- And also the Chittenden County
Child Protection and Family Support Team.
She co-chairs Vermont's Federally Mandated
Vermont Citizens Advisory Board to the Vermont DCF,
Department of Children and Families,
and serves on the Vermont Child Fatality Review Team.
She has extensive professional experience
in the field of domestic violence, child abuse services,
and victims and witness assistance.
And she has been recognized
with the US Health and Human Services Administration
for Children and Families Commissioners Award,
and also the Vermont Agency of Human Services
Community Award and the Queen City Police Foundation
Antonio B. Pomerleau Medal of Honor,
which was presented by Senator Patrick Leahy.
Well deserved of all of this for her amazing work.
And she graduated from University of California Davis
and has a Master's in Education from Cambridge College.
So thank you very much, Sally.
Your work is invaluable.
- Thank you, Molly.
I certainly should have shortened that up.
I didn't know you're gonna do the whole thing.
Much more importantly,
my kids went to preschool with Molly's kids
and that was really all the introduction that we need.
So thank you.
So I think we have our panelists here,
and I'm delighted to be here and it's a little intimidating
to follow Andre Jones,
but we are eager to share with you all
a little bit about the collaborative work of the CHARM Team.
So I'm going to do my best to share my screen.
All right, is that showing up there?
It's showing on my screen,
but I don't know if it's showing on your screen, is it?
- It is, but if you put it in slideshow mode, it'll be full.
- Oh, yay.
Thank you for that little hot tip.
Okay, slide show from the beginning.
Okay, how's that?
We seem to have a very blank screen now.
Whoops.
- Now it jumped out of it. - Okay, sorry.
I'm so sorry.
I'm gonna try this one more time,
and if not, I'm, you know, just gonna wing it.
- And we could still see it the other way
if it doesn't work.
- Yeah.
I don't know why that suddenly, you know,
I even tested it ahead of time, of course, but.
Okay, now I can't see any of you, so.
You can hear me, right?
- Yep, we can hear you and we can see the slides.
It's not in slideshow view, but we can see them all.
- Well, that's awesome, but I can't see you.
No, I'll go ahead anyway.
I think I can.
For some reason my screen just went totally blank,
but I will just say it's my pleasure
to introduce a few of the CHARM partners
who are here with me today.
We are going to hear from Shara Tarule who is a nurse,
clinician at the Chittenden Clinic.
And we'll talk about the importance of MAT
and support services within a treatment environment
for pregnant and postpartum women.
We'll hear from Skyler Bryant,
who is one of our DCF partners.
And she will talk about the role of child welfare
in working with pregnant and postpartum women
and their infants.
And we'll talk a little bit about the very unique approach
that Vermont has with this population
and the importance of that.
And then we will hear from home health from Melissa Kahold
who has been a long time home health
nurse home visiting provider,
and the importance of that piece.
There are a lot of partners in our work, and I,
so I'm still not able to see my screen.
So I am going to take a moment,
and all right, one sec.
- Sally, this is Melissa.
That's happened to me four times during this meeting,
and I've had to rejoin each time.
So just a warning that that might be what you need to do.
Sorry. - Okay.
So let me just double check.
You guys can see the screen, the slides, but not see me.
Is that the deal?
- We can see you as well as the slides.
- Yep, everything looks normal from our end.
- Yay, well, okay then.
Well, let me just go right ahead.
I have another copy of my slides here.
Here, we can go ahead.
So obviously in Molly's introduction,
she mentioned what CHARM is.
And many of you already know we're a collaborative approach
that our goal is to improve the health
and safety outcomes of babies.
And we do that by coordinating medical care,
substance abuse treatment, child welfare,
and social service supports.
We'll just talk for a minute
about our collaborative partners.
Again, you will hear from a few of them today,
and our collaborative partners include
all of these disciplines.
And sorry to have to advance with this screen in this way,
but we'll just make it work.
