Provider screening practices

• According to a 1999-2000 Battelle Centers for Public Health Research and Evaluation study, 91.8% of prenatal providers usually or always include specific questions about drug use in their medical history.  The survey was focused on “STD Prevention, Risk Assessment and Counseling: The Investigation of Clinical Experiences” and was funded by the National Institutes of Health.
• Pregnancy Risk Assessment Monitoring System (PRAMS) data tells us that in 2002, 83% of the women who responded said their provider asked them about their alcohol use in pregnancy and 72% asked about their use of illegal drug use.
• According to a PRO-West 1998 chart review of 2,483 pregnant Medicaid women, 89% of Fee for Service and 91% of the Healthy Options clients showed evidence of a drug and alcohol use assessment completed by providers.

Purpose of the QI activities

• Establish universal screening by interview, observation and self-report as the standard of prenatal/post partum care in Washington State.

• Improve provider screening skill and effectiveness.

• Increase number of women identified and women who enter treatment.

Accomplished by:

• State level and Regional Perinatal Program training efforts.

• Special emphasis has been placed on working with the comprehensive programs for pregnant and parenting women who are using drugs and alcohol (Safe Babies, Safe Moms).

Perinatal programs outreach and education activities: 2000-2004

Funding of $170,000.00 per year was divided among the four Regional Perinatal Programs to provide professional education and training to prenatal care providers with an emphasis on physicians, nurse practitioners and midwives.  The Regional Perinatal Programs used a variety of approaches such as conferences, professional educational website, grand rounds, hospital and residency program in-services and individual OB practice office educational sessions to provide the training. Trainers used the best practice materials developed by DOH. 

Training staff found it difficult to engage office staff.  Historically, the Perinatal Regional Programs have provided continuing medical education, focused on intrapartum medical management issues at hospital- based training.  This project, which required regional program trainers to develop new strategies for engaging participants in the outpatient setting, had limited success.  Two significant challenges were encountered: getting providers to attend training and difficulty scheduling the educational session with office staff.  In addition, many health care providers believe that they are already informed and are adequately screening, therefore this topic was not a priority.  Perceived lack of treatment options and difficulty with intervention steps following identification also affected provider motivation to change screening practice.  The project ended June 30, 2004.

Total health care professionals trained January 2000 – June 2004: 5462.  Of this number, 1217 were physicians and midwives.  This is approx. 61% of providers who deliver babies in Washington State.

State DOH Activities:

• Work with key professional organizations to develop and maintain this standard of care.

• Identify and work with physicians who are interested in this area and will work to change peer practice.

• Provide technical assistance and consultation to providers and other health care orgs related to conference planning and resource materials.

• Exhibit at professional meetings and conferences: WSOA, Fundamentals of Addiction, Reproductive Health Update, Primary Care Update, WAFP, and others.
• Worked with Perinatal Advisory Committee to develop changes to the uniform prenatal medical record developed by Physicians Insurance.  Suggestions were made to improve assessment and documentation of screening for substance abuse. Approximately 90% of the obstetric providers in Washington use this medical record.  The new chart forms will be available from Physicians Insurance in 2003.
• DOH conducted focus groups and key informant interviews with physicians who provide obstetric care to determine effective strategies for influencing and improving screening and intervention for perinatal substance abuse and violence.  This project was completed December 31, 2003.   

Other resources:

• Hospital Guidelines for Testing Drug Exposed Newborns.  DOH Maternal and Infant Health Program continues to receive calls from hospital staff and hospital legal counsel re issues around reporting positive newborn toxicology screens and testing/consent issues. DOH developed some guidelines to provide better guidance to providers and hospitals. These Guidelines have been developed in collaboration with DSHS (Children's Administration and HRSA formerly MAA), Regional Perinatal Programs, State Perinatal Advisory Committee and other experts in the field. The document has been reviewed by both the Assistant Attorney General for DSHS and DOH. For further assistance, please feel free to contact me at 360-236-3563 or via email at polly.taylor@doh.wa.gov
• DSHS Division of Alcohol and Substance Abuse Directory of Certified Chemical Dependency Services in Washington State.  This directory lists services by county and by type, such as residential services for women and children and chemical use in pregnant women.

• Substance Abuse During Pregnancy: Guidelines for Screening best practice booklet. This booklet is only available electronically.

• “Pregnant Women Chemical Dependency/Abuse Resource Guide” which updates and consolidates several DSHS documents from the early 1990’s.  This resource will assist health professionals who identify pregnant women in need of chemical dependency treatment. 

For more information contact Polly Taylor at DOH, (360) 236-3563 or email at polly.taylor@doh.wa.gov