discharge planning and ongoing … discharge...postpartum discharge planning & referral...

DISCHARGE PLANNING AND ONGOING SERVICES AND SUPPORTS FOR

MOTHER

The purpose of this information is to standardize peri-partum and postpartum care and

expectations for all women with substance use disorders. Nurses, social workers, case managers,

and other appropriate hospital staff can use this to aid discharge planning. This guidance is

designed to outline recommendations known to help in maintaining or establishing postpartum

recovery. Referral to these services and supports should be the standard of care.

Hospital Procedures & Discharge Planning All women with suspected or confirmed substance use disorders should:

• Have a social services consultation to identify concerns

• Be offered a nicotine patch on admission if they are a tobacco user

• Have a urine drug screen and, if clinically indicated, a confirmatory test

• Have a discharge letter sent to the woman’s primary care provider1 as well as her post-

partum provider to help communicate concerns. These may be two different providers.

• The discharge letter should be accompanied by two additional documents (when clinically

indicated):

o An overview of the Department of Child Services (DCS) process for newborns

referred due to maternal substance use2; and

o An Adult Addiction Services map and contact information.3

In addition, all women with suspected or confirmed substance use disorders should have the

following completed before discharge:

• An outpatient pediatric follow-up plan;

• Newborn safe sleep education; and

• Family planning/contraception plan.

1 https://www.in.gov/laboroflove/files/Postpartum%20Letter%20to%20Primary%20Care%20Provider.pdf 2 https://www.in.gov/laboroflove/files/DCS%20Process%20Overview%20for%20Medical%20Providers.pdf 3 ttps://www.in.gov/laboroflove/files/Addiction%20Services%20Map.pdf

For the best chance of success in getting healthy and parenting their child, all women with

substance use need a plan for ongoing social and mental health support as well as treatment for

substance use disorder. The plan will vary depending on the patient’s circumstances, local

resources and the mother’s stage of her treatment. Issues that should be discussed to include in the

plan4 are:

• Smoking cessation;

• Inpatient rehabilitation;

• Evaluation by mental health or addiction specialist;

• Intensive outpatient program;

• Counseling;

• Medication Assisted Treatment (MAT) provider;

• Community support group meetings;

• Recovery Coach;

• Relapse prevention plan;

• Home health;

• Parenting classes;

• Transportation assistance;

• Housing assistance;

• Lactation assistance; and

• Legal aid.

4 https://www.in.gov/laboroflove/files/Postpartum%20Discharge%20Planning%20and%20Referral%20Checklist.pdf

POSTPARTUM DISCHARGE PLANNING & REFERRAL CHECKLIST

PERINATAL SUBSTANCE USE TASK FORCE 1

Name: _______________________________________________________________

The purpose of this form is to standardize peri-partum and post-partum care and expectations for

all women with substance use disorders. Nurses, social workers, case managers, and other

appropriate hospital staff can use this to aid discharge planning. This checklist is designed to

outline recommendations known to help in maintaining or establishing postpartum recovery.

Referral to these services and supports should be the standard of care.

Prior to discharge, all new mothers should receive the following education. Please document plan

or initial box to indicate education completed.

Date Provided Notes

Outpatient pediatric follow-up plan

Newborn safe sleep ed.

Family Planning/ Contraception plan

DCS Patient Letter https://www.in.gov/laboroflove/files/DCS%20Patient%20Handout.pdf

For the best chance of success in getting healthy and parenting their child, all women with substance use need a plan for ongoing social and mental health support as well as treatment for substance use disorder. The plan will vary depending on the patient’s circumstances, local resources and the mother’s stage of her treatment. Please document plan or indicate N/A.

