Integrated care for pregnant women with Opioid Use Disorder/Substance Use Disorder

Pregnant women with OUD/SUD will present to (or be referred to) their obstetrician for prenatal care. The obstetrician will enroll the patient in MC3, create a care plan and upload that plan to EPIC and then consult anesthesiology. Mental health professionals at MC3 will regularly survey patients for depression, anxiety, among other conditions and make appropriate consultations when deemed appropriate. Obstetricians, in conjunction with the patient’s existing addictionologist (if applicable), will coordinate medication reconciliation both before and after delivery (up to one year post-partum). The obstetrician and anesthesiologist will coordinate care during the immediate peri-partum period.

RESOURCE:  Miniaturized version of the flowsheets here…links to full sized versions (reproduced below) when clicked – high quality versions to follow.  

Prenatal care will include normal screening/testing as per normal pregnancy protocol.  Patients will be referred to MC3, and, in addition to normal protocols, MC3 will screen the patients for:

• Depression:  Survey tool will be PHQ-9
  • Patients will be referred to a mental health specialist for scores of >13 antepartum and >10 postpartum or any positive answer for self-harm
  • This survey will be sent monthly during pregnancy, two weeks postpartum, 6 weeks postpartum, and then monthly for a year
• Anxiety:  Survey tool will be the GAD-7
  • This survey will be sent monthly during pregnancy, two weeks postpartum, 6 weeks postpartum, and then monthly for a year
• Catastrophizing:  Survey tool will be the Pain Catastrophizing Scale
  • Patients will be referred for cognitive behavior therapy with a score >30
  • This survey will be sent once during each trimester, two weeks postpartum, 6 weeks postpartum 
• PTSD:  Survey tool will be ???????
• Affirmations:  What are these?  Last input from Maria was “We will add this, we have some from our perinatal DBT work and also our collaboration with other projects in perinatal sphere”

Mental health concerns will be managed by the MC3 service and consultants as described, and opioid medications/suboxone/methadone prescriptions will be managed by either the obstetrician (if so licensed), addictionologist, or MC3 personnel.

Birth plan will be developed by the patient/obstetrician and loaded onto EPIC.  Anesthesiology will be consulted at approximately 28 weeks EGA.

• REFERENCE:  ACOG Committee Opinion on Opioid Use and Opioid Use Disorder in Pregnancy

Obstetricians enrolling patients into the program will consult anesthesiology at approximately 28 weeks EGA. The anesthesiologist and patient will discuss the birth plan that has been previously created (with the obstetrician and uploaded to EPIC) and the appropriate Shared Decision Making Tool will be discussed. 

The anesthesiology consult will be entered into EPIC to ensure that the treating anesthesiologist (on the days of labor/delivery) is aware of these discussions.

• LINK:  Shared decision making tool for vaginal delivery (not made yet)
• LINK:  Shared decision making tool for Cesarean delivery (not made yet)
• REFERENCE:  ACOG Committee Opinion on Opioid Use and Opioid Use Disorder in Pregnancy

The MC3 program provides psychiatry support to providers in Michigan who are managing patients with behavioral health problems. This includes children, adolescents, and young adults through age 26. It also includes women who are contemplating pregnancy, pregnant or postpartum with children up to a year. Psychiatrists are available to offer guidance on diagnoses, medications and psychotherapy interventions so that providers can better manage patients in their practices. Support is available through same-day phone consultations to referring providers. Remote psychiatric evaluation through video telepsychiatry is also available.

For this project, MC3 providers will interface with our obstetricians and addictionologists to provide the best possible care for pregnant women with OUD/SUD both before and after delivery.

In addition to normal protocols, MC3 will screen the patients for:

• Depression:  Survey tool will be PHQ-9
  • Patients will be referred to a mental health specialist for scores of >13 antepartum and >10 postpartum or any positive answer for self-harm
  • This survey will be sent monthly during pregnancy, two weeks postpartum, 6 weeks postpartum, and then monthly for a year
• Anxiety:  Survey tool will be the GAD-7
  • This survey will be sent monthly during pregnancy, two weeks postpartum, 6 weeks postpartum, and then monthly for a year
• Catastrophizing:  Survey tool will be the Pain Catastrophizing Scale
  • Patients will be referred for cognitive behavior therapy with a score >30
  • This survey will be sent once during each trimester, two weeks postpartum, 6 weeks postpartum 
• PTSD:  Survey tool will be ???????
• Affirmations:  What are these?  Last input from Maria was “We will add this, we have some from our perinatal DBT work and also our collaboration with other projects in perinatal sphere”
  

RESOURCE:  Link to MC3 enrollment information page here (see sample below of what it’ll look like)

Information to follow

Many of these patients will have their own docs, and this tells them how to mesh with this program

??? The scales that we mention for OB should go here too?