Prenatal Care and Addiction Medicine on One Team
A Community Health Center Model for Pregnant and Postpartum Clients with Opioid Use Disorder
Northern Nevada HOPES, a federally qualified health center in Reno, uses opioid settlement funding to run an integrated maternity program that pairs prenatal, postpartum, and couplet care with addiction medicine, behavioral health, peer support, and care coordination for pregnant and postpartum clients with current or past opioid use.
The Challenge They Were Addressing
At the front lines of community health since 1997, Northern Nevada HOPES is a federally qualified health center that has innovated to provide adult primary care, pediatrics, behavioral health, and a full addiction medicine department, including a board-certified addiction medicine specialist, alongside comprehensive case management services. What it did not have yet was maternity care. The obstacle was not a lack of clinical interest, but a lack of funding. In the state of Nevada, Medicaid pays for maternity care via “bundled” payments: a single payment to the clinician who performs the delivery. Thus, a federally qualified health center providing outpatient care had no clear way to sustain maternity services outside of the hospital system. A program geared toward maternal health remained on the shelf for several years until 2025.
State and public health data described what was happening in the meantime. The state identified 871 pregnant and postpartum patients with opioid use disorder, and only 13% of them were receiving medication treatment. The rate of inadequate or no prenatal care sat at roughly 16.5%, among the highest in the country. The same data pointed to elevated NICU admission, sharply elevated risk of intrauterine fetal demise, and a preterm delivery risk of about 17%.
Behind the numbers is a pattern the clinical team saw every week. Pregnant clients with current or past opioid use often avoid prenatal care entirely, not because they do not want a healthy baby, but because they expect judgment, a positive drug screen entered into a chart, and a call to child welfare. Many disappeared from care and reappeared only when they arrived at a hospital in labor. Standard prenatal care is largely protocol-driven, and that protocol assumes a patient who can keep appointments. Addiction, housing instability, and fear break that assumption. A chance conversation between the chief medical officer and a state Medicaid leader about opioid settlement dollars removed the sustainability barrier and let the program start.
What They Built
The program is integrated rather than referral-based. Medical and addiction medicine providers, prenatal and postpartum care, pediatrics for the newborn, behavioral health, a peer support specialist, case management, nurse care coordination, nutrition, and lactation support all sit inside one team at one site. The chief medical officer, an OB/GYN by training, and the program's lead physician, a family medicine physician with specialized training in maternity care and opioid use disorder, designed it that way together after concluding that a single practitioner cannot carry a patient with this level of medical and social complexity, and that a siloed model would send clients to appointments they would never reach.
Entry is deliberately easy. The program runs a direct phone line answered by team members Monday through Friday, accepts walk-ins, and runs a short screening on the first call. A weekly protected block on the medical provider schedule means a caller can often be booked while still on the phone and seen in less than a week, two weeks at the outside. The team does not turn people away. If HOPES is not the right level of care, staff still see the person at least once and connect them to the service that fits. Participation does not depend on choosing a particular treatment path: clients who take buprenorphine, clients on methadone, and clients reducing use on their own are all eligible.
Care follows the pregnancy and then keeps going. The team sees clients at any gestational age, carries them to roughly 34 to 36 weeks, then hands them off to a delivery partner for the final weeks and the birth. After delivery, staff visit the hospital if the client wants a visitor, check on the mother as a person rather than only as a parent, and bring toiletries or a car seat when needed. Parent and baby then return to HOPES for couplet care, with mother and newborn appointments scheduled close together so that one trip covers both. When the baby needs a specialty referral, the case manager and nurse care coordinator arrange it, and no one has to retell their history from the start.
Group care runs alongside individual visits. The pregnancy group is modeled on group prenatal care classes, with 10 to 12 clients meeting biweekly for about two hours instead of a 15-minute exam room visit. Sessions cover prenatal education, nutrition, breastfeeding, preterm delivery, and behavioral health, with the nutritionist and therapist joining the group. A separate weekly Moms in Recovery group, also peer-led, is open to anyone in the community. Funded by generous UnitedHealthcare support, community outreach workers meet community members where they are, maintaining a regular presence at the Washoe County Cares Campus Resource Center and community health events, and collaborating with mutual stakeholders and local street outreach teams to reach individuals who will not walk through the clinic door on their own.
Key Program Components
Who You Need at the Table
What made a willing partner essential vs. optional?
A partner is required when the program cannot complete a client’s care without them. The state is in that category because the settlement award is what closed the payment gap created by Nevada’s bundled maternity structure. The delivery hospitals are in that category because HOPES does not deliver babies and depends on them for a safe transfer of care at 34 to 36 weeks. The residential and transitional recovery programs are in that category because they hold the clients who HOPES cannot house and share the same people across the pregnancy.
What made those partnerships work was reciprocity and regular contact rather than a referral form. The team met with the largest delivery partner before the program opened and still meets weekly, reviewing shared clients closely enough that the hospital can call when someone arrives in the emergency department. The delivery partners sent some of the earliest referrals. Partners in the helpful column widen the reach: outreach funding, family medicine coverage, community visibility, and housing. Losing any one of them would narrow the program, not stop it.
