Hamot Health Foundation

Our goal is to reduce the incidence and impact of NAS by improving systems of care, coordinating services across clinical settings, and expanding family supports for rural pregnant and postpartum individuals and their families. Our innovative program will facilitate the adoption of evidence-based practices in our target service area designed in response to unmet needs and gaps in care that contribute to adverse outcomes among individuals and their families in NWPA. These include (a) a lack of trained providers to deliver "point of care" addiction medicine services including the initiation of medications for OUD (MOUD) for pregnant individuals, (b) a lack of dedicated personnel to support neonatal interventions to decrease NAS severity, (c) a lack case management services (e.g., Plans of Safe Care) to bridge the gaps between inpatient and outpatient clinical care settings, service systems, and recovery supports, and (d) a lack of outpatient services to address social determinants of health (SDOH) and physical health needs (e.g., HCV/HIV). Initiatives will address these gaps by developing, implementing, and sustaining programs and services across community and clinical settings including: a. a Parent Partnership Unit, a rooming-in unit that will utilize Eat, Sleep, and Console. b. a PPU Nurse Navigator providing case management , Plans of Safe Care and who will work with the Nurse Health Navigator to integrate inpatient with outpatient services c. a Peer Recovery Specialist d. a peer-to-peer addiction medicine education, mentoring, and consultation program e. the development of clinical pathways for SUD, HCV/HIV, intimate partner violence (IPV), and SDOH screening across clinical settings. f. remotely delivered telehealth HCV consultations designed specifically for pregnant and postpartum individuals with SUD g. outpatient SUD treatment services to seamlessly bridge care transitions that between inpatient and outpatient clinical settings.