4

PPW-PLT Findings

In this chapter, the committee presents its findings related to the activities conducted by the State Pilot Grant Program for Treatment for Pregnant and Postpartum Women (PPW-PLT) grantees and the outcomes of these activities. The findings are organized by the framework developed by the committee as described in Chapter 2, including grantee activities, partnerships and network building, environmental and structural change, and outcomes at the individual and community levels. The program purpose and a brief description of the information sources reviewed are presented as background and are described in greater depth in Chapters 1 and 2. Committee conclusions are presented in Chapter 7.

PROGRAM PURPOSE

Pregnant and postpartum women face significant barriers in locating treatment services that offer comprehensive substance use disorder (SUD) treatment and address the complex, multifactorial nature of perinatal SUD. Pregnant and postpartum clients also experience challenges of retaining in treatment for a variety of reasons, including stigma of receiving treatment, criminalization, fear of prosecution or reporting to child welfare, lack of childcare or transportation, and lack of knowledge of what programs may be available to them (Choi et al., 2022; Madden et al., 2022; SAMHSA, 2015). Simultaneously, maternal SUD and opioid use disorder (OUD) rates have risen significantly between 2010–2017, and a significant treatment gap continues to exist for this population (Meinhofer et al., 2020).

Title V, Addiction and Treatment Services for Women, Families, and Veterans, Section 501 of the Comprehensive Addiction and Recovery Act (CARA) established a pilot grant program (PPW-PLT) for nonresidential SUD and OUD treatment services to pregnant and postpartum women (PPW) and their children. The committee notes that this program shares several goals with its counterpart, the Grant Program for Residential Treatment for Pregnant and Postpartum Women, which SAMHSA initiated in the early 2000s. Though this grant program has also continued and, in fact, has had grantees in some of the same states, the PPW-PLT program is notable for expanding the grant opportunity to fund outpatient treatment settings.

The purpose of the PPW-PLT program is to

As a result of this program, “[the Substance Abuse and Mental Health Services Administration] SAMHSA seeks to: 1) reduce the abuse of alcohol and other drugs; 2) increase engagement in treatment services; 3) increase retention in the appropriate level and duration of services; and 4) increase access to the use of medications approved by the Food and Drug Administration in combination with counseling for the treatment of drug addiction” (SAMHSA, 2017b). Additional information about the program can be found in Table 2-1.

To be eligible for PPW-PLT funding, a potential awardee must be a State Agency for Substance Abuse (SSA; SAMHSA, 2017b). Massachusetts, New York, and Virginia were funded in fiscal year (FY) 2017 (SAMHSA, 2017h), and Georgia, North Carolina, and Tennessee were funded in FY2018 (SAMHSA, 2018g).¹ These SSAs are the primary recipients of the grant, but are required to partner with at least one direct service provider organization, which carries out a number of the grant activities (e.g., an SUD treatment organization) and which must meet the following criteria:²

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¹ See Box A-2 in Appendix A for a complete list of PPW-PLT grantees. The committee notes that some states are also recipients of the residential PPW grant.

² Program description text in this section is reprinted from the second report in this series (NASEM, 2021).

2 years; and is in compliance with all local and state licensing, accreditation, and certification requirements. Grantees may receive funding for up to 3 years (SAMHSA, 2017b).

Two grantees received no-cost extensions.

INFORMATION SOURCES AND LIMITATIONS

As discussed in Chapter 2, the committee reviewed information from three different sources. The committee received aggregate data from SAMHSA about client enrollment and outcomes submitted by PPW-PLT grantees through the Government Performance and Results Act (GPRA) reporting system. The committee also reviewed grantee progress reports. The committee reached out to grantees directly and requested comprehensive progress reports or most recent progress reports, as available. SAMHSA then submitted redacted progress reports from the remaining grantees. To supplement the information it received from SAMHSA, the committee subcontracted with NORC to conduct interviews with a sample of grantees. The report is reprinted in its entirety in Appendix B, and the limitations are discussed in greater depth there.

In this chapter, the committee has also noted relevant literature about the effectiveness of interventions similar to those grantees implemented. However, because the committee often did not have enough information about grantee contexts, it also cannot directly compare grantee efforts to this outside literature or directly extrapolate inferences about grantee effectiveness. Nevertheless, it notes some instances in which grantee plans were rooted in interventions that have potential to be effective.

