Integrating care and improving birth outcomes with SBIRT: An update from the field

August 2, 2015
Catherine Ulrich Milliken
Director, Addiction Treatment Program
Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

It’s hard to believe that almost two years since I first wrote in this blog about the Dartmouth Hitchcock Medical Center (DHMC) Perinatal Addiction Treatment Program (PATP).

The PATP is a joint, multidisciplinary, and interprofessional venture that spans two institutions, (Dartmouth Hitchcock Medical Center and The Geisel School of Medicine at Dartmouth College), three departments (Psychiatry, OB/Gyn and Pediatrics) and the inpatient and outpatient environments. 


In my first blog post in October 2013 (“Inspiring Change through SBIRT: Start with the “Why,”) I shared some background on how our multidisciplinary team identified the need and together, agreed to implement SBIRT in our OB/Gyn clinics. Attending an ATTC Training of the Trainers for SBIRT gave me the skills I needed to train teams in the departments involved. In a follow-up post (“What happens if they say yes?”) I talked about one of the first challenges we faced.

A lot has happened since then. Here’s a quick timeline: 


2013
     PATP begins, enrolling 5 participants,  SBIRT training begins

2014
     Certified nurse-midwife services added, providing prenatal care on-site
     Social worker joins the team to help women access resources
     Postpartum women transitioned to “maintenance groups”
     Change team completes PDSA cycles to fully implement SBIRT in all OB/GYN divisions
      SBIRT fully implemented across all three OB/Gyn divisions at the Dartmouth Hitchcock Medical Center as of September 30, 2014

2015
     Behavioral health specialist joins the team, providing integrated care in both the OB/Gyn and Addiction Treatment Program.

Our program provides comprehensive integrated care to pregnant and postpartum women with substance use disorders. Patients enter the program during pregnancy and are encouraged to continue through the end of the first postpartum year. At that point, they may transition to the DHMC-ATP adult outpatient program. The PATP include:

• On-site services at the DHMC Addiction Treatment Center
• Standardized screening and intervention (SBIRT) for perinatal substance use
• “Rooming-in” program for newborns experiencing neonatal abstinence syndrome (NAS). This component emphasizes non-pharmacologic treatment approaches through partnership with informed and prepared parents.

Here's a link to a recent story about the PATP from the Dartmouth Hitchcock online newsletter:

Helping Moms and Babies in the Heroin Crisis  

And we even made the NBC Nightly News.

Today, the PATP serves 40 pregnant and postpartum women. The program provides comprehensive evidence-based treatment, including psychiatric evaluation, medication-assisted treatment of opioid dependence with buprenorphine, individual addiction counseling, prenatal and postpartum recovery groups, social supports, and basic onsite obstetric care. Individual and group appointments are held weekly.

SBIRT is now the standard practice for all new OB visits. The implementation process has been iterative, using the NIATx rapid-cycle change approach. (More about those change cycles in my next post.)

We tracked the process for the first 386 patients who were screened via manual review of charts. That tracking tells us that SBIRT has increased SUD treatment for our pregnant and postpartum women who need it. We’ve found that SBIRT implementation has also increased patient and provider satisfaction.

Looking back on the past two years, it’s clear that the PATP has changed our practice and triggered a profound shift in attitude towards this vulnerable population. It’s transformed staff frustration at not being able to access treatment for pregnant women into great personal and professional satisfaction at being able to help patients get the resources they need.

The teamwork embedded in this integrated effort has also made a difference: Birth outcomes have certainly improved over the past two years. Today, less than 30% of infants born at DHMC require treatment for Neonatal Abstinence Syndrome, compared to approximately 50% two years ago. SBIRT, the staff training it requires, and the PATP’s multidisciplinary effort across departments have all contributed to this improved outcome.

I’ll be telling you more about how we used systematic Plan-Do-Study-Act (PDSA) cycles to implement SBIRT in multiple settings in an upcoming blog post. Stay tuned!

Catherine Ulrich Milliken, M.S.W., LICSW, MLADC, LCS, is the Program Director for The Dartmouth Hitchcock Medical Center Addiction Treatment Program and an instructor in Psychiatry at the Geisel School of Medicine at Dartmouth. Previous academic appointments included University of Southern Maine, University of New England, and University of New Hampshire. She has worked passionately to improve the care and treatment of women's mental health and substance issues for the last 15 years. Before working at Dartmouth, she was the Director of Outpatient Services at Crossroads for Women, which provides gender‐specific and trauma‐informed outpatient programs and services for substance abuse and mental health, as well as residential rehabilitation and halfway house services for substance abuse in Portland, Maine. During that time, she also saw clients in private practice, specializing in adult psychotherapy, substance use and women's issues and worked with clients struggling with HIV and AIDS diagnoses. She conducts training on the basics of chemical addiction, tools for leading groups, exploring the relationship between substance abuse and child maltreatment, and women's treatment concerns, among other areas.