PEDI Clinic at Healthy Start Coalition of Hillsborough County
The Promoting Early Developmental Intervention (PEDI) clinic was developed as part of the Hillsborough County Family Prevention Services Collaborative. The clinic is working to provide compassionate and comprehensive care to mothers and infants affected by opioid and other substance use. The Healthy Start Coalition of Hillsborough County partnered with University of South Florida (USF) Pediatrics, and Mary Lee’s House to design the clinic model and to create intervention points that include prenatal engagement, hospital-based screenings, and long-term home visiting programs. Some physicians from USF Pediatrics and the Division of Neonatology at Tampa General Hospital (TGH) are engaged with the Florida Perinatal Quality Collaborative (FPQC), which is a statewide partnership and network of health organizations, health professionals, advocates, policymakers, and hospitals seeking to improve the quality of care for mothers and infants affected by opioid use. Among its programs, the FPQC has been working on the Maternal Opioid Recovery Effort (MORE) and Neonatal Abstinence Syndrome quality improvement (QI) initiatives.
Referrals and Intake
Various community organizations, hospitals, medical practices, and providers for pregnant and parenting women in recovery refer women to the PEDI clinic and the TGH. Although referrals are predominantly made for opioid use disorder (OUD), they are inclusive of any substance use disorders (SUD).
New referrals are thoroughly reviewed by a Community Staffing Board comprised of USF Pediatrics, Drug Abuse Comprehensive Coordinating Office (DACCO), Early Intervention Services (EI), Department of Children and Families (DCF), home visitation programs and other community advocacy entities. The team gathers relevant background, conducts an initial assessment, and develops a family-based plan to inform the clinical care and wrap-around supports based on the family’s needs and willingness to engage.
During the initial intake, the team members discuss the challenges women experienced in their recovery, review the medical and substance use history, and their current treatment and medications. Additionally, the clinical team discusses with women history of traumas they experienced, living arrangements, and the status of any prior cases with DCF. A tour of the TGH, the USF primary affiliate hospital and delivery location, is also offered.
Anticipatory Guidance
During the prenatal visit mothers receive information about caring for a newborn with neonatal opioid withdrawal syndrome (NOWS) or neonatal abstinence syndrome (NAS) and managing withdrawal symptoms. The team educates women about the possibility that their newborn will need pharmacologic treatment, and provides information about the benefits of the Eat, Sleep, Console (ESC) approach. While the FPQC has been promoting the ESC approach, the TGH NICU has not yet made this transition. The TGH NICU is part of the National Institute of Health trial, Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW) Eat Sleep Console (ESC), and has agreed to not implement ESC before the specified time frame. The team is hoping to contribute to scientific knowledge regarding the utility and implementation of the ESC. Women are also educated about the importance of maternal mental health and well-being, the home visiting program, and other services available through the hospital and the clinic.
During the admission, the obstetric providers prescribe medication treatment for OUD and women receive health services from an interprofessional team. After mother’s discharge and while the infant is still in the hospital, mothers can continue receiving their medication from DACCO prescriber. The clinical team works with DACCO to facilitate transportation to the hospital after mothers obtain their prescription. Through a program between TGH and DACCO, mothers and other patients with OUD can receive medication treatment with Buprenorphine in the hospital’s emergency room (ER). After receiving an ER prescription, they are either transported to DACCO or are being fast-tracked for an appointment with DACCO.
A social worker involved in the family care throughout their hospital stay, meets with the mother during discharge and refers her to community services and resources. The DCF is also contacted to ensure the family and the infant can safely transition to community care.
Building a Therapeutic Alliance
Women are assessed for adverse childhood experiences (ACEs), resiliency, and mental health history. This initial assessment informs the clinical team on the best approaches to start building a positive relationship. The topics of this discussion, including misconceptions and stigma about the OUD and NOWS/NAS diagnosis are also promoted locally, in the inpatient and outpatient setting, and stateside through the FPQC. One of the primary messages, is that maternal love and care are the infant’s best treatment. The PEDI team acknowledges the stress mothers may have experienced due to past stigmatizing or insensitive interactions with other clinical teams and reassures patients that they are fully supported in their recovery at the clinic and hospital.
Care Accessibility
In the first months after delivery, the PEDI clinic maintains regular communication with mothers. Parents can use a telephone and text line to reach out to the clinic. To assure new mothers have all the support they need, the clinic also offers vouchers for transportation, infant carriers, and donated breast pumps.
While telehealth has been a permanent feature of the clinic with an average of 1-2 visits in the 5-year follow-up visit schedule, since the onset of the 2020 COVID-19 pandemic and lockdown, telehealth has been adopted for most of the encounters. Conducting the initial contact with parents via telehealth, demystified what would occur at these types of clinic visits, and ultimately improved the patient-staff relationship for subsequent visits.
