successes and challenges in implementing related quality improvement efforts.
Missed the event or looking to refresh your memory of the day? Find the materials, recordings, and related upcoming opportunities to engage linked below.
Materials and Recordings:
The work continues! While our world continues to look different, the CHoSEN Collaborative team is still here to support your efforts and connect you to related initiatives.
Opportunities to Engage:
Quality improvement efforts often use the phrase “share seamlessly, steal shameless” to describe the importance of learning from one another and building from each others’ strengths and past efforts.
With that sharing philosophy in mind, we’re happy to share that our first CHoSEN article will be published in Hospital Pediatrics (Volume 10, Issue 9, September 2020). The article is titled “The Colorado Hospitals Substance Exposed Newborn Quality Improvement Collaborative: Standardization of Care for Opioid-Exposed Newborns Shortens Length of Stay and Reduces Number of Infants Requiring Opiate Therapy” and includes aggregated CHoSEN QIC data from April 2017 to December 2019 demonstrating our statewide collaborative’s reductions in average LOS, the percentage of OENs requiring opiate therapy, and average LOS for OENs requiring opiate therapy.
Thank you to all the participating CHoSEN hospital teams who have made this opportunity to share our work with the broader pediatric community possible!
The CHoSEN QIC team is developing additional manuscripts to continue to share our lessons and successes, including a draft manuscript analyzing demographic disparities. If your hospital team is interested in disseminating your hospital’s work--whether to your C-suite, for a conference, or for publication, support is available. Please contact Dr. Susan Hwang to get the ball rolling to seamlessly share.
Lutheran Medical Center is one of the founding hospitals of the CHoSEN Quality Improvement Collaborative. Jillian Adams, director of strategic initiatives for Illuminate Colorado sat down with Dr. Erica Wymore to discuss how she and the team at Lutheran Medical Center are utilizing their electronic health record (EHR) system to support their hospital’s CHoSEN practice changes, particularly related to breastfeeding practices.
Dr. Wymore is the Medical Director of the Newborn ICU at Lutheran Medical Center, a faculty member at the University of Colorado School of Medicine, and a member of the Steering Committee for CHoSEN QIC has been part of this effort from the beginning, continuing to innovate around supporting opioid-exposed newborns and their families.
The Challenge: Communication Across Mother and Infant Provider Teams
Examination of data across CHoSEN hospitals revealed variability among breastfeeding rates for substance-exposed newborns, leading to a desire to improve these rates among mother-infant dyads affected by a substance use disorder.
To begin addressing this need, Lutheran Medical Center worked to create a process map to help them understand, reflect on, and identify room for improvement in their policies and procedures for determining a dyad’s breastfeeding eligibility and effectively and consistently communicating it between providers and to families.
Engaging in this process led to the identification of a challenge with ensuring that important information from the mother’s medical record and provider team is reflected in the infant’s medical record and shared with the infant’s provider team.
The Solution: Ask What Your EHR System Can Do for You
With this challenge identified, the team at Lutheran began collaborating with their electronic health record provider to develop improved and automated workflows within their EHR system to ensure that important information related to a mother-infant dyad’s breastfeeding eligibility is available in all of the necessary places. Watch the interview with Dr. Wymore to learn more about how Lutheran Medical Center developed their process map and is working with their EHR provider to create new workflows.
Looking for Solutions for your Hospital?
If your site is interested in implementing similar innovations, Dr. Wymore advises developing a process map to identify your hospital’s key players and then working to provide clear and consistent education that will ensure families affected by prenatal substance exposure receive the best and most consistent care. CHoSEN QIC is able to support hospitals through these innovations by conducting a virtual site visit and helping teams with steps like developing a process map. To request and schedule a virtual site visit, contact Jessica Scott.
Get news from the CHoSEN Collaborative on best practices and tools available to perinatal providers related to the care of SENs.