As described in Chapter 2, the committee reviewed the information from all three sources and organized the information according to the “logic model” discussed in Chapter 2. The findings are described below. Conclusions are presented in Chapter 7.³

FINDINGS: GRANTEE ACTIVITIES

The PPW grantees conducted a range of activities. Many of their activities were limited by the COVID-19 pandemic and other structural/policy barriers as detailed below. Nonetheless, grantees succeeded in notable ac-

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³ All information supplied by SAMHSA is available on request through the National Academies Public Access File, see https://www.nationalacademies.org/our-work/review-of-specificprograms-in-the-comprehensive-addiction-and-recovery-act (accessed March 6, 2023). Information used directly in the report are publicly available in an online appendix on the National Academies Press website as “additional resources” to the published report: https://nap.edu/26831 (accessed March 9, 2023).

complishments ranging from service delivery to capacity building via holding training sessions and creating toolkits for future use.

Accomplishments

Expansion of Services to Rural Areas

According to progress reports, many grantees intended to establish PPW programming for rural, underserved areas, which was a focus highlighted in many grantee reports and is currently a gap in available services in many areas (Cerdá and Krawczyx, 2020; Martin et al., 2020). One of the grantees set up PPW programming in rural counties that previously had no services for this population. One of the grantees serving a rural area described forming a Mobile Community Response Team during the COVID-19 pandemic to provide clients with continued access to basic resources. Highlights from the grantee reports included efforts to improve transportation options for clients in rural areas, some improved options for transitional and long-term housing, and working toward stigma reduction in these areas at the local level through partnerships and trainings.

Engagement of Peer Support Workers

In progress reports, several grantees reported on the addition of peer support workers in their programming. Peer support workers’ activities ranged from advocacy at the client level for obtaining resources; linking clients to community organizations and resources, including Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs; and attending appointments such as medical and court appointments with the client. One grantee conducted focus groups of PPW clients, and the results reflected the importance of peer support services for clients. Grantees reported that peer support workers increased participant engagement in PPW services. Studies suggest that the use of peer support and peer coaching programs have benefits for people with SUDs, including for pregnant and parenting persons (Newell et al., 2022; Paterno et al., 2019; Reif et al., 2014a). One grantee included a plan for sustainability funding for PPW peer support workers in their progress report, which is notable as peer support workers at this time are not able to bill for their services through Medicaid.

Training and Capacity Building

Several grantees described in their reports the importance of training, capacity building, and technical assistance (TA), especially in the early

stages of the PPW grants. One of the grantees utilized the SAMHSA Technical Assistance and Training on Women and Families Impacted by Substance Use and Mental Health Disorders to offer training on gender-based, family-centered treatment to each of its subgrantee sites; it also extended the training to six other outpatient programs that serve similar populations. This was a train-the-trainer model session, designed to build capacity and expand the use, across the state, of evidence-based, gender-based, family-centered treatment for the pregnant and parenting population.

Training staff in trauma-informed care/practices and managing trauma responses in recovery was also a notable accomplishment for some of the grantees. Trauma can impact childbearing outcomes, and as such, integrating trauma-informed care into SUD care is likely to benefit clients (Henry et al., 2021; Sperlich et al., 2017). Data in the reports demonstrated that a high percentage of participants had a history of trauma, according to screening tools. Some of the grantees described implementing formal training sessions on trauma-informed care both for their own staff and to other organizations serving similar populations. One of the grantees created a toolkit on “Developing Trauma-Informed Organizations” and utilized the skill set of its program director to train all of its staff members in its PPW subgrantees in this model.

Services Provided to Individuals with SUD

This section presents some of the data grantees reported, via the GPRA tool, about client characteristics and service provision. For a more detailed discussion of the limitations of this tool, refer to Chapter 2.

Between the two cohorts of grantees, the committee received intake data on a total of 1,392 clients [P1a].⁴ Among those surveyed, the majority of clients were white (62%), 18% identified as Black, and 8% identified as Hispanic/Latina [P2b]. The committee notes that the PPW-PLT grantees were tasked with addressing disparities in treatment access, and that Black women are disproportionately likely to be funneled into child protective services or other legal processes rather than into treatment (Hart and Hart, 2019; SAMHSA, 2015; Taxy et al., 2015). However, due to the aggregation of the GPRA data, the committee cannot comment on the demographic makeup or representativeness of the client populations relative to the communities and catchment areas in which grantees operated.

