Children and Recovering Mothers (CHARM): A Roadmap to Implementation in New York State

March 2019

The American College of Obstetricians and Gynecologists (ACOG), District II hosted a convening on the Children and Recovering Mothers (CHARM) Collaborative program to guide, educate and assist providers caring for expectant mothers with OUD and their infants. The event was made possible through CHARM funding provided by the New York State Legislature.

ACOG District II recommends that at least $1.5 million annually is allocated in the state budget for:

A CHARM champion at each of the Regional Perinatal Centers (RPCs);
A division for CHARM-related activities that includes a state coordinator specifically for “hub & spoke” implementation components given the geographic expanse of New York; and,
Provider education that offers implementation tools to better assist women’s health care providers in caring for pregnant women with OUD.

CHARM originally developed in Vermont, is an interdisciplinary and cross-agency team which coordinates care for pregnant and postpartum mothers with a history of OUD and their infants. New York, like many states, is suffering the consequences of the opioid epidemic. An intensive collaborative effort like CHARM
is necessary to address the complex needs of women with OUD during pregnancy and their families. Developing a successful and sustainable collaborative in New York State, requires commitment from multiple agencies, systems, and disciplines in a coordinated multiyear effort.

Key Recommendations on the Roadmap to Implementing CHARM in New York:

Develop Regional “Hub and Spoke” Model
Enhance Care Coordination and Linkage to Services Locally
Offer Multidisciplinary Provider Training

ACOG District II strongly encourages policymakers to utilize ACOG as a resource and to partner and work together to effectively support women and their families. ACOG District II recommends continued and enhanced funding in the New York State budget allocated specifically for CHARM.

Introduction

On February 13, 2019, the American College of Obstetricians and Gynecologists (ACOG), District II hosted a convening on the Children and Recovering Mothers (CHARM) Collaborative program to guide, educate and assist providers caring for expectant mothers with OUD and their infants.

At the convening, the 50 multidisciplinary health care providers and key stakeholders from across New York State identified key recommendations on how a CHARM-like model could be implemented in New York State at the hospital, community and state level which are outlined within. Representatives from the provider community who participated included obstetricians, midwives, pediatricians and corresponding nursing staff/teams, social workers, and addiction specialists. Representatives from various state agencies were also present, including New York State Department of Health Division of Family Health, New York
State AIDS Institute, New York State Office of Alcoholism and Substance Abuse, and various county health officials. The event was made possible through CHARM funding provided by the New York State Legislature.

As part of ACOG District II’s ongoing efforts to address OUD in Pregnancy, this roadmap aims to ensure sustainability of a CHARM-like model in New York by recommending continued and enhanced funding in the New York State budget allocated specifically for CHARM. ACOG District II recommends that at least $1.5 million annually is allocated in the state budget for 1) A CHARM champion at each of the Regional Perinatal Centers (RPCs); 2) A division for CHARM-related activities that includes a state coordinator specifically for “hub & spoke” implementation components given the geographic expanse of New York; and, 3) Provider education that offers implementation tools to better assist women’s health care providers in caring for pregnant women with OUD.

Background: Vermont CHARM Collaborative

Children and Recovering Mothers (CHARM), originally developed in Vermont, is an interdisciplinary and cross-agency team which coordinates care for pregnant and postpartum mothers with a history of OUD and their infants. The goal of CHARM is to improve the health and safety outcomes of infants born to women with a history of OUD by coordinating medical care, substance use treatment, child welfare, and social service supports. Today, the CHARM Collaborative includes 11 organizations that collectively provide this population of women with coordinated comprehensive care from child welfare, medical (including obstetrics and pediatrics) and substance abuse treatment professionals across Vermont.¹

Key elements of the CHARM Collaborative include a shared philosophy of improving care and support for mothers as the most important factor in helping to ensure safe, healthy outcomes of their infants. Shared information across agencies, including a memorandum of understanding (to address confidentiality
concerns), provides the framework for operation and successful coordination of services to improve child safety and health outcomes for both the mother and her infant.

