Statewide Risk Screening Program for Pregnant … Risk Screening Program for Pregnant Women: SBIRT Program Louisiana Community/State Collaborative Michael Kudla, M.D., FACOG Mary Craig,

Statewide Risk Screening Program Statewide Risk Screening Program

for Pregnant Women:for Pregnant Women:

SBIRT ProgramSBIRT Program

Louisiana Community/State CollaborativeLouisiana Community/State CollaborativeMichael Michael KudlaKudla, M.D., FACOG, M.D., FACOG

Mary Craig, RN, MSN, MSMary Craig, RN, MSN, MS

February 22, 2007February 22, 2007

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ObjectivesObjectives

Participants will be able to:Participants will be able to:

�� Increase understanding of Louisiana Increase understanding of Louisiana perinatalperinatal substance substance abuse dataabuse data

�� Identify the role of public health in development of a Identify the role of public health in development of a substance abuse screening programsubstance abuse screening program

�� Explore the role of the private provider in substance Explore the role of the private provider in substance abuse screeningabuse screening

�� Recognize the value of a communityRecognize the value of a community--based programbased program

�� Enhance tools for development of a state substance Enhance tools for development of a state substance abuse screening programabuse screening program

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Women and TobaccoWomen and Tobacco

Action Learning Lab: The National Initiative Action Learning Lab: The National Initiative

June 2003June 2003--July 2006July 2006

�� December 2004December 2004: Louisiana Collaborative: Louisiana Collaborative�� ACOGACOG--LA Section LA Section

�� Office of Public HealthOffice of Public Health--Maternal and Child HealthMaternal and Child Health

�� Louisiana MedicaidLouisiana Medicaid

�� Louisiana Public Health InstituteLouisiana Public Health Institute

�� 20052005: added March of Dimes, Planned Parenthood, : added March of Dimes, Planned Parenthood, collaboration with State Tobacco Initiatives collaboration with State Tobacco Initiatives �� Baton Rouge FASD grantBaton Rouge FASD grant

�� 20062006: Collaboration with State Office for Addictive : Collaboration with State Office for Addictive Disorders on development of a statewide substance Disorders on development of a statewide substance abuse screening tool for pregnant womenabuse screening tool for pregnant women

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Louisiana State Leadership TeamLouisiana State Leadership Team

�� Office of Public Health Office of Public Health –– Maternal and Child Maternal and Child Health ProgramHealth Program

�� ACOG ACOG

�� Office for Addictive DisordersOffice for Addictive Disorders

�� Office of Mental HealthOffice of Mental Health

�� March of DimesMarch of Dimes

�� Louisiana Public Health InstituteLouisiana Public Health Institute


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SBIRT SBIRT Program Program

��SScreeningcreening

��BBrief rief IInterventionntervention

��RReferraleferral

��TTreatmentreatment

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S.B.I.R.T.S.B.I.R.T.

�� Mechanism to screen pregnant women for Mechanism to screen pregnant women for

certain social risk factorscertain social risk factors

�� SBIRT screeningSBIRT screening

�� Substance useSubstance use

�� Alcohol useAlcohol use

�� Tobacco useTobacco use

�� Mental health / depressionMental health / depression

�� Domestic violenceDomestic violence

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Why Do We Need SBIRT ?Why Do We Need SBIRT ?

�� Screening and treatment is recommended by Screening and treatment is recommended by

professional bodies professional bodies –– including ACOGincluding ACOG

�� Current screening is often inconsistentCurrent screening is often inconsistent

�� Staff is often uncomfortable in screening Staff is often uncomfortable in screening

techniquestechniques

�� Treatment resources varies Treatment resources varies –– regionally poor, regionally poor,

unknown to provider, access difficultunknown to provider, access difficult

�� Mental health / substance use screening and Mental health / substance use screening and

treatment one of top priorities in 2004 MCH treatment one of top priorities in 2004 MCH

statewide needs assessment (FIMR/regions)statewide needs assessment (FIMR/regions)

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�� Nationally rates of alcohol, tobacco, drugs, Nationally rates of alcohol, tobacco, drugs,

domestic violence are underdomestic violence are under--reportedreported

�� We have limited information on stateWe have limited information on state--wide rates wide rates

in Louisiana, very little at the regional levelin Louisiana, very little at the regional level

