Innovations in plans of safe care implementation for infants with prenatal substance exposure.

INTRODUCTION: Federal legislation requires states to notify child welfare agencies of all newborns affected by prenatal substance exposure and to develop a plan of safe care (POSC). However, there is substantial variation in how states implement POSC and no best-practice standards. This study explored innovative state practices to understand how POSC policies can best support affected children and families across policy, health system, and child welfare contexts. METHODS: We conducted qualitative interviews with national experts on perinatal substance use policy, as well as state officials and birthing hospital staff from five states with innovative POSC practices (Connecticut, New Mexico, Oklahoma, Oregon, and Washington). Interviews explored child welfare reporting processes, novel strategies, and factors influencing implementation across systems. RESULTS: Thirty interviews were conducted with national experts (n = 8), state officials (n = 12), and hospital staff (n = 10). Experts highlighted key challenges, including unnecessary child welfare involvement for families without safety concerns, limited follow-up to ensure service connections, and insufficient support earlier in pregnancy. Innovative state models included dual notification-reporting pathways, partnerships with managed care and social service organizations, and prenatal POSC initiation. Respondents highlighted the importance of offering services outside the child welfare system and identified challenged related to communication and coordination across care settings. CONCLUSIONS: Innovative POSC models that emphasize dual notification-reporting pathways, cross-sector partnerships, and early engagement may strengthen service connections, support families earlier in pregnancy, and reduce unnecessary child protection involvement. Clarifying state statutes and broadening stakeholder roles could help states promote a family-centered public health approach to POSC implementation.