Relatively few clients reported using opioids in the 30 days prior to intake, and 69% of clients reported no drug use during that time [P2c]. This

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⁴ Citation refers to the source of the material from that submitted by SAMHSA and included in the online appendix. Indicates the program and Excel citation (PPW-PLT [P], workbook [1], and worksheet [a]).

statistic is difficult to interpret without more information; it is possible that participants did not use in the month prior to the intake interview because they had already been in the grantee’s programming prior to SAMHSA funding beginning (and thus prior to GPRA data being collected), had previously been enrolled in another program including residential programming, or had been incarcerated.

The GPRA data that SAMHSA provided to the committee also included information on the PPW-PLT grantees’ provision of selected services [P3a]. The committee has highlighted some of the core activities that are relevant to the PPW-PLT grant. However, as discussed in the Building Communities of Recovery (BCOR) chapter, there are a number of confounds that complicate analysis of these data. The services data were only reported for those clients that had a discharge interview (about 41.5% of enrolled clients; [P4a]), not all clients in the program; the committee did not have information on exactly which services were planned or expected for any given client or grantee; the data do not indicate the number of times a service was provided to each participant (e.g., whether a client received family/marriage counseling 1 time or 10 times). Thus, though the GPRA data about services provided might present a brief snapshot of the types of services provided to PPW-PLT clients, it may not be representative and does not indicate the intensity of services. Selected services relevant to the PPW-PLT program goals include:

• Screening and assessment
  • Screening: 50 percent of reporting clients
  • Assessment: 61 percent of reporting clients
• Treatment
  • Brief interventions: 23 percent of reporting clients
  • Brief treatment: 20 percent of reporting clients
  • Medical services: 13 percent of reporting clients
  • Pharmacological intervention: 7 percent of reporting clients
  • Peer coaching or mentoring: 60 percent of reporting clients
• Case management and related services
  • Case management: 88 percent of clients of reporting clients
  • Family services: 42 percent of reporting clients
  • Transportation: 35 percent of reporting clients
  • Pre-employment or employment coaching: 22 percent of reporting clients
• Substance abuse education⁵: 53 percent of reporting clients
• Information and referral: 32 percent of reporting clients

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⁵ The committee notes that it prefers the term “substance use” and is reflecting the language used in the GPRA tool.

• Aftercare
  • Continuing care: 13 percent of reporting clients
  • Relapse⁶ prevention: 29 percent of reporting clients

The committee did not receive information on exactly how grantees defined the services, and thus cannot comment on the evidence base or suitability of these interventions to the grantees’ client populations. The committee notes that it would expect a higher percentage of clients to receive screening and assessment after intake, which are essential for guiding care plans for patients (SAMHSA, 2018a); according to these data, 50 percent of reporting clients received screening and 61 percent assessment. It is unclear to the committee what might explain these numbers [P3a]. It also seemed that a relatively low percentage of clients received family-based services (one of the priorities of the SAMHSA Funding Opportunity Announcement), “substance abuse” education, information and referral, aftercare, or medical services [P3a]. The most commonly provided “medical service” noted in the GPRA services data was alcohol/drug testing (undergone by 43% of reporting clients [P3a]), which the committee notes is not a medical service. The committee notes that such a service can be the cause of adverse consequences for pregnant and postpartum populations, including discharge from treatment programs, reporting to child welfare, or probation (Angelotta et al., 2016; ASAM, 2017; Faherty et al., 2019; Falletta et al., 2018; Kozhimannil et al., 2019).

Barriers

Grantees commented upon several barriers to effectively implementing their programming, many of which were unique to the pregnant and parenting population affected by SUD. While some of these barriers were seen to affect the other CARA programs, such as the COVID-19 pandemic, systemic and policy barriers were frequently highlighted in the PPW-PLT grantee reports.

COVID-19 Pandemic

Though both cohorts of PPW-PLT grantees began their work prior to the beginning of the COVID-19 pandemic, their implementation periods did overlap with the pandemic. The FY2017 cohort was funded through September 30, 2020, and the FY2018 cohort was funded through Septem-

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⁶ This is the term for this service as used in the GPRA tool. For a discussion of the committee’s use of the term “relapse,” see Chapter 1 of this report.

ber 30, 2021; additionally, two grantees received no-cost extensions to continue their work beyond those time frames.

