A New Program is Working to Improve Perinatal Access, Coordination, and Treatment for Behavioral Health in Colorado
Every pregnant and postpartum individual and infant deserves safe, equitable, and quality care, which includes ensuring their behavioral healthcare needs are met.
Exacerbated by COVID-19, Colorado is in the midst of a perinatal mental health crisis where suicide and accidental overdose are the leading causes of maternal mortality during pregnancy and through the first year postpartum. Nearly 80% of the state’s maternal deaths are preventable. (1)
The Colorado Department of Human Services Office of Behavioral Health has identified a need to bridge gaps in perinatal behavioral healthcare for pregnant and postpartum people by embedding health care delivery system quality improvement initiatives within the meaningful connective tissue of a care coordination model that is fluid enough to meet the perinatal dyad wherever they are in the perinatal continuum of care.
“When left untreated, behavioral health conditions and toxic stressors experienced by pregnant and postpartum people have devastating consequences for infants and children, for parents, and for society. There are many contributing factors that lead to poor maternal or child health outcomes, and while some of those factors are a mystery, or outside of our control- many more are known, preventable, treatable, and are things we can and should do something about. This is why OBH believes the IMPACT BH Program is so important- continuity of and access to pregnancy and postpartum behavioral health care is something every pregnant and birthing person in Colorado should have access to. We're not there yet, but IMPACT BH is a step in the right direction.” -Kallen Thornton, MSSW, LCSW
Manager of Gender Responsive Services- Office of Behavioral Health
The IMPACT (IMprove Perinatal Access, Coordination & Treatment) Behavioral Health program will establish an integrated perinatal behavioral health care network which spans prenatal, hospital, and postpartum care and improves screening, diagnosis, and treatment of perinatal behavioral health needs through community-derived strategies, including care navigation and increased social and peer support. For individuals experiencing substance use disorder, IMPACT Behavioral Health will expand and integrate medication-assisted treatment programs into perinatal care.
With nearly $1 million in funding committed to this program and the recognition that Colorado’s rural birthing population is in dire need of behavioral health support and resources, IMPACT Behavioral Health will launch in Colorado’s western rural mountain region which has been severely impacted by the opioid epidemic and experienced a significant increase in Neonatal Abstinence Syndrome over the past few years.
Beginning with a pilot in Garfield County with plans for subsequent rollout in other counties in Health Services Region 12, the program will support behavioral health through the development and implementation of a perinatal behavioral health framework and associated set of coordinated, cross-sector behavioral health services, supports and information-sharing practices.
The framework and associated set of services will be developed and implemented collaboratively by local partners with leadership and support from Colorado Perinatal Care Quality Collaborative (CPCQC), Illuminate Colorado, Colorado Hospital Association, and the CU Practice Innovation Program.
By 2023, IMPACT Behavioral Health will establish a standard of care, expanding across the state to additional regions identified as having gaps in perinatal behavioral health services, with the potential to positively impact the state’s nearly 60,000 new maternal-infant dyads each year.
Want to learn more? Contact the CPCQC team at firstname.lastname@example.org.
(1) Colorado Department of Public Health and Environment (2020). Colorado Maternal Mortality Prevention Program Legislative Report 2014–2016.
“We regularly hear from our colleagues that they recognize the importance of taking a trauma-informed approach to patient care, but very few have had the opportunity to receive formal training on trauma-informed care and communication,” said Dr. Laurie Halmo, pediatrician and toxicologist at Children’s Hospital Colorado and co-chair of the Colorado Substance Exposed Newborns Steering Committee work group focused on expanding healthcare provider education resources related to substance use and pregnancy with an emphasis on family leadership and addressing implicit bias.
Designed by Healthcare Providers, for Healthcare Providers
Now, thanks to Colorado Substance Exposed Newborns Steering Committee Provider Education Work Group and the Colorado Perinatal Care Quality Collaborative, a NEW Trauma-Informed Communication and Care Provider Educational Series designed by healthcare providers, for healthcare providers, is available beginning next Monday.
Each session is grounded in the perspective of someone with lived experience related to substance use and pregnancy underscores just why this topic is so important. Anyone who interacts with perinatal patients and their families in a clinical setting, from gynecologists, obstetricians, neonatologists, and pediatricians, to mental/behavioral healthcare providers and social workers, are encouraged to attend. Clinical professionals will walk away with the knowledge and tools to care for individuals in the perinatal period and those who are impacted by substance use in a trauma-informed way that leads to better experiences and outcomes for all.
The educational series includes:
Newly released CHoSEN Publication! "Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals"
CHoSEN Collaborative has been published again! We reached out to Blair Weikel, lead author of “Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals", to understand more about why this research is important, what was most surprising, and what she would like to see for Colorado’s efforts to improve care of families impacted by substance use in the future.
From your perspective, why was it so important to do this research?
