Milestone 1.1 - Practice communicates commitment to providing care for pregnant and parenting people with substance use.

Aligns with Building Block 1 - Engaging Leadership

Action Item(s):

• Leadership has a plan that has been communicated to staff and community (can be verbal or in writing).  

Resource(s):

• Clinical leadership and integrated primary care: A systematic literature review

Milestone 1.2 -  Practice has a defined champion or team for this work. Champion team takes an active role in training and educating the other clinic members on aims of the project. 

Aligns with Building Block 1 - Engaging Leadership

Action Item(s):

• Practices could consider hiring support staff (peer support specialist, CM, navigators, etc) to support the unique needs of this patient population.
  • Peer support specialists have lived experience with substance use and recovery. They can provide training and education to others in the practice by leveraging their experience and insights.

Resource(s):

Milestone 1.3 - Practice meets regularly (minimum monthly) to address quality improvement opportunities to improve patient care. 

Aligns with Building Block 1 - Engaging Leadership

Action Item(s):

• Practice team can use this document and suggested activities to plan, measure, and document change over time based on the interventions utilized in the project.

Resource(s):

• Institute for Healthcare Improvement - Science of Improvement: Forming the Team
• Agency for Heathcare Research and Quality – Creating Quality Improvement Teams

Milestone 1.4 - All clinic members receive education on substance use disorder and SUD treatments, de-stigmatization language, use of person first language, unique need of OB, BH, and SUD care for people.

Aligns with Building Block 1 - Engaging Leadership

Action Item(s):

• Provide current training and education on diversity, equity, inclusion and ability.
• Consider focusing on health inequities in local communities for the BIPOC community.
• Education for clinic providers and staff to use person first language and omitting outdated, stigmatizing language referencing SUD issues. Example: dirty UA = positive urine substance screen.

Resource(s):

• Your Words Matter – Language Showing Compassion and Care for Women, Infants, Families, and Communities Impacted by Substance Use Disorder - NIH National Institute on Drug Abuse
• Recovery Research Institute - Addictionary 
• National Movement to End Addiction Stigma – Addiction Language Guide
• Language Matters – Addiction Technology Transfer Center Network 
• Shatterproof
  • Words Matter Video
  • Addiction Language Guide
• Overcoming Stigma - NAMI
  • 7 types of stigma faced by patients experiencing a mental illness.
• More non-stigmatizing personal stories
  • Stamp out Stigma
  • National Alliance on Mental Illness (NAMI) CO
  • Lives of Substance – Personal Stories (AU)
  • Partnership to End Addiction

Milestone 1.5 - Practice defines roles and responsibilities in job descriptions and incorporates key aspects into annual performance reviews. (BB4)

Aligns with Building Block 4 - Team-Based Care

Action Item(s):

• Include elements from milestone 1.4 into annual employee reviews and goals 
  

Milestone 2.1 - Practice educates patients and family members/caregivers on availability of SUD and OB care within their region.

Aligns with Building Block 5 - Patient and Family Engagement

Definition - caregivers may include people to provide direct support or care for the patient, and/or the children of the patient.

Examples of care - emotional, financial, child custody.

Action Item(s):

• Educate team members and caregivers on the concept of Self-Management Support and available tools.

Resources:

• Supporting Change: Education and self-care options for patients who are interested in changing their alcohol use and loved ones who want to support them.

Milestone 2.2 - Practice utilizes feedback from patients and caregivers/family members to improve SUD and OB care.

Aligns with Building Block 5 - Patient and Family Engagement

Action Item(s):

• Determine mode of feedback (survey, Patient and Family Advisory Council comment box, etc.).
• Identify practice champion who will incorporate what is learned into the quality improvement plan or meeting.
• Ensure tracking of suggestions and changes.

Milestone 2.3 - Patients' own health goals are incorporated into treatment plans.

Aligns with Building Block 5 - Patient and Family Engagement

Action Item(s):

• Workflow for entering, updating, and tracking goals within EHR.

Milestone 2.4 - Practice routinely utilizes self-management support and shared decision-making principles with patients with SUD issues.

Aligns with Building Block 5 - Patient and Family Engagement

Action Item(s):

• Encouraging engagement in community peer support groups, parent support groups, Nurse-Family Partnership, use of apps and videos; documenting patient goals, creating action plans, engage with local resources, when available.

