STAR Program

State: NC Type: Promising Practice Year: 2018

The Gaston County Department of Health & Human Services is deserving of the Model Practice Award for its collaborative and innovative work around reducing the impact of maternal substance abuse on infants. In the United States, an infant is born with signs of drug withdrawal every hour. The impact of maternal drug use causes a wide range of short and long-term effects like low birth weight, congenital anomalies, and growth and behavioral problems. The Substance Treatment And Rehabilitation Program (STAR) was launched in February 2016 to provide drug treatment and supportive counseling to pregnant women. STAR has seen positive outcomes within its first year, not only among the women and children served by the program, but also through the agency's convening of stakeholders and partners around this issue. In addition, other counties in NC are in the process of replicating STAR within their own areas. The STAR program is a shining example of how local health departments through their emphasis on prevention, collaboration, and evidence-based practices can effect substantial and sustainable change within their communities. Gaston County is located in the south-central Piedmont of North Carolina, with Mecklenburg County (Charlotte) to the east, Lincoln County to the north, and Cleveland County to the west. In the mid-to-late 1800's, textiles became Gaston County's dominant industry, with many families living and working in mill villages. Over the past three decades, tens of thousands of textile workers have lost jobs to automation as mills have closed and others have relocated outside the U.S. Currently, efforts are underway to improve literacy, graduation rates, and establish a qualified workforce. Like much of North Carolina and the Southeast, Gaston County has experienced great loss from the current opioid epidemic. The Gaston County Department of Health & Human Services (Gaston DHHS) is a consolidated agency providing public health, social services, and transportation services to just over 206,000 Gaston County citizens. Its maternity program is the county's largest obstetric practice, having delivered 59% of the babies born at the local hospital in 2016. Enhancing the quality of life of Gaston County by caring for, protecting, and empowering the community to live healthy lives in a healthy environment,” is the mission statement of Gaston DHHS. Through its 2015 strategic planning process, the department identified the following priority areas: Integration of Mental Health Resources, Improved Family Functioning, Childhood Obesity, and Senior Livability and Support. The primary goal of the STAR program is to reduce the incidence of babies born with Neonatal Abstinence Syndrome. In its first year, the program has been successful. Website information :
Gaston County's women, many of whom are pregnant are in danger of overdosing from various opioids. In 2014, 21 women died from drug overdoses in Gaston County, accounting for 52.5% of total overdose deaths. In 2015 that number dropped to 16, but 44.4% of deaths were among women. In North Carolina women accounted for 36% and 36.5% of overdose deaths in 2014 and 2015. White women, ages 45-54, have the highest rates of overdose deaths. From January 2016-January 2017, 80 Gaston County residents were treated in local emergency departments for opioid overdoses; 32% were women. The county's overall rate of medication or overdose deaths per 100,000 residents for 2013-2015 is 21.0 compared to 13.5 for North Carolina. Prescription opioids are the most common substances contributing to unintentional medication or overdose deaths in Gaston County, followed by heroin. The need for STAR is reflected by a high rate of substance abuse in Gaston County. Opioid deaths among county residents exceed the State rate as well as the rate for Mecklenburg County, Gaston County's neighbor. Further, among women who received prenatal care at a DHHS Maternity Clinic, 131 had positive substance screens in calendar year 2014. CaroMont Regional Medical Center, Gaston County's local hospital, reported treating 36 infants for drug withdrawal, or NAS, from May 1, 2014 through April 30, 2015. The STAR concept was conceived in 2012 by Christie Bartell, MD, a pediatrician with the Gaston County Health Department. In the Child Health Clinic, Dr. Bartell routinely saw children affected by their mothers' untreated substance use disorders. She was also aware that pregnant patients in the Health Department's Maternity Clinic frequently had positive drug screens, but