Overview

In 2024, almost 46,000 infants in the U.S. were referred to child protective services with prenatal substance exposure,¹ and over a third of children who entered out-of-home care had parental alcohol or drug use as an identified reason for removal.² Parental substance use and prenatal substance exposure often are cited as factors for children entering foster care. The presence of a substance use disorder alone should never be the determining factor on child removal. Instead, decisions on family separation must be based on an assessment of how substance use disorder within a family is affecting child safety.

A Plan of Safe Care is designed to ensure the safety and well-being of an infant affected by parental substance abuse by addressing the health and treatment needs of both the infant and the affected family or caregiver. Plans of Safe Care (POSC) can respond to child safety risks, help keep families safely together, and prevent the need for foster care.

For infants affected by substance abuse, POSC bring together affected families and various service providers — including maternal and infant healthcare, substance use disorder treatment, mental health treatment, early childhood, and child welfare. This collaborative approach ensures a comprehensive response that prevents crisis-based reactions, addresses infant safety, promotes healthy child development, and strengthens family protective factors.³ This brief describes key considerations, decision points, and jurisdictional examples for implementing POSC.

Evolving requirements

Since 2003, three significant changes have been made to requirements for implementing POSC. Variation is wide among states, both in the implementation of policy and procedures⁴ and the rate of infants placed in out-of-home care due to substance use disorder-related issues.⁵

The Keeping Children and Families Safe Act of 2003 created new conditions, including POSC, for states to receive grant allocations under the Child Abuse and Prevention Treatment Act (CAPTA). Requirements include policies and protocols for the following:

• Appropriate referrals to child protection services and other relevant systems to address the needs of infants born with and identified as affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure.
• A requirement that health care providers involved in the delivery or care of such infants notify the child protective services agency of the occurrence of such condition “except that such notification shall not be construed to establish a definition under federal law of what constitutes child abuse or require prosecution for any illegal action.”
• The development of POSC for infants born with and identified as being affected by illegal substance abuse or withdrawal symptoms.
• Immediate screening, risk, and safety assessment, and prompt investigation of such reports.

The CAPTA Reauthorization Act of 2010 amended the requirements by adding fetal alcohol spectrum disorder (FASD) to the definition of an infant affected by parental substance abuse. More recently, the Comprehensive Addiction and Recovery Act (CARA) of 2016, which was passed in response to the nation’s opioid epidemic, included the following changes to the CAPTA provisions:

• Removed the term “illegal” when referring to substance abuse.
• Required that POSC meet the needs of both the infant and the family or caregiver affected by substance use disorder.
• Specified data reporting on infants and POSC, including the number of infants: a) identified as being affected by substance abuse, withdrawal symptoms resulting from prenatal drug exposure, or FASD; b) with a Plan of Safe Care; and c) receiving referrals for appropriate services including those for the affected family or caregivers.
• Required states to develop and implement monitoring systems for POSC to determine whether — and in what manner — local entities provide, in accordance with state requirements, referrals to and delivery of appropriate services for the infant and affected family or caregiver.

National implementation of Plans of Safe Care continues to evolve as jurisdictions incorporate lessons, adopt technological innovations, and respond to emerging federal and state priorities.⁶

Evolving terminology

An increasing number of jurisdictions are adopting the term “Family Care Plan” in lieu of — or used interchangeably with — “Plan of Safe Care.” “Family Care Plan” is considered a less stigmatizing term and therefore may enhance engagement of services. The Office of National Drug Policy’s Model Substance Use During Pregnancy and Family Care Plans Act supports the development of family care plans.

Plans of Safe Care for Tribes

State child protection agencies have obligations under the Indian Child Welfare Act (ICWA) to notify Tribes of any involuntary proceeding in a state court involving a Native American child. States also must provide active efforts to prevent family separation and, if separation occurs, reunify the family. Tribes do not directly receive CAPTA funds, so they are not obligated to implement POSC. However, some Tribes have initiated wellness plans to support infants affected by prenatal substance exposure, as well as their families.

Tribes have unique considerations when implementing family wellness plans. For example, Tribes must consider whether to create a standalone program, integrate with a state’s Plan of Safe Care approach, or a combination of both. In part, these considerations are informed by a Tribe’s available resources, relationship with state or county child protection agencies, whether the Tribe has tribal dependency courts or joint jurisdiction courts, and the support of tribal governance and leadership of an approach that best meets the needs of a Tribe’s infants and families. Understanding the intent behind POSC and how the state is implementing CAPTA is an important step in deciding whether to integrate with the existing system or develop a tribal program for the infants and parents or caregivers.

