Hi I'm Beverly Glasspell a massage therapist here at A&M Chiropractic Wellness Center.
I am a massage therapist here and I'm also a patient of Dr. Milne receiving the NATE
treatments.
For years I've been diagnosed with Urticaria, which is pressure induced hives.
Basically if I carry something heavy, a purse over my arm or my massage table over my shoulder,
I break out in a huge hive and its very uncomfortable for days.
Upon receiving those NAET treatments after she treated me for calcium, which is maybe
the 3rd or 4th treatment, I was able to carry my massage table and I didn't break out in
a hive.
And I had a couple of those things that I knew would probably break me out in a hive
and it didn't and so I got really excited and I said let me get more of these.
So I received...
I just went through the cycle and after she treated me for B complex I was able to eat
a full-blown fresh salad, which in the past I've been allergic to fruits and vegetables
and it's very uncomfortable to eat those and almost to a point to where I was avoiding
them even though I love them.
For more infomation >> Chiroprator NAET treatments for allergy induced hives - Duration: 1:09.-------------------------------------------
Opioid Use Disorder: Treatment and Barriers to Employment Among TANF Recipients - Duration: 1:30:49.
Good afternoon everyone, and on behalf of Clarence Carter,
Director of the Office of Family Assistance
and the entire OFA team,
we'd like to thank you for joining today's webinar.
Opioid use disorder in the United States has skyrocketed
since 2010,
yet little contemporary research
has been conducted on the effects of this surge
on the TANF population.
Existing research about the opioid crisis
primarily focuses on its effects in the general population,
while TANF-centered studies
almost exclusively examine general substance use.
Moreover, opioid and substance use disorders
have been shown to be significant barriers
to employment for low-income individuals.
Such an information gap makes it difficult
to properly address TANF recipients'
needs for effective opioid use treatment.
This webinar will explore how opioid use disorder
affects the TANF-recipient population
and also TANF-eligible individuals,
as well as emerging strategies for assessing
and treating these populations.
Through this webinar, we will examine the prevalence of opioid
use disorder among TANF recipients
and the TANF-eligible population,
as well as barriers to employment it creates.
We'll learn two promising programs
connecting TANF-eligible individuals to opioid
use disorder screening,
assessment, and treatment services.
We'll reflect on how state, local,
and community-based opioid use disorder treatment organizations
can address TANF recipients' distinct needs,
and we will hear from the Kentucky
Targeted Assessment Program,
which is a collaborative comprehensive assessment
of multiple barriers to self-sufficiency
for Kentucky residents receiving or eligible for TANF.
We will also hear from the CHARM Collaborative,
a group of ten Vermont medical and social service agencies
providing comprehensive care coordination
for opioid addicted pregnant women,
their families, and their children.
We want to first bring up our first poll
and get some information from you.
To what extent is opioid use disorder
a problem among clients and your program?
I'll give you about 30 seconds to vote.
Again, to what extent is opioid use disorder
a problem among your clients in your program.
It looks like there's quite a bit of unsure.
There's also a large problem, initial problem,
but none at all.
We'll keep collecting those.
First, we want to hear from Justin Germain,
who is a researcher at MES Associates.
At MEF, he is involved with large-scale random assignment
evaluations of employment and training programs,
as well as research on technology's role
in workforce development.
Justin received his Bachelor of Arts degree
from the University of California at Berkley.
As the author of "Opioid Use Disorder Treatment and Barriers
to Employment among TANF Recipients,"
a paper that we at OFA hope to have published
in the next couple weeks,
Germain will present an overview of current research
on the opioid epidemics' effects on TANF recipients
and TANF-eligible individuals.
He will highlight how opioid use disorder
creates barriers to employment,
as well as some promising strategies aimed at assessing
and treating effective populations.
Justin.
Thanks, Damon.
Hello everyone.
Thank you for coming to today's webinar.
My name is Justin Germain,
and I'm a researcher at MEF Associates.
We're a social policy research firm
specializing in rigorous research
to shape the design and implementation
of social programs.
I've been working with OFA to identify the state
of current research
on the prevalence of opioid use disorder and treatment services
among TANF participants
and the TANF-eligible population.
There's a lot of research about the opioid crisis
swelling around these days,
so I've designed my presentation
to curate what would be most helpful to TANF agencies
and administrators for your program.
Now, as a quick roadmap of what I'll be speaking about today,
I'll first provide an overview of the prevalence of opioid
use disorder within the general population
before identifying what we know about its prevalence within TANF
and other low-income families.
Then I'll share some of opioid
use disorders effects on employment,
specifically for low-income individuals.
Finally, I'll tell you about treatment
and prevention strategies
that appear promising for this population,
followed by some of the common challenges
that can prevent these strategies from being effective.
Now, as a disclaimer, while there are many ways
of referring to opioid use disorders,
for this presentation, I'll be using the acronym OUD.
And before diving into the specifics,
I think it's important to quickly look
at how prevalent opioid use disorder
is across the United States.
OUD is a problematic pattern of opioid use,
which includes heroin, Fentanyl, and certain prescription
painkillers that lead to clinically
significant impairment or distress.
As of 2015, two million Americans had a substance use
disorder involving prescription opioids,
and over 590,000 experience a heroin use disorder.
As shown on the slide in front of you,
deaths caused by opioids have more than quadrupled
since 2000 and continue to increase in alarming rates.
According to the CDC, opioids contributed
to over 42,000 American overdose deaths in 2016 alone;
however, a study released just last month
claims that opioid-involved drug deaths
are actually to 20 to 35% higher
due to different state standards of reporting causes of death.
Now, as shown on the map in front of you,
rural areas experience
45% more drug-related deaths per capita that urban centers,
and also have higher rates of opioid overdoses.
Almost twice as many men experienced opioid
overdose deaths as women in 2015;
however, heroin and prescription
OUD rates
have increased much faster for women
in the last 15 years.
This is increasingly important
when we look at opioids' effects on TANF families,
since over 85% of adult TANF participants are women.
Now, OUD influences individuals and communities
differently than other forms of substance use disorders.
The fact that opioids are primarily
taken for pain reduction
is key to understanding how opioids connect to unemployment.
40% of non-working men age 25
to 54 claim that pain prevents them from securing a job.
Furthermore, regions with greater opioid medication rates
have also experienced declines
in their labor force participation.
Now, unlike the general population,
limited research is available
about the prevalence of OUD within the TANF
and TANF-eligible populations.
Much existing data is at least ten years old
and prior to the current opioid crisis.
We do know that individuals in poverty
are more likely to be dependent on opioids
than those with incomes over 200%
of the federal poverty line,
yet, research examining the TANF population
tends to emphasize findings
about general substance use disorders
that aren't specific to any single substance.
One study estimated that the 1996 introduction of TANF
correlated to a 10 to 21% reduction in illicit drug use
by women at risk of welfare.
TANF drug sanctions, work incentives,
and a strong economy likely contributed to this result.
Currently, approximately 5% of TANF clients are estimated
to be addicted to any illicit substance,
and 10% have used an illicit drug in the past month.
Long-term public assistance participants
are more likely to experience a substance use disorder
than a short-term participant.
And although more relevant information is needed,
research into Medicaid can help draw limited parallels
to the TANF system
due to the program's overlapping membership base.
About 636,000 Medicaid enrollees had an opioid use disorder
in 2013,
and subsequent Medicaid expansion
has likely increased this number.
Physicians prescribe painkillers to Medicaid and relief
twice as often as they do for other patients,
increasing their exposure to opioids in the process.
And now it's important, when we go over these studies,
to remember that these studies are not arguing
for a causal link between public assistance receipt
and substance use disorders,
they're simply detailing the correlation between the two.
Furthermore, these prevalence rates must be taken
with a grain of salt.
Many researchers believe that precise rates
are difficult to obtain
because people with substance use disorders
may hide their use.
Individuals across all income levels do this,
while individuals on public assistance
may misreport due to the stigma attached
to substance use disorders
and fears that they'll lose their benefits
if they reveal their addiction.
As of 2005, over 75% of state welfare offices still relied
on participants self-disclosure
of substance use disorder concerns
instead of more comprehensive screening tools.
Concerns over drug testing
exacerbate the fear of disclosure.
Fifteen states had versions of mandatory
drug testing for public assistance participants
as of March 2017.
Depending on the state, positive drug tests
can lead to mandatory treatment,
reduction in assistance,
or even a temporary denial of assistance.
Therefore, the frequency of substance use disorders
among the TANF population may be higher than reported,
which underscores the need for more research,
screening options,
and policies that reduce incentives to hide abuse.
Now, OUD also creates obstacles to the attainment
and maintenance of secure gainful employment.
Opioid use has a direct relationship
to higher workers compensation claims,
costlier medical expenses, and fewer days worked.
42% of individuals with an opioid use disorder
have worked for more than one employer in the past year,
which is twice the national average.
Moreover, a Brookings study suggests
that the increase in opioid prescriptions over the last two
decades could account for nearly 20% of the decline
in American males' labor
force participation rate
and 25% of American women.
