In the prenatal setting, the BPC Specialist, a perinatal mental health clinician, will have an individual appointment to meet with families following their routine first-trimester prenatal visit with their obstetrician. In that first visit, the BPC Specialist will introduce the program, educating families about the importance of the first thousand days and ways in which they can work together towards optimal outcomes. Families will be screened for unmet social needs and connected to a care navigator who will walk the family through connecting with community-based organizations, most of whom are serving on the BPC community advisory board. In order to capture unmet emotional needs and break the cycle of intergenerational trauma, families will also be screened for ACEs, depression and anxiety. During the process of screening for ACEs, the BPC specialist will discuss adversity and resilience factors and ways to address or enhance these together. The BPC Specialist will continue to engage with families based on a tiered model of need and use a resilience-based model of care to connect families with community-based services, provide evidence-based therapy, and offer wraparound support throughout pregnancy as they prepare for parenthood.

Immediately postpartum, our BPC Specialists, three maternal child health social workers, will connect with families during their routine postpartum hospital stay as well as with families who have children in the Neonatal Intensive Care Unit (NICU). Families will be universally screened for unmet psychosocial needs (SDH, mental health, ACEs, Counter ACEs), and offered brief therapeutic interventions as well as referrals to our community partners to ensure they have the resources they need after leaving the hospital. For families with children recovering in the NICU, our team will offer ongoing support through individual and group sessions. During this touchpoint, parents can also participate in parenting classes that will allow families to ask any questions about the first week of life and receive peer support from families with children the same age. Our specialists will utilize this time to emphasize the foundation for positive parenting and attachment.

In the pediatric primary care office, families will be seen by our Healthy Steps Specialist at routine pediatrics visits during the first two years of their child’s life. Healthy Steps is an evidence-based interdisciplinary pediatric primary care program designed to promote positive parenting and healthy development for infants and toddlers. This approach includes universal screening for developmental, social-emotional, and behavioral needs, consultation around addressing behavioral challenges and developmental concerns, care coordination and systems navigation for young children with identified needs, and positive parenting guidance and access to early learning resources. The program also includes comprehensive, intensive services for families with significant psychosocial risk factors identified through screening at well child visits.