So thank you for indulging me with this process.
So key partners, obviously prenatal care
and the importance of OBGYN care.
And we work closely with the COGS clinic
at UVM Medical Center,
which is Comprehensive Obstetric and Gynecological Services.
And at COGS, COGS includes what many of you
are familiar with the term a spoke program.
So while Chittenden Clinic is a hub,
the clinic at COGS is a spoke,
and both of those work closely together
to serve those who are identified
as CHARM patients or clients.
UVM Children's Hospital.
Obviously the baby end of the collaborative.
Child welfare.
Again, so happy to have a Sky here with us.
We'll talk about the unique role of DCF Family Services
and how that plays out here in Vermont.
Economic services.
ReachUp is an instrumental partner to our work.
Maternal child health through the health department.
And that includes, importantly, WIC.
Home health.
As I said, Melissa is here to share that.
The Lund has been part of that,
Lund being a residential and outpatient treatment program
for women and their children
or those who are women identified and their children.
And of course, ADAP is a partner
in all things related to SUD,
the SUD clients and patients that we serve.
Most important for CHARM, I think,
and Dr. Jones alluded to this.
And I think, I guess the one thing that I really wanna say
is that having a shared goal and a shared framework
for the work is key,
and I also wanna say that that didn't happen overnight.
So if some of you are just starting out
with a collaborative partnership,
it's not always smooth and easy.
There's a lot of bumps in the road.
And really, a lot of those bumps in the road come down to
do we sort of have a shared approach to this work?
And so starting with the point
that we know that we all want, a healthy and safe infant,
then we come back up and look at
what is our shared philosophy about reaching that?
Improving care and supports for mothers
is the most important factor in helping to ensure
healthy and safe infants.
And that's a lesson that
we don't always come to this work with,
but it's something that many of us have learned
over the years, and a shout out to Dr. Johnson,
because I certainly learned that from her
many, many years ago.
And then the other thing is just have a framework
for operation of the collaboration.
That shared information across agencies
improves child safety and healthy outcomes.
For us, we have a framework for that.
We have a memorandum of understanding
and a release of information that's shared
by all of the agencies and organizations
and departments that are part of our collaborative approach.
We're empaneled as a multidisciplinary child protection team
under the Vermont laws that guide those teams
around the state.
We have that infrastructure and facilitation.
That's my job.
I facilitate it, make sure we can all come together
and we have the infrastructure to do that.
And then just having regular team meetings
where we have a structure for sharing that information
and we get together.
And it's obviously changed since COVID
and we're all online now
and we're not all gathered in a room and sharing chocolates,
thanks to Heather Simpsons who is here, I see,
and Heather always brought chocolate to our meetings,
and now we just have imaginary chocolate as we're on Zoom.
So a couple of things about the prenatal care,
and then they're very similar to what Dr. Jones shared.
And so in the interest of time,
I'm going to just move on and share with you
how the CHARM team works.
We have about 11 different agencies and departments
that come to each meeting.
We meet monthly and there are sometimes
multiple participants from different departments.
We spend about 10 or 15 minutes sharing systems issues,
and that is one of the ways
that we really interface with CHARM.
I mean, with Icon, sorry,
and making sure that we share information back and forth
where we're working on improving channels of communication
around the issues that we see sort of on the ground at CHARM
and with Icon.
And at each meeting, we go through who's due this month,
you know, who are the high risk prenatal patients,
who are new pregnant patients,
and then you of course go over all the babies
that were born in the past month,
and those that are prioritized
by any of our members for discussion.
There are a lot of services that aren't
part of our team meeting, but we make sure to connect with.
And so the peer support that we heard so much about
earlier this morning is something that we really
try and refer people to.
CIS and making sure that we have developmental screens
and so on is key.
And sorry.
Nope, sorry about that.
Okay, all of a sudden, my little,
I'm so sorry.
My little cursor switched,
so I think we can go here and just skip right down to here.
