Plans of Safe Care: Effective Implementation in the U.S.

March 10, 2019

Cagla Giray, Ph.D.

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Over the last decade, the number of infants affected by prenatal substance exposure, withdrawal symptoms or alcohol use has significantly increased with the opioid crisis.[i] Plans of Safe Care, implemented by states under the Child Abuse Prevention and Treatment Act (CAPTA), address the needs, safety and well-being of substance-exposed infants and their families/caregivers.[ii]

How effective are Plans of Safe Care?

  • Plans of Safe Care are progressing in identifying and addressing the intervention and treatment needs of infants with prenatal substance exposure and their families, but there is room for improvement such as capacity building and interstate collaboration.
  • States have their own strategic plans for and accomplishments in implementing Plans of Safe Care.
  • Best practices support the value of collaborative action across multiple agencies around the country.[iii]

In what ways can Plans of Safe Care be implemented effectively versus ineffectively?

  • A sensitive, unbiased, and standardized screening process is the first step for an effective implementation. Not using sensitive toxicology screens may cause inaccurate reports in identifying at-risk infants. Further, subjective and selective screening across private and nonprofit hospitals may lead to biased and inconsistent referrals and reports to Child Protection Services.[iii],[iv],[v]
  • Early and accurate diagnoses guide the development of effective Plans of Safe Care.[ii]
  • Comprehensive and inclusive treatment approaches are needed. Pregnant and perinatal women in rural areas have limited options.3 The use of alternative methods (e.g., telemedicine), and increasing the number and capacity of treatment centers across the country may facilitate equal access to services.[v]
  • Family-centered and culturally sensitive models, such as home visitations and recovery homes, engage mothers in seeking treatment and provide stable settings for strengthening the infant-mother bond.[vi],[vii]
  • Collaboration across child welfare, substance abuse treatment, health and social service agencies, state legislatures, medical professionals, and other stakeholders is the key for long-term impacts.[iv]

What forms of technical assistance are needed for states to more successful implementation?

  • Resource Development. Provision of educational materials, public education and media campaigns for prevention, and increasing awareness about the state systems and legislation.
  • Capacity Building. Increasing the capacity of hospitals and birthing centers, establishing standards for state initiatives, and supporting post-natal intervention programs for developmental disabilities.
  • Training. Increasing educational and hands-on opportunities for medical professionals for complex diagnoses (e.g., opioid withdrawal) and treating addiction among pregnant and post-partum women.
  • Facilitating collaboration. Conducting multi-agency workshops and networking meetings. Information sharing is a key ingredient for the successful implementation of Plans of Safe Care.[iii],[iv]
  • Impact Evaluation. Producing annual evaluation reports documenting the numbers of substance-exposed infants and mothers who completed Plans of Safe Care in each state. This report will improve understanding for the model’s cost-effectiveness before and after the 2016 CAPTA amendments.[v],[viii]



[1] Patrick et al. (2015). Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. Journal of Perinatal, 35(8), 650–655.

[2] Substance Abuse and Mental Health Services Administration (2017). Substance-Exposed Infants: A report on progress in practice and policy development in states participating in a program of in-depth technical assistance. HHS Publication No. (SMA) 16-4978. Rockville, MD.

[3] Substance Abuse and Mental Health Services Administration (2016). A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD.

[4] Wright et al. (2016). The role of screening, brief intervention, and referral to treatment in the perinatal period. American Journal of Obstetrics and Gynecology, 215(5), 539–547.

[5] Bishop  et al. (2017). Bridging the divide white paper: pregnant women and substance use: Overview of research & policy in the United States. Jacobs Institute of Women’s Health.

[6] Wright et al. (2012). Implementation and evaluation of a harm-reduction model for care of substance using pregnant women. Harm Reduction Journal, 9, 5.

[7] Isler et al. (2017). Relationship themes present between parents and children in recovery homes. Alcoholism Treatment Quarterly, 35(3), 200–212.

[8] Young et al (2009). Substance‐Exposed Infants: State Responses to the Problem. HHS Pub. No. (SMA) 09‐4369. Rockville, MD.

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