The CHARM Collaborative works by organizing a monthly team meeting with representation from all key stakeholders. At each of the monthly meetings, the CHARM team reviews a list of current cases and prioritizes them, identifies patient/family needs, gaps in services, and focuses heavily on monitoring patient progress throughout pregnancy and postpartum.

This collaborative has resulted in family needs identified and addressed sooner, and fewer families “falling through the cracks” than if the services these families received were not coordinated among providers.

How Can New York Implement a CHARM-like Model Statewide?

New York, like many states, is suffering the consequences of the opioid epidemic. An intensive collaborative effort like CHARM is necessary to address the complex needs of women with OUD during pregnancy and their families. Developing a successful and sustainable collaborative in New York State, requires commitment from multiple agencies, systems, and disciplines in a coordinated multiyear effort. The CHARM Collaborative is an example of a highly successful collaborative that has developed and implemented multiple elements of system linkages.² Developing a similar CHARM-like model in New York State focusing on the hospital, community, and state level can assist communities in developing approaches within their region locally that support health, safety, well-being, and recovery of pregnant women with OUD and their infants.

Convening participants developed key recommendations that should be funded at the state level but implemented at the local level incorporating key aspects of the Vermont CHARM Collaborative model. Given the varying level of resources available in each region of New York State, the CHARM Collaborative strategies/approaches must be tailored to accommodate a larger state implementation model. By implementing the CHARM model at the regional level, hospital teams are better equipped to implement the fundamental components of the CHARM model. The variations in care that currently exist in New York State within each discipline, hospital setting, community, and region need to be resolved to facilitate a coordinated cross-system, multidisciplinary approach for the management and treatment of pregnant women with OUD and their infants. When communities recognize the positive and often cost-effective impact of a collaborative approach, public agencies and private entities, including providers, have a powerful incentive to work together in innovative ways.³

Key Recommendations on the Roadmap to Implementing CHARM in New York

1. Develop Regional “Hub and Spoke” Model*

Utilizing the regional perinatal centers (RPCs) in New York State to develop a “hub and spoke” model was a key recommendation. The RPCs would be funded to serve as the center (Hub) for care coordination and establish “mini hubs” (Spoke) within the community (RPC catchment area). The RPCs would provide comprehensive best practice guidelines including support for care coordination and referrals for ongoing care, consultation to physician offices (spokes), and ongoing care and referrals for the clinically complex patient. If appropriately funded, this hub and spoke model could mimic CHARM in Vermont at the regional level. Recognizing that an RPC may not lead every team locally, allowing for freedom in the framework will be critical to its success.

Implementation strategies

RPC secures a CHARM champion who coordinates with affiliate hospital champions and other
“spoke” providers. CHARM champions are responsible for convening regular meetings with
CHARM hospital teams (see below) and maintaining the cases to be discussed.
RPC ensures each affiliate hospital has a local CHARM champion and opioid treatment resources
and services are mapped locally so that all providers understand the patient resources available
within their region.
Process for mapping of local resources should be developed and updated regularly at the
community level with local hospitals.

*A hub is a specialty treatment center responsible for coordinating care of individuals with complex addictions and co-occurring substance
abuse and mental health conditions across the health and substance abuse treatment systems of care.
A spoke is the ongoing care system comprised of a prescribing provider and collaborating health and addiction professionals who monitor
adherence to treatment, coordinate access to recovery supports, and provide counseling. –SAMHSA

Key resources to identify

Medication-assisted treatment (MAT) providers/treatment specialists
Home visiting services
Women, Infants, and Children (WIC) services
Peer advocates
Primary care providers
Transportation services
Behavioral health counseling services
Child welfare/family services
County correction services

2. Enhance Care Coordination and Linkage to Services Locally

Communication and information sharing through regular team meetings is essential to ensure the effectiveness of a care coordination model. A formal Memorandum of Understanding (MOU) and/or information-sharing agreement signed by the patient and all those who care for the patient and her infant would be necessary for the appropriate exchange of information.

