On a recent Monday morning, about 20 people met in a conference room of the Butte Child and Family Services office on Casey Street.
Most of these people were CFS workers, intently listening to what both St. James Healthcare social worker Joslin Hubbard and obstetrician and family medicine doctor George Mulcaire-Jones had to say about the importance of the first 1,000 days of life.
"This is absolutely the most critical time in human development," Mulcaire-Jones said. "It's when the foundation of lifelong health is set in place."
Mulcaire-Jones explained to CFS workers that the first 1,000 days of life, which include the 270 days of human gestation, is when an embryo develops into a toddler. Over this period, billions of neural networks are laid down in the brain, which is at 80 percent of its adult size by a child's second birthday, Mulcaire-Jones said.
Using examples from Romania and his work in Africa, Mulcaire-Jones explained how negative environments at each stage of development within this 1,000 days can be detrimental to the rest of a person's life — and noted that similar detriments affect Butte children, too.
"Butte is not an exception, it's an example. Children get hurt in every town, USA," Mulcaire-Jones said. "Tragedies within the first 1,000 days of life can haunt a child forever."
On Jan. 1, all pregnant patients who walked through the doors of St. James Healthcare were given a packet with information on the first 1,000 days of life and a 34-question healthy pregnancy screener. The universal screener includes questions about physical, emotional, and relational health along with alcohol and substance use.
At an expecting patient's first prenatal visit, Hubbard, who has become the First 1,000 Days program coordinator, goes through the screener questions with the person and their family.
If their responses are of concern, Hubbard adds them to her caseload to ensure the patients and their partners receive the services they need, aligning with the First 1,000 Days program's three priorities: make the womb safe, make the birth safe, and make parental-child attachments secure for all St. James Healthcare's prenatal patients.
"Pregnancy helps women relook at life because there is a life inside of you," Hubbard said. "But people still need a lot of support. We are hopeful that support will help families get in a better place to parent and end cycles of sadness and trauma."
One of the keys to breaking these cycles is combating substance abuse, Hubbard and Mulcaire-Jones have said. Since Jan. 1, 63 new OB patients have been screened through the universal healthy pregnancy questionnaire . Of those patients, 20 have screened either at high or moderate risk for substance use concerns, and four babies have been born with substances in their system, according to St. James Healthcare stats.
Mulcaire-Jones and Hubbard said the substance their patients have struggled with most is meth but that they also see problems with opioid and marijuana use.
To help treat opioid substance abuse specifically, Mulcaire-Jones and St. James family medicine doctor Dennis Salisbury have become certified as addiction treatment providers. This means they can prescribe buprenorphine-based medications like Subutex and Suboxone to the pregnant patients in their care struggling with opioid addiction.
As for meth and marijuana, Mulcaire-Jones said he and the other St. James Healthcare providers can really only work to educate families on the two drugs' negative impacts. Mulcaire-Jones explained that THC can negatively impact a child's learning later in life and that meth can change a person's whole brain chemistry.
"My eyes have been opened to how absolutely gripping meth addiction is. There's nothing that makes you feel as good, and it is nearly impossible to quit," Mulcaire-Jones said. He also mentioned that unlike opiate abuse, there is no addiction treatment medication for meth.
But while drug addiction was one of the key drivers in starting the First 1,000 Days program, Hubbard has found the universal screener has also helped her catch more anxiety and depression issues — behavioral health concerns that often drive drug addiction.
Since Jan. 1, about 28 percent of St. James's new OB patients screened either at high or moderate risk for emotional health concerns, according to healthcare stats.
"There are people I would have never met with if he hadn't started this screening," Hubbard said. "It's opened a platform that gives women the opportunity to talk about their struggles and concerns."
Joan King, an integrated health consultant for the National Council for Behavioral Health, has worked to help St. James and the other Montana Healthcare Foundation partners better connect physical and behavioral health services for pregnant mothers. According to King, her role is to help these hospitals understand the importance of bringing physical and behavioral health together in the perinatal world and to help teams figure out how to make this integration happen.
