The NJ Project ECHO® for Substance Exposed Infants (SEI) and Their Parents
Statewide adoption of best practice clinical care & community based interventions to support substance exposed infants & their parents
Updates: How has your idea changed or evolved throughout the Prize? What updates have you made to this submission? (1500 characters)
The NJ Project ECHO Academic Medical Center (AMC) Hub is a statewide program led by Rutgers Robert Wood Johnson Medical School. The AMC Hub has successfully launched three ECHO Clinics covering: Endocrinology, Pediatric Behavioral Health and Pain Management. In 2016-2017, the Hub has engaged over 100 primary care providers & demonstrated improvements in the use of evidence based guidelines and self-efficacy. What has changed: We are reconfiguring an existing tele-mentoring model for healthcare providers to create a multi-sector community collaborative. We will connect community providers with an interdisciplinary team of neonatal abstinence syndrome (NAS) and substance exposed infants (SEI) medical specialists, substance misuse experts as well as child welfare and social service providers. These experts will remotely mentor and collaborate with physicians, nurses, and social workers at local hospitals and in the community to enhance their knowledge and clinical skills to manage the bio-psychosocial needs of these infants. In addition, the goals of the collaborative will include engaging parents in substance use disorder treatment and integrating local community child welfare and social services to support recovery, family formation, and child development. We will utilize human design techniques outlined in the field guide such as contextual inquiry to prototype various elements of the model in a single community before expanding to other communities and statewide.
Name or Organization
Applicant: Rutgers Foundation on behalf of the Robert Wood Johnson Medical School, Office of Community Health
Initial Partners: NJ Department of Children & Families (NJDCF), NJ Department of Health (NJDOH), NJ Department of Human Services (NJDHS), Children's Specialized Hospital, The Southern New Jersey Perinatal Collaborative, Central Jersey Family Health Consortium, The Nicholson Foundation & the Rutgers Foundation. Additional community partners will be recruited. See NJDCF letter of support
The NJ Project ECHO SEI Clinic will be implemented throughout NJ in a phased approach. The Clinic will be prototyped in a community with a high prevalence of SEI births as well as with health care providers and community organizations that have a demonstrated commitment to serving this population in an innovative way. Once operational, the model will be refined & scaled to service the remainder of the state. Other interested states could utilize the Hub and integrate local community resources.
What is your stage of development?
Early Stage Innovator, with at least one-year experience in ECD
What is the stage of your proposal?
Prototyping: I have done some small tests or experiments with prospective users to continue developing my idea.
Describe your submission in one clear sentence
The NJ Project ECHO SEI Program aims to expand the widespread adoption of best practice clinical care and community-based interventions for substance exposed infants and their parents to support recovery, family formation, and child development through a multidisciplinary case-based learning platform.
Describe how your solution could be a game-changer for your selected Opportunity Area (600 characters)
This intervention will revamp the culture and service delivery paradigm so that the bio-psychosocial needs of mothers and infants can be addressed jointly in order to improve opportunities for recovery from addiction and promote child development. The intervention will extend beyond the hospital stay and coordinate community services for the first year of the infant's life. Lastly, the program will advance prenatal and pre-conception interventions to reduce the new incidence of SEI. These multifaceted strategies will reduce avoidable healthcare costs and support family unification.
Select an Innovation Target
System design: Solutions that target changing larger systems.
Tell us more about your innovation (1500 characters)
Project ECHO (Extension for Community Healthcare Outcomes) uses telecommunications technology and case-based learning to foster mentoring partnerships between specialists (the “hub”) and community based providers (the “spokes”). Project ECHO was founded in New Mexico by Dr. Sanjeev Arora, UNM and was designed to to enhance community providers’ skills, knowledge, and capacity to provide quality care for individuals with complex chronic illness, such as diabetes and hepatitis C.
NAS is a postnatal drug withdrawal syndrome in newborns caused primarily by in utero exposure to opioids and SEI refers to infants exposed to alcohol or other drugs ingested by the mother in utero, whether or not this exposure is detected.