�� Most screening tools were developed for:Most screening tools were developed for:

�� Use in general population, i.e. menUse in general population, i.e. men

�� Not developed for specific use in pregnancyNot developed for specific use in pregnancy

�� Do not detect low levels of useDo not detect low levels of use

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�� Alcohol is leading known cause of preventable mental Alcohol is leading known cause of preventable mental retardationretardation

�� Alcohol use is being recognized with increasing wide Alcohol use is being recognized with increasing wide assortment of fetal /adolescent disordersassortment of fetal /adolescent disorders

�� Fetal alcohol spectrum disorders (FASD) are 100% Fetal alcohol spectrum disorders (FASD) are 100% preventablepreventable

�� Knowledge of risks associated with alcohol use in Knowledge of risks associated with alcohol use in pregnancy is limitedpregnancy is limited

�� Best message: Best message: ““There is no safe amount of alcohol There is no safe amount of alcohol use in pregnancyuse in pregnancy””

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Why Do We Need SBIRT ?Why Do We Need SBIRT ?Research Triangle Institute / LSUMC StudyResearch Triangle Institute / LSUMC Study

�� Low income public hospital study of women giving Low income public hospital study of women giving

birth birth

�� Personal interview and medical record reviewPersonal interview and medical record review

�� Alcohol Alcohol –– 43% use in last 18 months, 11% during pregnancy43% use in last 18 months, 11% during pregnancy

�� Tobacco Tobacco –– 30% use 30% use

�� Illicit drugs Illicit drugs –– 9% use, 5% during pregnancy, UDS detected 9% use, 5% during pregnancy, UDS detected

additional 7%additional 7%

�� 29% showed need for treatment of alcohol, tobacco or drug 29% showed need for treatment of alcohol, tobacco or drug

useuse

�� Perception of risk was lowPerception of risk was low

Delivery Hospitals in New Orleans and

Lafayette – 1998 N=501

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�� Louisiana PRAMS (2003) Louisiana PRAMS (2003) –– Survey of all socioSurvey of all socio--

economic classes of birthseconomic classes of births

�� Alcohol use Alcohol use -- 46.7% of women reported drinking 46.7% of women reported drinking

during the 3 months prior to pregnancy; 2.9% drink during the 3 months prior to pregnancy; 2.9% drink

during the last trimesterduring the last trimester

�� Tobacco Tobacco –– 24.7 % of women report smoking within 24.7 % of women report smoking within

the 3 months prior to pregnancy; 14.7% smoke the 3 months prior to pregnancy; 14.7% smoke

during the last trimester, 22% after deliveryduring the last trimester, 22% after delivery

�� DepressionDepression

PRAMS: Pregnancy Risk Assessment Monitoring System

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�� Capital Area Human Services District Capital Area Human Services District

�� 31% of children born in Baton Rouge are 31% of children born in Baton Rouge are

exposed to alcohol, tobacco, or illicit drugsexposed to alcohol, tobacco, or illicit drugs

�� Depression Depression –– 17% screen positive17% screen positive

�� Domestic violence Domestic violence –– 5.5% positive5.5% positive

4Ps Plus Screening: May 2005-June 2006

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What is the What is the SBIRT SBIRT process?process?

��SScreeningcreening

��BBrief rief IInterventionntervention

��RReferraleferral

��TTreatmentreatment

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4Ps Plus Screening Tool for 4Ps Plus Screening Tool for PerinatalPerinatal

Substance Abuse, Depression and Domestic Substance Abuse, Depression and Domestic

ViolenceViolence

�� Parents:Parents: did either of your parents have any problem did either of your parents have any problem with alcohol or drugs (*Yes/No) with alcohol or drugs (*Yes/No)

(*no referral to brief intervention)(*no referral to brief intervention)

�� Partner:Partner:�� Does your partner have any problem with drugs or alcohol? Does your partner have any problem with drugs or alcohol? (Y/N)(Y/N)

�� Is your partnerIs your partner’’s temper ever a problem for you? (Y/N)s temper ever a problem for you? (Y/N)