The COVID-19 pandemic affected PPW-PLT grantees in numerous ways. First, as noted in the NORC report, the pandemic saw increased rates of overdose and relapse or return to substance use across the country, increasing the need and demand for the types of services PPW-PLT grantees provide. Most of the grantees were not able to reach target enrollment and cited in progress reports as one of the obstacles the fact that in-person programming was discontinued due to COVID restrictions implemented at local levels. The COVID-19 pandemic contributed to delays in hiring staff, and, for some grantees, contributed to staff turnover. Adding to staffing challenges and service delivery, grantee reports stated that staff required to work from home may not have been as effective in providing outreach, enrolling individuals, and performing follow-up through remote technology. The committee notes that some grantees had difficulty with client enrollment and staff turnover prior to COVID-19; the pandemic likely exacerbated their challenges.

Grantees commented in progress reports about the challenges faced by discontinuing in-person services. Several grantees discontinued childcare services during the COVID-19 pandemic or were not able to provide consistent childcare. Childcare was described as an important component of the treatment services that allowed clients to participate in SUD treatment. In addition, due to school closures, grantees reported that several clients were forced to choose between SUD treatment participation and supervising remote schooling for their children.

The provision of telehealth and tele-services, including implementation of family treatment sessions delivered over virtual technology, was viewed by grantees as an overall solution to the discontinuation of in-person services during the COVID-19 pandemic. In the NORC interviews, some highlighted unexpected benefits, such as cost-savings conferred by virtual services, and a broader client reach. However, in progress reports, grantees noted specific barriers to the implementation and delivery of tele-services for the participants in the following settings:

• participants living in rural settings,
• incarcerated women living in criminal justice settings,
• enrolled participants who did not have stable housing,
• enrolled participants experiencing homelessness,
• enrolled participants at risk of losing telephone access, and
• enrolled participants who had to prioritize working or caring for their children over SUD treatment.

Staffing

Another barrier experienced by grantees was staffing. Staffing shortages were cited in progress reports as a contributing factor to delays in starting their implementation, and an obstacle to providing services. Grantees serving rural areas, in particular, identified staffing as a significant barrier, especially finding qualified staff with the skills/competencies to care for PPW clients. A notable barrier for rural grantees and subgrantees included long travel times for staff that may have contributed to high staff turnover, but nonrural grantees also reported high staff turnover.

Systemic and Policy Barriers

PPW-PLT grantees consistently identified lack of recovery housing and suitable transitional housing for PPW clients/families as a barrier for service delivery in achieving PPW-PLT program goals. Grantee reports indicated that many clients did not have any housing options available to them that were viable long term during the time they were participating in the grantees’ programming; housing options were particularly limited for PPW clients living in rural areas. Grantees highlighted stigma around addiction as a barrier to securing housing for PPW clients. PPW-PLT grantees working with clients in the criminal justice system also identified lack of housing and the role of stigma as a major barrier to achieving PPW-PLT program goals. Notably, one grantee included in its report that it reached out to a legislator about housing support. The committee notes that housing is a crucial determinant to outcomes for the PPW population (Frazer et al., 2019; Petzold et al., 2022); as such, such outreach could carry benefits for the patient population in the long run.

Another barrier grantees reported in progress reports was lack of transportation. Most individuals did not have their own transportation and relied on the grantees to provide transportation or sought out transportation through their insurance. This barrier was especially an issue for grantees in rural areas; grantees reported that transporting clients was extremely difficult, as some participants lived in mountainous areas and van transportation sometimes took several hours. Transportation through Medicaid services was noted to be inconsistent. The COVID-19 pandemic placed additional challenges on some grantees’ plans for transporting both staff and participants (this ranged from the grantees being unable to provide transport at all to limiting the number of individuals who could ride on the program van, for example). Overall, inconsistent transportation to services led to inconsistent attendance, as well as missing medical appointments such as prenatal care.

The NORC interview findings echoed these findings: grantees in both the BCOR and PPW-PLT programs highlighted that a lack of infrastructure in the broader environment for wraparound services (e.g., transportation, and housing)⁷ and for medications for opioid use disorder (MOUD) availability presented barriers to treatment.

