PORT

(PRENATAL OUTREACH AND RESOURCE TEAM)

Purpose and Scope:

The Prenatal Outreach Resource Team (PORT) is a multi-sectoral approach that includes partners in health, social services, and the community. The program is designed to create a culture shift in Saskatchewan that wraps supports around pregnant women with complex life situations by providing early and effective interventions in pregnancy that will reduce health complications in mothers and their infants and prevent children from being apprehended at birth. With the overwhelming success of Sanctum 1.5 which focus on harm reduction, culturally safe and trauma-informed strategies to keep the mother-baby dyad intact, this Implementation Plan describes the expansion of this care model across Saskatchewan (through the PORT team) as a means of reducing the long-term impacts of foster care on women, children, and the families, while also improving health outcomes for both mothers and their babies in Saskatchewan.  

SCG has also identified that not all pregnant women at risk of having their children apprehended need the full support of Sanctum 1.5 or “in-house” programming. Early intervention in their pregnancy through the use of a specialized Prenatal Outreach Resource Team (PORT) will meet the needs of women in the community as soon as possible in pregnancy in an effort to reduce the need for supportive living where possible and prevent children being apprehended at birth. PORT will coordinate services between all community organizations equipped to support women in complex life situations. 

PORT will be implemented in a phased approach. It is recognized that the PORT team is a direct response to the end of the provincial Birth Alert System. 

Wrap Around Services and Approach to Care

SCG’s programs are developed through the identification of gaps in current services and provides supports for people living with complex health and social issues such as those experiencing homelessness and housing instability, addictions, stigma, chronic disease, and other vulnerabilities. The focus is on bridging identified gaps between healthcare, social services, and community-based organizations by working collaboratively with government, not-for-profits, front-line groups, and individuals who may utilize these programs. The primary focus is on women who are at risk of having their child apprehended at birth in Saskatoon, Prince Albert, and Regina, including surrounding areas to network services in other Saskatchewan communities.

SCG attributes its successes to adopting and implementing a harm reduction philosophy of care while providing wrap around services that are culturally safe and rooted in trauma-informed care. Harm-reduction services recognize the importance of providing ongoing education with a focus on pragmatic rather than moralistic interventions. Clients are not required to abstain from drugs or alcohol to receive services and support. Our programs work with clients to address root causes of risk behaviours such as substance use as opposed to imposing conditions that prevent clients from accessing care. The wrap-around approach to care and philosophy of meeting people where they are at, is core to  SCG’s mission, vision, and values and focuses on the understanding that the challenges our clients face are complex and multi-faceted and calls for non-judgmental services that support the well-being of the individuals supported in programs.

Training Model:

Target Population:  PORT will identify and begin working with at-risk pregnant women as soon as possible in their pregnancies to address the risk factors that lead to children being apprehended at birth. Team members will connect with the women who have been identified through referral to build a relationship and help the woman identify her needs and desires for health and social supports and/or services. The team will ensure the woman is aware of the supports and services available and will work to ensure the woman can make an informed choice as to what supports/services she would like to access and when. The Team will follow clients through their pregnancies and coordinate and offer practical, tangible supports that will improve the health and social circumstances that lead to child apprehension.   The Team’s services will operate within SCG’s culturally safe, harm reduction stigma-free philosophy and wrap-around model of care that aims to practically address individual, social, and systemic barriers to care.

PORT will function as a single point of contact coordinating hub to ensure women at risk of having their child apprehended are connected to care, support, and services to meet all of their needs – physical (shelter, food, clothing, medical needs), mental (counseling, support, specialists), social (peer navigators, and social support programming offered in the community), spiritual (cultural support worker who will connect mothers to: Elder, cultural teachings and safe care, other spiritual care, and connections that fit the woman’s belief system and needs). A ‘case management’ approach will be taken to identify, coordinate and connect the woman to the needed existing health and social services. Efforts will be made to ensure each woman has multiple contacts from PORT staff, as her needs may change throughout her pregnancy. By providing wholistic, trauma-informed, stigma and barrier-free, wrap-around support and by facilitating access to services that address the myriad of social, physical, emotional, mental, and relational needs, the PORT team seeks to reduce the intersecting risk factors, thus increasing prenatal support and engagement and reducing children entering the foster care system.  

PORT will support women in determining their own case plan, aiming to reduce the need for supportive living where possible through the utilization of agencies and supports that will keep mother and infant safe together in the community. Women who can successfully be supported within the community can be followed by the PORT team prenatally and postnatally, following the birth of the child; until they can be successfully supported by exiting services in the community 

Staff Training: SCG policy and training framework will be utilized in developing key competencies, including principles of Case Management, Seek and treat, Harm Reduction, Trauma Informed Care, cultural competency and wrap-around models of care.  Current policies developed for SCG will be on-boarded to the PORT team and additional policy development will occur through the first 6 months of operations 

Referral Process

Client Criteria: Women who are pregnant and at risk of their child being apprehended at birth who are experiencing any of the following:

1. At risk of contracting HIV/HCV while pregnant 
2. Mental health and/or addiction
3. Previous and/or current MSS involvement
4. Transient or experiencing housing uncertainty and vulnerability
5. Interpersonal violence
6. Complex life situations

Access to Program: Can occur through health or social services referral, Community identification (through CBOs and partner organizations), and self-identification/referral.

Goals of the Program (care cascade):

1. To mitigate the risks associated with children being apprehended at birth and reduce the number of children entering/or remaining in the foster care system
2. To provide Access and support for obtaining culturally safe, stigma-free treatment and care
3. To provide Access and support through harm reduction and preventive strategies that can lower health risks
4.  Access to prenatal care to increase women’s wellness 
5. To reduce the risks associated with vertical transmission of HIV and syphilis 
6. To provide stability to women in the prenatal period, while offering long-term stability to optimize health and social outcomes 
7. To provide time-sensitive care, and ensure adequate support are provided while optimizing health outcomes for mom-baby dyads - and by extension families and communities in the Province.