�� Have you ever felt out of control or helpless? (Y/N)Have you ever felt out of control or helpless? (Y/N)

�� Does your partner threaten to hurt you or punish you? (Y/N)Does your partner threaten to hurt you or punish you? (Y/N)

4Ps Plus Screen copyright 2001 National Training Institute4Ps Plus Screen copyright 2001 National Training Institute

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4Ps Plus Screening Tool4Ps Plus Screening Tool

�� Past:Past:

�� In the last two weeks have you felt worthless, down, In the last two weeks have you felt worthless, down,

depressed or hopeless? (No/Yes)depressed or hopeless? (No/Yes)

�� In the last two weeks have you lost interest in things In the last two weeks have you lost interest in things

that used to be fun to you? (No/Yes)that used to be fun to you? (No/Yes)


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4Ps Plus Screening Tool4Ps Plus Screening Tool

�� Pregnancy:Pregnancy:

�� In the month before you knew you were pregnant, In the month before you knew you were pregnant,

how many tobacco cigarettes did you smoke? how many tobacco cigarettes did you smoke?

(none/any)(none/any)

�� In the month before you knew you were pregnant, In the month before you knew you were pregnant,

how much beer/wine (wine cooler)/daiquiri/liquor how much beer/wine (wine cooler)/daiquiri/liquor

did you drink? (none/any)did you drink? (none/any)


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4Ps Plus4Ps Plus

�� Positive responses result in followPositive responses result in follow--up questionsup questions

�� FollowFollow--up question examples:up question examples:�� During the month before you knew you were pregnant, about During the month before you knew you were pregnant, about how many days a week did you usually use marijuana?how many days a week did you usually use marijuana?

�� And last month, about how many days a week did you usually And last month, about how many days a week did you usually smoke tobacco cigarettessmoke tobacco cigarettes

�� Referrals to: Brief Intervention, Fax tobacco Referrals to: Brief Intervention, Fax tobacco quitlinequitline, , domestic violence, substance abuse treatment, mental domestic violence, substance abuse treatment, mental health, other (specify: ___).health, other (specify: ___).


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4Ps Plus Brief Intervention4Ps Plus Brief Intervention

�� ScriptedScripted

�� ““I am concernedI am concerned……..””

�� Bridging comment Bridging comment ““I am glad you mentioned that you I am glad you mentioned that you are using ____. We know a few things about the are using ____. We know a few things about the effects of ____ use during pregnancyeffects of ____ use during pregnancy……....””

�� PrePre--Treatment Curriculum is drugTreatment Curriculum is drug--specific and includes specific and includes information and photos of a wide variety of substances.information and photos of a wide variety of substances.

�� Training VideoTraining Video

----------------------------------------------------------------------------------------------------------------------------------------------�� Reference: Reference: ChasnoffChasnoff, Ira J and , Ira J and McGourtyMcGourty, Richard F. , Richard F. ““I Am I Am ConcernedConcerned…”…” PrePre--Treatment: A Brief Intervention for the Primary Treatment: A Brief Intervention for the Primary

Prenatal Care Setting. National Training Institute: 2003.Prenatal Care Setting. National Training Institute: 2003.

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Louisiana Pregnant WomenLouisiana Pregnant Women’’s Risk s Risk


�� Capitol Area Human Services DistrictCapitol Area Human Services District’’s Executive s Executive

Director and the project manager for its Baton Rouge Director and the project manager for its Baton Rouge

FASD Prevention Collaborative previously adopted the FASD Prevention Collaborative previously adopted the

4Ps Plus for their own project4Ps Plus for their own project

�� OAD, OPHOAD, OPH--MCH, OMH, ACOG, the Louisiana MCH, OMH, ACOG, the Louisiana

March of Dimes, Louisiana Public Health Institute March of Dimes, Louisiana Public Health Institute

and representatives from three pilot regions developed a and representatives from three pilot regions developed a

strategic plan for the programstrategic plan for the program

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SBIRT ProgramSBIRT Program�� July 1, 2006 July 1, 2006 –– June 30, 2007June 30, 2007