Some grantees identified the criminal justice system as a source of barriers to engaging with clients, as participants were often at risk of re-arrest and reincarceration. Grantee reports detailed challenges with reaching clients once incarcerated, and when clients were released, they were often difficult to locate and re-engage in services.

Several grantees identified the child welfare system and the associated family court system as sources of barriers to achieving the PPW-PLT program outcomes. Grantees wrote in progress reports that it was difficult to retain clients in treatment if they were not actively parenting their children, and that if a client were to lose custody of their child, often there was little motivation to stay enrolled in services. In addition, it was noted that some child welfare agency workers were accustomed to only residential-level services for this population and did not find outpatient-level service programs appropriate to meet child welfare service plan requirements.⁸

SAMHSA and Grant Management

Grantees cited a number of challenges that the grant management presented to carrying out activities and services. First, in the NORC interviews, “several CSAT [Center for Substance Abuse Treatment] grantees” cited delayed funding from SAMHSA as a source of delay in implementation start-up; they highlighted “strained or nonexistent” relationships with SAMHSA government program officers “due to a lack of communication and/or having a new PO [program officer] assigned up to three times during their grant” and short implementation/funding periods.

In progress reports, grantees reported facing challenges with collecting GPRA data, and some reported that implementing the initial GPRA tool

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⁷ Given that the outpatient approach is a pilot for SAMHSA’s PPW-PLT program, a complete evaluation would include assessment of recovery housing, suitable transitional housing, and transportation availability in the catchment areas of the grantees. However, the committee did not have adequate information to investigate this or connect it to client outcomes.

⁸ Similarly to above, such hesitation, if widespread among child welfare workers, could present a challenge for outpatient PPW-PLT programs and warrants further investigation. Collaboration among SUD programming for pregnant and postpartum persons, the child welfare system, and the family court system is crucial for health and equity. One of the most common reasons for entering foster care presently is parental substance use (Meinhofer and Angleró-Díaz, 2019); further, Black and Brown families are disproportionately represented in foster care overall (Roberts, 2022).

was viewed negatively among some grantee staff. Staff reported that the tool contained stigmatizing language and did not serve to build trust between the client and implementing staff. Staff faced obstacles in performing follow-up GPRA surveys due to some of the challenges highlighted above: staffing, the COVID-19 pandemic, and difficulty locating clients. They also noted that these factors were compounded by the realities of the lives of their patients—for example, housing status, having their phones turned off, or reincarceration—that rendered the GPRA targeted follow-up rates difficult to achieve.

The NORC interviews underscored a number of challenges that grantees identified in implementing the GPRA data collection tool. Some grantees felt that the tool:

• did not “capture the full story of the program”
• focused on follow-up rates over quality of care provided
• created unnecessary administrative burden
• focused on follow-up rates that might lead grantees to “cherry pick clients that are more likely to follow up”

FINDINGS: PARTNERS AND NETWORK

Effective partnerships and networks, as with other CARA programs, were noted to play an instrumental role in grantee implementation of the PPW-PLT program. As noted in the PPW-PLT program’s purpose as outlined by SAMHSA, a major goal included promoting a coordinated, efficient, and effective state system via new models of service delivery. Grantees were required to partner with at least one treatment provider with SUD treatment expertise. The PPW-PLT grantees created partnerships with a range of actors, including medical service providers, such as OB/GYN providers and addiction medicine specialists, and state agencies. According to the NORC interviews, both PPW-PLT and BCOR grantees identified the strengthening and building of partnerships as a “success” of their work.

Partnerships with Medical Providers

As grantees’ clients were either pregnant or postpartum, several grantees sought to form partnerships with hospitals and health systems to provide prenatal care, addiction medicine treatment, and psychiatric care. Many grantees included in their reports examples of building partnerships with emergency departments and OB/GYN providers by holding informational sessions about their PPW services in order to encourage referrals from medical partners. In the NORC report, some CARA grantees (exact program is not specified) encountered difficulties in partnering with emer-

gency departments and federally qualified health centers (FQHCs) during the COVID-19 pandemic, given the many demands on staff time; it is possible these challenges impacted PPW-PLT grantees.

