FOCUS Program at University of New Mexico
The FOCUS (Family Options Caring Understanding Solutions) Program started their work in the early 1980s by taking care of infants diagnosed with HIV/AIDS .While there was little interest at the time, particularly among primary care medicine (eg, pediatricians, family physicians, obstetrician-gynecologists (OB-GYN) and psychiatrists), in working with pregnant women with substance use disorder (SUD) and opioid use disorder (OUD), FOCUS developed protocols to provide care and support for families and infants affected by prenatal substance exposure, such as alcohol, opioids, cocaine, methamphetamines and marijuana. These protocols demonstrated that positive engagement and partnering with the mothers in recovery and their children, co-locating services, and incorporating home-based early intervention services into the infants’ care, generates positive health outcomes for the mother-infant dyad. Today, the FOCUS clinic within the University of New Mexico (UNM) Family and Community Medicine Department and the Early Intervention Program (EIP) within the UNM Center for Development and Disability is working in partnership to provide seamless care and support to pregnant and parenting women affected by opioid use.
An Interprofessional Clinical Team
The FOCUS clinical team includes pediatricians, family physicians and a psychiatrist from the Departments of Pediatrics, Family and Community Medicine and Psychiatry and Behavioral Sciences. The EIP includes a team of social workers, child psychologists, developmental specialists, occupational therapists, speech therapists, as well as trainees from these disciplines. In partnership with the EIP, the clinic provides home-based developmental therapy and parenting support services, substance use treatment, and behavioral and mental health professional services for both parents and children.
The interprofessional approach was assembled to reduce the barriers to accessing care and treatment encountered by women with OUD. Multiple services across different clinical areas offered in one location saves families precious time, that other way would have been spent trying to find specialists and behavioral health services or traveling to multiple locations for appointments.
A Pediatric Medical Home
At FOCUS clinic, the interprofessional clinical team knows their patients and can confer on providing individualized care for each family member within the family- and patient-centered care framework. The FOCUS clinic plays the role of a pediatric medical home for infants diagnosed with neonatal opioid withdrawal syndrome (NOWS) or neonatal abstinence syndrome (NAS) up to the age of 3. Children can receive services directly from the Center for Development and Disability which is a University of New Mexico Health Sciences affiliated program, and a University Center for Excellence in Developmental Disabilities Education, Research, and Service (UCEDD).
Continuity of Care
The EIP at the Center provides direct services to children with developmental disabilities, as opposed to only diagnostic or consultative services. During the early intervention (EI) intake, children received a comprehensive developmental evaluation, and annually thereafter, to monitor development and guide developmental interventions. After the transition into the school system, the EI teams conduct transition meetings with schools to provide information and recommendations regarding’s the child developmental needs. When the children turn 3, the parent(s) and the infant transition to seeing a family primary care physician within the same location. This approach to transition in care assures continuity, and keeps the families within the established medical home, and allows them to work with a team who knows them. Children are referred to specialists offsite such as audiologists or ophthalmologists, as needed.
Birth parents, partners, and other family members can receive comprehensive adult medical care at the clinic including routine care, reproductive care services, as well as care and treatment for conditions such as sleeping and eating disorders, diabetes, and hypertension. Birth parents are referred to offsite specialists for conditions such as immune disorders, gastrointestinal disorders, or cardiac conditions. While offsite specialist referrals are sometimes needed, the clinic tries to offer multiple services, and comprehensive management onsite, since it can be difficult to secure offsite appointments with specialists who have experience working with this patient population, and who will provide empathetic and nonjudgmental care.
Mothers can receive medication treatment for SUD/OUD and psychobehavioral services within the clinic. The FOCUS clinical team knows that the support offered to mothers is essential to assure positive results. Team members will renew prescriptions as needed and will support long-term medication treatment to prevent the return to use especially in the first year after delivery, which is the most a challenging time for mothers in recovery. The evidence-based psychotherapies therapies offered to families include Child Parent Psychotherapy and Circle of Security.
Home Visiting
The EIP has been providing home-based services for over a decade to families affected by opioid use and other substances use. The program focuses on supporting mothers in achieving their parenting goals, as well as their child’s health and development goals. Families receive weekly visits from EIP staff, and weekly or bi-monthly visits from home visiting program staff. The frequency of these visits is based on each family individual needs.
