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Care Coordination Offers Expecting and New Parents a Central Medical Home

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

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