Care Coordination Offers Expecting and New Parents a Central Medical Home
May 2, 2022
NYC Health + Hospitals connects pregnant patients to medical and community-based resources to address maternal mortality health risks and has increased postpartum visit attendance by over 12%.
Clinicians at NYC Health + Hospitals obstetric clinics administer a mental, physical, and social health screening to all prenatal patients. Based on the results, patients are referred to a maternal medical home (MMH) program for support services, with higher risk patients assigned to a care coordinator or social worker. In 2020, the MMH team members at NYC Health + Hospitals made over 2,700 referrals to medical and community-based resources and helped increase postpartum visit attendance for enrolled patients by over 12%.
How They Did It:
Screened all pregnant patients to assess their medical, psychosocial, and socioeconomic needs
Assigned staff to high-risk patients to provide education and parenting support
Referred patients to resources to address risk factors and social determinants of health
