Casita de Milagros, New Mexico’s only residential treatment center for pregnant women battling addiction, closed this summer. Thanks to community outcry, the facility might soon be resuscitated. But Milagros’ advocates are discovering that the devil is in the details. Carrie didn’t learn she was pregnant until after she was in jail. After six stable years of sobriety, she made the mistake of returning to New Mexico and reconnecting with her ex-husband. With him, Carrie—not her real name—slipped back into selling and using drugs. Six months later, she was once again addicted to crack cocaine and heroin and sitting in a cell. She learned she was expecting when a jail official told her she wasn’t allowed to sleep on the top bunk because of her pregnancy. Already three months along, she despaired at the thought that she’d been using before she knew she was pregnant.Carrie’s life was full of problems, but she was about to learn she had another. A blood incompatibility between her and the baby threatened the baby’s life. The pregnancy would have to be managed by specialists. During an early prenatal visit, one of Carrie’s nurses referred her to Milagros. It was a referral that Carrie calls a blessing. Upon serving 60 days in lockup, Carrie was released directly to the intensive round-the-clock residential treatment facility. Suddenly, activities filled her day, from parenting classes to recovery groups to prenatal care. “There was a lot of homework,” she says, smiling.The baby received her first in utero blood transfusion two weeks into the program. Carrie credits Milagros for saving her daughter’s life. Surrounded by support and structure, Carrie says she didn’t even think about touching drugs. Instead, she poured her energy into a healthy pregnancy and recovery. Her daughter, now an energetic toddler, was born prematurely. Carrie continued to stay at Milagros during her baby’s hospitalization. After a total of six months, Carrie transitioned out of the facility and now lives with her daughter. Carrie has remained stably housed and works taking care of others. She shudders to think what would have happened if Milagros hadn’t been there when she was released from jail. “I’d probably be homeless, or reincarcerated. I wouldn’t have known that my daughter needed a transfusion. I would have lost her.”Carrie says she and some of the other Milagros moms cried together when they learned the facility would be closing a few months ago. They wrote letters and signed petitions in an attempt to keep Casita de Milagros open. But their efforts couldn’t counteract the cuts in Medicaid and city funding that obliterated the program’s budget. The Aftermath Casita de Milagros closed its doors on July 1. The building where the lives of women and their babies were saved sits empty and gathering dust, waiting for another shot. Its future remains uncertain, but Bernalillo County Commissioner Michelle Lujan Grisham feels optimistic that the program will reopen. Lujan Grisham has been pushing to save Milagros since word of the budget slash reached her office. She, along with fellow commissioner Maggie Hart Stebbins, requested a 60-day extension for the inpatient program before it closed. The extension never materialized. The commissioners say they became involved, in part, out of responsibility to Bernalillo County taxpayers. The University of New Mexico Hospital, which operated Casita de Milagros, receives about $90 million annually from Bernalillo County, according to UNM financial reports. This money is intended to help UNMH meet the needs of the underserved. Now that Milagros’ Medicaid funding has evaporated, advocates are exploring how to use county money to keep the program going. Only a tiny fraction of the county funding would be needed to cover Casita de Milagros’ expenses. But Hart Stebbins says Bernalillo County doesn’t have much power to allot the money to special programs. Gaps in Care When Casita de Milagros closed, the women receiving residential services transitioned into an outpatient program. Therapy moved to the Department of Family and Community Medicine to enhance coordination of care and follow-up. Dr. Andrew Hsi, who helped establish Milagros, says the outpatient program is flourishing. But the loss of inpatient services has left a huge gap in the care of women and their children. Hsi says that no matter how strong the outpatient program is, some women simply require more intensive therapy. He recalls patients sleeping in their cars or returning to toxic domestic situations at night. Situations like these harm a woman’s chance at treatment success. When an unborn baby’s health hangs in the balance, every chance matters. Lujan Grisham says the stakes get higher as the temperature plunges. Without the residential facility, pregnant women may be returning to the cold streets