Family and Children's
23, No. 2
Developing a Plan of Safe Care in North Carolina
The opioid epidemic has been far reaching and has impacted the lives of many. This is especially true for pregnant women and their babies. From 2000 to 2009, the number of women using opioids during pregnancy increased five-fold nationwide (Cleveland, et al., 2016). In North Carolina, hospitalizations associated with drug withdrawal in newborns increased 893% from 2004 to 2015 (NCDHHS, 2017).
Substance use by pregnant women and new mothers can affect the safety and well-being of children. In North Carolina, we develop a Plan of Safe Care (POSC) to support these families. These plans are required by the Comprehensive Addiction and Recovery Act (CARA) of 2016, which also requires:
- Healthcare providers must notify county DSS agencies when they are involved in the delivery or care of a substance-affected infant (as defined in policy).
- County DSS agencies must develop a POSC based on the information from the healthcare provider.
- County DSS agencies must refer the child (and the child's POSC) to Care Coordination for Children (CC4C) for services; this must be done before a CPS intake screening decision is reached.
- CC4C must engage the family to implement the POSC; CC4C services are voluntary. (Click here to learn more about CC4C.)
The following answers to common questions about POSCs in North Carolina are based in part on our state's child welfare policy on substance-affected infants, which can be found here.
What should be in a Plan of Safe Care?
A POSC should address both the safety and well-being needs of the mother, infant, and family. The most successful treatments for opioid use disorders combine medication assistant treatment (MAT) and behavioral therapy (SAMSHA, 2016). (Click here for more about MAT.)
The POSC should also include screening the infant to determine whether they require early intervention services through the local Children's Developmental Services Agency.
Families with a POSC may also benefit from social support, parental education, parent/caregiver support groups, childcare, housing, and economic assistance (SAMSHA, 2016). Note, however, that each POSC should be individualized to address the unique needs of the family.
Must DSS accept all healthcare providers' notifications as
No. Prenatal substance use does not inherently mean there is child maltreatment (Jones & Kaltenbach, 2013; NPA, 2017). We must look at the impact on the infant's health and safety. For guidance, see North Carolina's revised Intake policy and screening tools, which can be found here.
Why must we refer to CC4C before we make a CPS intake decision?
County DSS agencies cannot share information with CC4C if a child protective services intake decision has been made. To ensure we comply with confidentiality laws and meet the requirement to create a POSC for every infant identified as substance-affected, we must refer to CC4C before a screening decision occurs.
How many Plans of Safe Care have been developed?
Between Aug. 2017 and Feb. 2018, county DSS agencies received 2,727 notifications about substance-affected infants from healthcare providers, 2,641 POSCs were developed, and 2,637 families were referred to CC4C. There is currently no waitlist for families to receive CC4C services. CC4C staff are charged to manage the entire target population in their county, which requires use of population management strategies to prioritize children.
How does the POSC requirement change our work with families?
If the report is screened in, we must conduct our assessment as usual, while collaborating with CC4C as they implement the POSC. The POSC should go beyond immediate safety concerns to address caregivers' substance-use treatment and the infants' well-being and developmental needs. CC4C is a required collateral contact in these cases. If the family continues to In-Home or Permanency Planning services, activities on the POSC must be included in the family-services agreement, if these activities are still necessary to ensure safety and well-being.
POSCs and the increased focus on substance-affected infants also underscores the importance of consistently and thoroughly addressing safe sleeping arrangements (AAP, 2016). (For more on this, click here.)
How can we best work with hospitals/healthcare providers?
Healthcare providers are very concerned about confidentiality when notifying DSS of substance-affected infants. This is due to federal laws protecting information related to substance use and its treatment. Encourage medical providers to have mothers sign consent forms allowing them to release information to DSS. This addresses hospitals' confidentiality concerns while ensuring DSS receives enough information to complete a POSC and make a referral to CC4C.
Also, be sure to normalize mothers' fears and highlight the benefits of releasing their information. For example, point out that if a mother is in active recovery and following treatment recommendations, the hospital notification may be screened out by CPS.
Build relationships and trust with medical providers. Most do not understand the child welfare system. Provide frequent and consistent education about our role, legal and policy mandates, and goals/priorities in our work with families. Have providers explain their treatment recommendations and how we can support families. Ensure that DSS expectations align with provider recommendations, especially about treatment. For example, if we require the mother to stop using opioids (as opposed to participating in MAT), we will significantly increase the risk of relapse and overdose (SAMSHA, 2016). Having a Child and Family Team meeting before the infant is discharged is a great way to ensure consistency.
What else do we need to know?
Substance-affected infants are NOT born addicted to opioids--even if they are dependent and experience withdrawal (SAMSHA, 2016). "Addiction is a brain disease that causes people to continue to use substances even though it harms them. Physical dependence is when the body gets used to having the substance and only functions normally with it" (Townsend, 2017). Labels have power, and the term "addict" carries a lot of stigma. We want to be careful about our language in case records, documentation, and in conversations due to the potential long-term impact on the child. Children labeled as "addicts" may face discrimination in the community or at school (SAMSHA, 2016).
It's also important not to judge or penalize mothers who struggle with substance use disorders. Doing so makes it unlikely they will be honest about their substance use and engage in treatment--ultimately increasing risk to children (NPA, 2017). Instead, we must focus on getting mothers the resources they need to manage their illness.
Families affected by the opioid epidemic are often in crisis, but with this crisis comes an opportunity. We can build upon a huge strength--mothers' love for their children--to create a catalyst for recovery. As one mom put it, "Keeping my children is my reason for staying clean. I'm willing to fight [my addiction] for the rest of my life" (Cleveland, et al., 2016).
In the Buncombe County Department of Health and Human Services (DHHS), healthcare providers and child welfare professionals proactively ensure substance-affected infants and their families get adequate, timely support. Buncombe DHHS has embedded an assessment worker at the county's primary hospital, Mission. When Mission identifies a substance-affected infant, this worker is on hand to initiate screened-in reports that involve a child or parent at the hospital. This worker also collaborates with families and the medical team in discharge planning. CFT meetings are often conducted in the hospital as part of the planning process.
Buncombe DHHS also has two prevention staff who work with pregnant substance-using women, frontloading services and educating them about what to expect when the baby is born. Because these families know in advance about the notification requirement and possible DSS involvement, they are less likely to go into crisis if a CPS Assessment occurs. Mothers are encouraged to seek MAT to assist with cravings and stabilize opioid use, as they are more motivated to modify their substance use during pregnancy than any other time in their life.
Buncombe DHHS is currently collecting data to track the outcomes of this work. Anecdotally, many families have reported feeling supported throughout the CPS process. Hospital staff have noticed an increase in home health support and other community resources due to front-loading services.
Based on a May 1, 2018 interview with Buncombe County Health and Human Services
References for this and other articles in this issue