Key implementation steps

The National Center on Substance Abuse and Child Welfare (NCSACW) provides expert technical assistance and learning opportunities to help state and tribal governments make policy and practice changes that improve outcomes for children and families affected by substance use and mental health disorders. NCSACW has worked extensively with states, Tribes, courts, and communities on POSC, and recommends the following planning steps:

1. Establish a collaborative structure that considers the various systems involved in caring for families affected by substance use disorders, including maternal and infant care providers, substance use disorder treatment, child welfare, early childhood providers, mental health treatment, and individuals with lived experience. Since CAPTA does not identify a single entity as responsible for developing POSC, the governor’s office plays a critical role in leading and driving state collaboration by creating a state-level task force.
2. Review current state policies and practices to ensure state teams have comprehensive knowledge of relevant legislation, policies, and statutes that drive procedures and practice with families affected by prenatal substance exposure.
3. Create an inventory of existing programs for families affected by prenatal substance exposure to highlight strengths and gaps in services and inform a strategic approach. An inventory based on the stages of child development can be particularly informative.
4. Develop clear guidance that includes clarification of the CAPTA requirements. Where states have flexibility, several key decision points should be discussed and explored, including: What is a Plan of Safe Care? When is a Plan of Safe Care developed? Which families need a Plan of Safe Care? Who develops and implements a Plan of Safe Care? How is child welfare notified of an infant with prenatal substance exposure?
5. Convene local implementation teams to pilot protocols and policies. These teams serve as effective vehicles for testing out different strategies.
6. Develop and implement a cross-systems data tracking and quality assurance system for resource allocation and strategic planning.
7. Develop universal screening protocols. Ensure pregnant women are universally verbally screened for substance use disorders by their health care providers to reduce bias and ensure equitable access to services. Integrate clear pathways to services.

Additional guidance

After passage of CARA, the Children’s Bureau issued the following:

• Program Instruction 17-02 (2017) helps states implement the CAPTA provisions pertaining to infants affected by parental substance use disorder.
• Information Memorandum 16-05 (2016) informs states of the changes in CAPTA as a result of CARA and describes collaborative-based best practices to improve outcomes for families affected by prenatal substance exposure.
• Program Instruction 23-01 (2023) offers guidance to states on updating the 2024 Annual CAPTA Report including:
  • An update on states continued efforts to support and address the needs of infants born and identified as being affected by parental substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or FASD.
  • How states are using CAPTA State Grant funding to support the development, implementation, and monitoring of POSC.
  • Changes made to policy or practice and/or lessons learned from implementation of POSC.
  • Any multi-disciplinary outreach, consultation, or coordination states have taken to support POSC implementation.
  • The current monitoring processes of POSC to determine whether — and in what manner — local entities are providing referrals to and delivery of appropriate services to infants and affected family members and caregivers.
  • Implementation challenges.

Jurisdictional examples

The following examples illustrate how several jurisdictions have implemented POSC and operationalized key decision points. For additional information about state approaches, see: How States Serve Infants and Their Families Affected by Prenatal Substance Exposure, a series of briefs developed by NCSACW highlighting innovative policies and practices.⁷

Connecticut

State leaders in Connecticut launched an online portal that enables hospital health care providers to enter information on all infants born affected by prenatal substance exposure. The system collects de-identified family data on existing support and service needs. It also provides guidance about whether a report to the Department of Children and Families (DCF) is warranted. A DCF report is required only when there are concerns about the safety of the infant.

POSC (referred to in Connecticut as Family Care Plans) may be developed at multiple points, including during pregnancy or prior to discharge from the birthing hospital. When a prenatal plan has not been established, birthing hospitals are required to collaborate with families to develop a plan prior to discharge.

Through the CAPTA Newborn Notification Portal, DCF receives: de-identified family demographics including ZIP code; type of substance(s) involved; reporting hospital; education provided; ongoing need/existing services identified; and services referred. DCF aggregates the data to assess statewide needs, guide resource allocation, and monitor trends in prenatal substance exposure and Family Care Plans.

Data from the portal is integrated into Connecticut’s Substance Exposed Pregnancy Initiative, co-led by DCF and the state Department of Mental Health and Addiction Services, to support continuous quality improvement and coordinate statewide responses. The data is also used to evaluate outcomes, such as the rate of foster care placements. A 2025 study noted a decrease from 2019 to 2022 in both CPS reports and foster care placements for infants born affected by parental substance abuse who received a Family Care Plan.⁸

Orange County, Calif.

Referred to locally as Family Wellness Plans (FWP), the Orange County’s comprehensive model promotes infant safety, supports healthy pregnancies, coordinates services, and helps parents maintain stable care of their children and themselves. FWP serve as personalized roadmaps that link families to needed resources and enhance communication across providers.

Orange County providers create FWP with all pregnant women affected by substance use disorders and all infants born affected by parental substance abuse, including those exposed to prescribed medications. Hospitals play a central role through coordinated training, standardized assessments, and multidisciplinary communication strategies that support safe discharge planning, parental recovery, and prevention of unnecessary child removal and family separation.