Implementation strategies

RPC CHARM champions help facilitate establishment of regional CHARM teams with recognition that an RPC may not lead every team locally.
CHARM champions and affiliate hospital team members should share information on patients who have signed a comprehensive release of information form allowing care team members to discuss the needs of each family during a monthly meeting and exchange health and safety
information between meetings.
Through facilitation of the CHARM champions, CHARM team members should meet on a regular (ie., monthly) basis to review a list of current cases to identify patient/family needs, gaps in services, and focus on what needs to be done to address any barriers to care.
o Team members may include:
-RPC CHARM champion
-County health department lead
-Social and family support services
-Addiction specialist/MAT provider
-Social worker/patient navigator
-Obstetrician(s)
-Pediatrician/neonatologist(s)
-Team nurse lead(s)
-PCP (if applicable)
New York State agencies could assist with implementation through statewide guidance in the following areas:
o Plan of safe care - Who develops the plan? Who manages throughout prenatal and postpartum period?
o Memorandum of Understanding (MOU) and multiagency release of information form (for patients to sign, allowing for appropriate sharing of information for care coordination purposes).

3. Offer Multidisciplinary Provider Training

New York State training should be multidisciplinary and offer implementation tools that better assist women’s health care providers in caring for pregnant women with OUD and their infants through development, dissemination and implementation assistance on the standard process for care and sharing of best practices. The state may consider partnering with ACOG to offer training/education.

Implementation strategies

RPCs should regularly offer educational resources to affiliate hospital sites.
Provider training should focus on the standard approach to care such as the OUD education
developed by ACOG District II
Training may include (but not limited to):
o Evidence-based treatment guidelines for pregnant women with OUD and opioid exposed newborns
o Use of a common language- addressing stigma/bias
o Universal screening
o Trauma-informed care
o Screening Brief Intervention Referral to Treatment (SBIRT)
o Understanding addiction
o Multidisciplinary care coordination

Other Policy Recommendations

Other policy recommendations discussed during the convening include:

Exploring the role Medicaid and managed care plans could play in addressing the opioid crisis (ie., how they can help coordinate patients’ care with the various players involved in the health care system, etc.)
Changing policies to provide Medicaid coverage up to one year postpartum
Offering universal home visiting services in New York State
Increasing funding for peer recovery coaches/navigators
Access to more patient navigators/MCH nurses/community health workers
Expansion of MAT/treatment resources in county jails

In Summary

This convening served to raise awareness of current collaborative approaches, gaps in coordination of care/treatment services and recommendations in addressing and implementing a CHARM-like model in New York State. Ultimately, pregnant women with OUD require careful attention and optimized care from a multidisciplinary team of providers knowledgeable about the unique circumstances of pregnancy and addiction. The recommendations outlined above require the commitment of health care providers, public health professionals, policymakers, community based organizations, the public, and patients to advocate on behalf of women battling OUD in pregnancy in New York State. ACOG District II strongly encourages policymakers to utilize ACOG as a resource and to partner and work together to effectively support women and their families. For the reasons outlined in this roadmap, ACOG District II recommends continued and enhanced funding in the New York State budget allocated specifically for CHARM.

Acknowledgements

ACOG District II would like to thank the CHARM Collaborative faculty for their expertise and time during the CHARM Convening. We also thank our key state partners, community partners and our committed hospital team members for their continued support and guidance, and recommendations during the convening. Finally, a special thank you to the New York Legislature for recognizing the impact of opioid use disorder on pregnant women and their families through funding this initiative.

¹Substance Abuse and Mental Health Services Administration. “A Collaborative Approach to the Treatment of
Pregnant Women with Opioid Use Disorder.” https://ncsacw.samhsa.gov/files/Collaborative_Approach_508.pdf
² Ibid
³Ibid

Children and Recovering Mothers (CHARM): A Roadmap to Implementation in New York State