The percent of patients who are screened for social determinants of health (SDOH) during the first trimester of pregnancy declined between Q1 and Q2 2024. This trend is impacted by circumstance both within and outside of the Welcome Baby partnership agency's control. 

Contributing Factors:

• Universal screening of all pregnant patients for SDOH.
• Community awareness of prenatal care options and importance. 

Limiting Factors:

• In-migration of pregnant moms to the area who haven't had the resources to receive treatment. 
• Inability to connect with patients to be able to provide a SDOH screening. 
• Unwillingness from patients to accept referrals to resource agencies. 

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.    

Numbers reflect the percent of pregnant patients screened for social determinants of health during the first trimester of pregnancy.