The NJ Project ECHO for Substance Exposed Infants and Parents aims to: 1) Build capacity in the birthing hospitals throughout the state to screen, identify, report and provide best practice bio-psychosocial care to substance exposed infants using a case based learning model; 2) Create an educational platform, tailored to the needs of the community linking healthcare providers, case managers, substance misuse treatment experts specializing in mothers with infants, and other early childhood and social service providers to support recovery, family formation, and child development during the first year of the newborn’s life. The bi-weekly collaboration will be designed to address the needs of the participants' active cases and determine actions to support intervention.
What problem are you aiming to solve? (3 sentences)
The NJ NAS cases reported has nearly doubled from 340 in 2008 to 634 in 2014, roughly 6 percent of NJ’s births. Most NAS infants are treated in an intensive care setting, where charges are high and Medicaid bears about 80% of the costs. Infants are under reported and trained medical & social service resources are scarce. We intend to improve: reporting of SEI, timely diagnosis, access to care, use of best practices in order to improve outcomes for families, as well as impact the cost of care.
Explain your idea (5000 characters)
The NJ Project ECHO for Substance Exposed Infants and Parents model would be used to build capacity among the States’ maternal-child healthcare, substance misuse, child welfare, and social service system of care to:
o Implement best practice protocols for the care of substance-exposed infants and delivering mothers using or dependent on opiates
o Facilitate hospital adherence to the recently adopted regulations NJAC 3A:26 for Substance-Affected Infants and the amendments to the NJDOH regulations, requiring hospitals and birthing centers to report substance-affected infants to the Division of Child Protection and Permanency
o Develop practice standards in collaboration with NJ DCF for plans of safe care for SEI
o Coordinate with the NJ DHS Maternal Wraparound Program offering intensive case management and recovery support services for opioid dependent pregnant and postpartum women
o Collaborate with the nonprofit organizations that have recently received state grant funds to expand substance-abuse treatment and medical care for pregnant women and new mothers. The Program is anticipated to provide residential treatment for nearly 900 women residing in 13 counties, as well as help coordinate other medical and behavioral health care
o Support the adoption of best practice interventions to ensure the social and emotional development of infants
o Educate pregnant women and women pre-conception about the dangers of opioids and the appropriate prenatal treatment
The Project ECHO infrastructure is designed to rapidly bring new ECHO clinics to scale. The Hub administration provides facilitation training, curriculum development, and IT support to the interdisciplinary subject matter experts and the participating providers. The Project ECHO AMC Hub also provides evaluation support to all the ECHO clinics. The Project ECHO AMC Hub is well positioned to expand the ECHO model to address the urgent and growing needs of substance exposed infants in the state.
RWJMS employs a four phased approach to the development of each ECHO clinic, utilizing human centered design principles and techniques. The first two phases are especially important for the SEI clinic since it will be focusing on engaging a broader array of partners than prior clinics. In addition, the fourth phases of on-going evaluation and monitoring will demonstrate the value of Project ECHO to support its future sustainability. Below is a more detail on each phase:
1) Planning: This phase focuses on defining the market need, identifying the target participants, understanding their social systems, pinpointing the value proposition from the participants’ perspective, understanding the barriers to participation, and defining the program scope and deliverables. Human centered design techniques inspired by ethnographic research methods like contextual inquiry to test fit are utilized. Early prototyping using schematic diagramming to outline the structure and identify essential components of the program is used for elements such as identifying target community organizations and providers, performing a gap analysis, defining education and training needs and developing a recruitment plan
2) Training, Recruitment & Protocol Phase: The second phase involves training Hub members on facilitation, and developing the didactic curriculum as well as the template for case reporting. Simultaneously we build the recruitment plan and call to action based upon our knowledge of the gaps and needs. Town Hall meetings, newsletter email blasts and individual meetings with the community agencies and birthing hospitals are included in the recruitment process.
3) Operations: Once the team and the curriculum are established a mock ECHO Clinic is scheduled and a soft launch of the clinic begins. The ECHO clinic meets biweekly for 90 minutes. The clinic session includes a 20-minute didactic and the remainder of time is devoted to active case presentations and discussion. The didactic presentation and case studies are coordinated as much as possible but time is also allocated for follow-up on previous cases and spontaneous requests. The Hub team members review the case and develop potential recommendations prior to the session. Each session is recorded and offers the Hub team an opportunity for review.