Yet, it's important to remember that OUD falls within
a web of co-existing problems
that worsen low income individuals' difficulties
in securing employment.
Many studies conducted on this issue
have focused on low-income women.
A 2003 study found that female TANF participants
who participated in CASAWORKS
for Families, a program created to provide
collaborative case management services
to low-income people with substance use disorders
displayed an average of six different
potential barriers to employment.
Some of these barriers included limited work experience,
domestic violence, low levels of education,
and mental health disorders.
Now, currently a 1% increase in county unemployment rates
correlates to a 3.6% increase in opioid-related death rated.
Yet there's mixed evidence whether employment alone
can decrease substance use disorders.
For example, the National Center for Children in Poverty
recommends using both treatment services and employment
to address substance use disorders.
Multiple studies have also indicated that employment
before or during substance use disorder treatment
can increase retention and success.
Therefore, substance use disorder treatment methods
that consider such coexisting problems
may help decrease barriers to both employment and abstinence.
Now, TANF participants and other low-income individuals
with substance use disorders
typically utilize treatment options
designed to serve the general population.
These are a selection of strategies
that appear promising for OUD,
but which are not representative
of all approaches currently in use.
For those with an opioid use disorder, medical treatments,
typically administered through Methadone, Buprenorphine,
or Naltrexone,
often provide the best chance at recovery.
Medication-assisted treatment, or MAT,
combines counseling with medication
designed to normalize body functions
and relieve opioid withdrawal symptoms.
It's been clinically proven to reduce the need
for in-patient detoxification
and increase patient's ability to gain employment,
yet it isn't used as widely as experts recommend.
This may stem from misconceptions
about drug substitutions,
inadequate physician training,
or the need for daily clinical visits
for patients using methadone.
These barriers make it difficult for TANF participants
to meet work requirements if their treatment
is not an allowable activity
under their state's TANF program.
The 21st Century Cures Act and 29-states expansion of MAT
funding have been to improve these accessibility problems.
Now, strategies aiming to curb improper prescribing practices
have also become widespread.
As of March 2017, all states except Missouri
kept track of controlled substance prescriptions.
Some states require practitioners to check
their state database
before prescribing opioids to patients,
while others have enacted opioid prescribing limits.
A few states have also passed pill mail laws
that heavily regulate providers who prescribe opioids
improperly or for non-medical purposes.
The CDC has also collaborated with the American Pain Society
to create recommendations for providers
about proper prescribing habits.
Contingency management, which provides prizes to people
with an opioid use disorder
when they attend counseling sessions, pass a drug test,
or perform other activities promoting abstinence
is effective at increasing time spent in treatment.
While this can be expensive in resource-limited communities,
lower-cost versions have also
improved treatment attendance and completion.
Finally, community prevention coalitions
initiate collaboration
between multiple stakeholders,
dedicated to decreasing
OUD and overdose rates in their communities.
Some common members of these groups include hospitals,
medical societies, law enforcement agencies,
NGOs, and addiction treatment centers.
Community prevention coalitions focus more on public engagement
and treatment collaboration
than other strategies.
And while there are few OUD treatment and prevention
strategies specifically targeted to the TANF population,
we may be able to identify relevant strategies
by examining practices
used to address general substance use disorders
that are tailored to TANF and other related populations.
Screening and assessment procedures, for instance,
help identify individuals who need assistance
to address their substance addiction.
As mentioned earlier, low-income populations,
especially those on TANF,
are often hesitant to report drug use
due to legal or public assistance concerns.
While generic screening methods,
like caseworker relying on people
to fill out self-disclosure forms,
have limited effectiveness,
specialized screening raises the chance
that a TANF participant will disclose their substance use.
In this method, higher risk populations receive
more screening,
and trained caseworkers conduct one-on-one interviews.
While this is generally used to supplement generic screening,
it's been shown to increase substance use disorder referrals
of New Jersey public assistance participants from 4.4 to 10.3%.
Now, Miss Ramlow will show how the University of Kentucky
has expanded off this method
through the program she oversees.
Intensive case management,
which involves long-term personal monitoring
and social service assistance,
has been shown in a random assignment study
to improve TANF- participants' employment,
substance abstinence, and treatment attendance outcome.
By meeting with participants multiple times a month,
and covering their child care, transportation,
and housing needs before treatment,
caseworkers successfully reduce substance
use disorder rates for women on TANF.
After 15 months of treatment,
43% of intensive case management participants were abstinent,
compared to 26% of a control group
receiving basic screening and referral services.
The individualized placement and support model
of supported employment
has also proven effective in randomized control trials
to improve employment outcomes.
Successful programs have assisted individuals
with substance use disorder and vocational services
and have encouraged employment that promotes recovery.
While most commonly it's been evaluated among individuals
with mental health concerns,
a 2017 randomized control trial
showed this was a promising strategy
to help secure employment
for people with opioid use disorders as well.
After one year, 50% of individualized placement
and support participants with OUD
secured competitive employment,
compared to 22% of a control group.
Finally, family-centered treatment
shows promise at addressing substance use disorders
among women with dependent children.
Women make up over 85% of TANF participants,
and 70% of women entering substance
use disorder treatment programs have children,
making them a crucial demographic to study.
Family-centered treatment includes parenting education,
employment readiness, behavioral therapies,
and close collaboration with the child welfare,
criminal justice, and social service systems.
Our panelists from CHARM will show
that there's promising evidence
to support such treatment methods.
Now, child welfare families are another relevant group
to study in this scenario.
By working with courts involved with these families,
family treatment drug courts promote treatment
through incentives and intensive judicial supervision.
A 2008 study found that these specialized courts
have led to longer treatment participation.
Non-court-based treatment programs
working alongside the child welfare system
have shown mixed engagement and accessibility results.
An Illinois study examined programs with a recovery coach
who conducted repeated outreach,
facilitated access to services,
and ensured that patients were engaged in treatment.
Researchers suggested that completion rates
for this program
could have been improved through services
targeting co-existing problems,
treatment tailored to people's drug of choice,
and additional employment assistance.
Now, TANF service providers and public assistance
policymakers face many challenges
when working to stem the opioid crisis for the TANF
and TANF-eligible populations,
and these are some of the most salient.
There is limited information about opioid
treatment strategies, targeted employment,
and work readiness for TANF participants.
Since there is a scarcity of research
about the effects of opioid crisis on the TANF population,
it's difficult to determine ways to reduce employment barriers.
Secondly, co-existing barriers may hinder the accessibility
of effective treatment services,
especially medication assisted treatment.
Methadone-based medication assisted treatment
requires a patient to visit a clinic daily.
A 2004 study of these programs discovered that bureaucracy,
work schedules, mental health issues,
family situations, discrimination,
and other factors all hindered patients' access to treatment.
This is especially relevant for TANF families,
since low-income individuals
are more likely to receive methadone for treatment
instead of Buprenorphine,
which does not require daily clinic visits.
Also, limited collaboration across social service systems
can hinder screening and treatment.
Public assistance agencies, treatment providers,
and courts often collaborate with each other
to serve individuals with OUD,
yet they may not be doing so enough.
Without sufficient collaboration,
it is difficult to identify
and monitor individuals
requiring treatment.
OUD also harms individuals
throughout the entire workforce system.
In addition to hindering unemployed individuals
and treatment to the workforce,
OUD decreases workforce activity and job tenure.
To improve TANF employment outcomes,
it's important to promote OUD services
for incumbent workers as well.
Finally, individuals at risk of losing public assistance
or custody of their children
simply fear disclosing their opioid use disorder.
To understand the actual prevalence of OUD
among these groups, comprehensive screening measures
and policies reducing incentives to hide abuse are needed.
So, overall, in terms of key takeaways, there are two.
There's limited research about the opioid crisis
among TANF participants, and we simply don't know enough.
Furthermore, OUD is one of many co-existing problems
that worsen difficulties in securing employment.
Finally, in terms of future research,
there is a need for more reserve on the prevalence of OUD
along the TANF and TANF-eligible populations.
And as mentioned previously,
certain treatment strategies have been shown to be effective
and simply could be evaluated for TANF.
The opioid crisis is an incredibly critical situation,
and we need to know more about
how it affects the TANF population
in order to be effective at fighting it.
If you'd like to reach out to me about this research
or want to know where certain assistance come from,
the paper that Damon mentioned will be out
within a few weeks that I authored.
Furthermore, my contact information is on the screen.
Thank you so much, and I really look forward to your questions
at the end of the webinar.
Thank you very much, Justin.
Good afternoon everyone.
My name is Stephen Broyles,
and I'm with the Peer Technical Assistance Team,
and I just wanted to mention a few
housekeeping tips through the webinar.
First of all, the webinar is being recorded
so you are on mute; however,
if you have any questions or comments,
please feel free to use the chat box
or place questions in the question box.
At the end of all of the presentations,
there be a Q&A, so please submit any of those questions
and we'll make sure that the appropriate presenter
gets the information.
Also, during the webinar, if you need any technical assistance
with the webinar platform, please raise your hand.
It's at the top of the screen in the bar
where you see the picture of an individual with the hand raised.
