The Behavioral Health Initiative has
been working with our community partners and helping them understand what
integration of care, what a model might look like within their own organization. We have a very important role for healthy moms and healthy babies, so we
started to look in an integration of care model. Terri brought in a consultant,
as well as offered to other partners in the community that we start to work
together and we start to learn how to integrate behavior health and capitalize
on what we do and our expertise in the different areas. They really saw the
importance of doing full integrated care – to look at not just the medical side of
a woman’s life but also looking at the social and emotional side, and making
everything connect, as well as anything outside of their maternal needs. And now
she is doing screenings and universal screenings for all of our women that
come into the Circle of Care site. So they started with the PHQ-2 –
the depression screen and also for substance use disorder screening. I also
screen for adverse childhood experiences, which a large, very large number of these
women have experienced either abuse or neglect, lots of trauma,
lots of domestic violence. I then sit down and do a brief psych social
interview with them and assess if they have any further needs. And what she has
developed is, I want to say, systems of care. And working with other community
organizations after she does assessments to make sure that they are going for
their medical assistant treatments, that they have housing. We have a
communication system, with their drug and alcohol provider, with their behavioral
health provider, with the hospital where they’re going to deliver. We’ve had growing concerns of addicted
mothers in our programs. We have seen triple the numbers. We felt that we
needed to somehow play a role in this space. An example of good integrated care: Just recently, a young mother presented to a local ER due to an opiate-related emergency. She was given the news that she was pregnant, and upon hearing
that news, she was terrified. You know, ‘I’m addicted to drugs, I’m
pregnant.’ And while in inpatient – she’s still in inpatient – we have already been
able to set her up with prenatal care, we have a WIC referral set up for her, and
we’re in the process of setting up a nurse family partnership referral, and we
have a mental health evaluation already set up. And so when she’s discharged, and that is weeks away, we already have her aftercare plan set up for her and she
already has a case manager working with her. We’re all here waiting for her to
come back and everything is already set up. We are trying to cut the barriers of
stigma more now than we ever have.

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