1. 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

2. 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

3. 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

4. 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

5. 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

6. 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18 withdrawn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

7. Our Participants

8. 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

9. 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

10. 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

11. 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?

12. thank you matt. broom@health. slu. edu amy. ladley@health. slu
thank you