Click on that and we'll reach out to you
or just contact myself,
Steven Boyles or Deidre Young, and we will follow up with you.
Also, there will be an evaluation at the end,
and we just want to make sure that you please stick around
and get the information,
and also, as many of you noticed,
there will be a recording and a transcript of this webinar
that will be posted on the Peer TA website in a few weeks.
So, thank you, and I'm going to turn this back over to Damon.
Thank you, Steven.
And before we get into our next presentation,
time for another poll.
So, everyone, how do you screen and assess your clients
for substance use disorders?
How do you screen and assess your clients
for substance use disorders?
We'll give that a couple seconds.
Okay.
You can keep voting on that while well move
into our next presentation.
Our next presenter, Barbara Ramlow,
is a director and cofounder of the University of Kentucky
Targeted Assessment Program.
A former clinician working in inpatient, outpatient,
and other community non-profit settings,
she has been with University of Kentucky Center
on Drug and Alcohol Research since 1994,
serving as the assistant director of the Institute
on Women and Substance abuse from 1994 to 2003,
and director from 2003 to 2006.
She began to provide consultation
to the Kentucky Cabinet for Health and Family Services
during the advent of welfare reform in the mid-1990s
and has partnered with CHFS
and other statewide agencies on multiple
initiatives to improve Kentucky's capacity to identify
and address barriers to employment,
self-sufficiency, family safety, and family stabilities.
The Targeted Assessment Program identifies and addresses
barriers prevalent among low-income parents,
including substance abuse,
substance use, mental health problems,
intimate partner violence,
learning deficits and disabilities,
and basic needs,
as well as participant strengths and engages participants
in action plans to support progress.
This presentation will highlight the key components
of TAP's approach
in the context of the opioid crisis.
Case examples will illustrate engagement strategies,
pretreatment, effective referral and support
for ongoing recovery, individual,
and systems-level interventions.
Barbara.
Thank you, very much.
I'm very pleased to be here today
representing the Kentucky's Targeted Assessment Program.
As noted, our program, which we tall TAP, was developed
and implemented through a partnership
with the Kentucky Cabinet for Health and Family Services,
the Department of Community-based Services
and the University of Kentucky Center
on Drug and Alcohol Research,
which is a part of the College of Medicine.
It is supported a hundred percent with TANF funds,
and we are assisting parents involved
in Kentucky's public assistance
and child welfare systems.
The purpose of TAP is to identify and address barriers
to self-sufficiency, family stability and safety,
including, as noted, substance use, mental health,
intimate partner violence, learning problems,
that would be deficits and disabilities,
and basic needs.
Before I talk more about the program and the research,
I'd like to tell a story.
Participants come to us through many, many doors,
and one of the strengths of the program
is that that is possible.
I want to tell you about an individual
who is already involved with a Kentucky Works program,
which is our TANF program.
At the time that we met her --
and I'm going to call her Sandy --
she was a 26-year-old woman with two children.
She was referred to TAP by her Kentucky Works Program
case manager when staff at her community service placement
expressed concerns
because she seemed to be sedated.
In addition, her attendance was inconsistent
and she complained about transportation problems.
The staff were both annoyed with and worried about her.
The TAP assessor got the referral from the case manager
and then arranged to meet with Sandy,
whom she met at her home.
And Sandy agreed to participate in the program.
TAP's assessment revealed that she had a substance use disorder
that was being treated with Suboxone
by a physician with brief monthly check-ins
but no additional treatment services.
Sandy had a history of failed treatment attempts
but found medication-assisted treatment,
or MAT, through recommendation of a relative.
Sandy described a history of childhood abuse
and intimate partner violence
and was experiencing verbal abuse
and controlling isolating behaviors
in her current relationship
with the father of her young child.
She and her children were dependent on him
for transportation, child care, and other supports.
She had an aunt and uncle nearby
who could play a more supportive role in her life
but were kept at a distance by the boyfriend.
Sandy reported she had liked school before she dropped out
when she got pregnant in high school.
She reported current mental health symptoms
that were indicative of depression
and post-traumatic stress disorder.
The assessor developed a plan with Sandy,
and, with release, communicated
with Kentucky Works case manager.
TAP helped Sandy transfer to a different MAT provider,
where her Suboxone dosing was corrected,
and also helped her engage in outpatient evaluation
and counseling for co-occurring disorders, trauma,
and intimate partner violence.
The assessor drove her to her first appointment
and, at Sandy's request, sat in on the first session.
Once Sandy stabilized, TAP provided education about MAT
to the case manager
and the community service placement supervisor,
and Sandy was allowed to return to her placement.
The assessor met with Sandy regularly,
followed up with her treatment providers,
and communicated regularly with the TANF case manager
about her progress.
When Sandy was able to identify her current relationship
was abusive and decided to leave,
TAP helped her to find housing through collaboration
with Kentucky's Domestic Violence Program
that has a HUD grant for victims.
TAP also helped Sandy obtain childcare
and helped her with job applications.
Her aunt and uncle gave her an old car that wasn't working,
and the Kentucky Works Program helped with car repairs.
TAP also helped her with applications
to the local community college,
and she was accepted into Kentucky's Ready to Work Program
that supports TANF recipients attending college.
Through Ready to Work,
Sandy was able to obtain a work steady job,
and this eventually led to regular employment.
She chose to continue her education as well.
She began to talk to her treatment providers
about whether and when she could begin tapering off
Suboxone.
So, back to the barriers and how TAP came to be.
This is all based in the early work
we were doing throughout the country,
research into women and substance use,
because over the dearth of research available
until that began to grow in the '80s and '90s.
And we learned a lot that helped us know how we could do better.
So, estimates of drug and alcohol use disorders
are almost double for individuals who receive TANF.
Women who are receiving TANF and have substance use disorders
report co-occurring depression, anxiety,
and high levels of PTSD.
Studies have shown intimate partner violence
to be higher among women receiving TANF
than other low-income women not receiving TANF.
Mental health problems have also been found
to be more prevalent in the population,
as have childhood experiences and adult trauma.
In terms of learning problems, studies in three states
indicated that between 20 to 50% of women
have some type of learning problem,
and 20 to 25% have IQs of less than 80.
In addition, unmet basic needs have been strongly correlated
with mental health and intimate partner violence.
And finally, the presence of multiple barriers
continues to be the strongest predictor
of non-participation and work activities
and continues to be linked to poor employment
among low-income parents.
I wanted to share with you some data from our program.
This is fiscal year 2017,
when we assessed about 2,200 participants,
both male and female, but mostly female.
And you can see that the highest prevalence
in the four targeted barriers is mental health,
59% for substance use,
and then lesser degrees of intimate partner violence
and learning problems.
Now, individuals might be experiencing these barriers
in combination,
which isn't shown in this particular chart.
What we find is that 63% of the participants in fiscal year
2017 experienced two or more of these barriers,
and some as many as all four.
In terms of unmet basic needs for that same group,
we see our common top two are housing and transportation.
In recent years, social support has come up to be almost equal
with those as a barrier self-reported by participants,
and you can see parenting legal help,
and children's needs follow.
With regard to opioid use, I wanted to share a study
that looked at 2012 to 2016,
and this is lifetime self-reported data
for more than 12,000 TAP participants during that period.
And you could see that opiates are pretty steady up there
at the top, the green line,
as is OxyContin and methadone.
Those are pretty steady.
And Kentucky has long had an opiate problem.
It is not new with this particular crisis
that we're experiencing now.
What you can also see, then,
is the increasing prevalence
of IV drug use
and heroin use, along with Buprenorphine,
which could be used either as a treatment or on the street.
So, our program exists in 35 Kentucky counties.
We hire and place, now, 58 target assessment specialists
at our community-based services offices.
So that's Kentucky Social Service System,
and we are there to receive referrals
from both child welfare
and public assistance referral sources.
The fact that we are co-located with the DCBS staff
is a critical and key component of our program.
Our TAP staff are University of Kentucky employees.
They get their salaries and benefits through the University,
and their travel is paid through the university.
But their computers and their phones and their worksite
is full time
with their coworkers, community -based services workers.
So that eases referrals, that eases communication
and collaboration about cases,
and has made all the difference in terms of,
I believe, increasing the number of individuals
that we're able to serve.
We hire folks who are skilled clinicians.
They are trained in all of the barriers that I've discussed
previously,
and their job, in addition to -- well, first of all,
their job is to develop good relationships
with their colleagues
and with all participants, and with all community partners.
When they meet a participant, or a potential participant,
to offer services,
if the individual agrees to work with TAP,
they conduct a really holistic assessment
across barriers and strengths.
They're not doing one screening,
they're not looking just for substance use disorders,
and they are looking across all of the barriers.
What we believe is that these moms and dads
are people with lives who live in a context,
live within their families and their communities,
and that there is always a lot going on with individuals
living in poverty that make life difficult
and may ease their success or hinder their success,
and the more that we can learn about them, the better.
The more that they feel heard and understood, the better.
So that is part of the process
of conducting a holistic assessment,
is developing a really good rapport, trust,
and mutual trust and understanding,
and they know that they have somebody on their team
who is going to help them,
and that we can offer them help in a wide range of ways.