Partnerships with Local- and State-Level Agencies

Multiple grantees wrote in progress reports about partnerships with local- and state- level child welfare agencies. This was primarily done through advisory councils, through which PPW-PLT staff would invite child welfare agency representatives to regularly attend PPW-PLT meetings and learn about their services. Grantee reports included several examples about building positive partnerships between single state agencies, PPW-PLT programs, and child welfare, which helped increase referrals from child welfare to PPW-PLT programs and include PPW-PLT programs in plans of safe care for clients involved in the child welfare system.

Grantees did note that several of the intended partnerships were delayed due to the COVID-19 pandemic (e.g., conferences delayed or switched to virtual, less meeting attendance than expected). However, overall, this was noted to be a critical area for partnership with positive improvement as so many families were already involved or at risk of child welfare agency involvement due to SUD.

Partnerships with Community Organizations

All PPW-PLT grantees described, in both progress reports and the NORC interviews, forming partnerships with community organizations. Benefits of these partnerships were cited by grantees as essential and included dissemination to the community of information about the grantee’s services; improved access for PPW clients to resources for basic needs (e.g., diapers, wipes, food pantries); and linkage of PPW clients to other essential services such as employment and education. Grantees described that identifying potential useful community partners was a key focus of PPW-PLT staff, and that peer support specialists relied on these partnerships to assist clients in obtaining essential resources.

FINDINGS: STRUCTURAL AND ENVIRONMENTAL CHANGE

Accomplishments

Some PPW-PLT grantees engaged in activities intended to make some inroads into changing the structural systems and environment for families impacted by SUD and to ensure programming sustainability. PPW-PLT grantees noted in reports that multiple factors affect PPW clients, includ-

ing the child welfare system, social determinants of health, and the locality of the client, all of which directly impact individual- and community-level outcomes in SUD treatment.

These types of efforts may have eventual impacts on the populations targeted by grantee activities. Though it was not always possible to identify the extent to which these activities produced their desired effects—in part because structural change and sustainability efforts require a longer time frame to assess impact—the committee has highlighted the following as those activities with the potential to create such change.

Creating Treatment Infrastructure in Rural Areas

Some of the grantees described working intentionally to identify counties in rural areas that were deserts for SUD services for PPW clients. In many areas of the United States, treatment services for pregnant/postpartum individuals do not exist, or those individuals face additional barriers to accessing care (Martin et al., 2020; Patrick et al., 2020). The limited availability of specialized SUD treatment providers and programs has been noted to contribute to the treatment gap for pregnant persons with SUD (Meinhofer et al., 2020); PPW programs that offer a range of services (childcare, linkage to MOUD, linkage to behavioral health services, for example) have been noted to improve treatment outcomes by addressing the full context of the family affected by SUD (Short et al., 2018).

Though these grantees faced significant barriers, including staffing, transportation, and housing, the establishment of PPW-PLT services in rural areas constitutes a step toward reducing the treatment gap for the PPW population. These grantees used peer service workers in their service delivery, and detailed, in progress reports, their work in establishing partnerships with community-based organizations.

Coordination Between Child Welfare System and SUD Treatment System

All the PPW-PLT grantees noted in their progress reports that their clients were either involved in, or at risk of, child welfare involvement. Several grantees engaged in efforts to promote cross-sector collaboration, which the committee notes has the potential to effect structural and policy change for the PPW population by moving toward authentic collaboration between single state agencies administering PPW programs and child welfare agencies.

Such efforts took several forms. As noted in the partnership section, many of the grantees included in their reports efforts to establish advisory councils/boards where child welfare agency leadership representatives were included. One grantee included a grant objective to work on CAPTA (Child

Abuse Prevention Treatment Act) plans of safe care⁹ collaboratively with the state child welfare agency. Some grantees reported that child welfare caseworkers began to refer to their services as part of a family’s plan of safe care or other types of indicated SUD treatment. This suggested that the two state agencies were moving toward higher levels of collaboration with that system for the benefit of the PPW population.

Partnership Building

The committee notes that efforts to form connections and partnerships, as described in the previous section, could have long-term ramifications. Such efforts may, by strengthening the safety net of services that could benefit the PPW-PLT population, ultimately improve care available in grantees’ service areas, increase community-level awareness of SUD, or reduce stigma.