Resource Identified

Smoking cessation assistance

Inpatient rehabilitation

Evaluation by mental health or addiction specialist

Intensive outpatient program

Counseling

POSTPARTUM DISCHARGE PLANNING & REFERRAL CHECKLIST


Resource Identified

Outpatient addiction counseling

MAT (Medication Assisted Treatment) provider Plan to attend community support group meetings

Recovery coach

Relapse prevention plan

Home health

Parenting classes

Transportation assistance

Housing assistance

Lactation assistance

Legal aid

Other

POSTPARTUM PROVIDER LETTER


Dear Postpartum Provider,

This letter is regarding Patient __________________________________ DOB_________________.

During her hospitalization, your patient was identified being high risk for substance use.

During her hospitalization, your patient was identified as someone who uses substances of abuse.

Substances of concern include:

Tobacco Marijuana Alcohol Opioids Cocaine Other____________________

During her hospitalization, your patient was identified as someone who has a substance use disorder.

Substances of concern include:

Tobacco Marijuana Alcohol Opioids Cocaine Other______________________

Your patient was informed about the risks of substance use and the benefits to her and her baby of not

using substances.

During her hospitalization, a social work consult was completed.

Social worker: __________________________________ Contact: _____________________________

Your patient should be seen for an early postpartum visit 1-2 week after delivery.

Your patient should be encouraged to breastfeed so long as she is abstinent from substances of abuse

(Breastfeeding with tobacco, Buprenorphine and Methadone is permitted).

If your patient does not desire more children at this time, Long Acting Reversible Contraception is

recommended due to low likelihood of failure and high patient satisfaction.

Patients who use substances are at a higher risk of perinatal mood and anxiety disorder (postpartum

depression) and should be screened. The Edinburgh postpartum depression scale can be used.

Your patient would benefit from follow up or further evaluation for domestic violence/food

insecurity/problems with transportation/getting connected to a mental health professional.

Recommended discussion:

Your patient is currently using substances of abuse or at high risk of using substances of abuse. It is

recommended that the postpartum provider let the patient know that he/she is concerned about how

her substance use can affect her health and well-being. Let her know that you want to help her and

believe that getting help for her substance use will help her and give her the best chance for success in

parenting her children.

Your patient is currently at some stage of recovery from substance use.

POSTPARTUM PROVIDER LETTER


• It is recommended that the postpartum provider ask your patient how treatment is working for her.

• Ask about her personal goals regarding substance use and what aspects of treatment help her.

• The postpartum provider should applaud her effort and success with recovery and ask how the patient

is coping to elicit whether she is at risk of relapse or needs additional support or evaluation by a mental

health professional.

• Asking about patient’s recovery should be part of every future routine checkup.

Optimal care of women with substance use disorders in the peripartum period requires a multidisciplinary

approach that emphasizes respect, compassion, and flexibility. While pregnancy and a new baby are often

a significant source of stress, at the same time, this serves as an extraordinary opportunity for women to

engage in healthy change. Although there are many challenges, successful identification and treatment of

substance use offers a chance to improve the lives of generations to come by helping women deliver and

parent healthier children.

Hospital Contact: ___________________________________________ Date: ______________________________________

Phone: _______________________________________ Email: __________________________________________

DCS Contact: ___________________________________________ Date: ______________________________________

Phone: _______________________________________ Email: __________________________________________