We provide strength-based case management.
That's one of our evidence-based practices.
We provide pretreatment and intensive case management
and create a customized service plan with the participant.
So, we're going to be identifying what they see
as their most critical needs and help figure out
where they are in their understanding of their problems
and what their readiness is to change.
So, if they do have a substance use problem,
where are they in the stages of change?
We use motivational interviewing
and other evidence-based practice
to help determine where they are
and what are the next best steps to take.
Many referrals have been made at the point that a problem
is identified that a participant doesn't follow through on,
so we use motivational interviewing and pretreatment
to really work to prepare people to engage in treatment
and make good use of that referral.
That can be working on internal barriers,
their understanding of their addiction; for example,
their understanding of the effect of trauma on their life
and their understanding of the resources that are available,
their ability to feel hope about their situation,
their sense of who is their support system.
All of those things are used to help
put together a good plan for each individual,
and that is a very individualized plan.
They have the ability to say, "No."
They have the ability to say, "I don't want to do that,
but I will do this."
For example, they might need a more intensive
in-patient substance abuse treatment service
but if they're not willing to do that,
what are they willing to do?
And we're going to work with them on that
and come up with a plan,
and then try it and see, and continually meet with them
and talk with them about how things are going with their plan
so that they can move forward.
We're also going to be working in that,
as we develop the plan, on any external barriers,
because with low-income populations,
those are often, and certainly in our state,
often things that get in the way.
If they don't have transportation,
which incredibly common in Kentucky,
which is mostly rural, how are they going to get there?
How are they going to keep going to appointments?
If they don't have child care for their kids,
what are the things that need to be put in place?
And sometimes before we ever get to that,
we're working on getting the utilities turned back on
because they don't have heat.
We're working on finding them decent housing
because they don't have that.
We work with many individuals
who are homeless or sleeping on couches
and having their kids in other people's homes
but don't have a stable place to live.
So, working with participants on housing barriers
is often very important and useful,
as well as finding ways to ensure
that they're going to have transportation.
I think some of things that are different, as I said,
we get referrals through the Child Welfare System
and through the TANF Public Assistance Program
here in Kentucky, and the needs of the workers
and the case plans are different in those systems,
and so we're going to be always collaborating
with the referring worker
to make sure that we're helping the participant
make progress on the plan that is set forth within,
that they're able to meet the requirements as best they can.
And sometimes we're able to help shape
the nature of those requirements,
which sometimes are quite unreasonable
and not in keeping with what services
are available in a community.
For example, a service might be ordered for somebody,
and they're required to do something
that simply is not available,
and we're going to be able to advocate
with that referring caseworker about that requirement,
and get it changed, perhaps to something that is doable.
We're going to constantly follow up
with our participants with a referral source
and with a community partner.
So, in many cases, the community partner is a referral for agency
for mental health problems,
for partner violence, for substance use,
and we're going to be -- with a release,
we could communicate back and forth,
so if our participants stop showing up at treatment,
we're going to be in good communication
with that provider.
They're going to get in touch with us.
We're going to be able to get in touch with the participant
and figure out what happened.
Was it a relapse?
Was it their transportation fell through?
Did they have a crisis?
Often yes.
And it's our job to help do that crisis intervention,
that problem solving with that person and help figure out,
okay, what do we need to do to get back on track.
In the TANF program we're working,
also, with job readiness programs,
community services sites, employers.
We get referrals quite often,
as is the example of Sandy, we get referrals,
more often than from the case managers,
we get them from the adult education programs,
from the community service placements,
where they are seeing people on a daily basis
or a few times during the week,
and they're really much more likely to notice
when something isn't right,
something's not going right for somebody,
and they know TAP, they know exactly who to call,
and they know that we're going to do something to help,
and so those collaborations are very, very important.
It's very important that we communicate effectively
with both child welfare agency
and with our case management.
In Kentucky, we have online information system
that has made this quite easy,
and we are required and enabled to communicate
in writing through the online system.
So, we can communicate in real time to the case manager
when there are significant developments,
successes, progress, when things don't work out well
and we're needing to step back and reevaluate the plan.
So that communication has been really, really valuable,
and for both TAP and for the case managers.
We also provide consultation and training
about these multiple barriers
whenever we're asked to do that,
and whenever it seems appropriate.
Sometimes that's in a formal way,
where we're training case managers
about medication-assisted treatment,
but much more often,
it occurs when we are talking about a case, which we do a lot.
We talk in people's offices.
We communicate on e-mail.
And there's a lot of case collaboration
and talking about what's going on
and what needs to happen next.
And through those interactions, we can really help those workers
gain an understanding,
both of the individual that we're serving
and their particular unique needs and circumstances,
but also the nature of addiction,
the nature of intimate partner violence,
the likelihood of relapse,
the likelihood that a woman might return to her perpetrator,
and talk about the cycles
and keep instilling in the TANF agency,
the Child Welfare agency,
that even though these events occur, there is always hope.
There is still hope and that this is
part of the process of people
making their way forward.
So, I think that that's very valuable.
We're right there onsite and we can do
that both informal and formal training,
and case consultation whenever we're asked.
We also provide a lot of information.
We do an extensive report.
Our assistant findings and recommendations with our plan,
which we update.
We do written monthly updates and status reports
on all of the participants that we're serving.
We also have a role in advocacy.
I would say over the years,
since we've been doing this for a while --
I should say we've been doing this now for 18 years,
so have gone through many,
many phases of development
in our own program,
but also changes within the social services systems,
in our economy, in the nature of the substances
that are being used at the time.
The recommendations for treatment
have changed vastly during those year,
and when we first started, MAT was really hardly available.
There were a few methadone clinics in the state
but nothing else.
And now we have Suboxone readily available,
not necessarily well-regulated treatment,
and a lot of misunderstanding of MAT,
a lot of experience of poor quality MAT.
And part of our job is to educate
and advocate for participants,
and that includes identifying those treatment programs
that are of not good quality
and steering our participants
into those programs that are good.
For example, with MAT, it is best practice
that in addition to receiving the medication,
the person is involved in treatment, in counseling,
and if they're not, that's not good treatment.
So, as in the example of Sandy,
we're going to make sure that that happens
and that everybody understands why that needs to happen.
So, we can really support good practice.
We can talk to treatment providers about a rule
that they might have that is really prohibited.
For example, up until somewhat recently,
a lot of our treatment providers
did not allow people into a treatment program
if they were receiving MAT.
And that was a huge barrier and made no sense.
And, actually, most of our providers now,
I think, have changed that practice and have welcomed MAT,
folks on MAT to participant in treatment as well.
TAP exists in several different communities.
There are 35 different counties in our state.
We have regional administrations for community-based services,
and we have a central office in the state,
in our state capital of Frankfort.
And TAP is, from the very beginning,
engaged in multiagency collaborations,
and has found that that has also been essential
to the success of our program.
So that we work with the administrators
at the state level, at the regional level,
and that in our local offices
to make sure that we're implementing the program
according to our protocols, according to best practice;
that we're figuring out how to set up referral mechanisms
in a way that works for the DCBS and works for TAP;
that we are keeping everyone aware of the resources
that are available for participants.
We have multidisciplinary advisory councils in our sites.
They help with the hiring of staff.
They help with implementation through quarterly meetings
and examining our data, and we share data back and forth
and have lots of conversations about both what's working
but also what's not working,
and I think that that's been a key
strength of our program as well,
is that we have always been willing to acknowledge
when something wasn't working and look
at what our part might be in that
and look at solutions with our community partners,
and that has served us well over the years
as we have continued to improve the program and learn as we go.
I wanted to share a little bit of our outcomes.
These are very specific to the Kentucky works Program
and those of you who are in your TANF programs,
those of us who are having to deal
with allowable and accountable activities.
TAP is an allowable component not countable,
which has been a deterrent to referral,
but we persevere nonetheless,
and one of our responsibilities is to ensure
that when we get a referral,
that if they're not already in accountable work activity,
that we're going to get them into accountable activity
as soon as possible.
And another thing is that if someone is looking like
they're going to drop out and fail and they're accountable,
that we're going to help see what can we do to shore them up
so that they can maintain in their accountable activity.
So, of the terminating participants
in the Kentucky's Works Program,
65% of them were participating in accountable work activity
within six months of TAP assessment,
and the average amount of time to enrollment
in that work activity was seven weeks.
TAP has conducted several outcome studies.
I wanted to share one that was published in 2012.
It was a six-month --
from baseline to six months follow-up study.
It was for 322 participants.
And, in general,
we saw statistically significant decreases
during that timeframe in mental health symptoms,
substance use, partner violence,
the percentage of our participants
had an open child welfare case,
a percentage of participants experiencing work difficulty,
and a decrease in reliance on TANF while employment increased.
We don't have perfect outcomes,
and we certainly have individuals
with whom we are not able to help.
A good many we are, and we think it's due
to this really unique approach
that we take, which is very, very personal,
with really skilled compassionate individuals
who then operate in a really non-traditional way.
They're at the DCBS office
but they are able to go to people's homes.
