Structured Protocols: Although protocols may have been developed years ago in response to CA Penal Code 11165.13 and Health and Safety Code 123605, new evidence supports best practices that address the effects of adverse childhood events (ACE) on long term health and wellbeing, attachment and bonding, early intervention, the treatment of substance use disorder (SUD), and the role of protective factors in eliminating or mitigating risk in families and communities. While no one template fits all situations, domains covered in the Plan of Safe Care might include:
- Maternal primary, obstetric, and gynecological care, including interconception care and family planning
- Behavioral health and substance use prevention, treatment, and recovery
- Parenting and family support
- Infant and family safety, including intimate partner violence
- Infant health and child development, including primary care, early intervention, and infant and early childhood mental health (IECHM) services
The adoption and implementation of standardized protocols to develop, execute, and monitor a Plan of Safe Care for all women and children in need is critical. Further, the Plan of Safe Care protocol should reflect the collaborative expertise of key agencies at the county level (e.g., behavioral health and substance use treatment departments, social service departments, Child Protective Services (CPS), etc.), and multiple disciplines in the hospital and other health care settings (e.g., pediatric and OB/GYN health care providers, medical social work, etc.).
Collaboration: To provide a Plan of Safe Care for the dyad, community-based organizations and agencies must collaborate to make wrap-around services covering the above domains easily accessible. To address the needs of the mother, communities must come together to support her with a network of programs and providers that transcend stigma and engage mothers with respect and trust, are trauma-informed, and have expertise in the care of women with substance use disorders (SUDs). Similarly, addressing the needs of the infant should include providers and agencies skilled in high risk infant follow-up, Early Head Start and other early intervention programs, and primary care pediatric providers with expertise in managing infants exposed to substances or at risk for neurodevelopmental challenges. The mother/caregiver must be the core member of this partnership. The partnership should include:
- Primary care providers
- Medication assisted treatment (MAT) providers (office-based or narcotics treatment programs) or other treatment and recovery programs
- Public health nursing, including home visitation programs
- Behavioral health providers
- Peer support
- Board-certified lactation consultant if the mother desires to breastfeed or provide expressed breastmilk (and it’s not medically contraindicated)
Providing Transparency: From the initial meeting with the mother, clarity of purpose is fundamental, and expectations are based on how each individual program or service can meet the needs of the dyad. Assessment of the mother’s needs, with consideration for her self-efficacy, SUD treatment, and recovery, will support her goal attainment. Follow through with plans and interventions developed with her input will further a sense of security in the relationship. Communication between community supports should occur with full knowledge and consent from the mother and include her whenever possible. Community partners should maintain transparency with each other to avoid duplication of services and provision of conflicting information to the mother, which may confuse and overwhelm her.
Presently, guidance regarding interpretation of the federal and state legislation in this area is not straightforward, and hopefully will be clarified soon. Counties vary in how they address the Plan of Safe Care requirement within their communities. In many instances, CPS will take the lead; however, if there is no CPS involvement, or CPS does not address the provision of services to the mother, the community should be ready to support mothers with trauma-informed programs and partners that employ the Five Protective Factors model (refer to the Resources Section of this Best Practice). If CPS engagement is anticipated, full understanding of the laws and resources will afford medical and other service providers the ability to have more transparent conversations with mothers.
Community Partners: The partners from the community may include: CPS, Cal-Works eligibility, behavioral health providers, peer support workers, hospital social workers, MAT providers, recovery programs specific to parenting women, First 5, mother-infant intervention programs (e.g., Minding the Baby or Parents as Teachers), Regional Center, Early Start, Medicaid, and Women, Infants and Children (WIC). Communities may identify and designate additional partners specific to their region.
Federal and State Child Welfare Regulations: In 2016, the Comprehensive Addiction and Recovery Act (CARA) amended the Child Abuse and Prevention Treatment Act (CAPTA) to require the development of a Plan of Safe Care for all children referred to their agency who are born affected by legal or illegal substance use, have withdrawal symptoms resulting from prenatal drug exposure, or have indications of Fetal Alcohol Spectrum Disorder.
