SOFAR Clinic at Boston Medical Center – Massachusetts
The SOFAR (Supporting Our Families through Addiction and Recovery) Clinic at Boston Medical Center (BMC) provides a pediatric primary care medical home for children of parents in treatment and recovery for opioid use disorder (OUD). The SOFAR Clinic started with a group of clinicians that acknowledged that many families affected by prenatal opioid use were less likely to keep up with the visits to the pediatrician’s office and had additional needs. The SOFAR Clinic creates a medical home that addresses the numerous challenges in accessing continuous and coordinated care and services that meet the individual needs of families affected by opioid use. The SOFAR Clinic goal is to streamline and improve access to multidisciplinary care for both mothers and infants. The clinic’s philosophy is that if mothers with OUD receive adequate care and recovery services for themselves, infants are more likely to be healthy. The clinic has an unofficial tag line, stating, a child will thrive if the mother is well.
Collaborations and Referrals
The SOFAR Clinic partners with Project RESPECT (Recovery, Empowerment, Social services, Prenatal care, Education, Community and Treatment). Part of the Obstetrics and Gynecology (OB-GYN) Department at BMC, Project RESPECT offers comprehensive, multidisciplinary care and treatment services to pregnant and postpartum women with OUD. Many women travel to BMC from outside of Boston, and even from out of state to deliver at BMC and to access the services offered by the SOFAR Clinic and Project RESPECT.
After delivery, newborns are transferred to the inpatient pediatric services for monitoring and treatment of opioid withdrawal, and mothers can room-in with their infants. The SOFAR Clinic is notified by inpatient services when a newborn is ready to be discharged. When possible, a member of the SOFAR team meets with the mother in the hospital and provides information about the services available through the clinic, as an option for their infant’s care.
After discharge, mothers visit the SOFAR clinic for the newborn’s first appointment, and they meet with a pediatrician and a social worker. Most mothers sign an information release form allowing their own health information to be shared with the SOFAR Clinic. During the first visit at SOFAR, mothers receive a welcome packet with information and anticipatory guidance materials, breastfeeding and lactation information, resources related to OUD recovery, and other standard information for new parents. The intake process is done collaboratively with the families and caregivers, and in the first month most families return to the clinic for weekly visits. The SOFAR team recognizes that the intake process can be overwhelming for new mothers with OUD, therefore the team demonstrates empathy and support around the stress and challenges parents are experiencing during this time. The SOFAR team ensures that new families are adjusting well and that parents have the resources they need.
Building a Therapeutic Alliance
The SOFAR Clinic serves in a medical home capacity, providing families with care stability that positively influences a mothers’ recovery and treatment course. The team members are transparent in all their communication pertaining to the infant’s care, and if a referral to Child Welfare Services is needed, the families can be present in the room during the call.
Most mothers bring their infants to their appointments alone, but some are accompanied by their partners, family members or other support person. The clinical staff recognize that the amount of support a woman with OUD has during pregnancy and delivery is key to successful recovery. Therefore, the SOFAR team members provide all the support they can to their patients.
The first year after delivery is the most challenging time for new mothers with OUD when the risks of return to opioid use is high. Staff members hope to positively influence a mothers’ recovery by collaborating with them and develop a relapse prevention plan. At each visit, mothers are asked about their own care and recovery, including what medications they are taking, how their recovery is going, if they have a medication assisted treatment (MAT) provider, a therapist, etc. The team also identifies the support people parents have, their living arrangements, transportation, and any custodial challenges involving other children.
Patients appreciate that during the office visits, physicians focus on the medical aspects of OUD. This nonjudgmental approach encourages mothers to discuss openly their substance use history and have a trusting relationship with the members of the SOFAR team.
A Multidisciplinary Team
The SOFAR Clinic is staffed by a multidisciplinary team that includes primary care pediatricians, a social worker/case manager, and a patient navigator. Also, part of the team is a developmental and behavioral pediatrician, a family physician, a child and adolescent psychiatrist, an infectious disease nurse practitioner, and an ophthalmologist. The patient navigator centralizes the patient care and services coordination. The social worker meets with families, participates in intake visits, and serves as a liaison to community programs. The behavioral health care team is trained in trauma-informed approaches including trauma-focused cognitive behavioral therapy. The team members meet weekly to review cases, and at times they can discuss up to 30 cases a week.
Through the BMC programs linked to SOFAR, parents can access adult primary care, addiction services, and Hepatitis C treatment. Many mothers with OUD and other substance use disorders (SUD) have mental health conditions requiring increased access to comprehensive mental health care and services. New mothers are screened for postpartum depression at every visit. The social workers connect parents with mental health providers in the community. Additionally, mothers are linked to services offering long-term contraception options to avoid future unintended pregnancies and focus on their recovery.
Care Continuity
Most patients seen at SOFAR clinic are children under the age of three years, but some are older children who were placed in foster care. Members of the mental health team are working with children and adolescents who were in foster care on issues related to trauma, anxiety, and adverse childhood experiences. Developmental screening is performed for all infants exposed to opioids and when children turn 2 years old, they receive a full developmental evaluation.
Care Accessibility
The clinic is exclusively open to families affected by substance use 3 half days a week, but mothers can bring their children in for pediatric services any day of the week. When possible, the patient navigator helps group the child and the mother’s appointments on the same day. During the COVID-19 pandemic, telehealth enabled physicians to keep in closer touch with parents in recovery and who found it difficult to come in for an office visit. It also allowed physicians to see their patients and families in their home environments. The telehealth visits were particularly beneficial when scheduling appointments with the psychiatrists especially with for difficult to reach patients.
Financing and evaluation
Most families seen by SOFAR are insured by MassHealth, which is the Massachusetts state Medicaid combined with the Children’s Health Insurance Program. The clinic recently received a grant to support the intensive time needed from the program’s social worker and patient navigator.
Families are always encouraged to provide feedback to the clinic. While the SOFAR team has seen many success stories, some of which were very surprising, many difficult outcomes have happened as well. Given that since its inception SOFAR has cared for almost 300 infants exposed to opioids, the funders have expressed their interested in supporting research on patient outcomes.
The SOFAR clinical staff is also interested in addressing generational substance use and is hoping to increase its focus on care and services for older children and adolescents at risk for SUD. In average, the mothers seen as SOFAR started using substances at 11. For this reason, the clinical staff understands that the substance use prevention is key to addressing multigenerational substance use. Additionally, providing support and mental health services to children and adolescents is very important among SOFAR team members.
Advice for Other Practices
The SOFAR team recognizes that many primary care physicians in the community do not feel confident in caring for mothers with OUD and their infants, and is eager to be available as a resource for other programs when possible. Clinical team members should make efforts to learn about OUD and about trauma-informed care. When possible, a multidisciplinary team approach should be used, that includes patient navigators, social workers, nurses, and developmental and behavioral specialists, as well as addiction and recovery trained staff.
Most importantly, physicians and staff must have open hearts and be willing to take this journey with the parents. Inevitably there will be hard times, but OUD is treatable, and many patients succeed in their recovery. A similar practice should embrace the chronic disease model of SUDs. Sharing success stories can empower and encourage both patients and staff. An OUD diagnosis can carry a heavy stigma and despite the difficult times, success stories will bring hope that mothers and pregnant women with OUD do succeed in their recovery and parenting goals.