WHITLEY

WHITE WELLS

WAYNE

WASHINGTON

WARRICK

WARREN

WABASH

VIGO

VERMILLION

VAND

ERBU

RGH

UNION

TIPTON

TIPPECANOE

SWITZERLAND

SULLIVAN

STEUBEN

STARKE

SPENCER

SHELBY

SCOTT

ST. JOSEPH

RUSH

RIPLEY

RANDOLPH

PUTNAM

PULASKI

POSEY

PORTER

PIKE

PERRY

PARKE

OWEN

ORANGE

OHIO

NOBLE

NEWTON

MORGAN

MONTGOMERY

MONROE

MIAMI

MARTIN

MARSHALL

MARION

MADISON

LAWRENCE

LA PORTE

LAKE

LA GRANGE

KOSCIUSKO

KNOX

JOHNSON

JENNINGS

JEFFERSON

JAY

JASPER

JACKSON

HUNTINGTON

HOWARD

HENRY

HENDRICKS

HARRISON

HANCOCK

HAMILTON

GREENE

GRANT

GIBSON

FULTON

FRANKLIN

FOUNTAIN

FLOYD

FAYETTE

ELKHART

DUBOIS

DELAWARE

DEKALB

DECATUR

DEARBORN

DAVIESS

CRAWFORD

CLINTON

CLAY

CLARK

CASS

CARROLL

BROWN

BOONE

BLACKFORD

BENTON

BARTHOLOMEW

ALLEN

ADAMS

12/6/17

Indiana Family & Social Services AdministrationDivision of Mental Health and Addiction

Adult Addiction ServicesCounties with Syringe Exchanges in Blue

2

2 1

1 62

2

2 1

1

1 411

3

1 111 1

1 921

1

1

2

1

1

4 1

3 1

1 133

1

1

2

3

1

1

11 1

1

2

2

2

1

2

2

4

4

1 92 1

2

1

6 1

2 534 5

8 11

4

42 354 2

4

1 1

2 1

1 92 1

2

2

1

1

3

2

5 2

6

5

1

6

5 1

2

1 31

1

1

1

2

6

2

11 1

1

3

3 1

3

1 51 1

2

1

2

2

1 61 1

3 1

1

1

4

1

1

4 1

1 115 22

3

Addiction Outpatient Services – This count includes counseling, groups, intensive outpatient services and partial hospitaliza-tion services. Currently, every entity, which can be an individual practitioner, needs to be certi�ed by the Division of Mental Health and Addiction.

Opioid Treatment Programs - This count includes providers who are able to prescribe Buprenor-phine and Methadone to help individuals with opiate use disorder recover.

New Opioid Treatment Programs - This count includes programs that will be opening in 2018.

Addiction Residential Treatment Services – This count includes residential facilities that are providing at least �ve hours of clinical addiction treatment. Halfway House or Recovery Houses are not included on the map.

Addiction Inpatient Services - This count includes hospitals, licensed by the Indiana State Department of Health and the Division of Mental Health and Addiction, that provide inpatient addiction services to adults.

PROVIDERS AND TREATMENT SERVICES FOR PREGNANT WOMEN FACILITY LOCATION CONTACT INFORMATION SERVICES

Limestone Bloomington Bloomington, IN 765-391-0848 Opioid Treatment Program (OTP)

Southern Indiana Treatment Center Charleston, IN 812-283-4844 OTP

Evansville Treatment Center Evansville, IN 866-369-5540 OTP

Bowen Recovery Center Fort Wayne, IN 866-239-6053 OTP

Center for Behavioral Health Fort Wayne, IN 260-420-6010 OTP

Edgewater Systems for Balanced Living Gary, IN 219-885-4264 ext 4235 OTP

Semoran Treatment Center Gary, IN 219-938-4651 OTP

New Vista Greenwood, IN 317-883-5330 OTP

Midtown Narcotics Treatment Program Indianapolis, IN 317-686-5634 OTP

Indianapolis Treatment Center Indianapolis, IN 866-575-8186 OTP

Limestone Lafayette Lafayette, IN 765-391-0848 OTP

East Indiana Treatment Center Lawrenceburg, IN 866-823-8540 OTP

Premier Care of Indiana Marion, IN 765-664-0101 OTP

Northwest Indiana Treatment Center Merrillville, IN 219-769-7710 OTP

Richmond Treatment Center Richmond, IN 877-762-3740 OTP

Victory Clinical Services South Bend, IN 574-233-1524 OTP

Western Indiana Recovery Services Terre Haute, IN 812-231-8484 OTP

Porter-Starke Services Valparaiso, IN 219-531-3500 OTP

LifeSpring Jeffersonville, IN 812-283-7116 Detoxification and Residential

Regional Mental Health Center Merrillville, IN 219-769-4005 Detoxification and Residential