Budget Breakdown
What is the minimum viable budget to replicate this?
The floor is a medical provider who can deliver prenatal and postpartum care, prescribe medications for opioid use disorder, or work in close partnership with someone who can, and a case manager or care coordinator hired at the same time rather than later. The team is direct about this sequencing: if the medical side is running at full speed before care coordination is in place, coordination never catches up, and clients stop making it through the door. Everything else can be phased. A small county could start with one weekly protected clinic block, a shared phone line, a modest barrier reduction fund for gas and grocery cards, and a written agreement with the nearest delivering hospital. Peer support and group care add substantially, and should be the first additions once the base is stable.
What Worked and Why
Specific decisions or design features that drove success
Putting every service on one team, rather than referring out, is the design decision the clinical leadership points to first. A pregnant client with opioid use disorder needs prenatal care, addiction medicine, behavioral health, housing help, and pediatric care for the newborn. Handing her a stack of referrals guarantees missed appointments. Keeping those services inside one team, with shared records and shared staff, means the clients who show up once tend to stay.
Removing steps from intake changed who came in. A direct line answered by a person, walk-ins accepted, a two-minute screening, an appointment booked during the first call, and a standing weekly provider block combine into a wait of less than a week. Staff also decided that no one gets turned away: even when HOPES is not the right level of care, the person is seen at least once and walked to the right service.
Separating program participation from treatment choice removed a common reason to stay away. Clients who choose buprenorphine, clients on methadone, and clients who are reducing use without medication are all in the program. That decision reframes the clinic as a place to get prenatal care, not a place that will withhold care until a client agrees to a particular plan.
Group care built a peer bond that individual visits cannot. The group prenatal care class model normally groups clients at similar gestational ages, which is not possible with a caseload this small and this complex. That mattered less than expected, because these clients bond around recovery and parenting rather than around the trimester they are in. A two-hour group session, with the nutritionist and therapist present, delivers education that no 15-minute visit can.
Following clients past the hospital doors, including the postpartum visit and couplet care, is what clients themselves name as the difference. One of the first clients came in already in early recovery to establish care, was found to have elevated blood pressure, was sent to labor and delivery, and delivered that afternoon. She still points to the support afterward as what mattered: she never felt alone. She is in recovery, housed, working, and parenting her child. Staying connected even to clients who disengage protects that outcome. The team tracks every enrolled client to the delivery date, checks hospital records weekly, and reaches out through community partners. When a client left the hospital in early labor with ruptured membranes, against medical advice after a relapse, the team located her, and she returned and delivered safely. Without that outreach, the likely path was a serious infection, an intensive care admission, and a NICU stay, at a cost measured in hundreds of thousands of dollars.
Early outcomes and data
Active caseload of 10 to 12 pregnancies at any one time, tracked to delivery even when a client disengages from visits.
NICU admission rates are below what the state data predicted for this population.
No intrauterine fetal demise has been reported in the program to date, and the preterm delivery rate is running below the state's reported rate of about 17% for this population.
Approximately 80% of clients leave the hospital with effective contraception.
More clients now reach the program through word of mouth from other clients, not only through partner referrals.
Well-child visit completion at the newborn, one-month, two-month, four-month, and six-month marks is tracked for every baby in the program.
At least one documented case in which team outreach returned a laboring client to hospital care, avoiding a likely admission to intensive care and the NICU.
Full annual served count and formal outcome reporting are still being compiled for the state.
Lessons Learned
Listen to clients before you design anything. The team expected people to flock to a welcoming new program. Instead, many arrived carrying fear built up over years of clinical encounters. Asking clients directly about their previous pregnancies surfaced that early and changed how staff talk, screen, and schedule.
Bring the state along as a partner, not just a funder. Conversations with state Medicaid and settlement leaders reset expectations about what a caseload of this complexity should look like and what counts as a win. State leadership visited the site, reviewed the model, and now treats it as an example for maternal health priorities.
Build the whole team, because the model is the intervention. The chief medical officer describes the biggest lesson as the model itself. Prenatal care alone, addiction medicine alone, or behavioral health alone will not hold a patient with this complexity. The integrated team is what makes the outcomes possible.
Count cost avoidance, not just visit volume. A caseload of 10 to 12 looks inefficient next to a standard obstetric panel. Set against an avoided intensive care admission, an avoided NICU stay, or an avoided fetal loss, the arithmetic looks different. Build that case for funders early and keep the examples documented.
Be adaptable and write flexibility into the budget. The team learned in the first year that they needed outreach workers, gas cards, and teaching materials they had not fully anticipated. Grant language that allows barrier-reduction spending and staff training enables a program to respond to what clients actually report.
Plan for staffing depth from the start. Multiple hands make light loads is how the team describes it. Cross-trained staff, each bringing different experiences, keep the program running when one person is unavailable and reduce the risk of burnout associated with a small, high-acuity caseload.
Taylor Tomlinson, M.D., Board Certified Family Medicine and Addiction Medicine