They're able to meet them in other safe locations,
like libraries or McDonalds,
able to work with them on safety planning,
able to drive them to an appointment
if their transportation falls through at the last minute,
able to help them with all sorts of critical basic needs,
and help them address their multiple difficulties
if they have problems in the areas of substance use,
mental health,
and partner violence most prominently,
as well as learning disabilities and deaf silts.
I will say that our data --
we've been collected data now for 18 years,
a lot more data than we share in our reports to the state,
and I think one common thing
that we know in our TAP participants,
be they male or female,
is the prevalence of childhood trauma
in almost all of them,
very, very difficult experiences.
They were not all raised in poverty.
Some were.
But most of them have had really difficult
adverse childhood experiences,
other kinds of trauma, sexual abuse,
and many --
and almost most of the women
have experienced some kind of partner violence
in their teenage years
and in their adult relationships,
and they are all well deserving of our support
and of trauma-informed approach,
which we didn't really even know about trauma-informed care
when we started this program.
We were getting there in terms of the research
and the findings that we were seeing,
but that hadn't been put all together
at the beginning of TAP.
But we have learned,
along with the researchers and service providers,
about the need trauma-informed case,
sensitivity and caring and empowering individuals
to make decisions and choices for their own lives.
We're very grateful that we've been able
to contribute positively.
I have included -- I'm not going to go over these slides.
You'll be able to see the PowerPoint.
The follow-up study is included.
That just will give you a sense.
That's the State of Kentucky, and those the sites where TAP
is currently located across the state,
and that represents very rural communities,
Appalachian communities, and urban communities.
I thank you very much for your attention
and look forward to speaking with you
if you have questions at the end of the presentation.
Thank you.
Thank you so very much, Barbara.
We did get a couple of questions,
and we'll put those in the Q&A queue
for the end of the webinar.
Now we want to bring up another poll.
Do you believe your community
has the adequate resources and services
available to assist low-income individuals
with opioid use disorder?
Do you believe your community has the appropriate resources
to assist low-income individuals
with disorders related to opioids?
It looks like B is a clear winner.
Now we'll move on to our final presentation,
beginning with Sally Borden
who is the executive director of KidSafe Collaborative,
a community-based non-profit organization
in Burlington, Vermont.
Miss Borden started with KidSafe in 1998.
In that role, she leads numerous community
initiatives to preserve the safety, health,
and wellbeing of children,
including the Children And Recovering Mothers,
CHARM, team, a multidisciplinary group,
which coordinates services for pregnant and postpartum women
with a history of opioid use disorder,
and their infants.
Dr. Johnston was a founding member
of CHARM, Children And Recovering Mother,
team approach to working with pregnant women
with a history of opioid dependence and their infants.
She leads the University of Vermont Child
Health Improvement Program, VCHIP,
quality improvement project on Improving Care
for Opioid-Exposed Infants or ICON.
She'll be presenting with Dr. Anne M. Johnston,
who was also a founding member of CHARM
and was working on a team approach
to working with pregnant women
with a history of opioid dependents and their infants.
She, too, leads the University of Vermont Child
Health Improvement Program, VCHIP,
quality improvement project
for Improving Care of Opioid Exposed Infants.
Dr. Johnston developed an interest
in the follow-up care of infants discharged from the NICU,
and in 2000, started a neonatal medical follow-up program
at the University of Vermont Children's Hospital,
then the Fletcher Allen Health Care Center.
At that time, she also developed an interest
in opioid-dependent infants.
With her team, she created a novel way
of weaning infants off opioids
by weaning doses of methadone in the outpatient
setting while in the care of their family.
To date, Dr. Johnston and her team
have followed over 1,200 infants
exposed to opioids during pregnancy,
through getting to know these women and their families
and hearing their struggles remarkable strength
in overcoming their obstacles,
their journey into a life of recovery
has become a passion of Dr. Johnston.
She also has an incredible team that works with her
and shares her passion for the care of these patients.
Anne and Sally.
Yes, this is Anne Johnston, and thank you for the introduction,
and I'm going to get right into it.
And Sally and I have done this presentation a number of times,
and if I go quickly through something,
she will actually remember and talk about it.
So, what we're going to be talking about, the two of us,
is opioid dependence in pregnancy,
and this is very briefly, opioid exposed newborns,
and some of my reflections about that,
and then the CHARM collaborative.
I just wanted to start this with putting out some context here.
People tend to focus on neonatal abstinence syndrome,
and, of course, I feel that neonatal abstinence syndrome
is just an expected event that happens
when the newborn is prenatally exposed to opioids,
and it's a much bigger issue
and what all you are focused on
are the families and the family health,
and I appreciate that from the previous two talks.
And this is an article put out by the CDC,
reviewing neonatal abstinence syndrome,
or NAS, incidence rates in 25 states,
of which Vermont was one,
and Maine and West Virginia
were the highest
in terms
of the neonatal abstinence syndrome rates,
and, also, Vermont had the highest annual rate
increase of states surveyed.
And when we look at that, I had a reaction,
and my reaction was not necessarily
that the opioid problem
was particularly bad in Vermont,
although we have certainly seen it,
and, really, what we have to think about
is what's making this increased diagnosed and increased rate.
And what we know is that this probably represents
increased access to safe treatment,
both prior to pregnancy and during pregnancy,
and that certainly happened in our state,
and Sally will be talking more about that,
and that we have had this increased focus
over the last 18 years
since I started working with these families,
in terms of identifying those families and babies at risk.
And, lastly, this is a good thing.
Now, I do review a few myths,
and perhaps these are well recognized
as myths to all of you,
but they may not be.
So, the first myth is that opioids during pregnancy,
so prenatal exposure of the fetus to opioids,
will result in a damaged baby.
And I still find that a lot of people have that opinion.
So, what's clear is that there's no evidence that opioid
exposure in and of itself results in developmental delay
or any other lasting effects on the exposed child.
On the other hand, alcohol exposure,
as well as tobacco exposure,
nicotine exposure, can result in physical, developmental,
and behavioral effects.
The next myth is that every baby born to a mother on opioids
is born addicted,
and this may be a little bit semantic,
but I refer to opioid-exposed babies
as those who were exposed
prenatally to prescribed or illicit opioids,
"prescribed" meaning methadone or Buprenorphine usually.
Opioid dependent infants and newborns
are those that exhibit signs of withdrawal severe enough
to need medication.
And there is no such thing as opioid-addicted babies.
Infants cannot be addicts.
The disease of addiction requires obsession,
compulsion, loss of control, breaking the rules.
And in our data from Vermont, we really have found
that only 20% of opioid-exposed infants
require pharmacologic treatment.
It used to be higher, but that has been the case
for the last number of years.
There's a lot of reasons for that.
And primarily in other --
the national data shows more like 50 to 60%.
Myth number three, if a baby needs treatment
for opioid withdrawal it must be
because the mother used opioids during pregnancy.
And when I say "used," I say in quotation marks,
obviously supplementally used.
And that is, clearly, not true.
The severity of withdrawal is not associated
with the dose of medication
or whether a mother has used or not during pregnancy.
However, exposure to nicotine and tobacco
can increase the severity of withdrawals,
and certainly higher scorers of abstinence
or withdrawal in a baby
do not indicate that a mother has used during pregnancy.
And myth number four, opioid abuse and pregnancy
leads to child abuse and neglects.
And we have had a fairly broad experience
over a number of years.
We have over 1,500 babies born to opioid-dependent women
through our clinic,
over 80% of these babies were discharged
in the care of their mother or father, or both,
and the majority of parents we see
are actively engaged in treatment
and display good parenting,
although they may need quite a lot of support,
as we've heard, in order to do so,
and have many needs and challenges.
If a parent is not adhering to treatment,
does not want to receive treatment
and is actively using, they may not be ready to parent a child,
and that's certainly something we've seen also.
And why is medication-assisted treatment for pregnant women
with opioid use disorders a standard of care?
It has remarkable health benefits,
both for the mother and the baby,
including decreasing the rate of prematurity,
a decrease in the rate of small babies,
improves the health of the baby, lowers infant mortality,
and it's important to recognize the pregnant woman
does not feel high
but, usually, feels well and has no cravings
if she is on the appropriate dose of MAT.
Successful engagement and treatment
increases the probability of good parenting,
and we generally recommend
that detoxification not occur during pregnancy.
It's rarely successful and can be dangerous to the fetus.
And lastly, one of my concerns, big concerns,
one of our concerns is that anything we do
as a society that drives pregnant --
or as healthcare providers or care providers,
anything that drives pregnant opioid-dependent women
from seeking treatment results in more prematurity,
higher infant mortality
and less probability of successful parenting,
so we have to be very, very careful about that.
What happens when an untreated woman with opioid
use disorder delivers a newborn,
who's probably hiding her opioid use disorder?
We have higher incidents of neonatal complications,
including opioid withdrawal perhaps.
If it's recognize that had the mother is opioid
dependent in the birthing hospital,
there's often Child Protective Services involvement
and there's a challenge of taking care of a newborn
and starting treatment for addiction,
which might result in temporary placement for the child.
