Successfully Connecting People and Services Through the Care Transition Program: One Partner’s Success Story

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Mothers and Babies Perinatal Network has seen huge success in working with new mothers through the Care Compass Network Care Transitions program. In collaboration with the two hospital systems in Broome County, Lourdes Hospital and Wilson Hospital of United Health Services, their team of Community Health Workers (CHWs) have met with over 600 new mothers, with a 68% acceptance rate of post-hospital home visits. “It’s really rewarding to see how things come together and how we are able to work with families and get them connected to resources. It’s really nice to be able to have connections with other programs to be able to help moms in ways that she maybe didn’t know were available to her,” says Christie Finch, Director of Perinatal Programs at Mothers and Babies.

CHWs meet with new mothers while they are still in the maternity ward. During this introduction the CHW explains how the Care Transitions program works to connect them to community resources and helps them understand that if there are any questions they might have as new parents the CHW is available. Because Mothers and Babies covers an eight-county region, when a mother delivers in Broome County, she is connected to a network of resources within the county she resides. This is a huge benefit to the new parent and the health systems that are serving them.

A home visit is offered to every new mother along with three follow-up phone calls, per the Care Transitions guidelines. During these calls the CHW ensures that the parent has selected a pediatrician or Primary Care Provider for their new baby, that follow-up appointments are scheduled for the new mother, and to check in to see if they need support with breastfeeding, connecting with WIC or any other services that are available. “It’s really to help them understand where in the community they can access resources,” says Finch, “Most people are really receptive.”

As part of the NYS Infant Mortality Collaborative Improvement & Innovation Networks (IM COIIN) Safe Sleep Initiative, Mothers and Babies provides safe sleep education and offers the new family a sleep sack at the home visit. They are also a Cribs for Kids regional contractor so CHWs work with parents to ensure that there is a safe space for their baby to sleep. If the space for the baby isn’t up to standard the CHWs provide Pack and Plays, free of charge, to the families.

Since April 2018, seventy-seven Pack and Plays have been distributed to people who would not have otherwise had a safe place for their baby to sleep. “That’s a huge success,” says Finch, “if it wasn’t for Care Transitions, we wouldn’t have known that these parents didn’t have a safe place for their baby to sleep. They likely would not have told anyone that they didn’t have a safe place because they are afraid that they wouldn’t be able to go home with their baby or they think they have a safe space but it’s not an appropriate device for their baby to sleep in.”

The CHWs also conduct a Behavioral Health Assessment, the PHQ-9, allowing them to pick up on any symptoms of post-partum depression (PPD). Because this generally happens at the 6-week follow up appointment with their doctor this allows the CHW to help the mother get the care she needs in the first 30 days post-partum. Mothers and Babies has a social worker on staff that can speak with the new parent, even going out for a home-visit if needed, until they can get an appointment with a provider. Of the 451 PHQ-9s that have been administered by the organization 24 referrals have been made to mental health services.

Because of the capacity and breadth of the services that Mothers and Babies provides they can also work with mothers who have had their babies removed at the hospital for various reasons as well as the people who are taking the baby home. The CHW can work with both the mother, to help her navigate the system to get the services she needs to work towards being reunited with her child, should she choose to do so, as well as the baby’s caregiver, supporting them with resources. Additionally, supervised visits can be held at the PAL center. The Parents as Leaders (PAL) center provides support to families where they can hone their parenting skills, get connected to community resources, received one-on-one mentoring, and more.

To learn more about the programs and services offered by Mothers and Babies perinatal, visit