Sky's gonna talk a little bit more about DCF policy
and how that works,
and I'm not gonna go into plans of safe care
'cause Michelle covered that.
And so, again, in the interest of time,
just quickly, what's the value of a collaboration?
Starting prenatal care in starting early in pregnancy.
These are the things that we look at in each meeting.
And then I guess the bottom line for us
is that improving our collaboration means safe for babies.
And quoting one of my esteemed mentors
who sadly is no longer with her,
but I carry her with me all the time.
And she said anything that drives pregnant women
with opioid use disorder from seeking treatment
results in more prematurity, higher infant mortality,
less probability of successful parenting.
And I give her an extra shoutout because she said that
to a legislative committee.
And it wasn't the most popular thing to say at the time,
but it was so important.
There's a lot of benefits to collaboration,
but really the improved understanding,
minimizing misunderstandings and misinformation
is I would say the most important part of our collaboration.
CHARM was written up as a model collaborative approach
a few years back, and I've included a link here.
And of course, we'll share the slides afterwards.
And just listing our contact information
if there are questions after today.
So with that, I'm gonna turn it over to Shara
and go right ahead.
Thank you.
- Yeah, thank you.
And wanting to make sure that we have a chance for Sky
and Melissa to join in as well.
I wanted to emphasize the part of the conversation,
part of our collaboration.
I'm just gonna jump right into
the differences of the philosophies
and the approaches that we have.
I am with the Chittenden Clinic.
That's Vermont's largest methadone clinic.
We are nationally known as an OTP
and opiate treatment program.
In Vermont, we are called hub.
Spokes being the primary care and other providers
that can prescribe Suboxone for opioid use disorder.
Nationally, methadone can only be prescribed
for opioid use disorder out of a hub like ours.
Our philosophy, our approach is harm reduction.
As you can imagine,
that means that I am in a different position
than the philosophy and approaches
of other members at the table.
Skyler DCF, you can't be harm reduction in child protection.
Oh, just a little bit less abuse than neglect?
No, no, no.
That doesn't work in that.
And yet we have to figure out how to work together.
I think there's a lot of things that support us in this.
I think recognizing, first of all,
that we are all humans who are working for the same outcome.
Just because the philosophy of our approaches are different,
all of us want what's best for babies, mothers, families,
and yet, how do we navigate these things?
Means that I do work with a number of women,
people who are pregnant here, sorry,
working on that languaging still,
who has declined to sign the term agreement.
That is our easiest,
if somebody agrees to sign the term agreement,
then we've got that blanket coverage
for all of the coordination that is so valuable
out of that term team.
So what do I do if I'm with somebody
who won't sign the term agreement?
We do have a requirement that they sign an agreement
for us to be in touch with the OB.
When I'm navigating people through pregnancy,
what are things that are most important to me
that the medication that we are managing,
methadone or Suboxone or buprenorphine,
that that is adequate and is where it needs to be
throughout the pregnancy and that they are at least
following up with their OB care and getting regular OB care.
Part of the reason I can hold the philosophy
of harm reduction is that here, we do not,
I do not treat the unborn child.
That, again, is part of the philosophy of our approach.
I am treating the pregnant person.
I am treating the child bearing person.
So I that's where I focus it,
but I also obviously prioritize the care
of the unborn child.
Need to be sure that the person that I'm working with
is having their regular OB care.
And then if they're not,
that's where incredible coordination of care can come in
so that I can work with the OBs.
I can flag reminders here.
There are times where a person's so out of touch
with their OB that I'm able to say,
well, just schedule them appointment because I see them.
We see them here at the clinic every day
or quite frequently,
then we can give those reminders of the appointments,
we can ask do you need a ride?
Do you need a ride from the clinic?
How can we help you get to those appointments?
So the other place that we do
is really an opt out, we're evolving this,
but an opt out of working with Melissa Cofield
and the VNA and the Home Health Maternal Child Programming.