Technical Assistance, Training, and Capacity Building

Grantees recognized in progress reports that providing services for PPW clients required a particular set of skills and competencies and the use of evidence-based practices.

Training sessions and capacity building around evidence-based practices were viewed by grantees as critically important for several reasons. First, grantees highlighted the creation of manuals and protocols for service delivery and train-the-trainer model trainings as tools in increasing sustainability of grantee efforts; even if staff or key personnel were to leave, these structures could enhance the probability that services could be continued. Additionally, grantees felt that trainings and capacity building ensured that staff—both their own and in the broader service provision system—were better prepared to deliver services to clients. Finally, they provided opportunities for grantees to bring together community and medical/behavioral health stakeholders.

Several grantees, by the end of their 3-year period, had implemented formal capacity building trainings not only for their internal staff but also for other providers/stakeholders. As highlighted previously, examples grantees noted in progress reports included the use of SAMHSA’s TA program to lead a statewide training to establish a set of standards for gender-based SUD treatment, called Family Centered Treatment, and Project CARA, a partnership that included a wide variety of stakeholders, and also used

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⁹ The committee notes that implementation of compliance with CAPTA policies has varied widely (Lloyd et al., 2019). Analysis of the impact of CAPTA is out of the scope of this report.

SAMHSA clinical guidelines along with an evidence-based parenting model to hold several trainings across the state for a variety of providers.

Efforts to Secure Funding Past the End of the Grant

The NORC report noted that grantees across the four CARA programs were “applying for additional federal, state and/or local funding to maintain internal supports (e.g., staff) and processes (e.g., trainings),” and progress reports highlighted specific efforts undertaken by PPW-PLT grantees. Two grantees discussed exploring Medicaid as a source of sustainability for funding the services they offered to the pregnant and postpartum populations in their states, which has potential to improve sustainability of these services. One grantee included a plan for sustainability of funding for PPW peer support workers in its report. The committee does not have information on the outcomes of these efforts.

Barriers

External factors influence population-level outcomes for pregnant and postpartum women affected by SUD and their families. Despite the establishment of services, grantees noted how external factors continue to negatively influence treatment outcomes. Upon review of the grantee reports and the NORC interviews, structural factors such as the criminal justice system, the child welfare systems, the lack of available and affordable housing, the stigma of addiction, and the geographic distribution of services were all identified as key barriers to grantees’ goals of supporting families affected by SUD, as described in this chapter’s section under grantee activities, titled “Systemic and Policy Barriers.”

The overall health and well-being of families affected by SUD is heavily influenced by systems, as described above. Grantee reports highlighted the need for policy-level changes at multiple levels that could increase client engagement in services. Such policy changes, as derived from grantee reports, would include addressing criminalization of pregnancy, improving opportunities for family reunification through CAPTA plans of safe care, and increasing recovery housing for PPW clients. Stigma reduction efforts through cross-sector efforts (e.g., among single state agencies administering SUD treatment, child welfare agencies, and public health department) would also be necessary to impact population- and patient-level outcomes, improve treatment services, and increase access to housing and employment opportunities for PPW clients. Based on grantee reports, intentional efforts to join government, individual actors, and community organizations to eliminate policies and structures that work to increase stigma and punishment in the PPW population are needed to improve the health and well-being of families affected by SUD.

Finally, the barriers to grantee activities described in the first section of this chapter (the COVID-19 pandemic, staffing, grant management) likely hindered efforts related to structural and environmental changes.

FINDINGS: INDIVIDUAL-LEVEL OUTCOMES

The PPW-PLT grantees were required to track their clients’ individual outcomes using the GPRA tool, through which they submitted data to SAMHSA on a rolling basis. As explained in Chapters 2 and 3, the GPRA data the committee received from SAMHSA had several key limitations that prevented the committee from assessing the grantees’ effectiveness in impacting individual-level outcomes.

Though all the PPW-PLT grantees were represented in the GPRA data that the committee received from SAMHSA, it was still unclear that the committee received data from all fiscal years for those grantees (see discussion in Chapter 2).