Resources:

• Tough as a Mother
• Illuminate Colorado - Circle of Parents
• Reducing health-related stigma among moms and babies - March of Dimes

Milestone 2.5 - Practice routinely screens OB patients with SUD for social needs.

Aligns with Building Block 6 - Population Management

Definition: Social needs can include identifying and addressing unmet social needs such as safe and affordable housing, food insecurity, transportation needs, intimate partner violence, and/or other unmet needs preventing access to health care.

Action Item(s):

• Practice has a method to track screening and referral rates. 
  

Milestone 2.6 - Practice routinely facilitates family planning discussions with patients with substance use concerns.

Aligns with Building Block 6 - Population Managment

Action Item(s):

• Practice should identify the areas in patient workflows when these conversations would or should happen.
• Practices should refer patients to providers who can have those discussions with patients.

Resources:

• Reproductive Health National Training Center 

Milestone 2.7 - Practice screens at least 80% of pregnant people for substance use to identify people who would benefit from SUD services.

Aligns with Building Block 6 - Population Management

Action Item(s):

• Build in an evidence-based SUD screening tool into rooming or exam process.
• Determine if outreach to external supports if needed (example Community mental health providers, AA, Ala-non, etc.)

Resources:

• The 5Ps Prenatal Substance Abuse Screen For Alcohol and Drugs
• Accuracy of five self-report screening instruments for substance use in pregnancy - PMC (nih.gov)
• National Institute on Drug Abuse – Screening and Assessment Tools Chart

Milestone 2.8 - Practice ensures people who screen positive for SUD are offered connections to behavioral health care and MAT services.

Aligns with Building Block 9 - Comprehensiveness and Care Coordination

Resources:

• IT MATTTRs™ Chapter 3 Induction, Stabilization, & Maintenance
• Providers Clinical Support System 
• Harm Reduction | SAMHSA
• Access Point - Syringe Exchange - Colorado Health Network Inc.
• The Naloxone Project
• Fentanyl Information and Safety Tips | Health Network (colostate.edu)

Milestone 2.9 - Practice reassesses SUD symptoms at regular intervals and adjusts treatment plans if patients are not achieving their health goals.

Aligns with Building Block 9 - Comprehensiveness and Care Coordination

Questions to consider: What is the plan for follow up, documentation, community connection, referral to higher level of care, when needed etc.?

Action Item(s):

• Ensure prenatal and postpartum continuity.

Milestone 3.1 - Practice has on-call representative with EHR access that includes SUD, OB and/or behavioral health information.

Aligns with Building Block 8 - Access

Action Item(s):

• Assure appropriately trained staff are available at designated times. 

Milestone 3.2 - Patients can receive OB, SUD and/or BH tele-health services, when needed.

Resources:

• Diagnostic overshadowing: worse physical health care for people with mental illness - Published in 2008, the author describes the tendency for clinicians to attribute symptoms or behaviors of an individual with a mental health diagnosis to their underlying mental illness. As a result, clinicians’ decision-making regarding physical diagnosis and treatment may be influenced by the presence of a mental illness in their patients.

Milestone 3.3 - Practice ensures bidirectional information sharing between OB and SUD providers, peer support specialist, and/or care coordinator.

Aligns with Building Block 9 - Comprehensiveness and Care Coordination

Action Item(s):

• Practice considers creating templates to support co-visits with Behavioral Health/SUD specialists with new patient visits.

Resources:

• CFR 42 – Confidentiality of Substance Use Disorder Patient Records 
• SAMHSA Substance Use Confidentiality Regulations 
  • *Note - see number 10 for specifics on substance use, diagnosis, treatment, and referral for treatment in primary care

Milestone 3.4 - Practice coordinates care with hospital birthing centers to support patient-centered treatment plan.

Aligns with Building Block 9 - Comprehensiveness and Care Coordination

Action Item(s):

• Plan for pain control for people receiving MOUD or opioid tolerance.
• Coordinate with nursery or NICU, inpatient SW and lactation specialists.
• Education for outpatient and inpatient care teams. 
  

Milestone 4.1 - Practice offers patients connections to community resources to address their social needs and recovery supports.