Amethyst House, Inc Bloomington, IN 812-336-3570 Residential

Park Center Fort Wayne, IN 260-481-2721 Residential

Salvation Army Harbor Light Indianapolis, IN 317-972-1450 Residential

Southwestern Behavioral Health Evansville, IN 812-423-7791 Residential

Tara Treatment Center Franklin, IN 812-526-2611 Residential

YWCA North Central South Bend, IN 574-233-9491 Residential

OpenBeds Call-211

Command center to provide real time

assessment and facilities with open beds

*All OTP's administer Methadone. Some will provide Buprenorphine and Naltrexone

DCS PATIENT LETTER


What happens to me if I’m pregnant and using drugs or alcohol?

When women are pregnant and using substances like pain pills, marijuana, cocaine,

methamphetamines, heroin or alcohol, we know that getting help is extremely

important. Decreasing drug and alcohol use in pregnancy will increase the chances of

having a healthy pregnancy and a healthier baby.

It’s best when health care providers and patients work together to create a plan for the

patient to stop using drugs and alcohol. Depending on individual circumstances, the plan

may include the following:

• Finding a safe living environment

• Starting medications

• Seeing a mental health specialist

• Going to community recovery support meetings ( 12 Step, Smart Recovery,

Celebrate Recovery etc.)

• Counseling

In addition to regular prenatal visits, women with substance use disorders may need

additional care while pregnant. The ultimate goal is to set every patient up for success in

life and in parenting their baby.

Every baby requires a safe and nurturing environment. Parents who have substance use

disorders may find it difficult to provide this safe, nurturing environment without support

and assistance. It is not possible for a health care provider to know which babies are at

greatest risk for unsafe environments.

Indiana Department of Child Services (DCS) exists to help make sure children are safe and

that families have the necessary resources and treatment to keep their children safe. DCS

may become involved if a baby is born positive for substances that were not prescribed to

the mother or substances that were not used per the prescription. If DCS does become

DCS PATIENT LETTER


involved, a Family Case Manager (FCM) will be assigned to complete an assessment.

Involvement with DCS can be scary but knowing more information about what to expect if

your family becomes involved with DCS can help reduce some of the fear and help families

have more control in planning for the safe care of their baby.

There are many important things patients and families can do before the baby is born to

help ensure the safety of their baby after birth. Making these plans prior to birth may help

a family feel more prepared and in control if they do become involved with DCS.

• All caregivers in the home with substance use disorders engaged in treatment and

recovery

• Identification of a sober caregiver who is willing to be present 24h/day and able to

provide safe care for the baby if the parent relapses

• Establish a safe place for baby to sleep

• Ensure the home is free from drugs and/or violence

• Develop a Relapse Prevention Plan for all caregivers

• Develop a team of friends, family and providers who are willing and able to support

both the baby and the family

o Working to establish a supportive team and safe plan for both the baby and the

parents is one of the most important things a patient can do, not only to ensure

that their baby is safe and healthy, but also to decrease the need for DCS

intervention. DCS encourages and helps families to form their own teams and

having the patient’s medical provider as a team member is often very helpful.

It is important to remember that while the primary goal of DCS is to ensure the safety of the

baby, DCS strives to keep families together and only places children in out of home care if

no other safe options are available. It is also important to know that parents have a voice in

making these decisions and that DCS wants to work with parents to create plans to ensure

the safety of the baby while remaining in the care of the parents. If a child does need to be

DCS PATIENT LETTER


placed in out of home care, DCS works to place the child back in the home as quickly as

possible while ensuring the safety of the baby.