The primary limitation of the GPRA outcomes data, however, lies in the questionable representativeness of the outcomes data due to the low rates of follow-up interviews. Across the six grantees, the average followup rate at 6 months was 51.1 percent [P1a] and 41.5 percent at discharge [P4a]. Follow-up rates also varied greatly between grantees. As noted in the BCOR chapter, the committee was unable to determine whether clients lacking follow-up data had dropped out of the grantees’ programming, were lost to follow-up, or were simply still in treatment but had not yet reached the 6-month or discharge follow-up interviews. The committee also did not know the program completion status of the clients before dropout or loss to follow-up.

The grantee progress reports and NORC interviews described several difficulties grantees faced in using the GPRA data system. These shed light on some of the potential causes of grantees’ low follow-up rates (51.1% at 6 months, below the 80% follow-up goal laid out by the grant [P1a, P4a]), and suggest that these rates may, in reality, reflect issues with the GPRA tool or point to SAMHSA proposing unrealistic targeted rates (an opinion expressed by CSAT grantees in the NORC interviews), rather than to shortcomings on the part of the grantees. As noted in the previous chapter, in the NORC report, CSAT grantees reporting trying to provide client incentives and gift cards as one strategy to addressing low follow-up rates, though the committee notes that it does not have enough information to confirm whether such strategies increased follow-up rates. For a more detailed discussion of barriers to follow-up rates—including challenges in utilizing the GPRA tool and in retaining clients due to factors like homelessness and incarceration—refer to this chapter’s section about barriers under “Grantee Activities,” particularly the section on “SAMHSA and Grant Management.”

The committee determined that the nonrandom reporting and low follow-up rates created potential for selection bias and made it impossible to conclude whether the outcomes data SAMHSA shared are generalizable across grantees or across clients. As one example, Hispanic/Latina clients were underrepresented in the group of clients with follow-up interviews (4.7%), compared to those with intake (8.0%), suggesting that the outcomes data may not be representative for that population [P2b]. As such, the committee was not able to use the GPRA outcomes data to draw conclusions about the effectiveness of these grantees or of the PPW-PLT program overall in impacting individual outcomes. The committee presents Table 4-1 with these caveats in mind and to illustrate the very low number of participants with follow-up data.

TABLE 4-1 Outcomes from Participants for Which Grantees Have Both Intake and Follow-Up Data (N = 762)

^a Note that for some clients, the 6-month follow-up interview occurred before a discharge interview, and for some, the reverse was true. These outcomes are for the “first” follow-up, so whichever of those two interview types occurred first for a given client.

^b Note that only 54.7% of clients with intake had a follow-up interview; thus, these outcomes may not be representative of all clients.

SOURCE: P2f.

The confounds of the GPRA data also limited the committee’s ability to analyze the data on length of stay in treatment [P2a] and on client discharges [P4a]. According to the length of stay data SAMHSA provided, the mean time in treatment was between 6 and 7 months; however, about one-third of clients who were interviewed had missing data for this question, and it is unclear whether that is because those clients were still in treatment. Further, the committee cannot determine whether that was an appropriate length of stay without more details on clients’ progress in treatment, the recommended length of treatment of relevant modalities, and the grantees’ imposed limitations on length of stay. The committee also notes that treatment mandated by child services or the criminal justice system may have length of stay requirements, which could vary by grantee state, and was not noted in the GPRA data. The discharge data SAMHSA provided were similarly limited; the committee received such data for only a small portion of the clients with intakes and does not have criteria for the different discharge status (which may have varied across grantees), rendering it difficult for the committee to interpret the data.

FINDINGS: COMMUNITY-LEVEL OUTCOMES

The committee lacked the data that would be necessary to comment on the PPW-PLT program’s impact on community-level outcomes such as changes in the public’s knowledge about SUD services or community-level stigma reduction, which often require a longer time frame to evaluate. Such evaluation also requires baseline data and outcomes that grantees were not instructed to nor supported in collecting.

However, the committee notes that many of the efforts that grantees undertook, particularly around structural and environmental change, are consistent with strategies that could contribute to community-level outcomes such as these in the long run. Such efforts included (1) partnership building, (2) training and capacity building of other service providers, (3) efforts at cross-sector collaboration, and (4) advocating for policy change. The committee notes that these activities may have influenced community knowledge about SUD and recovery services, and potentially reduced stigma, but data to draw these conclusions were not available. Though some of the approaches may be evidence-based, the committee did not have adequate information to determine whether implementation in these contexts was effective.