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Plans of Safe Care

(Originally published May 2024)

Since 2016, the federal Child Abuse and Prevention Act (CAPTA) has required that, a) hospitals notify or report to CPS all newborns identified as exposed prenatally to legal or illegal dangerous substances and, b) that a plan of safe care be developed for these infants. Prior to 2016, CAPTA required a notification or report only if a newborn was exposed prenatally to an illegal substance. During recent years, a number of states, including Washington, have developed policies that make a strict distinction between a notification of prenatal substance exposure (PSE) and a CPS report of PSE, and have issued guidelines to hospitals for deciding whether a notification or CPS report is called for in a specific case. It remains unclear whether CPS intake staff can decide to screen in notifications for CPS investigation, though I would be surprised if CPS intake staff lack this discretion.  


A number of states have narrowed the grounds for a CPS report of PSE by developing a public health model in which parents and children who need services are offered assistance absent a CPS investigation or assessment. Before discussing a few of these initiatives, it may be useful to describe how hospitals in Washington were responding to CAPTA requirements and rates of out of home placement of infants with PSE before recent changes in policy.  


A study of 760,863 children born in Washington State from 2006-13 (Rebbe, et al, 2019) found that hospitals made a CPS report on less than half (42.2%) of newborns prenatally exposed to illegal substances; 13.3% of infants with PSE were placed out-of-home during the neonatal period. Hospital staff who encountered PSE in Washington were clearly making   judgements about child safety and whether a CPS report was needed before the recent change in POSC policy.  CPS caseworkers, in turn, placed about a third of infants named in CPS reports, slightly more than  one in eight infants with PSE. Almost half of infants with PSE had been exposed to opioids. Unfortunately, there is no information in this study    regarding in-home services offered or utilized by parents whose infants remained in their care.


Family Care Plans in Connecticut

In Connecticut, plans of safe care are referred to as family care plans (FCP). Since 2019, FCPs are developed in hospitals or in treatment     settings, according to Lloyd Sieger, et al, in their article, “Family Care Plans for Infants with Prenatal Substance Exposure” (2023). A prior study by  Lloyd Sieger, et al, found that more than half of identified infants with PSE   received an FCP with notification (to the state child welfare agency) only. During the years, 2019-2021, 8% of births in Connecticut received a notification. To put this number of notifications in perspective: if 8% of  newborns born annually in Washington received a notification due to PSE,  this would result in more than 13,300 infants and their parents eligible for a   plan of safe care each year.   


In Connecticut, infants reported to CPS due to safety concerns had the lowest rate of FCP. Lloyd Sieger, et al, comment: “… hospital workers may be forgoing the FCP process if they believe that a child maltreatment investigator will visit the family and complete the FCP.” However, the authors point out that “The most recently available data from 24 states indicate that 17.1% of IPSE (Infant Prenatal Substance Exposure) reports were screened out.”


The most concerning findings in this study were that infants exposed to alcohol abuse had among the lowest rates of FCP and “Less than one third of FCPs included substance abuse services and less than one fifth included children’s services.” The authors comment that the lack of substance abuse services and children’s services in FCPs indicate that the CAPTA goal of “identifying dyads with unmet health and developmental service needs who are vulnerable and at risk of child   maltreatment” was not being achieved in many cases. They remind readers: “substance use disorder is a relapsing behavioral health disorder that requires ongoing intervention and management,” a need not reflected in about two thirds of FCPs.


The authors comment: “If CAPTA’s goal is to ensure that all mothers and IPSE who need them receive FCPs that address substance abuse   treatment and early intervention needs, additional federal implementation support is needed.” My view is that a different way of engaging parents and delivering services is needed, as explained below.  


New Mexico’s Implementation of the Comprehensive Addiction and Recovery Act (CARA)

In October 2023 the Program Evaluation Unit of New Mexico’s Legislative   Finance Committee issued its evaluation of CARA implementation, a law passed in 2019.  This report is among the most critical evaluations of a state program I’ve ever read. The report states: “In 2019, New Mexico passed legislation requiring staff in hospitals and birthing centers to develop plans of care for substance-exposed newborns, which refer families to voluntary support and treatment services.” As in several other states, New Mexico’s CARA law “takes a public health approach by    treating drug and alcohol use during pregnancy as a disorder requiring services rather than as a reason for reporting suspected child maltreatment …”


According to the report, in New Mexico “the state pays Medicaid managed care organizations (MCO) roughly $1.5 million in federal funds each year to have care coordinators connect CARA families to services and state agency staff to monitor plans of care. Despite this spending, CARA is not meeting its intended purposes of keeping substance exposed newborns safe and directing families to treatment. Two out of three families with plans of care are not directed to or accepting substance abuse treatment services,” a finding similar to the Lloyd Sieger study of FCPs in Connecticut. Further, “Even when families accept services the state does not regularly track family follow-through with treatment and services.” The   evaluation asserts that “1300 families with substance-exposed newborns receive plans of care each year, roughly 500 infants … do not receive a plan of care … only 306 families receive early intervention services … and only 190 accept referrals to addiction treatment.”


