System of care pilot in medical office addresses siloes, social determinants of health

The Coalition launched a new system of care/medical office pilot this spring to address the social determinants of health that impact birth outcomes and break down the barriers between the medical and social service fields. The pilot, funded by Baptist Health, places a Coordinated Intake & Referral staff person at Ascension St. Vincent’s Family Medicine Center to screen clients, enroll them in services and help them navigate challenges. Since the inception in May, the colocated CI&R staff person has completed several dozen initial intakes to connect women with a home visiting program.

Expanding the pilot to additional prenatal care offices is a key focus of the Coalition. Three more OB partners have been identified and will join the pilot in early 2022.

The pilot was developed as a recommendation from the 2018 Fetal & Infant Mortality Review process. With support from Florida Blue, Baptist Health and UF Health Jacksonville, the Coalition examined records of all infant deaths in Northeast Florida in 2018. The review examined key medical, system, social and environmental risk factors contributing to these deaths and linked them to actionable strategies. A key finding was that health and social services are fragmented and uncoordinated, along with the funding that supports them. There is a disconnect between clinical/medical/hospital and community support services that are needed to effectively address health behaviors and ensure compliance with medical care during pregnancy.  This creates a siloed, fragmented system of care.