And if this is unrecognized and the infant
exhibits no withdrawal in the early period,
after discharge the infant may be particularly irritable,
and that family's ability to cope
is impeded by the fear of discovery,
the mother will probably remain active in her addiction,
continuously flying under the radar,
may expose her baby to unsafe situations,
and is often unwilling to come forward
for fear of losing her child or children.
As we know, the medication part of medication-assisted
treatment,
generally in pregnancy, we use Methadone or Buprenorphine,
with advantages specific to patient populations to both.
We have a very high rate of Buprenorphine
maintenance here in Vermont,
because we were sort of late coming to the game
with Methadone maintenance
and we have a rural population
and did extensive training on Buprenorphine
with our physicians.
And just to clarify and look at some of the issues
that face substance-using pregnant women
and their children,
there's often generational substance use,
untreated mental health problems,
limited parenting skills and resources,
unstable housing, unstable transportation,
some legal involvement,
and then, hugely, exposure to childhood trauma
as we've heard about from Barbara.
And underneath it all is this great degree of shame,
which prevents women from being able to be open
and share the truth
and keeps them in their fear
and fear of discovery.
What we try to do in our program, and also at CHARM,
is build trust,
focus on the respect and strengths,
decrease fear and shame, and promote breastfeeding.
And our hospitalists, as was said,
we do actually treat babies with Methadone,
but only 20% of the exposed babies are treated.
They are discharged home on Methadone,
so not in hospital for very long,
and then we have an infrastructure
putting in a neo med clinic,
where they come within a week,
and every two weeks for weaning of the Methadone
and monitoring of growth and development.
They are tiny amounts of methadone,
Sally is reminding me, so not enough to be abused,
but that was one of the main concerns 18 years ago
when we started this, was how was this going to be safe.
And so, if we look at up until the end of 2016,
how many women or babies we follow born
to moms on Methadone or Buprenorphine at delivery,
you can see that in the red it is predominantly Buprenorphine,
with some on Methadone.
And then just looking at outcomes, for us,
based on 277 babies,
and we have more at this point,
their cognitive, language and motor
outcomes at 7 to 14 months of age are actually excellent.
This is percentiles that you're looking at.
And, in fact, it looked, at one point,
like they did better than the average baby,
and that's sort of evening out now.
And there's certainly no developmental issues
at this early age.
They are, of course, at risk due to their family environments,
to having some learning problems, school problems,
and certainly at risk for addiction,
the disease of addiction or alcoholism,
just based on the genetic potential,
but this is a good start.
I think my key points that I wanted you to get from this
is that the incidence of neonatal
abstinence syndrome is increasing,
but we have to really look at whether this represents
increased identification cases,
increased access to care for pregnant opioid-dependent women,
or what does it represent.
Behind every case of neonatal abstinence syndrome,
it is important to recognize there is a mother,
and perhaps a family, suffering from the disease of addiction,
and this is where efforts need to be the greatest.
We need to decrease our judgment,
increase access to trauma-informed treatment.
Developmental and behavioral outcomes are overall
not affected by opioid exposure in utero
on its own, unlike alcohol exposure,
and community strategies that focus on punishment
will result in increased morbidity and mortality
for children and their families.
And lastly, healthy collaboration between partners,
such as in CHARM,
has been essential to supporting these families.
And I'm going to turn this over to Sally at this point.
Thank you, Dr. Johnston.
Hi. This is Sally Borden,
and I'm going to take a few minutes
to talk about our CHARM team,
which, as you heard in the introduction,
is a multidisciplinary team,
focusing on health and safe outcomes for babies
born to women with a history of opioid use disorder,
and we were cited as a model collaborative
approach by SAMHSA.
And there will be more information sent out to you
with a link to that
if you want more information about the program.
We see, you know, a lot of challenges
that were mentioned earlier for TANF recipients,
and often that is around meeting their work requirements,
as well as housing and childcare.
If they need to go into treatment,
what are the requirements for that treatment program,
and does that interfere
with their other work or requirements?
So, those are all very relevant, as was described earlier.
And we see this also as a promising prevention model,
because it's so important for all of the service providers
to work together,
and for TANF providers to understand
that the standard of care for treatment for pregnant women
does involve being on medication-assisted treatment,
and also to be cognizance of the myths
that Dr. Johnston explained.
So, just a quick view of our beginnings, really, this is just
so that you can see that our collaboratives
did not happen overnight.
It took many years of hard work
to develop the kind of framework for sharing information
and working together that we have in place now.
And we started way back when a few doctors said,
wait a minute, let's work together to figure out
how to best treat and support these women
and make sure they have healthy babies.
So that has evolved as we have gone along over these years.
There are a number of partner organizations involved,
UVM Medical Center, and UVM Children's Hospital --
and UVM is University of Vermont --
are the key sort of foundation of this collaborative approach,
and then child welfare is also a very important partner,
and a number of different state
and community-based organizations come together.
One of the things that's really been significant
is our Public Health Department has developed
a very robust infrastructure
for providing medication-assisted treatment,
and that has really improved access throughout our state.
They call it the "Hub and Spoke System,"
and the hubs are the more intensive treatment locations,
and the spokes, as they were,
are often community-based providers,
providing Buprenorphine and integrated
with other health care
and wellness and treatment services.
Just over the last few years,
we have significantly increased
the number of people on treatment
and decreased our wait time,
which has been tremendously important for this population.
For our CHARM collaborative, there are a few key pieces
that we find are essential to making this work,
this team approach work.
First of all, coming to a shared philosophy,
and this didn't happen overnight, I must say.
It took lots and lots of discussions
even to reach that point.
But really coming to an agreement
that while many of us on that team,
our primary focus for support
is making sure that infants are safe and healthy,
that in order for that to happen,
improving the care and supports for moms
is the most important factor,
and I would say families overall,
but our focus on the team
is really the pregnant and postpartum moms.
So, sharing information is key to child safety
and to healthy outcomes.
We have our memorandum of understanding
that we have developed as a framework for sharing
information and coordinating services,
and we also have a Vermont law
that allows for some information
sharing as an impaneled child protection team.
We have about 11 agencies and departments
that come together, we meet monthly,
and we focus on some of the system issues and case reviews,
and we focus on what are the most important things
that we need to know,
because there are so many patients to review,
like, well who are the pregnant women
who are doing the due in next month,
who are the babies that have just been born,
and who are those that we're most concerned about.
And we start with the prenatal care,
and that care involves confirming the pregnancy,
initiating treatment, medication-assisted treatment,
and other treatment services,
intensive prenatal care for high-risk women.
There may be a residential program option
that's available in our community
where women can go when they're pregnant or with their babies.
We also look at the case management and referrals,
and as others have described in more in-depth
than we have time here,
but really taking a strengths-based focus,
a family-centered focus to address some of the barriers,
such as housing and transportation.
We've recently been able to access some private foundation
funding to provide gift cards
and bus passes
and gas station gift cards,
and so on, to support these women
in accessing the services that they need.
And then, of course, there's the postpartum
and neonatal medical follow ups
that Dr. Johnston described.
We know that we need to start prenatal care
early in pregnancy.
That is really the key element.
It's probably the single key most important element
for patient success,
making sure that pregnant women
receive pharmacological treatment,
whether that's methadone or Buprenorphine,
and that starts as early in pregnancy as possible,
engaging in substance abuse counseling,
and depending on what the level of treatment is needed,
that can vary, coming to their appointments,
and making sure that they are receiving the kinds
of supports and services that they need.
Our numbers are pretty small.
We're a small state.
But it does give you a sense of those
that we review and coordinate services for each year.
Our child protection system, our child welfare system
has taken a very innovative approach,
and that's been a key factor in our collaborative,
and they have started a practice that is pretty unique,
nationally and that is using the differential response system
to begin an assessment approximately a month
before the due date.
And that is not identifying the fetus as a child
but rather looking at the safety of the home environment
that that child will be born into,
and so allowing for a planning process,
again, as an assessment, not a child abuse investigation,
but looking at what kinds of services
and supports a family might need in order
to be able to safely care
for that infant when it's born.
Probably the key outcome there is avoiding
unnecessary placement crises at birth.
We're able to plan much more effectively,
if a child is going to need to come into custody,
to know that ahead of time.
So, what we've found through this process
is more pregnant women are in treatment
earlier with better prenatal care.
We have fewer premature births
and fewer small birth weight infants,
and we look at pregnancy as a real opportunity.
Women are often motivated to engage in treatment,
whereas they wouldn't be otherwise.
Better care for infants, supports for mom,
shorter hospital stays,
and we are really working now
to implement the plans of safe care
that were required by recent changes to federal law.
With child safety we've made,
I think, some very significant inroads,
being able to assess safety and support services,
providing support services,
initiating both of those things prior to birth.
So, we have seen a reduction in the number of emergency
custody orders at the time of birth,
and decisions being able to be made
with input from all of the project partners
has been very important.
For process outcomes, our team participants really value
the time saved,
the amount of information that can be shared
when we're all sitting in the same room
and talking with each other is incredible,
and we've all learned from each other.
Those myths and misconceptions that you heard
from Dr. Johnston are all things that many of us
came to this team with many years ago.