4) Evaluation: At the conclusion of each clinic, participants and hub members complete a survey in order to receive CME/CEU credits. The survey measures changes in knowledge and self-efficacy. Monthly dashboards are shared with the Hub, looking at attendance rates, satisfaction & learning. For the SEI ECHO, we are pursuing access to Medicaid claims data to evaluate the program impact on SEI birth rates, outcomes and healthcare costs. A community survey will be developed to measure changes in family unification, timely access to care and use of social services
Who benefits? (1500 characters)
1. There are 4 beneficiaries: A) Pregnant women & mothers with opioid use disorders & their newborns. They will benefit from earlier identification of SEI and improved access to comprehensive medical and psychosocial services from birth through the first year of the infant's life; B) Women who may become pregnant and/or use opiates. Early education and intervention are expected to reduce the incidence of SEI births; C) Healthcare providers, birthing hospitals and community-based programs. They will increase their knowledge, self-efficacy and use of evidence based practices, including certification in buprenorphine treatment. They will become an integral part of a continuum of care supporting substance exposed Infants & their parents; 4)The State Medicaid and Child Welfare agencies. Cost effective treatment protocols, prevention and early intervention will reduce costs and increase family unification.
2. The Project ECHO Hubs are already working with health care providers throughout the state to improve their ability to address pediatric mental health issues, complex endocrine issues, and complex pain issues in the context of their primary care practice. Children's Specialized Hospital, a potential partner and a national leader on the treatment of NAS, already participates in the Pediatric ECHO. RWJMS Project ECHO is working with NJ DOH to launch a substance use disorder ECHO. Hub members & our partners are actively engaged with low-income families.
What kind of impact will your idea have? (1500 characters)
By 2020 we aim to bring our SEI ECHO to NJ's 20 birthing hospitals, engaging providers across the state and establish Community Collaboratives in 5 of the communities with a high incidence of SEI births. Our impact: A reduction in SEI birth rates, an increase in rates of family unification & an improvement in transitions of care to home. Further analysis of current SEI outcome data will help us establish our metrics. Our track record with the current PEDS and ENDO ECHOs demonstrates we have had a material impact on provider self-efficacy and knowledge (attachment Year 1 Summary). The following data has been collected:
0 Real-time provider assessments at baseline & six months
0 A two-sample t-test was conducted to compare the difference between the mean baseline and 6-month composite scores
0 A composite score was calculated for each participant, averaging the scores of the self-efficacy questions. Results indicate a statistically significant difference (95% confidence level) in mean self-efficacy score from baseline to 6 months. Between assessments there was a 13.5% increase in the mean self-efficacy score for Pediatric Developmental ECHO participants and a 7.7% increase in the mean self-efficacy score for Endo ECHO participants
0 For Overall Knowledge: There was a 12.1% increase in the mean knowledge score for the Pediatric Developmental ECHO group and an 8.5% increase in the mean knowledge score for the Endo ECHO group. NOTE: Small N, not significant at 95th %tile.
How does or how could your idea impact low-income children? (1500 characters)
New Jersey’s neonatal abstinence syndrome rates were 5.2 per 1,000 hospital births in 2013. These births were disproportionally to low-income families. Nationally, State Medicaid programs covered an estimated 80% of the $1.5 billion in NAS-related annual hospital charges in 2012. Taken together these factors make improving the health and well-being of parents and infants affected by opioid use a public health priority particularly for low-income families. Project ECHO SEI has the endorsement of State Medicaid and NJDCF because of its focus on low-income children. The program will engage with Medicaid recipients providing pre and post natal education and support to influence the SEI birth rate in the state. It is anticipated that the recent adoption of regulations requiring birthing hospitals to report all babies born substance exposed, will result in better identification of SEI. By establishing a seamless continuum of care post discharge and through the infant's first year life, the program will have a material impact on low-income SEI families. This may include: improved access to care (such as timely follow-up of appointments) and better coordination of care. In addition, the multifaceted focus on the bio-psychosocial needs of the mothers and infants will aim to improve the attachment process and reduce the impact of the exposure on the infant's development.
