America's opioid crisis has many faces. One belongs to a young woman from the Appalachian county of Athens, Ohio, who supports herself with a job at a fast food restaurant. Prescribed a course of Percocet after foot surgery, she was still in pain when the pills ran out. So she bought opioids on the street.
“I never knew I was addicted,” she says, “until I found out I was pregnant.”
Her baby, due on Christmas Day, is likely to be born in withdrawal. Her health faces challenges that transcend addiction: food insecurity, lack of stable housing, trouble with reliable transportation.
But in her corner of Ohio, a group of healthcare providers has piloted a program that addresses those obstacles head-on, through coordinated care from a team of obstetricians, addiction specialists, and nurse navigators. State officials believe it could become a model for addiction treatment — and the state’s best hope against the staggering human and financial costs of neonatal abstinence syndrome, or NAS.
NAS is a problem that’s growing, in Ohio and nationwide: A Reuters investigation found that more than 27,000 U.S. babies were born with the condition this year, suffering tremors, seizures, and other symptoms of withdrawal from opiates their mothers took during pregnancy.
Because so many of these babies require hospitalization in neonatal intensive care units, NAS has become a hefty burden on state Medicaid budgets and commercial payers. According to the Ohio Department of Mental Health and Addiction Services, the cost of NAS in Ohio totaled $105.2 million in 2014 alone.
Several years ago, Ohio public health officials turned their sights on NAS — searching for innovations, not just in neonatal care, but in prevention.
“We said that we really need to not look at just the baby,” says Mark Hurst, M.D., medical director of the state agency, “but at the maternal-child unit as early as we can in pregnancy.”
Before long, they found their way to Athens.
The Athens circle of care
Pam Born, practice manager for OhioHealth O’Bleness Athens Medical Associates Obstetrics and Gynecology (known as AMA), had long managed a troubled patient population. Fully 32 percent of the county’s residents live in poverty, twice the national average. Born’s team was accustomed to treating women with diabetes, heart disease, and other chronic diseases — exacerbated by economic and social conditions, the social determinants of health.
And by 2010, Born could see that many patients were in addiction’s grasp, as well.
“One day, one of our obstetricians came out of an exam room and said, ‘I don’t know how much longer I can do this. These patients have problems I can’t take care of,’” Born recalls. “I thought, ‘I have to do something, or I’m going to lose my doctors.’”
Born reached out to Joe Gay, Ph.D., executive director of Health Recovery Services, an addiction counseling facility in Athens. She wanted to see if he was witnessing a swell of opioid addiction among women of reproductive age. The answer was yes: His data showed a disproportionate impact of opioid addiction on women, particularly those between 21 to 30 years old.
When Born and Gay realized they were serving the same patients — pregnant women addicted to opioids — they began working together.
“If we could get these women help during their prenatal period,” Born says they wondered, “could we impact the risk of NAS? That’s when we formed our little alliance.”
To help women out of addiction in time to deliver healthy babies, AMA manages their obstetric care. Vinayak Shukla, M.D., in AMA’s family practice clinic down the hall, provides medication-assisted therapy to treat their addiction.
Health Recovery Services offers counseling. And the nurse navigators of the Family Navigator Program, led by Sue Meeks at Ohio University’s Heritage College of Osteopathic Medicine nearby, perform case management.
Each agency can be an entry point for mothers, immediately alerting other providers of a new patient in their circle of care. All providers view the same electronic patient information, adding notes from their meetings with patients and consulting each other in real time by texting within the electronic health record. Along with a shared EHR, monthly meetings and daily hallway huddles keep all the caregivers continuously informed on the status and needs of every patient.
Communication overcomes barriers
As AMA’s intake nurse, Tiffany Holt greets every new obstetric patient with a warm smile. And if that patient’s urine test is positive for opioids, her smile is just as warm.