And we've all learned from each other,
and we are so confident that we're able to provide
the quality of services that we do
because of the understanding that we have from each other.
There's so many challenges to collaboration,
and especially challenges to serving this population.
It's very complicated lives that they have.
If somebody needs to go to an IOP,
how are they going to maintain their work or their work search
when they're in treatment for six hours a day,
or if they need to go to residential care,
how are they going to get childcare
for their other children?
So those are the kinds of issue that is continue to,
and will continue to,
be a challenge in working with this population.
But by working together, that's our best chance
for addressing the issues.
Where we're headed, and really long overdue,
is having a much stronger peer support component
to the work that we do.
Like all of us, the women that we're working with
are most likely to listen to others
who have been through the same thing,
and so we're connecting with a new program
in our recovery center.
We're also working on expanding the kinds of supports
that we can offer through addressing
the needs of these women
in having diapers
and gift cards and gas cards.
And listening to you all this afternoon gave me some ideas
about partnering better with our reach out
for TANF providers around doing this
in a more collaborative way.
So, that is really, in a quick nutshell,
what the CHARM team does,
and, again, having that framework
that the health of the baby depends on the mother's health
and the family's health.
And you can get some more information
when this is sent out from the publication in SAMHSA,
as well as some other resources listed here.
So, thank you very much.
Thank you, Doctors Johnston and Borden.
We have time for just one question,
but the rest of the questions we will share with our presenters,
and once we make the presentation available
through the Peer TA website,
we will have the responses to those questions,
so stay tuned for that posting in the next couple of weeks.
The one question for both presenters,
for all three presenters,
four, have there been any training programs,
certifications, or promising practices
that you can share with the presenters,
share with the people on the webinar,
developed for welfare or TANF or workforce development staff
in order to improve their ability
to work with opioid-involved clients?
So, have you come across any training programs
or certifications
or promising practices that TANF programs,
workforce development programs,
and staff can use to work with opioid-involved clients?
So, this is Sally Borden.
I'll jump right in.
Children and Family Futures, based in California,
is a wonderful resource, a national resource,
that provides a lot of information
about working with this population in particular,
and they also operate the National Center
on Substance Abuse and Child Welfare,
so it's not specific to TANF recipients,
but they really provide a wealth of information.
Children and Family Futures, you can Google that
and then find their website,
which can link you to a lot of trainings,
and they do provide national trainings on this topic,
as well as family treatment courts
and other related resources.
This is Justin Germain.
The one program that I'm familiar with
is the can have Life Link program in Santa Fe, New Mexico.
It's a Social Services 501(c)3
nonprofit that runs the SBERT program,
which stands for Screening Brief Intervention
and Referral to Treatment.
I know they work with a lot of other community organizations
in order to offer services that provide trauma-informed care.
While I'm familiar with any specific trauma-informed
care programs or certifications,
the concept of trauma-informed care
has started to grow in terms of social service, welfare,
and workforce providers.
That might be worth looking into it.
And we'll definitely follow up with the presenters
on those promising practices
and those different activities out there
and post them with the materials
that are going to go up with the webinar.
There's one final poll before we close out,
but while you're answer that poll,
I did want to say thank you again to our presenters,
and also to everyone who participated in today's webinar.
Once the webinar closes out,
there will be additional feedback.
We do take very seriously all the feedback
we receive from our webinar participants
because it helps inform future webinars
and other technical assistance.
So, audience poll number four, to help us plan future webinars
that address your interest and needs,
please tell us what topics
you would like to see on future webinars.
So, we'll keep collecting those ideas for future webinar
and technical assistance topics,
and, again, we will collect all the questions
that were submitted through the chat feature.
We'll submit them to the presenters,
and we'll request that once they get a chance to complete those,
we'll post them with the webinar.
So, on behalf of the Office of Family Assistance,
thank you all for logging in today, and have a good day.
-------------------------------------------
Does Neem Treatment Work for Head Lice - Duration: 8:18.
Does neem treatment work for head lice
Head lice are parasites that live on the scalp hair and ears which feed on the blood it is one of the common problems
Faced by children a person or child can get head lice
Infestation through head to head contact sharing hair care products like combs and wearing clothing of people who have the head lice
Though head lice spread from one person to another they don't spread or carry any disease with them. They reproduce very quickly
A female louse can lay up to ten eggs per day
They hatch in five days and become mature to lay eggs in another five to seven days
It requires patience and regular inspection for completely eliminating these stubborn head lice
For example, they live up to six hours under the water and live up to 24 hours without human contact
One of the biggest problems about head lice removal is that lice have become resistant to many chemical based or over-the-counter solutions
Even chlorine present in swimming pools is not able to remove the head lice does need more neem oil work for head lice
removal neem or neem oil contains an
Insecticidal ingredient called a Satyricon which disrupts the reproduction and growth of head lice
It restrains the swallowing systems of lice which starve them to death
Lice don't like the pungent smell of neem oil which restricts its crawling into your head the healing and soothing
Properties of it will reduce the irritation attaching
Apart from dealing with head lice it helps to add shine to your hair and moisture to your scalp
How to use neem oil for head lice removal both neem leaves and neem oil can be used to treat head lice
Infestation the methods don't cause any damage to your scalp and hair
In fact, they help in strengthening the hair and prevent the hair loss
We have mentioned different remedies below try any method as per your convenience
Neem for head lice removal the below methods need fresh or dried neem leaves if you have fresh neem leaves
You can dry them and store for regular use one fresh neem leaves
Process one take a handful of neem leaves and boil them in two glasses of water
Let it boil until the liquid turns into green
Remove from the flame strain and let it cool down
After regular shampoo use this neem water to rinse your hair to three times
Repeat the process once in three days
Process to grind handful of neem leaves into a paste apply the paste on the scalp and leave it on for thirty minutes
Rinse off the water with shampoo and lukewarm water
Repeat the process two to three times a week
alternatively, you can blend boiled neem leaves to dried neem leaves blend some dried neem leaves into a
Fine powder or use store-bought neem leaves powder
Combined neem powder and enough amounts of water to make a thick paste
Apply it to the scalp and along the hair leave it on for an hour wash your hair normally with shampoo
repeat the process once in a week neem oil for head lice removal
Use only pure neem oil while trying the below methods
It provides effective results in removing the lice and restricts premature graying of the hair
One neem oil with shampoo add neem oil to your regular shampoo and mix well
Use this shampoo to rinse and wash your hair
Repeat the process two to three times a week
Alternatively, you can use a shampoo that contains neem extracts two neem oil wash and dry your hair thoroughly
Apply undiluted neem oil to the hair and along the hair let it stay for a few minutes
Now the comb along the hair to remove the head lice
Repeat the process twice in a week for extra benefits use a comb that is meant for head lice
Removal three neem oil with coconut oil the fatty content present in coconut oil
suffocates the lice the
Lubricating nature of it restricts its crawling on the scalp mix few drops of neem oil into enough of coconut oil
Massage the mixture into the scalp leave it on for at least an hour rinse off with shampoo and water
Repeat the process once in two to three days for at least one month
alternatively you can use olive instead of coconut oil for
Neem oil with tea tree oil tea tree oil contains an insecticidal property which kills and prevents head lice
Infestation it soothes the irritation caused by scratching
olive oil suffocates the head lice
Combine one part tea tree oil and four parts neem oil add two teaspoons of olive oil and mix well
Apply the solution into the scalp and along the hair leave it on for a few minutes now
Comb the hair thoroughly to remove the lice wash your hair with shampoo and water
repeat the process once in 3 days 5 neem oil with sesame oil sesame oil contains antibacterial
And natural pesticide properties which deal with the head lice
Apart from that it also helps in hair growth
Rinse your hair with dilute apple cider vinegar and let it dry completely in a bowl mix 1/8 cup neem oil
1/4 cup of sesame oil 1 TSP tea tree oil 10 drops each of lavender oil
eucalyptus oil and rosemary essential oil
Stir the ingredients well and apply it into the scalp and along the hair
Cover the hair with shower cap and let it stay overnight in the morning comb the hair thoroughly to remove the head lice
Rinse the hair normally repeat the process once in 3 days until the hair is head lice free
6 neem oil with olive oil olive oil
Suffocates head lice by depriving them of oxygen which makes it easy to remove them by combing
Combine 2 ounces of olive oil and 15 to 20 drops of neem oil
Mix well and apply it on to the scalp and along the hair leave it on for at least 12 hours
Comb through the hair to remove the head lice rinse off normally in that dry completely
repeat the process twice in a week
Seven neem oil with tea tree oil tea tree oil contains pesticide properties, which kill the head lice
Apart from that it soothes the irritated scalp and encourages hair growth this process helps to prevent the head lice
infestation combined neem oil tea tree oil and lavender oil
pour the mixture into a spray bottle
Spray the solution onto the hair repeat the application
Daily tips and precautions if you are allergic to neem then avoid using it dry the remedies
regularly to get rid of head lice completely as head lice spread from one person to another
It is better to avoid head to head contact and share personal belongings with a person who is infested with head lice
Wash the bed sheets clothes towels hats and scarves regularly if you have an infestation
Seats in airplane theater and public transport can have head lice
So cover them with your sweatshirt or jacket before you sit clean your hair accessories and combs regularly
Repeat the process regularly which ensures the newly born head lice are removed to prevent the infestation
Try to use the methods once in a while
-------------------------------------------
Harry Kane's penalty box treatment by Tunisia prompted VAR crackdown by FIFA - Duration: 4:59.