Innovation: What makes your concept innovative? (1500 characters)
The project is designed to disrupt the customary fractured approach to providing treatment for mothers with substance use disorders and their infants . Often the treatment needs of the infant and the mother are not addressed jointly and holistically. Frequently hospitals are unfamiliar or unwilling to identify the maternal substance use and infant exposure. Even in situations when the clinical team has identified an issue they lack the clinical knowledge to effectively medically manage the infants withdrawal to minimize the negative consequences for the infant's development. When issue are identified, infants are frequently sent to specialized hospitals outside of the immediate community for medical management This decision can interfere with the attachment process between the infant and the mother that is so essential to early childhood development. This project aims to address mothers' and infants' needs in an integrated fashion, and develop a plan of safe care that embraces the interdependent well-being of parents and children. The project is also expanding upon the traditional Project ECHO focus on primary care provider and specialist collaboration to incorporate local community-based agencies working in the child welfare, early childhood development, substance use disorder, and mental health sectors. The program offers a broader collaboration using a case based learning model and offers a forum for identifying system barriers and a means to address them.
Scale: Describe how your idea could reach a significant number of end-users. (1500 characters)
While the initial plan is to prototype the model in one community in NJ with a high prevalence of SEI, Project ECHO-- by design--is scalable. Ultimately the goal is to engage the birthing hospitals around the state that have the highest number of babies born substance exposed. The model will reach beyond the hospital settings to engage the surrounding community, utilizing the 20 birthing hospitals in NJ as one of the starting points.
From a sustainability standpoint we are partnering with NJDOH, NJ DCF and NJ Medicaid. NJ DCF is charged with developing plans of safe care for all substance exposed infants the vast majority of who are covered by Medicaid. If this model can reduce the number of babies born substance exposed, put in place more cost effective treatment protocols, and improve outcomes for infants and parents, we anticipate future state level funding may become available. Additionally, we will continue to apply for state, federal and private sector grants.
Feasibility: Where are you with understanding the feasibility of your idea? Describe what you’ve done so far and your plans. (3000 characters)
As discussed above, the Project ECHO model in NJ is already successfully underway for three other clinics. A slightly expanded Project ECHO AMC Hub administrative team will be able to utilize the existing infrastructure and processes for planning, training, developing curriculum, operating, and evaluating the SEI ECHO. The Project ECHO AMC Hub already has a process for prototyping, testing and refining the model thus, creating a clear pathway for implementation.
From the outset we have worked to build stakeholder support for the project. The workgroup membership represents state designees assigned by the Commissioners of Health, Human Services, and Children and Families. In the attachment section of this application, you will find a letter of support from the newly appointed Commissioner of Children and Families for the project. This support from leadership at the highest level in NJ State government, across multiple departments, is a positive indication of the potential for future success and financial support.
In addition to these targeted efforts to build stakeholder support for this particular ECHO clinic, Project ECHO also has an overarching strategy for sustainability. An active statewide sustainability committee is currently undertaking a four pronged approach. The committee is; 1) Applying for grant opportunities, 2) Collaborating with NJ Medicaid to explore federal financial reimbursement opportunities, 3) Working with Medicaid Managed Care health plans to use data to demonstrate proof of concept, and 4) Looking beyond Medicaid to commercial health plans for funding.
Business Viability: How viable is your business model? (1500 characters)
Project ECHO has been supported nationally and worldwide through grants. We are pursing the approach to sustainability outlined above and believe that over the course of the next 2-5 years, we can demonstrate a return on investment that is attractive to the State as well as the commercial and Medicaid health plans. Additionally we are investigating a broader strategy of integrating Project ECHO with "e-consults" and telehealth services to create a comprehensive continuing education and clinical services program. This integrated array of tele-health options would expand access so that the right services can be offered at the right time and cost. Ultimately this will result in better utilization of health care resources and improved outcomes. By using data analysis to capture these improvements, we can position Project ECHO to become a natural extension of continuing education and clinical services.