“So often we assess data in aggregate and report success when overall average outcomes improve. However, we all know that health is not equitably distributed, a phenomenon that is masked unless we disaggregate data by the social constructs that predict disparate healthcare experiences and health outcomes. It is critical that researchers of all populations, but especially highly sensitive ones such as the SEN population and their families, consider the ways that discrimination can intensify the difficulties these families may face.”
As you were analyzing the data, what most surprised you?
“In theory, CHoSEN QIC's interventions were rolled out in a hospital at a single time, meaning they should have been implemented for all patients at one time. However, the trend in the data in a delay for improvement for Hispanic families was pretty clear and initially surprising. In retrospect, it makes sense that certain families would have barriers to being engaged in the interventions, such as language or schedules that do not allow for visitation during normal business hours and that it would take hospital teams more time to determine how to best support them - which the data shows they ultimately did.”
How can hospitals who participate in the CHoSEN Collaborative support the ability to do more of this kind of research in the future?
“Assessment and publication of this work could not be done without the hard work and dedication of CHoSEN QIC hospital teams. To continue to share our statewide progress and struggles, hospitals can continue to enter data reflecting their work.”
Thinking about these kinds of data analysis efforts, where do you hope to see Colorado go next?
“I would love to see all hospital systems in Colorado engaged with the CHoSEN collaborative, especially as we work to expand our focus from opioid-exposed newborns to infants exposed to any substance during pregnancy. Having a statewide consistent approach to the treatment of these infants and support of their families will likely lead to improved and more equitable outcomes.”
Read the full publication, “Ethnic Disparities in the Care of Opioid-Exposed Newborns in Colorado Birthing Hospitals" here, and reach out to Blair Weikel with any questions!
Multidisciplinary professionals already engaged in or hoping to learn more about Colorado Hospital Substance Exposed Newborns (CHoSEN) Collaborative’s efforts to increase consistency in implementation of best practice in the identification of and response to newborns prenatally exposed to substances convened virtually on October 19, 2021 to engage in shared learning and receive updates on work happening across the collaborative.
Dr. Susan Hwang kicked the day off by rooting in data on Colorado’s overdose-related mortality over the last 20 years, the international increase in perinatal mental health challenges during the pandemic, challenges in accessing substance use treatment experienced by Coloradans who need it, and the disparities that exist within this data. Reflecting on data around the spike in substance use and maternal mortality that occurs during the first year postpartum, Dr. Hwang invited the multidisciplinary professionals on the call to ask themselves:
“What are we doing to support mothers, children, and families after birth? And why is it that substance use rates increase astronomically, and moreover, why is it that maternal mortality increases, not immediately after birth, but into the first year postpartum?” -Dr. Susan Hwang
This question set the tone for participants, who all care for families impacted by substance use, to reflect on all of the work that needs to be done to better support families and to address the barriers to receiving the support that they deserve.
The day included vulnerable and inspiring stories about personal experiences with addiction and recovery from Colorado Public Radio’s Vic Vela and Dr. Robert Dietz. Vic Vela, Colorado Public Radio news host and host of the recovery podcast, “Back from Broken”, openly shared his experiences and set the tone for the event with a message of hope:
“There’s a reason I’m here and able to talk to you about very painful things. It’s because I got help. [...] Don’t give up on yourself. Imagine the impossible. But it’s not as impossible as you might think.” -Vic Vela, Colorado Public Radio news host
Dr. Robert Dietz shed light on his own experiences and shared words of wisdom about addiction and recovery through his perspective as a physician, offering guidance on what healthcare professionals can do if they or a colleague they know is struggling with substance use.
In addition to these moving stories of personal experiences with substance use, the CHoSEN Collaborative was honored to be joined by Dr. Elizabeth Krans, Assistant Professor of Obstetrics, Gynecology and Reproductive Medicine at the University of Pittsburgh and Director of the Pregnancy and Women’s Recovery Center at Magee-Womens Hospital, for the day’s clinical keynote presentation. Dr. Krans’ presentation included valuable information on the importance of using evidence-based practices in the care of pregnant individuals with substance use disorders and concrete examples of how to use them for a variety of topics, including substance use screening, medications for opioid use disorder, and sexual and reproductive health.
Updates on work happening within the CHoSEN Collaborative itself included:
Data, Funding and Policy/Multisystems Updates:
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:
If you are interested in getting more involved in CHoSEN, need a presentation for your stakeholders, have specific data needs, or would like to schedule a virtual site visit, please reach out to Susan Hwang at Sunah.Hwang@childrenscolorado.org.
To learn more about or get involved in any of these perinatal behavioral health related funding projects shared during the Data, Funding, and Policy/Multisystems update, reach out to email@example.com.
To learn more about or get involved in any of this systems/policy work shared during the Data, Funding, and Policy/Multisystems update, or the implementation of the 2021-2022 Colorado SEN Steering Committee priority areas, contact Cassie Davis at firstname.lastname@example.org.
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
Get news from the CHoSEN Collaborative on best practices and tools available to perinatal providers related to the care of SENs.