DCS PROCESS OVERVIEW FOR MEDICAL PROVIDERS


Specifically related to infants born exposed to substances

1) The Indiana Department of Child Services (DCS) receives a report of alleged child abuse

or neglect

a) The allegation for infants born exposed to substances is typically that either the

infant tested positive for an illicit substance that was either not prescribed or if

prescribed not used per the prescription.

b) The hotline in collaboration with the local county office makes a determination as to

whether the allegations are legally sufficient to open up an assessment.

i) If the allegations do not meet legal sufficiency the report is not assigned and

there is no further DCS involvement

2) Once a report is assigned for assessment, a Family Case Manager (FCM) will initiate the

assessment by making face to face contact with the baby and ensuring the safety of the

baby.

a) The FCM will complete a safety assessment and if needed a safety plan in the first 24

hours of the assessment

i) The safety assessment will assess safety across a variety of factors not limited to

substance use disorders

b) The FCM has 30 days to complete the assessment and make a determination to

either substantiate the allegations or unsubstantiate the allegations.

c) If the allegations are substantiated the FCM and DCS will determine if ongoing

intervention is needed and the level of intervention needed. All levels of

intervention include individual plans designed to reduce the risk to the child in

support of permanency. The differing levels are based on the need or lack thereof

for coercive intervention from the court.

i) Possible DCS intervention may include:

(1) Informal Adjustment (IA):

(a) Lowest level of formal case with DCS

(b) Child remains in the care of parents

(c) Documents are filed with the court but parties are not typically required

to appear in court



(d) Typically six month involvement but could be extended for a short term

after the initial six months

(2) In-home CHINS

(a) Child remains in the care of parents

(b) Documents are filed with the court and parties are required to appear in

court

(c) Parents can deny the allegations in the CHINS petition

(i) If this occurs a fact finding hearing is held and the judge will

determine if DCS had sufficient evidence to support the CHINS

(3) Out of home CHINS

(a) An out of home CHINS is processed in the same manner of an in-home

CHINS with the primary difference being that the child has been placed in

out of home care

(i) In addition to an initial CHINS hearing, at which parents can deny the

allegations in the CHINS petition, a detention hearing is also held as

the judge must approve DCS’ decision to place the child in out of home

care.

1. A detention hearing must be held within 48 hours after DCS places

a child in out of home care.

a. Parents have the right to be heard in court and object to out of

home care

(ii) If a child is placed in out of home care, DCS is required by federal and

state law to provide evidence as to why this is in the best interests of

the child and why remaining in the home is contrary to the welfare of

the child.

(iii) If a child is placed in out of home care, DCS is required by

federal and state law to provide reasonable efforts to reunify the child

with the parents for a minimum of six months before changing the

permanency plan for the child to anything other than reunification

with the parents.



3) If at any time during an assessment or case the FCM and DCS determine that the safety

of the baby cannot be ensured while in the care of the parents, the baby may be placed

in out of home care (see above for court process and parents’ rights if this occurs).

a) DCS makes every attempt to partner with the parents to create a safety plan which

keeps the parents and baby together

i) Parents are encouraged to and assisted in forming their own Child and Family

Team which should include both formal and informal supports

(1) Parents choose their team members and formal supports from the medical

team are welcome

(2) Safety plans are best developed within the team and with parents driving the

team.

(3) If out of home care is necessary, the team can determine the least restrictive

placement for the child as well as the best plan to maintain bonding between

the parents and baby.

(a) Relative or kinship care is the first option

(i) Parents can identify who they would like to care for their child if out

of home care is necessary

(b) Creative plans, while ensuring child safety are encouraged

(i) In some instances a parent could live in the home with a relative

caregiver – so while not being the primary caregiver for their child

they still have opportunity to bond.

4) The Child and Family Team is also crucial in developing a plan for sustainable case

closure that may include ongoing mental health needs, supports, relapse prevention

and other factors.

(a) Helping families develop informal support and access to services after

DCS closes the case is key in preventing further involvement with DCS

and ensuring long term safety and well being for the baby.