�� OAD and OPH collaborated in a contract with OAD and OPH collaborated in a contract with Dr. Ira Chasnoff and the National Training Dr. Ira Chasnoff and the National Training Institute in Chicago to provide leadership training Institute in Chicago to provide leadership training to launch a program to to launch a program to routinely androutinely andconsistentlyconsistently screen pregnant women for riskscreen pregnant women for risk

�� The contract also includes licensure of a screening The contract also includes licensure of a screening tool that has been validated for use with pregnant tool that has been validated for use with pregnant women women -- the 4Ps Plusthe 4Ps Plus

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�� July 1, 2006 July 1, 2006 –– June 30, 2007 (continued)June 30, 2007 (continued)

�� Program data, analyzed by NTI, will Program data, analyzed by NTI, will

be available to tie back to state data for be available to tie back to state data for

further valuable state outcome analysisfurther valuable state outcome analysis

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SBIRT OverviewSBIRT Overview

�� Screening will identify pregnant women Screening will identify pregnant women at at

risk risk for Alcohol or Drug Use, Depression for Alcohol or Drug Use, Depression

and Domestic Violenceand Domestic Violence

�� The above factors:The above factors:

��Adversely affect pregnancy outcomes Adversely affect pregnancy outcomes

and and

��Cause lifeCause life--long adverse impact to the long adverse impact to the

children of the affected pregnancies children of the affected pregnancies

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What is the longWhat is the long--term goalterm goal??

��To risk screen all Louisiana pregnant To risk screen all Louisiana pregnant

women women

��At the site of their prenatal care, At the site of their prenatal care,

public or privatepublic or private

��As a routine part of their prenatal As a routine part of their prenatal

carecare

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Where will SBIRT start?Where will SBIRT start?

�� Plan will pilot in 3 new regions:Plan will pilot in 3 new regions:

�� Florida Parishes at St. Tammany Regional Hospital Florida Parishes at St. Tammany Regional Hospital

and private OB offices in Covington and private OB offices in Covington

�� Alexandria/PinevilleAlexandria/Pineville, at private OB offices and the , at private OB offices and the

public hospitalpublic hospital

�� Monroe, at the public hospital and public health Monroe, at the public hospital and public health

clinicclinic

�� Continue the work with Capital Area Human Continue the work with Capital Area Human

Services District in Baton RougeServices District in Baton Rouge

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The screening tool, the 4Ps Plus The screening tool, the 4Ps Plus

is:is:

��SimpleSimple

��BriefBrief

��ValidatedValidated

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�� The 4Ps Plus is one page, a 3The 4Ps Plus is one page, a 3--5 minute 5 minute screen screen

�� Ideal scenario: Health care provider, who Ideal scenario: Health care provider, who has a relationship and rapport with the has a relationship and rapport with the patient, performs the screen as a routine patient, performs the screen as a routine part of the patientpart of the patient’’s health cares health care

�� Screen optimally occurs at 3 visits during Screen optimally occurs at 3 visits during pregnancypregnancy

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Why address risk in this way?Why address risk in this way?

�� Pregnant women who use alcohol or Pregnant women who use alcohol or

substances that can harm their babies may substances that can harm their babies may

feel a sense of shame and carry stigma. feel a sense of shame and carry stigma.

�� Best practices dictate a sensitive approach Best practices dictate a sensitive approach

that reduces stigma and shame.that reduces stigma and shame.

�� The most effective place to identify these The most effective place to identify these

risks is at the site of a womanrisks is at the site of a woman’’s prenatal s prenatal

health care.health care.

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WhatWhat’’s next after screening?s next after screening?

�� Positive Screen: Brief InterventionPositive Screen: Brief Intervention

�� Counselor expresses concern for her and Counselor expresses concern for her and

the health of her baby, the health of her baby, ““I am concerned I am concerned

that...that...””

�� Counselor provides information about Counselor provides information about

potential harmful effects and engages potential harmful effects and engages

discussion through motivational discussion through motivational

interviewing techniques.interviewing techniques.

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Importance of the Brief InterventionImportance of the Brief Intervention

�� Research shows that a pregnant Research shows that a pregnant

womanwoman’’s concern for her unborn s concern for her unborn

child strongly motivates her to child strongly motivates her to

respond positively to her medical respond positively to her medical

providerprovider’’s advice to abstain from s advice to abstain from

drugs or alcohol.drugs or alcohol.