The evaluation states that “Fifteen of the infants born in 2020-2021 and provided a plan of care died (15 out of a total of 218 New Mexico infant deaths); however, infants with a plan of care experienced mortality rates similar to infants without substance exposure (5.9 compared to 5.0 per 1000 live births)”. The report states that, following the passage of CARA, “New Mexico’s removal of infants from the home declined by 23.2 percent …,” which was a stated goal of the legislation.


New Mexico’s CARA law, unlike revisions to law and policy in Connecticut   and Washington (see below), requires “for hospitals to create a voluntary plan of care for all substance-exposed babies instead of requiring reports of suspected abuse and neglect” to the state’s child welfare agency. The plan of care is referred to a care coordinator employed by an MCO.  Care coordinators attempt to connect a parent with supportive services before a newborn leaves the hospital.


The evaluation found that “Almost 1-in-3 families who received a plan of care had a previous substantiated investigation from CYFD (Children Youth and Family Department), i.e. there were many high-risk families involved in care plans. “A 2021 evaluation by DOH found … the substantiation rate for infants with a plan of care (49 percent) was nearly twice that compared to the substantiation rate of infants of the same age without a plan of care.”


Bottom line: “Almost half of families with a plan of care are not referred to substance use treatment and only 15 percent accept referrals.” (bolding in the report). New Mexico’s CARA program is a poorly designed, poorly implemented prevention initiative inspired by a view of foster care so    negative that policymakers have been willing to leave newborns with PSE in high-risk families that refuse substance abuse services, and with inadequate follow up once a family care plan is developed. This is a public   policy debacle which has endangered the health, safety and well-being of infants with PSE, as described by the evaluation report. 


Some of the recommendations for revising CARA proposed by the report include:


  • “Amending CARA statute to require a family assessment or differential response when a report involving a CARA family is made to CYFD,” i.e., these reports must be screened in for a CPS response.   

  • “Amending statute to require CYFD to conduct a family assessment of families who refuse substance abuse treatment or do not comply with their plans of care.”

  • “Promulgate rules requiring hospital and birthing center staff to report families to CYFD if referrals for substance abuse treatment for illegal drugs in a plan of care are declined.”


Surprisingly, the report’s recommendations do not include changing the limited (or nonexistent) role of care coordinators after care plans are developed and referrals are made to service agencies. Prevention programs that expect troubled families to follow up on referrals absent case management services, or some other type of ongoing emotional support, have a misunderstanding of what is required to engage and maintain parents with chronically relapsing conditions in treatment programs. Effective programs require supportive relationships, not just monitoring of compliance with a care plan.


Washington State’s Plans of Safe Care 

In June 2023, the Washington State Department of Children Youth and Families (DCYF) issued a press release with the headline: “State agencies announce changes in policy and best practice for infants.” The press release stated that “If there are no safety concerns, state policy now allows substance exposed infants to use voluntary wrap around services without being reported to Child Protective Services.” DCYF policy (per state law) continues to require that hospitals make a CPS referral when a newborn has been exposed prenatally to an illegal or non-prescribed drug. The DCYF press release was either misinformed, disingenuous or aspirational in nature.      


As described above, hospital staff are required to either notify DCYF of PSE or make a CPS report. An online portal outlines these two pathways.

Hospital staff are expected to answer five questions to determine whether safety concerns indicate the need for a CPS report:

 1) Are there safety concerns? (unspecified);

 2) Has a positive tox screen indicated PSE to an illegal or non-prescribed substance?

 3) Is there evidence of current substance use by the birthing parent, creating safety issues?

 4) Is there indication of Neonatal Abstinence Syndrome (NASD) or Neonatal Opioid Withdrawal (NOW), i.e. symptoms of drug withdrawal?

 5) Is there indication of Fetal Alcohol Spectrum Disorder (FASD) or of PSE exposure to alcohol?  

