NYC Health + Hospitals Announces Maternal Medical Home Program From Harlem To Hawaii

NYC Health + Hospitals today announced the launch of its Maternal Medical Home program. The program is designed to improve high-risk obstetric (OB) outcomes by providing referrals to necessary specialty care, mental health services, and enhanced wraparound services to address socioeconomic challenges, as well as parenting support and education.

Every pregnant patient receiving prenatal care within the City’s public hospital system undergoes a health and social screening during a prenatal visit to evaluate who could benefit from additional coordinated care and/or support services.

The program aims to create a stable, safe, and healthy environment for expectant patients to successfully take care of themselves and their newborns.



Since the program’s launch, more than 1,226 pregnant patients have been referred to additional care or support services, such as nutrition, dental, and housing.

Since the program’s launch, more than 1,226 pregnant patients have been referred to additional care or support services, such as nutrition, dental, and housing.

The Maternal Medical Home program will be live at all 11 hospitals later this year.

“The City’s public health system has had an emphasis around coordinated care for years, understanding the critical role social determinants have on a person’s health and their ability to provide a child a prosperous environment,” said Chief Medical Officer of NYC Health + Hospitals Machelle Allen, MD. “The Maternal Medical Home program puts pregnant patients at the center of their care and facilitates coordination to necessary support services that help provide the strongest foundation for a healthy delivery and safe care for their newborn.”

“A safe and healthy delivery more often than not depends more on the pregnant patient’s access to nutrition, elimination of stressors, maintenance of chronic diseases, and so much more that our new Maternal Medical Home program helps coordinate support for,” said Chairperson of the Department of Obstetrics, Gynecology and Women’s Health at NYC Health + Hospitals Wendy Wilcox, MD. “This program combines nearly every corner of our comprehensive health system – from Community Care to Population Health, Ambulatory Care, Women’s Health, Behavioral Health, Pediatrics, and beyond – to help pregnant patients and new parents create the healthiest version of themselves for their growing families.”

Patients may be referred to the Maternal Medical Home program at any point in their continuum of prenatal to postpartum care.

Patients may be identified at their initial prenatal visit, from a visit to OB triage during the pregnancy, from the high-risk obstetrics practice, or once a postpartum issue has been identified.

Once a need is detected the patient is referred to other necessary specialty care, such as substance use disorder treatments, oral health, mental health, or smoking secession, or to socio-economic support services, which can include financial counseling, food access programs (i.e. WIC, SNAP), and affordable housing.

In addition to working through the health system’s social workers for wraparound services, more than 450 patients have been referred to community-based organizations for additional support.

A multidisciplinary team of clinicians and advocates system-wide, which included the Women’s Health Clinic Council to Address Maternal Mortality and Severe Morbidity, collaborated to develop a program that would focus on delivering high-quality care to patients with guiding principles based on the Patient-Centered Medical Home model.

The public health system’s Maternal Medical Home program was piloted at NYC Health + Hospitals/Kings County in 2019 and expanded thereafter to the current ten hospitals that offer the program to its pregnant patients.

To help carry out coordinated care and psychosocial services, each site was assigned at least a licensed social worker or a care coordinator.

Funding for the Maternal Medical Home program was included as part of the City’s previous $12.8M allocation for a comprehensive plan to support programming aimed at reducing maternal deaths and life-threatening complications from childbirth among women of color.

Funding for the Maternal Medical Home program was included as part of the City’s previous $12.8M allocation for a comprehensive plan to support programming aimed at reducing maternal deaths and life-threatening complications from childbirth among women of color.

Prenatal Coordinated Care and Medical Home models have been shown to improve birth outcomes, including fewer infants transferred to a neonatal intensive care unit.

To learn more about NYC Health + Hospitals maternal health services call 844-NYC-4NYC.

NYC Health + Hospitals is the largest public health care system in the nation serving more than a million New Yorkers annually in more than 70 patient care locations across the city’s five boroughs.

NYC Health + Hospitals is the largest public health care system in the nation serving more than a million New Yorkers annually in more than 70 patient care locations across the city’s five boroughs.

A robust network of outpatient, neighborhood-based primary and specialty care centers anchors care coordination with the system’s trauma centers, nursing homes, post-acute care centers, home care agency, and MetroPlus health plan—all supported by 11 essential hospitals.

Its diverse workforce of more than 42,000 employees is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

Its diverse workforce of more than 42,000 employees is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible.

For more information, visit www.nychealthandhospitals.org and stay connected on Facebook at https://www.facebook.com/NYCHealthSystem or Twitter at @NYCHealthSystem.

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