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Pregnant WomenPregnant Women’’s Risk SBIRT s Risk SBIRT

Importance of ReferralImportance of Referral

�� A vital part of the screening process is to have A vital part of the screening process is to have

services available to address the risks that we services available to address the risks that we

identify.identify.

�� Pilot Regions are developing resource manuals Pilot Regions are developing resource manuals

to address regional availability of resources to to address regional availability of resources to

address Substance Use, Mental Health issues, address Substance Use, Mental Health issues,

Domestic Violence and other needed services.Domestic Violence and other needed services.

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Substance Abuse TreatmentSubstance Abuse Treatment

�� Appropriate level of careAppropriate level of care

��Ongoing follow up in prenatal care siteOngoing follow up in prenatal care site

�� Case managementCase management

�� GroupsGroups

��Outpatient Outpatient

�� Residential Residential

�� GenderGender--specificspecific, , trauma informedtrauma informed treatmenttreatment

�� Closed link back to prenatal care siteClosed link back to prenatal care site

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SBIRT Overview: Who is involved?SBIRT Overview: Who is involved?

�� Initial Collaborators in the project are:Initial Collaborators in the project are:

�� Louisiana American College of Obstetricians and Louisiana American College of Obstetricians and

Gynecologists (ACOG)Gynecologists (ACOG)

�� Louisiana Fetal Infant Mortality Review teamsLouisiana Fetal Infant Mortality Review teams

�� Louisiana March of DimesLouisiana March of Dimes


�� Louisiana DHH Louisiana DHH

�� Office for Addictive DisordersOffice for Addictive Disorders

�� Office of Public Health Office of Public Health ––Maternal and Child HealthMaternal and Child Health

�� Office of Mental HealthOffice of Mental Health

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SBIRT Overview: Who Will Be SBIRT Overview: Who Will Be

involved?involved?

�� In addition to those already engaged, each In addition to those already engaged, each Pilot Region will provide training and Pilot Region will provide training and solicit involvement from:solicit involvement from:

��Private / public medical providersPrivate / public medical providers

��HospitalsHospitals

��Community action groupsCommunity action groups

��Anyone involved with successful Anyone involved with successful pregnancy outcomespregnancy outcomes

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SBIRT TrainingsSBIRT Trainings

�� Developed in collaboration with Action Learning Lab Members Developed in collaboration with Action Learning Lab Members (ACOG, MCH, March of Dimes, Louisiana Public Health (ACOG, MCH, March of Dimes, Louisiana Public Health Institute, Planned Parenthood) and Office For Addictive Institute, Planned Parenthood) and Office For Addictive Disorders.Disorders.

�� Incorporates current trainings: Make Yours A Fresh Start Incorporates current trainings: Make Yours A Fresh Start Family tobacco cessation training, Family tobacco cessation training, QuitlineQuitline/Fax Referral, OAD /Fax Referral, OAD awareness trainings, ACOG CDawareness trainings, ACOG CD--ROM, ACOG ClinicianROM, ACOG Clinician’’s Guide s Guide to Helping Pregnant Women Quit Smoking. to Helping Pregnant Women Quit Smoking.

�� Supported through AMCHP Tobacco Prevention Among Supported through AMCHP Tobacco Prevention Among Women of Reproductive Age MiniWomen of Reproductive Age Mini--Grant for awareness buttons, Grant for awareness buttons, posters, March of Dimes CEU modules on substance abuse.posters, March of Dimes CEU modules on substance abuse.

�� To be conducted: hospitals, private and public OB clinicsTo be conducted: hospitals, private and public OB clinics

�� Resources: InResources: In--kind from all participant organizationskind from all participant organizations

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SBIRT Overview: Who Will Be SBIRT Overview: Who Will Be

involved as the project matures?involved as the project matures?