A countywide Family Support Task Force staffed by healthcare providers, child welfare, treatment providers, community organizations, and peer support services has developed shared protocols that strengthen care coordination. This includes standardized tools — such as a Family Wellness Plan template, provider guidance, a care pathway, and a Newborn Risk Assessment — that promote consistent decision‑making and a structured yet adaptable framework across various care settings.

Overall, Orange County’s FWP demonstrate how jurisdictions can build a coordinated, family‑centered system of care that enhances infant safety, well‑being, and long‑term recovery for families affected by parental substance use disorder.

Michigan

In Michigan, a Governor’s Task Force on Child Abuse and Neglect, which included external partners along with state Department of Health and Human Service leaders, developed a Plan of Safe Care toolkit and e-learning modules to support implementation of POSC in the state.

The toolkit helps providers understand CAPTA requirements and provides an overview of POSC protocols as well as workflows to support local implementation. The workflows consider different points in time (such as pregnancy and birth) and different providers (including substance use disorder treatment, OBGYNs, or home visiting nurses). CPS workflows describe its responses to both notifications and reports. In Michigan, a notification is collected when an infant is born affected by substance use, including when it is attributed to medical treatment such as use of methadone. CPS intervenes with any infant born affected by substance use if there is an identified safety threat or risk to the child.

In addition to the toolkit, Michigan developed three e-learning courses to provide deeper support to providers implementing POSC. The three modules are:

1. Why? The background of the POSC in Michigan, as well as the fundamentals of substance use, trauma, and contributing factors
2. What? An overview of the POSC protocol, including how the POSC is developed and how to use it to support families
3. How? The components of a successful implementation of a POSC, including how to co-develop a POSC, maintain family integrity, ensure infant safety, and provide warm handoffs in care.

Washington

Washington state’s Department of Children, Youth and Families (DCYF) partnered with stakeholders to develop criteria for birthing hospitals that specify when a child protection report or notification is required. There are separate Plan of Safe Care pathways based on which families are determined in need of child protection agency intervention. For families not requiring intervention, DCYF partnered with Help Me Grow (HMG) Washington, a statewide early childhood resource navigation and service referral system, to implement the Plan of Safe Care community-based pathway and offer wraparound support. Maternal and infant care providers can make an online referral to HMG.

For all newborns with prenatal substance exposure, birthing hospitals use an online portal that guides them in their mandatory reporting requirement. The portal includes an anti-bias check tool and questions regarding safety concerns and criteria to identify the newborn being substance-affected. Hospital staff are then directed to call DCYF intake if required, or to continue through the online portal to complete a community-based POSC referral to HMG. This consent-based request for a connection to services is voluntary for families. When a family does require DCYF intervention, caseworkers develop and manage the Plan of Safe Care. De-identified family data from Help Me Grow and POSC data from open child welfare cases are used to meet federal reporting requirements, and to monitor and improve POSC.

Washington’s POSC implementation team works closely with lived experts and local community-based organizations to ensure that the plans improve access for families to POSC services and do not duplicate or derail local efforts.

Wyoming

Wyoming implemented POSC through a community-driven framework that reflects its rural geography and leverages regional partnerships. The state emphasizes collaboration among healthcare providers, public health agencies, child protective services, and community organizations to coordinate the timely delivery of supports for infants affected by prenatal substance exposure, as well as their families.

A distinguishing feature of Wyoming’s approach is its use of Patient Care Teams — defined statutorily as teams of providers, including one or more licensed provider, that deliver medical care services to a patient — to develop and coordinate a Plan of Safe Care. To expand access to services, these teams may also include non-medical professionals such as substance use treatment professionals, mental health providers, family support specialists, and early childhood partners. Working directly with families, teams co-develop plans, ideally during pregnancy and prior to hospital discharge. POSC in Wyoming are intended to function as ever-evolving living documents, guiding ongoing identification and coordination of services that advance infant safety and health, caregiver treatment needs, and family stability.

Patient Care Teams notify the Wyoming Department of Family Services (DFS) through a de-identified web-based form when a Plan of Safe Care has been developed for an infant and its family. State law requires the care team to develop the plan in partnership with the family, with the goal to keep the family safely together whenever possible. In practice, these teams help bridge gaps across systems — coordinating medical care, substance use disorder treatment, home visiting, and early childhood services. This coordination is especially valuable in remote communities with limited access to specialty care.

Wyoming also established Plan of Safe Care Collaboratives, which bring together cross-system partners at the local level to coordinate care and improve decision-making regarding infants and families affected by substance use disorder. By strengthening coordination and reducing duplication, the collaboratives enhance provider expertise, support more informed decision-making, and help connect families with a broad range of available services. These collaboratives also provide a deeper level of service coordination beyond what hospital-based care teams can achieve.

Through its emphasis on Patient Care Teams, local flexibility, and cross-systems coordination, Wyoming’s approach shows how POSC can be implemented effectively in jurisdictions with limited infrastructure but strong community partnerships.

Editor’s note: Jurisdictional information presented in this brief was updated September 2026. A previous version of this brief was published in 2023.