The percent of patients who are screened for social determinants of health (SDOH), identified for a social need and referred to an agency to assist with that need has declined between Q1 and Q2 2024. Strategies need to be assessed and put into place to verify these patients are being contacted throughout their pregnancy to assure they have the opportunity for assistance.  

Contributing Factors:

• Current process mapping from partners for outgoing/incoming referrals.
• Processes in place for identifying patients who have not received services. 

Limiting Factors:

• Invalid contact information to connect with patients outside of clinic visits.
• Lack of communication devices for some patient cohorts (e.g., no cell phone, no email address etc.)
• Lack of "closed-loop" process to identify gaps in service. 

Children and communities thrive when all families have support and the necessary resources to be confident in providing a safe, stable and supportive environment, prenatal to postpartum and throughout lifespan. The most rapid and sensitive period of development begins before and immediately following birth, this period is defined as perinatal. The perinatal period sets the foundation for long-term health and wellbeing.

Watertown Regional Medical Center

City of Watertown Public Health

Jefferson County Public Health

Dodge County Public Health

EasterSeals

Moreland OBYGN

BUILD KNOWLEDGE, providing family-centered perinatal education focused on supporting all family members as they move from one stage of development to the next, programs and tools

BUILD CONNECTIONS

• Support families in building protective factors, screening for needs: Universal Social Determinants Of Health (SDOH) screening (i.e. PRAPARE)

• Strengthen perinatal systems in communities, with stronger, coordinated referral system to connect pregnant people to resources: Pathways Hub, Community Resource Referral Platforms (i.e.Unite Us), Pre -Natal Care Coordination (PNCC), Family Navigators

TRANSFORM SYSTEMS 

• Eliminate barriers to quality perinatal care with best practices and evidence-based models: group prenatal care, centering pregnancy model, home visiting programs

• Universal postpartum depression screening

ADVANCE POLICY

• Prenatal to 3 Policy Roadmap advocates for paid family leave, income eligibility for insurance, SNAP, child tax credit, Early Head Start and more

• Increase access to perinatal mental health supports

Strategy:  Improve maternal and infant birth outcomes and reduce health disparities through implementation of a coordinated social determinants of health program for pregnant persons in Dodge and Jefferson Counties 

Program Strategic Goals:

1:  Ensure the continued operation and effectiveness of the existing SDOH screening process among 7 partner agencies.

2:  Ensure individuals identified with social needs receive timely and appropriate support services.  

3:  WRMC to deliver spanish-language, in person maternity classes and related written materials for Spanish-speaking population   

4:  WPH to work with community partners to enable earlier referral of pregnant persons for screening and support.  

5:  Conduct feasibility study of implementing a universal home visiting program (i.e Hello Baby) for patients who deliver at WRMC.  (test the practicality and viability / scalability of a universal home visiting program in Dodge and Jefferson counties)

6:  Watertown Family Connections, in partnership with community organizations, strives to support expectant and new parents, particularly those in need, by coordinating and hosting three community baby showers in Dodge and Jefferson Counties in 2024-2025 school year.    

Number reflects the percent of pregnant patients given a social determinants of health screening by a partner of Welcome Baby including Watertown Regional Medical Center, City of Watertown public health, Jefferson County public health, Dodge County public health and EasterSeals, that were referred to an outside agency for additional support services.