Referees committee chairman Collina, who was named FIFA's 'Best Referee of the Year' six consecutive times between 1998-2003, made the revelation when speaking about video assistant referees (VAR) in Moscow
The Italian who many consider to be the greatest football referee of all time, was asked why Harry Kane was not given a penalty for being held during the match against Tunisia and also why Serbia's Aleksandar Mitrovic was not awarded a penalty when they played Switzerland
Collina explained he would not comment on specific incidents, but said: "You might have appreciated there were some incidents that suddenly disappeared or started to be punished
"It's impossible to be right from the start but because we noticed, we intervened and we fine-tuned
Things have changed during the tournament." A stoppage-time header from Harry Kane gave England a 2-1 win over Tunisia in their opening World Cup Group G fixture
After the game England's captain said: "We could have had a couple of penalties, especially when you look at theirs
"A few corners, they were trying to grab, hold and stop us running. Maybe a bit of justice to score at the back post at the end
That's football, that's the ref. "It showed good character to get on with it." Collina said he believes that VAR has been a huge success in Russia and while admitting it is "not perfect", he argued it has helped referees make the correct decision
He also revealed that as well as asking referees to be more vigilant to wrestling in the penalty box, officials have been told they can ask for more on-field reviews than had initially been advised
"We were aware VAR could interrupt the flow of play and time could be lost, so we wanted as few interventions as possible," he said
"But we noticed there were a few complaints - understandable complaints - about maybe doing more on-field reviews, so we thought it would be a good idea to do that so the decisions were better accepted on the field
" 48 games into the World Cup Collina said there have been 335 incidents checked, resulting in 14 on-field reviews made by referees and three reviews made by the VAR team on "factual decisions", such as off-sides
Of these incidents, referees had correctly called 95 per cent of them without VAR
However, when using replays, this improved making the correct call to 99.3 per cent
"We have always said VAR doesn't mean perfection - there could still be the wrong interpretation or a mistake - but I think you would agree 99
3 per cent is very close to perfection," said Collina. Collina was cautious about whether FIFA would consider allowing the audio between the Referee and VAR to be broadcast
"Before running you have to learn to walk. I don't know what's possible in the future but I think it's a bit early for that now," he said
"I agree it would be interesting, though, and would perhaps make decisions better accepted by the football community
" VAR has raised concerns from some that it would cause delays to the game. During this year's World Cup the ball has been in play for an average of nearly 57 minutes and this is up from 55 minutes during Brazil 2014
As for VAR on average a review has taken 80 seconds. Former England international Stan Collymore said VAR could make the difference to winning or losing and backed the new system
He tweeted: "World Cup VAR decisions. 95% correct without VAR. 99.3% correct with VAR
"Decisions checked by VAR, 335. That 4.3% difference? Could be your team winning the league or not, a trophy or not, relegated or not
"No brainer. VAR is working."
-------------------------------------------
Who is involved in my child's treatment on the Adolescent Unit? - Duration: 1:12.
on a 24-hour basis with the children the nurses and the mental health techs are
right there with the patient so at any point during the day your child can
reach out to a mental health tech or they can reach out to a registered nurse
so they are always with your children during the day shift they would have
access to their social worker so if they just needed to talk with somebody or
they say I had a bad phone call or I'm feeling lonely or I miss home they have
a social worker therapist that they can talk to and reach out to they will meet
with their physician during the day so that's also another point of contact for
them they also then have some of the other therapies available to them we
have an art therapist we have music therapists and there's a movement
therapists for the patients to interact with they're mostly going to be
conducting groups but if somebody didn't want to spend a little bit of one-on-one
time or if they wanted a little extra we do everything we can to accommodate that
-------------------------------------------
Allergies Asthma helped with NAET treatments - Duration: 1:11.
Hello my name is Philip.
I came to Dr. Milne a few years ago for severe allergies.
I had heard a little bit about NATE, didn't know anything about it.
Dr. Milne was great in describing what the treatment was.
I have to admit the first treatments...
I was like...Oh no what am I doing...where have I gone to.
But after a few and I felt the difference in my body and my allergies began to subside...subside
for the first time in my life.
Because I've had allergies my whole life that's led to asthma, chronic congestion, post nasal
drip, just junk.
I was tired of it and now I'm no longer on drugs.
No longer on over-the-counter stuff.
I don't need it because Nate has made the difference, And I can't even explain that,
all I can say is NATE NATE NATE NATE NATE!
You need to do it.
Don't hesitate.
It's incredible non-invasive, actually a lot of fun.
So I would recommend it to anybody.
Do it today!
-------------------------------------------
Separation Anxiety Disorder, Severe Separation Anxiety Disorder Treatment and Permanent Cure - Duration: 5:27.
Separation anxiety disorder what is separation anxiety disorder?
separation anxiety is a normal part of childhood development it commonly occurs in
babies between eight and twelve months old and usually disappears around age two
However, it can also occur in adults
Some children have symptoms of separation anxiety during their grade school and teenage years
This condition is called separation anxiety disorder or sad
Three to four percent of children have sad sad tends to indicate general mood and mental health issues
Around one-third of children with sad will be diagnosed with mental illness as an adult
Symptoms of separation anxiety disorder symptoms of sad occur when a child is separated from parents or caregivers
fear of separation can also cause anxiety
Related behaviors some of the most common behaviors include clinging to parents
extreme and severe crying
refusal to do things that require separation
physical illness such as headaches or vomiting
violent emotional temper tantrums
refusal to go to school poor school performance
failure to interact in a healthy manner with other children
refusing to sleep alone
nightmares risk factors for
Separation anxiety disorder sad is more likely to occur in children with a family history of anxiety or depression
Shy timid personalities low
socioeconomic status
overprotective parents a lack of appropriate parental interaction problems dealing with kids their own age
Sad can also occur after a stressful life events such as moving to a new home
switching schools
Divorce the death of a close family member. How is separation anxiety disorder diagnosed?
Children that experience three or more of the above symptoms may be diagnosed with sad
Your doctor may order additional tests to confirm the diagnosis your doctor might also you interact with your child
This shows whether your parenting style affects how your child deals with anxiety
How is separation anxiety disorder treated therapy and medication are used to treat sad?
Both treatment methods can help a child deal with anxiety in a positive way
therapy, the most effective therapy is cognitive behavioral therapy CBT
with CBT
Children are taught coping techniques for anxiety
Common techniques are deep breathing and relaxation
Parent-child interaction therapy is another way to treat sad
It has three main treatment phases child directed interaction CDI
Which focuses on improving the quality of the parent-child relationship?
It involves warm attention and praise these help strengthen a child's feeling of safety
bravery directed interaction BDI
Which educates parents about why their child feels anxiety your child's therapist will develop a bravery ladder
The ladder shows situations that cause anxious feelings it establishes rewards for positive reactions
Parent directed interaction PDI which teaches parents to communicate clearly with their child
This helps to manage poor behavior. The school environment is another key to successful treatment
Your child needs a safe place to go when they feel anxious
there should also be a way for your child to communicate with you if
Necessary during school's hours or other times when they're away from home
Finally your child's teacher should encourage interaction with other classmates if you have concerns about your child's classroom
Speak with the teacher principal or a guidance counselor
Medication there are no specific
medications for sad
Antidepressants are sometimes used in older children with this condition if other forms of treatment are ineffective
This is a decision that must be carefully considered by the child's parent or guardian and the doctor
Children must be monitored closely for side-effects
Effects of separation anxiety disorder on family life
Emotional and social development are both seriously affected by sad the condition can cause a child to avoid experiences
Crucial to normal development sad can also affect family life
Some of these problems may include family activities that are limited by negative behavior
Parents with little to no time for themselves or each other resulting in frustration
Siblings that become jealous of the extra attention given to the child with sad if your child has sad
Speak with your doctor about treatment options and ways you can help match its effect on family life
-------------------------------------------
Bear Cub Burned In 416 Fire 'Responding Very Well To Treatment' - Duration: 0:28.
For more infomation >> Bear Cub Burned In 416 Fire 'Responding Very Well To Treatment' - Duration: 0:28. -------------------------------------------
Greiner Orthopedics Offers a Variety of Treatment and Care Options for All Ages - Duration: 0:34.
Greiner Orthopedics serves patients of all ages with bone, muscle, tendon, and joint
pain or injury and treats everything except the neck area.
Our board-certified orthopedic surgeon, Dr. Robert Greiner II, offers in-office treatments,
arthritis care, and surgical procedures, as well as non-operative treatment options.
Dr. Greiner treats bone and joint injuries, including joint replacement surgery, treatment
for sports injuries, and fracture and trauma management.
Visit our website to schedule an appointment!
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