Follow-up Care
The USF pediatricians and neonatologists are monitoring the newborn’s growth, behavior, and withdrawal symptoms. The PEDI clinic monitors the newborn development, social-emotional growth, and behavioral concerns to the age of 5 years.
The PEDI clinic screens all mothers for postpartum depression for the first 12 months after delivery. The mother’s recovery and treatment course are monitored throughout the duration of their engagement with the PEDI clinic. Concerns for postpartum depression result in a connection with the PEDI clinic physician, nurse, and home visiting contact to develop an individualized action plan. To assure streamlined access to the dyad’s physical and mental health history, the PEDI clinic and its partners use a unified tracking system.
Community Partners
The hospital maintains a close connection with DACCO which provides medication treatment for OUD/SUD, mental health services, workshops for parents, and training for health care providers. All families are offered access to home visiting services. The different home visiting models provide varying levels of intensity and intervention, depending on the family’s needs and desires. The state Medicaid program, health departments, child welfare agencies, home visiting programs, and hospitals all have been important stakeholders in collaborating to improve access to treatment statewide for pregnant and parenting women with OUD/SUDS and their infants. Community services coordinated through the PEDI clinic include domestic violence, human trafficking advocacy, job and parenting trainings, postpartum doulas, lactation specialists, and mental health services.
Training for Physicians Caring for Mothers in Recovery
A 2012 survey was conducted as part of a local QI effort by USF physicians and revealed dissatisfaction among clinical staff regarding Florida’s management of care for mothers and infants affected by opioid use. The assessment generated many positive recommendations. Physicians and other team members are now trained to be on message that mothers must be integrated into and engaged in the care and treatment of their infants. Staff are trained to have empathetic and non-judgmental attitudes toward mothers in their care and show support for their recovery goals.
Due to the misconceptions around OUD treatment and mothers in recovery, the FPQC has worked with hospitals throughout the state to improve care and access to care for this patient population. The FPQC finds value in the power of personal narratives and has featured mothers in recovery speaking about their experiences in hospital trainings and video educational resources. Narrated PowerPoints are distributed to hospitals across the state on topics such as trauma-informed care, the psychology of addiction, and motivational interviewing approaches. Specialists have also presented to other clinicians about the benefits of the ESC approach versus the Finnegan scoring tool.
Hospital staff receive learning materials, such as videos and posters, highlighting the importance of using non-stigmatizing clinical language that emphasizes medical aspects of the disease and how to move away from terms that impart blame on individuals with OUD. The Healthy Start Coalition for Hillsborough County, in conjunction with FPQC, has developed educational resources for mothers in recovery and for NOWS/NAS management. These resources are freely available for al hospitals and parents have been active in providing feedback about the benefits of these materials.
Financing
The PEDI clinic is partially funded through the Hillsborough County Board of County Commissioners in partnership with Eckerd Connects. In the past different community-based organizations operated in silos in their care for mothers in recovery and their infants. After securing the current grant, coordination between organizations has improved. The Healthy Start home visiting program funds the clinic care coordinator position and two full-time nurses. Adjunct care provided to mothers is not billed within the PEDI clinic and is funded through the Florida Department of Health and other state programs funded directly through the Centers for Disease Control (CDC). Ongoing assessment of the program’s impact and opportunities to improve quality and outcomes are continually conducted.
Advice for other Practices
The USF physicians and PEDI clinic team members state that the success of their approach depends on having positive, non-judgmental interactions with families and not starting with preconceived notions about OUD and women with OUD. They emphasize that mothers are central to, and must be engaged in, the care of their newborns. Additionally, it is critical to connect families with a variety of services and maintain a seamless continuum of care designed around families and their needs. Additionally, programs must take in consideration and adapt their approaches based on feedback from mothers.
The team has observed that the care for infants with NOWS/NAS is often fragmented and not always driven by evidence-based approaches. Close collaboration and coordination between interprofessional teams is crucial to generating the best care for the mother-infant dyad. Aside from improving care and treatment access, medicine needs to look at what leads to prevalence of opioid use and NOWS/NAS within certain communities and how to prevent it.
The PEDI clinic and other local and statewide efforts collectively feel that positive changes can occur more quickly when incorporating QI components in the clinical care approaches. According to team physicians, QI should look at six dimensions of care: (1) the patient experience, (2) family-centered framework, (3) NOWS/NAS prevention, (4) improved access to medication treatment for OUD, (5) reduced cost of care, and (6) reduced length of hospital stays. The PEDI clinic team believes positive changes can occur more quickly when incorporating a QI component in the clinical care approaches.