at night. “I don’t even want to think about winter,” she says. “I need [Casita de Milagros] to be taking patients again right away,” she says. “Every moment we waste is another life at risk.”Milagros’ closure has rippled through the community, says Hart Stebbins. Her office has received a tremendous amount of input from folks concerned about the program. “Milagros is something the community values,” she says. “It’s a good investment. Every commissioner has heard feedback that Milagros is valuable.”Lujan Grisham echoes the sentiment: “It’s really tough to treat addiction. Here you have a program that works. I’ve heard from families, from a wide range of individuals. This touches so many lives.” Limited Resources Harrison Kinney, executive manager of the Behavioral Health Services Division, says Casita de Milagros couldn’t be a big player in treating substance because it saw too few women. Part of the problem, says Kinney, is that women admitted to Milagros would stay for the majority of pregnancy. This meant that Milagros, as a six-bed unit, served about 18 women a year. Now that the facility has closed, Kinney says the grant funding that the program still receives from Behavioral Health Services Division will be used to enhance community and outpatient services. He says these services, which tend to take a back seat to residential services, are crucial in chronic, relapse-prone diseases like substance dependence. Yet studies published in the Journal of Substance Abuse Treatment and The American Journal of Drug and Alcohol Abuse show that residential treatment is an indispensable step for many pregnant women. Folks may argue over length of stay, but research shows moms must be given adequate time to recover. Women like Carrie who stay six months or longer have increased success in many areas of life. So while the cost of extended inpatient care might exceed cheaper options, there’s a long-term payoff. Residential treatment programs like Milagros decrease health care and legal cost, improve maternal productivity and enhance child wellness. Hart Stebbins points out that the baby will likely be a member of this community for 60 or 80 years. “There’s a clear financial benefit,” she says. Reopening the inpatient program is “the humane thing to do, and the fiscally responsible thing to do,” she finishes.Dr. Hsi says Milagros’ small capacity is a reason to expand residential services—not eliminate them. Lujan Grisham has been the driving force behind negotiations between the county, the city, the state, UNMH and OptumHealth (the private firm that manages New Mexico’s behavioral health Medicaid dollars). They’re working to put residential treatment back on the menu. “There’s been some disagreement, but everyone’s agreed to figure it out,” she says. “I’ve gotten commitments from everyone.” A Path Forward If the program is resurrected, it will most likely come in the form of a new county-owned facility. Kinney says Milagros may be incorporated into the Metropolitan Assessment and Treatment Services program, the county’s detox and treatment center. If residential services go through that program, Kinney says Behavioral Health Services Division money is available to help fund the facility—but not the treatment. The question of how to pay for this treatment still needs answering.While a county-owned facility offers a bright ray of hope, Dr. Hsi cautions that the county doesn’t have experience running a residential program for pregnant women. Casita de Milagros generated success through its therapeutic, rather than punitive, environment. This is why Dr. Hsi, along with Lujan Grisham, is looking to UNMH to staff and lead a second version of the program.While the kinks of this plan are hammered out, women like Carrie and their unborn babies still have nowhere to go. Lujan Grisham wants to see the empty Casita de Milagros readmitting patients until more permanent solutions materialize. But Milagros hasn’t reopened, and each day brings it closer to a crucial deadline. According to a UNMH memo, Casita de Milagros is licensed as a custodial boarding home by the Department of Health. This license expires at the end of December 2011. Advocates worry that UNMH might walk away from the residential treatment center if that license expires before the facility reopens.Carrie says that would be a shame. “I love UNMH. Excellent care. I knew exactly what was going on with my care,” she says. She adds that she hopes the same experienced treatment team she trusts will be there for other women in need. Like the women and babies it served, Casita de Milagros’ future dangles on a fragile thread. This program, which shepherded the birth of New Mexico’s most vulnerable babies and the rebirth of struggling women like Carrie, deserves a second chance of its own.
Whitny Doyle is a family nurse practitioner.
