News & Updates — Grantee Spotlight

Pregnancy can be a powerful motivator to seek treatment for opioid use disorder, but pursuing it can be daunting challenge for people who fear they’ll be subject to stigmatizing behavior, criminalization and/or a child welfare investigation, which could lead to being separated from their child or children. Dominika Seidman, MD, MAS, an obstetrician and gynecologist at Zuckerberg San Francisco General Hospital and a FORE grantee, has spent the last six years helping people who are affected by substance use disorders (SUDs), homelessness, pregnancy, and mental health conditions gain access to treatment and ongoing care. Her FORE-funded project, Team Lily, is designed to engage people facing multiple barriers to care in a city where voters recently approved a ballot measure that compels single adults who receive cash assistance to submit to drug testing and enroll in free treatment to retain the support. FORE asked Dr. Seidman how the program helps to engage pregnant people by fostering trust and removing logistical barriers to care.
 

 

“What we’ve learned, time and time again, is that people’s basic needs need to be met in order for them to be able to prioritize treatment and recovery.”

 
 
Where did the idea for Team Lily come from?

Seidman: It’s named after a former patient and modeled on a successful approach the city used to engage people with HIV in treatment. We launched the program in 2018 after seeing how many pregnant people with SUDs and mental illnesses were presenting to our labor and delivery unit without having received any prenatal care. At the time, San Francisco was facing worsening housing and opioid crises, and congenital syphilis had reemerged after years of effective elimination strategies. Our solution was to create a low-barrier clinic that offers both medical and behavioral health services, including medications for opioid use disorder, to pregnant and parenting people for up two years. We operate very differently from traditional practices. Instead of being turned away if you are 15 minutes late for an appointment, you can arrive at 4 p.m. and still see a pregnancy provider, a mental health clinician, a social worker, and talk about getting food through the Women, Infants, and Children program, among other services.

What happens in the absence of such a program?

Seidman: A person might turn up in the emergency department or hospital, have a baby, and have a traumatic experience as their baby is removed by child protective services (CPS). In these circumstances, we’ve seen people take off quite quickly, very understandably, because they were offered punitive responses rather than support and treatment of their health conditions. In other instances, we’ve seen people come in, have a baby, and have such severe withdrawal symptoms they have to leave before they are able to access care.

How are you going upstream to find people before they reach this point?

Seidman: We form relationships with the organizations that people are likely to turn for help: shelters, needle exchanges, safe sleep sites, urgent cares, and emergency departments, as well as the city’s crisis management system for people with significant mental illness. They refer people directly to us. We find this is more efficient than waiting for people to navigate into the prenatal care system. If a patient who’s been referred to us is not ready to come into clinic, we’ll send our outreach team to navigate them in or do outreach over time to build trust so that they eventually feel comfortable coming in. We are most proud of our referrals from current and former clients, who trust us to care for their friends and family members in the community.

How long does it take to build that trust?

Seidman: It’s so variable. For some people, our team is able to establish trust in a visit or two. For others it could take months and months. We find their number one fear — 99 percent of the time if they’ve had prior births — is that their baby is going to be removed from them. We also find people are expecting to be treated with disrespect, to receive sub-standard care, and to be discriminated against by the health care system.

What seems to help?

Seidman: What we’ve learned, time and time again, is that people’s basic needs need to be met in order for them to be able to prioritize treatment and recovery. Many people lack basics, like food, clothing, and toiletries, so we help them gain access to those supports. We also emphasize transparency and making sure we are asking permission — whether we are interacting with someone in the street or in the clinic. For example, a simple thing in pregnancy care is doing a urine culture. I have to say— often ten times —”I am not testing this for drugs. You can see the test I’m ordering on the screen.” We are also careful not to make promises that we can’t keep.

How so?

Seidman: Our program is designed to help people achieve the best outcomes, including finding safe housing, treatment for mental health needs and SUDs, and a safe delivery for the parent and the baby. We always talk about the ideal: getting into treatment and housing. But we have to be clear about what may happen if a person is still using drugs at the point of birth. We will say that if you are still using drugs, there is a pathway where you can still be with your baby and that is to move directly into residential treatment from the hospital. We point out CPS will be involved in overseeing that, but there usually won’t be a separation or removal, which is what most people have experienced or heard about.

How successful have you been in getting people into treatment by the time they are ready to give birth?

Seidman: With the influx of fentanyl, it has been much, more challenging to help people get into treatment. Their opioid needs are so high that using buprenorphine in an outpatient setting often isn’t working. They either have to receive methadone from an opioid treatment program or enter residential treatment, which requires stabilization on a medication for OUD in advance of entry, or cessation of methamphetamines. This is tremendously challenging for a population with transportation barriers, mental health challenges, and housing, as well as other barriers. We’re also finding health plans are limiting the length of stay for residential treatment to 90 days, instead of a year. People who are unsheltered and have SUDs and significant mental illnesses are barely stabilized in 90 days.

What happens when they are discharged?

Seidman: Often people are transitioned into housing where drug use is so prevalent, it’s almost impossible to maintain sobriety. We are fortunate that we have two psychiatrists on our team who help engage people in care and as someone is stabilized, help them maintain stability. What we see is if mental health needs are not addressed, it all comes crumbling down.

What sorts of results are you seeing in terms of CPS involvement and health outcomes?

Seidman: When we look at data for 2021 and 2022, we see some promising results. While CPS became involved in 57 percent of the 114 births we oversaw, three-quarters of patients left the hospital with their babies, either because they were entering treatment or were already in treatment. We are seeing some promising results. When we looked at longer term outcomes for that group, we saw there were no overdose deaths and 85 percent of babies were up-to-date on their well-child visits. The challenge is that, in our experience, CPS is quite unpredictable. The decision to remove the child often depends on who the worker is and their prior experiences with families affected by substance use. We always emphasize to patients that there is a lot of uncertainty built in and that we will advocate to keep them together if they are willing to go into residential treatment with their baby.

Have you had any discussions with CPS about improving the process?

Seidman: It’s an ongoing discussion and we’re very grateful to them for talking with us and hearing our point of view. We helped their workers understand the dangers of misinterpreting fentanyl tests and they’ve been much more willing to collaborate around an appropriate plan of care for our patients. The challenge is that there’s still a lack of transparency, and no reliable recourse when decisions seem unjust.

How about in terms of housing? What are the biggest gaps you see?

Seidman: Even though pregnant people are hypothetically prioritized for housing, placement is also very unpredictable. We have some patients who are unsheltered throughout their pregnancy and then sheltered a week or two before giving birth, and others who seem to move into housing right away. One of the challenges is that clients have to be reachable. If a housing program can’t get in touch with you within 72 hours of having a space, they will often move on to the next person.

Part of your grant is involves making the financial case for supporting program like yours. How are you going about it?

Seidman: Our goal is to document the benefits of the program in terms of avoided costs and benefits to health systems and local government. It costs roughly $1 million a year to run our program, and we launched in 2018 with grant funding. California’s Enhanced Care Management program is increasingly covering the cost of our social workers and navigator, who have a caseload of 10 to 20 patients per month. We bill for the outpatient visits with medical providers and are working to identify the revenue the hospital receives —or doesn’t — for providing substance use treatment and other services in the inpatient setting. Hospital billing is so complex, and it’s essential to understand so that we build a sustainable system, especially as patients require more and more complex care.