were not receiving substance abuse treatment. Determined to improve services to these women, Dr. Bartell envisioned a program that would help the department provide screening and assessment, education, supportive counseling and treatment, and advocacy, while also referring patients to community agencies. To achieve success, she also realized it would be critical for these agencies to play an active role in developing STAR. During this time, the Gaston County Health Department and the Gaston County Department of Social Services consolidated to create the Gaston County Department of Health & Human Services (Gaston DHHS). Because the Public Health and Social Services Divisions of Gaston DHHS work to achieve healthy birth outcomes, eliminate infant mortality, and prevent child abuse and neglect, the new department had an even stronger stake in STAR. In 2013, Gaston DHHS secured funding through Kate B. Reynolds Charitable Trust to develop a plan to implement STAR. DHHS hired former directors from UNC's Horizon's Center, a substance use disorder treatment program for pregnant and/or parenting women and their children, to guide recommendations for starting a program. This program is considered a best practice for substance abuse treatment for pregnant/parenting women. More than ten Gaston County agencies helped develop the STAR initiative and participated in stakeholder meetings. These meetings had substantial and consistent representation from clinical and drug treatment service providers –policymakers and clinicians – as well as representatives from agencies with less direct involvement with the target population. All agencies shared concerns about the rise of opiate addition among pregnant women and mothers, and with gaps in the community system of care for these families. After months of planning, stakeholder meetings, and data collection, Gaston DHHS was ready to launch the program. STAR was launched in February 2016, and serves all pregnant women who self-report or test positive for benzodiazepines, buprenorphine, cocaine, methadone, or opioids and are receiving care through the Gaston DHHS Maternity Program. The program goal is to increase the number of mothers who deliver abstinent or enrolled in medication assisted treatment (MAT) programs, which will reduce the incidence of NAS. This program is a collaborative effort between Gaston DHHS and numerous community stakeholders: neonatologists, pediatricians, behavioral health specialists, substance abuse treatment centers, law enforcement, the local Federally Qualified Health Center, and the sole county hospital. STAR services include: 24-hour full service care of pregnant women Medication Assistance Treatment (MAT) services for 18 months post-delivery Neonatal Abstinence Syndrome (NAS) education for expectant mothers Group behavioral health sessions Education on and the provision of naloxone to patients and their family members Nutritional counseling Providing information on child protection services Collaboration with the Pregnancy Medical Home and Care Coordination for Children programs Post-partum contraceptive counseling Post-delivery transition of care to a primary medical home In addition to the current services offered, DHHS staff are working hard to expand the scope of STAR by seeking funding to add childcare for women during appointments, transportation, and exploring a transitional housing facility for mothers and newborns. In its first year of operations, STAR provided care to 126 women and many have become abstinent or enrolled in a MAT program during the course of their pregnancy. Feedback from the hospital staff has been extremely positive: newborns born to mothers in the STAR program handle the transition more easily and are more likely to respond to environmental comfort measures only. For children whose exposure necessitated hospital evaluation and treatment, STAR intervention contributed substantially to reduced resource utilization and decreased length of stay, with significant cost savings to the community. Mothers and families are engaged and the patients and their medical team become partners with Child Protective Services to ensure that the home environment will be a safe haven for the newborn. The incidence of NAS dropped 25.7% among newborns in 2016 and while additional data will be reviewed to continue monitoring outcomes, this is certainly encouraging news. The start-up costs were approximately $75,000 for the STAR coordinator (with fringe benefits) as well as the $25,000 awarded from Kate B Reynolds. The rest of the resources were all in-kind donations.