So that at the minimum, you sign a CHARM consent.
Great, everything's covered.
If not, you'll sign a consent for us
to be in touch with your OBs and for the VNA Home Health.
That VNA Home Health referral to us
will mean also another way of variables to make referrals
if we're having trouble getting all of those
releases of information signed.
So like I said, I wanted to go really quickly
and sort of pick one part to focus on
of how I represent and how I come to the team.
I can get back into some of the other things
when we come back, but I'll turn it back to Sally now.
- Thank you, Shara.
That was a great overview of the services that you provide.
Sky, we'd love to hear about DCF Family Services
and your role on CHARM.
- Yes.
Hi, everybody.
Yeah, I think the,
I really enjoy sitting on CHARM.
I think like Shara just represented,
we all come with specific roles, philosophies,
like programmatic policies or directives,
but the collaboration and the relationships
that we develop are really powerful,
and I think help us better understand each other's roles
and responsibilities within the larger system.
A big piece of information that I think is sometimes
a misconception or misunderstanding is that,
Vermont is a very unique state.
I think we are the only, if not one of the only states
that allows for child protection intervention
prior to the child being born.
So we have a unique statute
that allows for us to get involved 30 days prior
to an estimated due date for various reasons.
One being a potentially substance use disorder
and positive screens during the third trimester.
I like to distinguish those two things because, oftentimes,
I think that there's a perception from parents
and providers that when we get involved,
we're investigating and we're trying
to kind of find something.
The model of these sort of early assessments
is really intended to provide intervention
that will allow for us to assess and screen
and access resources and referrals
to ensure that this baby that's on its way has a safe home,
has a parent that's connected
to the right level of treatment and care,
and it allows us to be intentional and proactive,
which I think, ultimately,
it yields the outcomes that we all invested in,
which is it prevents us from having court involvement,
allows newborns to remain with our parents.
Oftentimes, even if there are still some challenges,
we will safety plan with a parent.
We like to gather information about their family,
their network, who do they have for supports
in a way that allows for us to do
some real preventative work with them
and planning ahead of time.
Unfortunately, there are times where there's babies
that are delivered and we haven't received a report,
and it often creates a much more,
I guess I would say crisis type response,
where we haven't had the opportunity to gather information
about who they're connected to,
if they have the resources that they need for the baby,
if they have safe housing.
And so that feels like it's often rushed work.
It impacts our ability to,
or the worker's ability that I supervise
to really truly engage with a pregnant mom and a father
in a way that builds trust and understanding
in what our process is.
So within these assessments,
we also have a really great partnership with Lund
where we have co-located screeners.
And so there's sort of a teaming approach
to working with pregnant or postnatal moms,
in which DCF sort of, I don't wanna say steps back,
'cause there's a release of information
that's signed to share,
but one really takes the lead in screening a parent,
getting history from them regarding their substance use,
finding out who they're connected to for resources,
services, treatment providers,
and then looping back to DCF to kind of explore
any unmet needs or next steps.
And so that partnership has been hugely beneficial
to gathering information quickly and getting parents
connected to the right level of support
in a preventative way.
I think that one of the biggest things
that I appreciate about CHARM
is that we are often functioning in these silos,
no matter how hard we try not to.
And there's a sharing of information that goes on there
that oftentimes truly actually benefits
a lot of pregnant moms 'cause I'm receiving information
from professionals and providers that indicates
they're doing very well,
and there are times where we're getting reports
from perhaps a family member that might not have
that same level of information.
And so sometimes it really informs whether or not
we will be getting involved or we won't be getting involved.
When we're talking about a family or case
that is already open,
I have a system or practice where I'm looking at the notes,
connecting with the workers ahead of time
to get any updates,
and then looping back to them about any updates I received
or any particular provider that hasn't been able
to get in touch with them and I'm saying,
you gotta call Shara.
She can help you navigate this.