In response to California Penal Code 11165.13, and the Federal CARA/CAPTA amendments, the California Department of Social Services (CDSS) All County Letters (17-92 and 17-107) state, “when investigating a referral, the county child welfare agency must assess and identify any safety threats to the child, including any safety threat posed by the parent’s substance abuse. The caseworker must document such safety threats when completing statewide safety assessment tools. This also includes the completion of a risk assessment. If the caseworker determines the caregiver has the protective capacity to mitigate such safety threats and/or risks with appropriate services while keeping the child in the home or placement, the caseworker shall develop a safety plan as described in CDSS Manual of Policies and Procedures, section 31-002(s) (2)… to permit the child to remain in the home with specific, timely actions that mitigate the identified safety threats.”
Initial Steps to Consider
- Contact the county Public Health Department (Maternal Child and Adolescent Health), Child Protective Services, and/or Hospital Council to determine if a current protocol exists for the identification of perinatal substance exposure and the development of Plans of Safe Care that is consistent with state and federal law.
- If a county-level protocol does not exist, or needs revisions, establish a county-level multidisciplinary Plan of Safe Care Committee. Stakeholders to engage might include champions from the aforementioned agencies, Pediatrics, Obstetrics, Midwifery, Family Medicine, Addiction Medicine, Psychiatry, Behavioral Health, Family Treatment Court, and community organizations that serve this population (essential for culturally appropriate and engaging care). Protocols should address at least the following:
- Define which mothers and newborns will qualify for a Plan of Safe Care and whether it will be used only for substance exposed mothers and infants as mandated or for the many other families at risk (e.g., prematurity, intimate partner violence, mental health issues, etc.).
- Identify who will oversee implementation of the Plan of Safe Care, and at which stage of the pregnancy the plan of safe care may be initiated. Current CDSS All County Letters assign that responsibility to the local CPS agency regardless of whether the newborn is discharged in the care of the mother.
- Identify key community-based organizations and resources and establish relationships including with primary care providers, substance use treatment and recovery providers, community resources for collaborative support of vulnerable families, home visitation, parenting classes, lactation support, addiction support (if needed), and early intervention services.
- Outline ongoing care plans that identify family challenges and strengths (and tools to support those assessments, such as Protective Factors Survey 20 or 30), detail recommended/required resources and supports to ensure ready access to those services, and include contact information and appointments for benefit of the family and support network.
- Prioritize continuity of care with maternal treatment and recovery providers and with infant care providers wherever possible and appropriate
- Ensure that the Plan of Safe Care covers a sufficient duration to ensure a foundation of stability.
- Include a comprehensive release of information consent signature page (see Delaware’s Plan of Safe Care example) to facilitate timely information sharing and coordination between organizations to ensure shared understanding and accountability.
- Ensure that hospital protocols are in place for the identification of substance exposed mothers and infants and the development and implementation of Plans of Safe Care for the dyad. These should be consistent with local, state, and federal policies and regulations.
- Ensure families and providers are educated about the Plan of Safe Care, what to expect in the hospital and beyond, the focus on maintaining the mother/baby dyad, and the potential for CPS involvement.
- Engage the mother/caregiver in collaborative decision making around what supports are most valuable for them and any anticipated challenges for program participation while maintaining sobriety, work obligations, or court hearings.
- Consider using the Plan of Safe Care as a dynamic document that may evolve over time in response to regular assessments of the parent and infant health and well-being.
- Ensure sufficient monitoring of maternal depression and anxiety, continuing recovery, and parental capacity to meet her infant’s and her own needs. There are many conflicting demands placed on these mothers such as attachment, sustaining employment, recovery, and the voluntary programs we recommend.
- Consider using a consultant or the complete reference below to implement of a Plan of Safe Care.
The relationships we build across departments and in the community will afford us a greater support network, and transparency and accountability in caring for our most vulnerable new families during a peak emotional time. The dyad-centered Plan of Safe Care is an opportunity for providers to leverage community resources and ensure optimal support of new families impacted by substance use or other risk factors.