�� Ultimately, we plan to incorporate Ultimately, we plan to incorporate prevention messages for young women prevention messages for young women about potential risks to a healthy about potential risks to a healthy pregnancy:pregnancy:�� SchoolSchool--based health clinicsbased health clinics

�� Prevention advocatesPrevention advocates

�� PrePre-- and interand inter--conceptionalconceptional care, i.e., Planned care, i.e., Planned Parenthood, Family Planning Clinics, Family Parenthood, Family Planning Clinics, Family Planning Medicaid Waiver w/private Planning Medicaid Waiver w/private providers.providers.

36

SBIRT must be a Collaborative effort SBIRT must be a Collaborative effort

of state and community resourcesof state and community resources

�� Private/public partnership is keyPrivate/public partnership is key

�� OPHOPH’’s Fetal Infant Mortality Review groups in s Fetal Infant Mortality Review groups in all regions provide the medical provider teams all regions provide the medical provider teams and the Community Action Teams to be and the Community Action Teams to be intimately involved.intimately involved.

�� Collaboration with experienced researchers, Collaboration with experienced researchers, such as the Childrensuch as the Children’’s Research Triangles Research Triangle

�� A comprehensive community approach to A comprehensive community approach to SBIRTSBIRT

37

The SBIRT State and The SBIRT State and

Community Collaborative Community Collaborative

��Will positively affect birth outcomesWill positively affect birth outcomes

��Will contribute to healthy Louisiana Will contribute to healthy Louisiana

families.families.

38

The Pregnancy Risk SBIRT The Pregnancy Risk SBIRT

��LetLet’’s get the word out: s get the word out:

There is There is nono safe amount of safe amount of tobacco or alcohol while tobacco or alcohol while pregnant. If you are pregnant, pregnant. If you are pregnant, do do notnot smoke or drink.smoke or drink.

39

The Pregnancy Risk SBIRTThe Pregnancy Risk SBIRT

�� For more information about addictive disorders log onto the For more information about addictive disorders log onto the Office for Addictive Disorders website:Office for Addictive Disorders website:

�� www.addictionsla.comwww.addictionsla.com..

�� Louisiana Maternal and Child Health resourcesLouisiana Maternal and Child Health resources::

�� Partners for Healthy Babies: Partners for Healthy Babies: �� www.1800251baby.orgwww.1800251baby.org

�� 18001800--251251--BABY (2229) BABY (2229)

�� National Training Institute, Chicago, IllinoisNational Training Institute, Chicago, Illinois

�� Ira J. Ira J. ChasnoffChasnoff, M.D. (312) 726, M.D. (312) 726--4011 4011 http://http://www.childstudy.orgwww.childstudy.org//

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2007 Louisiana Action Learning Lab2007 Louisiana Action Learning Lab

Start Life in Louisiana Tobacco Free Consortium Members:Start Life in Louisiana Tobacco Free Consortium Members:

�� Michael Michael KudlaKudla, M.D., FACOG, M.D., FACOG

�� Julie Julie MickelberryMickelberry, Planned Parenthood, Planned Parenthood

�� Amanda Amanda AlbinAlbin, MPH, March of Dimes, MPH, March of Dimes

�� Mary Craig, RN, MSN, MS : Office of PublicMary Craig, RN, MSN, MS : Office of Public--Maternal and Maternal and

Child HealthChild Health

�� Sharon Lair, MPH: Louisiana Public Health InstituteSharon Lair, MPH: Louisiana Public Health Institute

�� TamannaTamanna Patel, MPH: Louisiana Public Health InstitutePatel, MPH: Louisiana Public Health Institute

�� Darla Ratcliff, RN, MSN: Louisiana MedicaidDarla Ratcliff, RN, MSN: Louisiana Medicaid

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Thank youThank you

�� Michael Michael KudlaKudla, M.D., M.D.

Email: Email: [email protected]@yahoo.com

�� Mary Craig, RN, MSN, MSMary Craig, RN, MSN, MS

Maternity Program Nurse CoordinatorMaternity Program Nurse Coordinator

Louisiana Office of Public HealthLouisiana Office of Public Health--Maternal and Child Maternal and Child

HealthHealth

Email: Email: [email protected]@dhh.la.gov

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Documents

Statewide Risk Screening Program for Pregnant … Risk Screening Program for Pregnant Women: SBIRT Program Louisiana Community/State Collaborative Michael Kudla, M.D., FACOG Mary Craig,