So yeah, I think that it allows for
not only better outcomes for families and for newborns,
but also allows for, I think strengthening
community partner relationships,
like unpacking and getting a better understanding
or depth of what our roles are
and why we do what we do and how.
I know that Shara and I have had some really great
philosophical conversations around that.
And so the better that we,
the more that we can understand why we are doing
what we're doing and do it in a collaborative way,
I really have seen a lot of success.
So I'm not sure, Sally,
if there's anything else that you wanted me
to particularly touch on.
- I think you've covered it, Sky.
And given our the time,
I'm gonna turn it right over to Melissa to go ahead.
- Did anybody hear any of that?
- No.
And I think-- - Okay, I'm so sorry.
- Somebody, did you share your screen?
'Cause it's not slides.
- I'm not sharing a screen, no.
- Okay, then just go ahead.
- Okay.
Much of which I planned to talk about this morning,
we've already talked about in the storytelling section
and some of the other places.
So I think we can safely say that most of us have
at least one thing over which we don't have control.
Some of us are fortunate enough that that thing
is more socially acceptable and leads
to less dire repercussions and substance use disorder.
And that also experience also helps us understand
that relapse is part of recovery.
My home health team,
and I know that there's some other home health people
on this call, we work through a primary relationship.
The family has their person.
We can develop a growing in intimate
and individualized understanding
of what will help that family be the strongest
that they can be.
Many families have multiple stressors.
Opioid use disorder is often one of them,
but there's often many, many others.
So I would say that our care is always,
we aim for it to be the same
for no matter what is going on for families.
That would include respectful advocacy,
so care coordination with other providers,
which sometimes includes helping care partners
understand a little bit more
about substance use disorder,
seeing strengths, and also it would include
sharing our concerns when they arise.
Support resources, being a witness or companion
with a historical understanding of how things are changing,
how things are progressing,
even if people feel overwhelmed by what's happening
and can't see that.
Our job is definitely,
this is mutual delight is one of my favorite terms.
So our job is definitely to help families
find that mutual delight with their children.
And in nursing, one of the biggest philosophies
or tactics is anticipatory guidance.
So we would much prefer hearing about referrals
when people are pregnant.
So we can develop that relationship
before they're learning to relate with their babies.
And two other things I think that are really important
is that it's crucial for pregnant people see their dose
as needing to be therapeutic.
I think a lot of people feel like,
sometimes out of guilt sometimes out of shame,
sometimes out of all kinds of other factors,
worrying that their baby's going to need to be dosed
if they have too high a dose,
which is not at all part of what research has found.
So really encouraging people to find the therapeutic dose,
'cause that's the most important thing.
And I would also say that another thing that happens a lot
for people is finding that they will over read
what's happening for people, for their babies as withdrawal
because they've experienced withdrawal themselves,
but it's often just a newborn behavior.
And I can't even tell if we're still,
I think we're not even together, are we?
- Yes we are.
- Oh, we are.
- You're doing great.
- I'm sort of going, trying to speed through.
So that's it.
I just wanted to get out a few points.
That's good.
- That was great, Melissa.
And I think so much of what you said and what you offer
through Home Health echoes what Dr. Jones was talking about
with the Horizons program,
and also what you were just saying,
I think addressing a lot of the myths and misconceptions
around substance use disorder and around treatment
is such a valuable part of what you do.
Just helping address that stigma and the myths
and misconceptions that are out there.
So thank you for that.
Molly, I'm not sure where we stand in terms of time.
I know she said we were going back at 11:20,
but I didn't see a prompt.
So what's the plan here?
We could take questions, we're happy to, or not.
- Some of them are my wine glasses,
but they say right on them.
- I think we need to head back,
but I think there's gonna be time in the larger group
to debrief a bit.
- Great. - And yeah,
and I'm gonna thank you all,
Sally, Skyler, Shara, and Melissa,
that was really wonderful and really nice.