Overcoming Biases
The team members recognize that existent healthcare biases are affecting the health services and the way these services are offered to families affected by opioid use. The biases impact birth parents in recovery and their infants, especially in the context of the home visiting and early intervention programs. Although many programs hire staff from communities of color, organizational culture may interfere with equity in the provision of health services. One example that may affect the way in which health services are being planned and delivered is caused by the providers’ interpretation of the concept of "safety". Staff frequently have understandable concerns about the homes’ safety, especially when other individuals live in the same home. In this context, an “unsafe” home may become coded language for biased care. To assure equity in the delivery of care, the FOCUS clinic advocates for addressing this issue at system and leadership level.
Building a Therapeutic Alliance
At every step, the physicians, the behavioral health professionals, and the early intervention providers are focused on building a therapeutic alliance with parents and supporting them in developing positive parenting skills. Through the sister program from MILAGRO (Mothers Invested in Life, Abstinence, Growth, Rehabilitation and Opportunities) clinic, which offers prenatal care, the FOCUS clinic often receives patient referrals for pregnant women in recovery and with chronic SUD. This referral process allows the team members to meet many patients before delivery and to schedule post-delivery appointments for both the infant and the mother. When communicating with the families, the team members are empathetic and use clinical, non-stigmatizing terms that focus on the medical aspects of the OUD as a disease. Whenever possible, mothers are praised for their parenting skills and accomplishments and strengths and resiliency are emphasized. Providing culturally competent care is also important to building a therapeutic alliance.
Anticipatory Guidance
The clinical team provides anticipatory guidance while patients are still in the hospital. Pharmacological treatment for infants with NOWS/NAS is completed prior to discharge. Before leaving the hospital, the families receive information about safe sleep, nutrition, and how to care for their infant at home including education about consoling a fussy newborn. Mothers are also connected to a newborn nursery follow-up clinic that provides information and support about nutrition and breastfeeding. At discharge, the hospital makes referrals for early developmental screening for infants prenatally exposed to opioids and other substances.
Recent mothers and their newborns will see a pediatrician at FOCUS clinic 2-4 weeks after discharge for the first pediatric supervision visit. During this initial pediatric visit, the team discusses with the family the services that are available through the EIP and assigns families to an EIP provider. In partnership with the EIP team, the physicians engage parents in conversations about recovery and personal goals. Parents are informed about the available treatment options, including medication treatment for OUD, and psychobehavioral and counseling services, and sign a treatment agreement. The EIP team also encourages birth parents to have a safety plan in place for their children, that includes identifying a caregiver for their child should they return to opioid use at any point through during recovery.
The medical and early intervention team uses the Facilitating Attuned Interaction (FAN) Model of engagement to guide interactions with families, including Empathetic Responses, Collaborative Exploration and Capacity Building technique to deliver information and education to mothers. Through this conversational technique mothers receive information gradually in small quantities, based on their elicited concerns, that does not exceed their attention span. Handouts may elicit a conversation and are generally limited to no more than a page.
Accessibility and Transportation
If an appointment is missed the clinic coordinator tries to reschedule right away. Additionally, the EIP team follows up with phone calls as often as needed to provide support and encouragement between appointments. The FOCUS clinical coordinator helps families schedule transportation to their appointments as needed, through Medicaid or other services available.
During the 2020 COVID-19 pandemic and lockdown the clinic learned some important lessons about family engagement. The home visiting services, and most healthcare and professional services were transitioned to telehealth due to social distancing requirements and the lack of available transportation. The team noticed that the families who lacked engagement prior to this transition, did not use the telehealth services. On the opposite end, most families ended up having more frequent and longer appointments and visits than they would normally have. While telehealth services will continue to be offered after the pandemic is over, the team recognizes the importance of in-person care.
Trauma-Informed Care
The physicians at FOCUS clinic and EIP use trauma informed approaches to caring for their patients because they understand most women in their care have lived through traumatic events. EIP clinicians use the Facilitating Attuned Interaction technique to engage with families in a trauma-informed manner and build a strong and positive relationship with mothers and birth parents.
Advice for Other Practices
The team members at the FOCUS clinic agree that underserved and stigmatized populations encounter barriers to accessing care at the systems level. The FOCUS clinic advises other practices to engage parents as partners and in their own recovery and treatment. Practices should be flexible in delivering care through a family practice if a pediatric practice is unwilling to provide care and health services to mothers. They also encourage educating clinicians to view OUD and SUD as chronic illnesses as means to reducing stigma and biases and positively influence women’s willingness to seek recovery.
The FOCUS team encourages developmental screening and surveillance for infants diagnosed with NOWS/NAS at birth and for all infants with prenatal substance exposure. As children transition into the school system, it is important to identify any developmental delays and work with the EI programs to support children as they transition into primary school. One physician stated, “if you are not willing to have that discussion with the schools and school system, kids will get lost.”