"Behavioral health is just as important as health of the body," King said. "We've known for a long time that pregnancy and postpartum are incredibly exciting times in life but also incredibly stressful."
King explained that pregnancy is filled with good stress, bad stress, and a lot of physical changes. These various factors, causing constant emotional ups and downs, put patients at risk for depression and anxiety, King said — and if patients have a history of coping with stress by using drugs, that can create problems.
"Providers really need to pay attention to this history and help these mothers develop other coping strategies," King said. She also mentioned that parents struggling with depression and anxiety in general negatively impact the behavioral health of their baby.
King said that by offering behavioral and physical health both in one place makes access to care easier for patients and helps combat the stigma of mental health services. Although St. James's program doesn't have a behavioral health provider on staff with Hubbard and the obstetrician team yet, King said she thinks their program has a great approach.
"The energy and compassion St. James providers bring to this makes my job so much easier," King said. "They've implemented this program beautifully."
As of early February, St. James was still in the interview process with potential behavioral health providers. If a pregnant patient needs counseling or other behavioral health services, Hubbard has been referring them directly to a handful of local counselors. She's also connected patients with other needed services through groups like Action Inc.
But while Hubbard and the St. James team plan to work with a variety of local organizations to provide all-encompassing care to pregnant patients and their partners, they see CFS as one of their leading partners.
At the recent meeting with Butte's CFS office, Mulcaire-Jones said one of the biggest goals of the First 1,000 Days program is to see less babies in foster care and facilitate healthy parenting.
"We see you as a vital part of our team and look forward to working together," Mulcaire-Jones said to the Butte CFS office employees.
After walking the employees through the First 1,000 Days program, Mulcaire-Jones and Hubbard talked with the office about incorporating them into their conversations with pregnant patients who may be at risk for using substances during their pregnancy. Both sides agreed that if a patient is at risk or has questions about CFS, a local employee could meet with them and Hubbard to explain the role of CFS and the processes they have in place to protect children.
"We want the opportunity to talk with these mothers and say 'here's how you keep us out,'" Jennifer Hoerauf, the Butte regional administrator for CFS, said at the meeting.
After the meeting, Hoerauf further explained how the local CFS office plans to be involved.
Montana statute does not allow CFS to be directly involved with children who may be subject to neglect or abuse until they are born, Hoerauf said. But through the St. James program, CFS workers are willing to talk with patients willing to meet with them about the consequences if they don't address things like substance abuse issues — along with the rewards if they do.
"We always believe in transparency about what we do," Hoerauf said. "This is a window for us to do more up-front work and talk with parents earlier, but they have to be willing."
Hoerauf acknowledged that a stigma exists against CFS and that it's a "scary situation" for a family when the agency is called on them. But Hoerauf also said removals are a small part of what CFS does and that the agency prefers to keep children with their families in a safe environment, if they can.
She hopes the St. James's perinatal program and the cross training between CFS and the hospital can both better educate families and providers and help lessen this stigma.
"Anytime we can work collaboratively to provide the best service to families all around is the best case," Hoerauf said. "We have to tackle problems like substance abuse as a community."
Both at and after the meeting, Hoerauf joined other Butte CFS employees in expressing excitement for the St. James First 1,000 Days program. Hubbard and Mulcaire-Jones also expressed excitement and told the office employees they have a lot of respect for the work CFS does.
The St. James team has more meetings like this planned with other local organizations and hopes the First 1,000 Days program will launch at the Southwest Montana Community Health Center soon. Team members met with Montana Chemical Dependency Center and Butte-Silver Bow Health Department officials a few days after meeting with the Butte CFS office, and they hope the First 1,000 Days program sparks a larger local movement.
"We're working to create a network of collaborators, but we're also looking to create larger community awareness," Mulcaire-Jones said. "What is the best thing we could do for the future of Butte? Make the first 1,000 days of life as safe as possible."