Matt Broom, MD Amy Ladley, PhD Nancy McEuen Bridge4STL continuous, personalized, service bridging gaps for chronically underserved families at risk for infant mortality Matt Broom, MD Amy Ladley, PhD Nancy McEuen

About Danis Pediatric Center Academic, pediatric primary care practice located in a children’s hospital 17 attending physicians 56 resident physicians 180 medical students High volume 9,500 patients over 22,000 visits per year

About Danis Pediatric Center Patient population that faces unique challenges greater than 85% insured through Medicaid disconnected to health and community services 70% low health literacy What about caregivers of infants, specifically? 69% report incomes less than $20,000 per year 47% have education that is high school equivalent or less 3 out of every 4 caregivers is less than 30 years old

What is Bridge4STL? Collaborative effort that’s seeks to bridge the gap caused by: lack of medical and mental health services lack of social support inability to access community resources chronic under-service Uses perinatal mood and anxiety disorders as a gateway Three-pronged approach free therapeutic services family navigation – care coordination and case management pediatric co-location

Why is Bridge4STL Unique? Pediatric co-location of family navigator more access more eyes whole family focus Embedded family navigator on postpartum ward early access builds strong relationships immediate resource for providers Reliance on collaboration ‘working backwards’ Meeting families where they are

Our Participants Enrolled 144 in the first 9 months first year goal was 40 18 withdrawn 10 transferred care 5 state custody Bridge families mirror overall Danis Pediatrics population trends

Our Participants

Participant Contacts Majority of patient contact through phone almost 2000 calls in first 9 months Strength of program is in personal contact redefining support through responsiveness

A Navigator’s Perspective The role of a family navigator support case management lite education Two stories the Brandys “talk to my baby” baby naming

How Can We Do Better? There have been challenges… Next steps engaging OB volume much higher than expected navigation and support limited by network and available resources Next steps data collection pediatric appointment compliance ED visits 71 participants with at least 1 visit < 1 visit, on average for all participants, half of clinic average 6-week postpartum check – 42% what other services can we bring to Danis Pediatrics? WIC, Medicaid, legal services

Prescription for Success Invest time uncovering the real problem choose your own adventure Intentional examination of stakeholders needs and values open doors to collaboration? Actively listen to recipients of care what they need vs. what you think they need participants set the agenda judgement-free Anticipate data collection and system-building what demonstrates value and sustainability?

thank you matt. broom@health. slu. edu amy. ladley@health. slu thank you matt.broom@health.slu.edu amy.ladley@health.slu.edu nancy.mceuen@ssmhealth.com