If the answer to any of these questions is “yes,” a prompt appears informing hospital staff that a CPS report is indicated; if the answer is “no” to all five questions, the family is eligible for a community based POSC, without CPS involvement.


Possibly the most distinctive feature of Washington State’s POSC policy is the implicit requirement that a parent must already be participating in substance abuse treatment to be eligible for the community based POSC. It appears from the portal (and information from DCYF staff) that if a parent of a newborn with PSE is not engaged in substance abuse treatment, this is viewed as a safety concern which rules out a community based POSC, absent a CPS report. However, the opposite is also true: if a parent of an infant with PSE is already receiving substance abuse treatment, this is taken as a sign of child safety, a dubious assumption to say the least. Some research studies (Gregoire and Schultz, 2001) have indicated that a large percentage (at least half) of parents who enter drug treatment programs continue to use drugs to some extent. Abstinence during drug treatment is the exception, not the rule. In addition, substance abuse is a chronically relapsing condition. If children are endangered by a parent’s substance misuse (some are and some are not), the young children of parents in treatment programs may periodically be in danger due to relapse, regardless of a POSC.


POSC Help Me Grow facilitators of community-based plans assist parents in accessing a variety of supportive services, including child care, entry into the Parent Child Assistance Program (PCAP), referrals to a peer recovery coach, housing supports, and applying for various public support programs such as TANF.


Help Me Grow facilitators work online. There is no initial team meeting, no in-person contact between a facilitator and parent, according to information received from DCYF staff.  Help Me Grow facilitators follow up with parents regarding their success in accessing services to which they have been referred and to assist parents with overcoming barriers to services as needed.  There is no check on child safety at any point in the community based POSC process. It is unclear whether there is any program response to relapse, or if a Help Me Grow facilitator would be informed of relapse. It is also uncertain whether there is a policy for how to respond to a parent’s withdrawal from substance abuse treatment. There does not appear to be a requirement that facilitators check on a parent’s continued involvement in substance abuse treatment.


Currently, there is no current data regarding CPS report or re-report rates, emergency room visits, hospitalizations, out-of-home placements or child deaths during or following a POSC in Washington. I have been informed such data may be available in the near future. In my view, it is likely that Washington’s POSC program will have better outcomes than in New Mexico, in part because Washington’s dual pathway policy is more prudent than New Mexico’s CARA, and also because Washington is a relatively wealthy state with better community-based services than New Mexico, one of the poorest states in the country.



It is apparent from the preceding discussion that the term, Plan of Safe Care, is a misnomer. These are not in-home safety plans with an emphasis on preventing unsafe sleep practices, helping mothers to calm inconsolable babies or confronting the challenge of how to prevent opioid overdose deaths or near deaths of infants and toddlers. Washington’s POSC initiative explicitly excludes families with identified safety concerns at birth, though I question the approach to assessing child safety reflected in the five questions on Washington’s POSC portal.


Community based POSCs are service plans intended to support recovery, reduce material hardship and parental stress, increase emotional support for parents, address infants’ developmental need and health challenges and strengthen parents’ capacity for emotionally responsive parenting. All of these services have the potential to increase child safety over a period of weeks or months but sometimes not immediately. For this reason, there needs to be rethinking of how to increase safety-oriented services that protect infants immediately in community based POSCs, while giving therapeutic services and family support services an opportunity to change families’ lives for the better. POSC initiatives should also utilize case managers who have periodic personal contact with families to provide emotional support and concrete assistance in sustaining service plans.     ©   



Gregoire, K. & Schultz, D.J., “Substance-abusing child welfare parents: Treatment and child placement outcomes,” (2001), Child Welfare, 80, pp. 433- 445.  


Lloyd Sieger, M., Nichols, C., Chasnoff, I., Putnam-Hornstein, E., Patrick, S., Copenhaver, M., “Family Care Plans for Infants with Prenatal Substance Exposure,” (2023), Child Welfare, vol. 101, #2, pp. 169-192.    


Rebbe, R., Mienko, J., Brown, E., Rowhani-Rahbar, A., “Child protection reports and removals of infants with prenatal substance exposure,” (2019), Child Abuse and Neglect,88, pp, 28-36.


Plan of Safe Care Online Referral Portal Flow, publication # CWP-0087, Washington state Department of Children, Youth and Families, available in Publications Library.    


“Program Evaluation: Implementation and Outcomes of the Comprehensive Addiction and Recovery Act, Program Evaluation Unit, New Mexico Legislative Finance Committee, October 27, 2023. Available online. 

See past Sounding Board commentaries     

©Dee Wilson 


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