“Have you used alcohol now or in the past?” she asks. And then, “Well, any drug use now or in the past?” If the patient says ‘no’ but Holt senses discomfort, she says, “Well, you know how it is in this area. I’m surprised you aren’t.”
Given an open door into a secure space, her patients enter: “Oh, yeah, you know, a few weeks ago, but it’s not that big a deal. I can stop.”
Then Holt delivers life-changing news: “Well, you’re in a good place, because we have tons of programs that can help you through this pregnancy and get you home with a happy baby.”
Nurse navigators Stacy Lee and Kristin Kerwin step in next. Registered nurses trained in trauma care and the impact of poverty on health, they build relationships with patients from the first obstetrics appointment through three months postpartum. They get to know each mother and her circumstances. Does she have a safe place to live? Is she hungry? Are her partner or parents addicted? Does she have a way to travel to medical appointments? Does she have a phone?
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Many patients do have cell phones when they have little else. They tend to have limited calling minutes, but unlimited text messaging, so they won’t pick up a call but will respond to a text. Lee and Kerwin see that circumstance as an opportunity.
While HIPAA concerns can prevent the physicians from texting patients, the nurse navigators have more latitude. “We can remind patients of their appointments, we can find out why they’ve missed one,” says Kerwin. “We can have whole conversations with them via text which is a real advantage.” And if a patient stops showing up for care and stops responding to text messages, Lee and Kerwin will drive miles to find her.
That problem-solving reaches over barriers put in place by generational poverty. Lee and Kerwin help with paperwork for food stamps, hand out $10 gas vouchers to cover the cost of fuel spent getting to and from appointments, and find assistance to pay a first month’s rent in a safe home. Each solution, every incentive keeps patients engaged in their care.
Pregnancy itself, Lee and Kerwin say, is a powerful incentive for recovery. “I don’t know of any moms who want their babies to be using heroin inadvertently,” Lee says.
And the nurses tell their patients that motherhood can be a new beginning. “Your baby will think you’re the most perfect person in the entire world,” Holt tells patients. “Let them continue seeing that.”
Word of mouth has spread about the nonjudgmental care, Meeks says. They’ve noticed women in the community coming for addiction treatment earlier in their pregnancies.
And the sooner medication-assisted therapy and other treatment is begun in pregnancy, she says, the more likely the outcome will be a full-term baby that does not require a NICU stay.
The MOMS Project
Soon after the Athens providers organized their alliance, the team from the state arrived to learn more about what they were doing. Eight months later, in 2013, the state launched the Maternal Opiate Medical Supports Project, known as MOMS.
A three-year grant to four locations, the project intended to discover best practices and care models that decrease NAS hospitalization rates and increase the long-term well-being of opioid-addicted women and their children. The alliance of providers in Athens was the only rural location selected, in part because it was already reaching the project’s goals.
WATCH: Nurse navigators discuss barriers to patient care
While data from the MOMS Project is still being analyzed, early results indicate that Athens’ approach reduces the rate and cost of NAS. From 2014 to 2016 in Athens, 93.8 percent of babies born to Medicaid-eligible women with addiction were full-term, compared to 85.5 percent of all babies born to Medicaid-eligible women in Ohio. By avoiding NICU hospitalizations, these births represent an estimated $2 million savings to Medicaid.
Now, Ohio officials say, the integrated MOMS approach needs to be scaled.
“The slightly less than 300 moms that were treated [in this project],” says Hurst, “are just a drop in the bucket in terms of the overall number of moms who are opiate dependent. It was really for us to acquire what the best practices are…that lead to better outcomes for the mom and for the baby.”
What the providers in Athens have proven, Hurst says, is that “the more integration you can have…the better chance you have of good outcomes. That is a major shift that we need to continue to endorse.”
But integration is only effective, he says, when providers are aligned in their approach — and when patients feel safe enough to be engaged partners in their own care.
Gale Pryor is a senior writer for athenaInsight. Video produced by Courtney Hayes. Photograph by Yanina Manolova.