Aligns with Building Block 9 - Comprehensiveness and Care Coordination

Resources:

• Nurse-family Partnership
• MotherWise Colorado 
• Invest in Kids - Child First
• Transitional Housing Programs 
• Colorado Parenting Programs
• Doula programs in Colorado 

Milestone 4.2 - Practice obtains permission from patients to coordinate care with Probation Officer, Child Protective Services, Attorney, local city/county jails, if needed.

Aligns with Building Block 9 - Comprehensiveness and Care Coordination

Action Item(s):

• Obtain signed releases of information, method for consistent documentation in EHR, contact information for case workers and others working with the patient.

(IMPACT only)

Milestone 4.3 - Practice connects patients to care navigation, which can be internal or external.

Aligns with Building Block 9 - Comprehensiveness and Care Coordination

Action Item(s):

• Practice will connect patients with the project funded care navigator.
• For ICWB: practice will connect patients with peer support specialists, when available.

Resources (for IMPACT only):

• Great Expectations
• Valley Settlement
• Illuminate Colorado
• FIRC, Family & Intercultural Resource Center (summitfirc.org)
• Building Hope Summit - Suicide Prevention | Mental Health | Find a Counselor
• Eagle County Human Services
• CPCQC

Milestone 4.4 - Practice coordinates with labor and delivery care team, postpartum care team, and establishes care for newborn.   If needed, practice coordinates care with community mental health, addiction specialist, pain management specialists or other specialists or professionals as appropriate.

Action Item(s):

• Practice obtains signed releases of information for all referrals for external specialty and/or continuing primary care.
  

Milestone 5.1 - Practice routinely diagnoses and documents substance use/SUD using DSM-V codes and bills accordingly.

Resources:

• MOUD Billing and Coding
• Reimbursement for SBIRT Table
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) | SAMHSA
• ASAM Billing & Coding
  

Milestone 5.2 - Practice connects with Managed Services Organization.

Resources:

•  Colorado Department of Human Services 

Milestone 5.3 - Practice develops consistent mechanisms to evaluate and integrate SUD and OB care into consistent EHR documentation.

Action Item(s):

• Periodically evaluate workflows.

Milestone 6.1 - Practice collects, reviews, and reports on ICWB/IMPACT Measures and incorporates them into continuous quality improvement activities specific to SUD care for pregnant and parenting people.

Action Item(s):

• Practice identifies champion, has a workflow in place and review regularly with team.  

Milestone 6.2 - Practice uses a registry to track outcomes and treatment engagement of OB patients with SUD.

Guidance: how long and in what circumstances, metrics to track outcomes

Action Item(s):

• Set up registry (can be electronic, within EHR or on paper).
• Assign team members to track and update registry. 

Milestone 7.1 - Practice leadership incorporates health equity into quality improvement initiatives and provides individualized staff development on health equity related topics. 

Action Item(s):

• Leadership has a plan that has been communicated to staff and community (can be verbal or in writing).
• Staff receive appropriate training on health equity and inclusion.

Resources:

• Harvard University Implicit Association Test
• Achieving Health Equity: A Guide for Health Care Organizations. Institute for Healthcare Improvement, 2016.
• Advancing Health Equity
• “Bringing Light & Heat: A Health Equity Guide for Healthcare Transformation & Accountability”
• Fact Sheets | Disability Law Colorado

Milestone 7.2 - Practice develops and implements a process to routinely gather and update patient demographics information, including race, ethnicity, language, sexual orientation, gender identity, and disability status. 

Guidance:

• Check with your EHR (Electronic Health Record) to see what is currently available to track and report within the existing framework.
• Begin small, with one pod/team and one data item.

Action Item(s):

• Complete workflow with staff members. 

Resources:

• American Medical Association EdHub: Collecting Patient Data: Improving Health Equity in Your Practice
• The Nuts and Bolts of SOGI Data Implementation: A Troubleshooting Toolkit
• Disability Equity Collaborative

Milestone 7.3 - After completing milestones 7.1 and 7.2, practice completes one quality improvement activity around one element of health equity and inclusion.

Guidance:

• As above, start small and do not try to solve the problem before the quality improvement work begins.
  

Action Item(s):

• Completes one quality improvement activity/tool (could be PDSA cycle, Fishbone diagram, GAP analysis, etc).

Resources:

• Using Data to Reduce Disparities and Improve Quality