In addition to the collaboration described above Gaston County has a strong Controlled Substances Coalition and drug diversion program. All of the members of the coalition may refer clients to the STAR program. In March 2016 local medical providers from private practices, the county's sole hospital, our local Federally Qualified Health Center (Gaston Family Health Services) and the Gaston County Department of Health and Human Services (DHHS) convened to discuss the growing opioid epidemic in our county. Using recent overdose data these individuals decided to organize to address this tragic issue, which was disproportionately impacting Gaston County's women. In April 2016 the group that became the Gaston Controlled Substances Coalition (the Coalition) was formed. The Coalition is comprised of county residents who are working together to reduce the number of opioid overdoses in Gaston County. It includes individuals who are affected by opioid dependence, clinicians who write prescriptions, nurses, behavioral health specialists, law enforcement officers, pharmacists, drug educators, and communication specialists. The Coalition is a program of the Gaston Community Healthcare Commission whose mission/goal is to engage professional and lay leaders to collaboratively develop and conduct programs that will: (1) prevent the onset of addiction to controlled substances, (2) assure the adoption of safe opioid prescribing practices, (3) deliver comprehensive drug treatment and mental health services for all persons in need, and (4) deliver professional and community education in support of these outcomes. The Coalition established three committees: (1) the Controlled Substances Policy Adoption Committee develops and implements programs that facilitate the full adoption of controlled substance policies and protocols by all prescribers in Gaston County; (2) the Treatment Linkages Committee works to assure Gaston County has an adequate supply of effective and accessible medical and behavioral treatment resources to meet the demand of all referred opioid-involved patients; and, (3) the Community Education and Prevention Committee, in its first phase, educates county residents and first responders about the content of new controlled substance polices and protocols and what they can expect from their clinical prescribers; in its second phase, it will work to assure the conduct of drug prevention education in our community and schools. The 85-member Coalition meets every other month, and committees meet monthly and recently approved its three-year and one-year strategic plans. In October 2016 the Policy Adoption Committee hosted a Continuing Medical Education event for local prescribers. One hundred and sixty-five physicians, dentists, podiatrists, advance practice nurses, physician assistants, nurses, pharmacists, behavioral health professionals, and medical office managers attended the event. Ninety-percent of participants either strongly agreed or agreed that The training improved my competence to safely address chronic pain and prevent, identify, and/or treat opioid use disorders.” Topics included Best Practices in Pain Management, Best Practices in Urine Screening, Case Studies, Practicing under New NC Medical Guidelines, and NC and the Opioid Epidemic: Looking to the Future. In November 2016, Gaston County launched the Drug Diversion & Treatment program (DDAT), a post-booking treatment program operated by Phoenix Counseling Center. Participants must reside in Gaston County, have a history of multiple offenses related to opioid/heroin use, be chronic and current users of opioids, have non-violent charges, and must be willing to complete a 120-day treatment program. These services can be inpatient or outpatient, as determined by the treatment provider and participant. Potential candidates are identified by the public defender's office, jail liaison, law enforcement entity or judicial entity. To date this program has served 11 clients, with the ability to serve 16 at a time; the residential component appears to yield the most positive outcomes. This program is based on the Law Enforcement Assisted Diversion (LEAD) model, a pre-booking diversion pilot program developed with the community to address low-level drug and crimes associated with sex work. DDAT allows police and the sheriff to redirect low-level offenders engaged in drug or sex work activity to community-based programs and services, instead of jail and prosecution. By diverting these eligible individuals to services, it improves public safety and public order, and reduces the criminal behavior of program participants. DHHS will provide DDAT program participants with STI testing, family planning resources and appointments, maternity care, and information on the WIC program. As needed it will provide the following social services: parenting programs, child support enforcement, child daycare subsidies, energy assistance programs, food and nutrition services, and support with Medicaid. These services are critical for women to understand and access, especially when in treatment. The Office of National Drug Control Policy encourages sentencing alternatives to incarceration and using trauma-informed interventions with women. DHHS and DDAT practice trauma-informed interventions.
The primary evaluation method for year 1 was the number of babies born with Neonatal Abstinence Syndrome. DHHS just hired a new data analyst who will be able to extract and analyze data from the STAR participants'' medical records. In addition, the first year of the collaboration with Gaston Family Health Services to offer Medication Assisted Therapy just ended. DHHS' medical director will meet with Gaston Family Health Services and discuss successes and potential changes to this program and develop additional protocols.
Initially, a STAR Coordinator helped convene stakeholders, developed materials and procedures, and ensured all clinical staff and community partners received appropriate training. The STAR Coordinator will now focus on assisting with developing the family's safety plans, data collection and post-partum home visits and planning. Now that the clinical program is in place, it is self-sustaining as STAR protocols are incorporated into the day-to-day work of the practice. Additionally, the collaborative nature of the STAR program continues to fuel the work of the community in addressing other issues related to the Opioid epidemic.
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