Community Care Coordination

Coordinating Maternal and Infant Care in the Pediatric Medical Home

Parenting can motivate people with opioid use disorder (OUD) to make positive changes and seek treatment and recovery. Ideally, coordinating care and services for parents affected by opioid use should begin before delivery.

Care and Services for the Infant

When a newborn is seen for the first health supervision visit, the community pediatrician may or may not have access to the family health history. If the newborn has been diagnosed with neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS), pediatricians know that the infants’ safety is paramount. In some cases, a plan of safe care (POSC) may be in place. Pediatricians can use a POSC to partner with the families and advocate for health services and treatments. Additional information is presented in the AAP fact sheet, Substance Use During Pregnancy and Plans of Safe Care: Implications for Pediatricians, Mothers, and Infants. Familiarity with state regulations about developing a POSC allows the pediatric care teams to collaborate with community partners and the child welfare agencies.

While the NOWS withdrawal symptoms diminish over the first few month of life, infants exposed to opioids and other substances prenatally may be at risk for other long-term developmental concerns. To ensure all infants diagnosed with NOWS or those known to have been exposed to opioids and/or other substances prenatally are developing well, pediatricians can coordinate follow-up care, health services and specialist referrals through their office as soon as possible.

• Developmental screening and surveillance
• Pediatric specialists and subspecialist
• Early intervention

Referrals and Support for Birth Parents

Due to past negative experiences and stigma parents with OUD may delay or avoid treatment for themselves, but they are likely to bring their newborn to pediatric visits. Qualitative data shows that birth parents diagnosed with a substance use disorder (SUD) are often willing to discuss how SUDs or OUD, including substance use during pregnancy, will affect their infant’s health. Pediatricians can facilitate access to treatment and recovery for parents with OUD. Similar to other chronic conditions, such as hypertension or diabetes, OUD can be successfully managed and treated.

Pediatricians are well positioned to support families by encouraging them to access and/or continue the treatment for OUD. Pediatricians can work with families and provide referrals, and/or warm hand-offs to services available in the community.

• Medication treatment for OUD providers and/or facilities
• Recovery and addiction medicine services and providers
• Psychobehavioral therapy
• 12 step recovery programs and other community supports

Individualized Care for Each Family

Each family is unique. The format, diversity, timing, care, and treatment that works best for each family is also unique. An empathetic and positive partnership can inform pediatricians about other challenges the family may face, such as food and/or housing insecurity, whether they have a support network, history of adverse childhood experiences (ACEs), other children at home or in foster care, legal matters, etc.

In the context of a therapeutic alliance, the parents are partners and are actively involved in all health care decisions affecting the infant and the family. Pediatricians can offer information and anticipatory guidance to birth parents, as well as referrals and connections to additional services.

• Breastfeeding and nutrition clinics
• Early Intervention
• Reproductive health and family planning care
• Home visiting
• Women infants and children (WIC) program
• Transportation

Parents in recovery can be the best caregivers to their child when they are supported in achieving their treatment and recovery goals. Pediatricians can discuss circumstances that can affect the mother and infant well-being, and work with parents to overcome these challenges. Pediatricians can consider flexible schedules, multiple appointments scheduled in the same day, and/or telehealth services to ensue families can come in or be seen for their regular appointments.

Continuous Empathetic Care and Support

To further support birth parents and caregivers during recovery, pediatricians can consider working with a recovery coach, a community health worker, or trained parent with lived experience. Local peer support groups may be beneficial for mothers that have used a substance during pregnancy.

• Pediatricians can map community-based resources so that the practice can collaborate with diverse clinical teams, community partners, and families to advance patient- and family-centered treatment approaches focused on family health goals.

A sample mapping tool is available through the Illinois Perinatal Quality Collaborative at ilpqc.org.

• Open communication about OUD treatment and recovery can reassure families that pediatricians are partners that can provide non-judgmental care and support. Pediatric clinics can integrate and reinforce non-stigmatizing language among all staff members to create a welcoming environment for parents.
• Pediatricians and other team members can praise parenting skills and encourage birth parents to care for their emotional and mental well-being as an essential component for achieving their health and recovery goals.