Treatment for HIV-Infected Alcohol and Other Drug Abusers
Treatment Improvement Protocol (TIP) Series: 15

Appendix H -- Sample Memorandum of Understanding

The purpose of this Memorandum of Understanding is to clarify agreements between the Stimulant Treatment Outpatient Program (STOP) and the Opiate Treatment Outpatient Program (OTOP) of Substance Abuse Services (SAS), the High Risk Clinic (HRC) of the Maternal and Child Health Division, both part of San Francisco General Hospital, and the Bay Area Perinatal AIDS Center (BAPAC). These agreements form the basis of a Pilot Project, MAMATOTO: Maternal Support Program, to provide comprehensive treatment to pregnant chemically dependent patients who are identified by the High Risk Clinic or BAPAC. This MOU covers arrangements for prenatal care and substance abuse treatment. A separate MOU covers postnatal care and substance abuse services.

It is understood that a MAMATOTO: Maternal Support Program patient may qualify for and be invited to participate in BAPAC, and if accepted, the patient's medical care would be totally provided under the aegis of BAPAC. It is also understood that if the patient fails to follow BAPAC's protocol she may be asked to leave the project. In this latter case, the patient would return under the care of the High Risk Clinic. As long as the Pilot Project patient were receiving medical care either through HRC or BAPAC, and she were complying with the agreed-upon requirements for treatment at Substance Abuse Services, the patient would be maintained in MAMATOTO.

Roles and responsibilities are defined as follows:

The High Risk Clinic (HRC) and BAPAC will provide medical and psychosocial services to pregnant patients who are referred and admitted to Substance Abuse Services for treatment under the Maternal Support Program. Lisa Ryan, N.P., will be the contact person for the HRC or Wendy Kahn, M.S.W. from BAPAC.

Referral protocol:

1. The High Risk Clinic (HRC) or BAPAC will identify chemically dependent pregnant patients receiving its services who desire and are motivated to undergo substance abuse treatment for cocaine or heroin abuse. Initially, only those patients who will not need childcare services will be admitted to treatment. These "motivated" patients will be referred to STOP for stimulant dependence or to OTOP for opiate dependence.
2. The HRC or BAPAC will call a meeting of the assigned SAS counselor and the HRC or BAPAC social worker to discuss the appropriateness of the referred patient for STOP or OTOP. The SAS counselor will then meet with the patient for a motivation evaluation.
3. The HRC or BAPAC will send the patient's medical chart to STOP or OTOP for review.
4. A treatment contract will be designed for the patient so that she will know the components of treatment, i.e., the length of treatment, the expectations from HRC and BAPAC, Pediatrics, and STOP/OTOP, and the consequences for failing to comply with treatment.
5. Once selected the STOP/OTOP counselor will meet with the patient to explain MAMATOTO, the program expectations, and the contract that she is expected to sign and abide by. If the patient agrees to participate, she will sign the contract.
6. HRC or BAPAC will have the patient sign confidentiality and release-of-information forms to insure that HRC, BAPAC, OTOP/STOP, and Pediatrics share pertinent information regarding the patients in the Maternity Support Program.
7. HRC or BAPAC will ensure that the patient presents herself at STOP or OTOP for a final intake interview on the day before she is discharged from MCHD, if hospitalized, or the day before substance abuse treatment is expected to start.
8. Maternity Support Program patients will not be admitted to SAS on Fridays. If the patient is discharged on a Friday, she will have to wait to be admitted at STOP or OTOP on the following Monday.
9. While patients are in treatment at STOP/OTOP, a program liaison (Lisa Ryan, N.P., for HRC or Wendy Kahn, M.S.W., for BAPAC) will contact the assigned counselor on a weekly basis to monitor the patient's continuing participation in treatment. If there is a problem with treatment compliance or participation in STOP/OTOP, the patient's case manager at HRC or BAPAC may contact the patient as appropriate and as agreed upon with the STOP/OTOP treatment staff. If child abuse or neglect is suspected CPS will be notified.
10. The treatment contract must include centralization of the prescription of psychoactive medication to the patient in order to prevent overlapping provision of medication.
11. Copies of documentation of treatment contacts with the HRC and BAPAC will be faxed to SAS, and STOP/OTOP will, in turn, fax copies of treatment contacts to HRC and BAPAC. This sharing of documentation is critically important for SAS for it must document that prenatal care and nutritional counseling are being provided to its patients.

Required medical and psychosocial services provided by HRC and BAPAC will consist of the following:

• Prenatal visits every other week or more frequently from 2nd to 36th week, then weekly until delivery.
• Social assessments
• Health Education
• Nutrition Education
• HIV counseling (BAPAC)
• Possible limited onsite childcare by BAPAC during treatment sessions and medical appointments.
• Supplemental food and transportation
• Initial postpartum care followed by referral to GYN or Family Planning Clinic
• Family planning.

SUBSTANCE ABUSE SERVICES

OTOP will provide a maximum of three patient slots for methadone treatment for heroin abuse. STOP will provide a minimum of two patient slots. OTOP's length of treatment will be 3 months postpartum with a tapering-off period of 1 month. STOP has 4-month treatment episodes and patients may be readmitted. All Pilot Project patients will have their physical and other medical examinations and treatment carried out at HRC or BAPAC.

Intake and Admission Procedures:

1. The MAMATOTO nurse counselor for all the pregnant patients is Danyelle Perrine, R.N., P.H.N. STOP will assign a female counselor.
2. The procedures No. 2 through 11 mentioned above.
3. Before the patient is discharged, if hospitalized, or before she enters substance abuse treatment, the OTOP/STOP admissions treatment team will meet with the patient at OTOP or STOP for a final intake interview that will present the expectations for treatment and will ask the patient to sign a specific substance abuse treatment agreement.
4. In cases of medical emergency, OTOP and STOP will send the patient to the ER if she is at less than 20 weeks gestation and to Labor and Delivery if at over 20 weeks. The liaison with the prenatal provider will be notified.

OTOP will provide the following services. These services are contingent on the provision of childcare for those patients who need them:

1. Methadone dosing seven (7) days a week
2. Urinalysis once a week
3. One pregnant and postpartum women's recovery group per week
4. One other recovery group per week
5. Psychiatric care, if no other provider.

STOP will provide the following services. These services are contingent on the provision of childcare for those patients who need it:

1. Recovery groups 5 days per week. They are held in the morning (9 a.m. to 10:30 a.m.).
2. One counseling session per week
3. Urinalysis once per week.

Both parties agree to the responsibilities and procedures stated above. This agreement will be in effect/valid for through FY 92 through FY 93 and will be reviewed and/or amended every 6 months. Any changes to this MOU will be made with the approval of both parties.

In the event of termination of this MOU, each party should give or be given a 30-day notice.