HCD: How have you used human centered design to build or refine your concept? (1500 characters)
Innovation is not a lightbulb moment of genius. It calls for careful investigation, curiosity and empathy. It also requires understanding and rigorous discernment. We have employed human centered design techniques to conduct thoughtful analysis and problem framing when identifying patterns and determining priorities. Our facilitation training helps the interdisciplinary hub team understand how to ask open questions, engage the participants, and summarize learning. We have developed monthly data dashboards that measure changes in participant knowledge, self efficacy, and adoption of evidence based practices. The dashboards provide insight into what is working so that we can make course corrections to the didactic content and case presentation selections. The use of interactive surveys measure interest and gather feedback during the sessions. We also adjust the curriculum based upon feedback from a weekly survey. The baseline survey and 6 month review gives us a longitudinal view of learning, satisfaction and self-efficacy. As one of our ECHO participants commented, “Project ECHO is the ultimate continuing medical education (CME) program I can imagine, in terms of achieving educational goals!”
Tell us more about you (3000 characters)
The human brain begins forming very early in life, just three weeks after conception, but, brain development is lifelong. The brain is far more impressionable --often referred to as “plastic”-- in early life than in maturity. This plasticity has both a positive and negative implications. On the positive side, it means that young children’s brains are more open to learning and enriching influences. On the negative side, it also means that young children’s brains are more vulnerable to developmental problems should their environment prove especially impoverished or un-nurturing.
The effects of prenatal exposure to drugs on brain development are complex and are affected by the timing, dose, and route of drug exposure. However, substance exposure in utero can have potentially deleterious effects on an infant’s brain development. Nonetheless, minimizing the physical and emotional distress of the newborn by employing evidence based medical interventions, and fostering a family based recovery model that nourishes the maternal infant relationship, infants can achieve developmental milestones while families remain unified. While simply stated, creating the right circumstances for these outcomes requires a thoughtful constellation of services from prenatal care through the first year of the infant’s life.
Our existing ECHO clinics are a microcosm of the transformational impact of collaboration in action. We started our first pediatric ECHO focused on developmental screening for autism, ADHD and developmental delays. We found that the economic incentives were not aligned to motivate pediatricians to treat autism and ADHD children in the context of primary care. We re-surveyed the pediatricians to understand better their true pain points. Based upon that reassessment we developed a pediatric behavioral health ECHO. The interdisciplinary team consists of a psychiatrist, a development physician, a clinical psychologist, a pharmacist and social worker. Within three months of this reconfiguration the ECHO clinic has successfully engaged up to 40 providers.
Building upon our experience with the pediatric population, we can apply a similar design approach and identify the right incentives for engaging each component of the continuum of care. In this way we can expand the ECHO model beyond the walls of hospitals and healthcare. Importantly, we will also be drawing upon on the experience of multiple experts in early childhood from Rutgers University, Rutgers RWJMS, Children's Specialized Hospital, and The Nicholson Foundation (see links to their websites below). With both the subject matter expertise and our growing experience in the program design process we can build an intervention that will have positive repercussions for children, families, and communities in NJ.
Project ECHO: http://www.rwjpartners.org/project-echo/
Nicholson Foundation: http://rightfromthestartnj.org/development.html
Do you have the people and partners you need to do what you’ve described? (500 characters)
We have established a work group of the following partners: NJ DCF, the NJ DOH, the NJ DHS, the Southern New Jersey Perinatal Collaborative, and the Central Jersey Family Health Consortium. We will expand this group to include: leading researchers on parent/infant mental health and leading medical and social service experts on the treatment of pregnant and parenting women with opioid use disorders and their infants. Local community partners will be added during program rollout based upon needs.
As you consider your next steps, what kinds of help could you use? Is there a type of expertise that would be most helpful? (1800 characters)
There are 3 areas of expertise that would be useful to us as we move into the development phase of the program: evaluation and research design; community and provider recruitment programs, educational evaluation and curriculum design
Would you like mentoring support? [Relevant only for Early Submission Deadline]
If so, what type of mentoring support do you think you need? (1200 characters) [Relevant only for Early Submission Deadline]
Mentorship: How was your idea supported? [Relevant only for our early submission participants] (1500 characters)
Are you willing to share your email contact information submitted on OpenIDEO with Gary Community Investments?
Yes, share my contact information
[Optional] Biography: Upload your biography. Please include links to relevant information (portfolio, LinkedIn profile, organization website, etc).
[Optional] Attachments: Please upload relevant attachments or graphics or show us how you prototyped.