Early Childhood Services Programs

The Family Journey Program

The Family Journey is a free care coordination program that provides support to expectant mothers and families from family planning through 18 months postpartum. A community health worker will connect parents, caregivers, and infants to the care and resources they need to have healthy pregnancies and births.

Care Coordination

A community health worker or social worker enrolls and onboards each patient into the program. This process helps our team understand the patient’s health history and identify how best to serve them and their family throughout their journey. Patients will be seen at least monthly to review education, set goals, and address identified needs. The team provides one-on-one education tailored to the patient’s prenatal or postpartum stage and connects them to group-based education opportunities. Based on social determinants of health (SDoH) screening from Obstetrics offices, the team facilitates appropriate referrals. Some patients may also receive mental health support or counseling.

Doula Program   

A certified birth doula is a birth support person who works with mothers and their families with education, birth planning and labor support. Our team works a unique role in staffing hours at both Memorial Hospital in South Bend, IN and Elkhart General Hospital in Elkhart, IN. Our doulas are not available to be on call or privately hired, but rather staffed throughout the week at the hospitals above to assist admitted and laboring individuals as needed/able.

BABE Store

The program provides goods and services that new parents need to nurture healthy babies and foster skills to help the family through life. B.A.B.E. coupons are earned by keeping prenatal appointments, attending in-person and virtual B.A.B.E. classes, parenting classes, and other activities that improve child development and family health. Doctor’s clinics and other social service agencies distribute the coupons, which can be redeemed at the B.A.B.E. store for items ranging from diapers to child-proofing essentials. The B.A.B.E. store regularly provides car seat education and installation checks.

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Postpartum Care Program

The Focused Postpartum Care Program is an evidence-based, integrated group care model designed to support postpartum women from birth through 12 months. The program combines clinical assessment, health education, and peer support in a structured group setting to promote maternal health, infant well-being, and family stability.  This initiative is also being conducted as a research project to evaluate whether this type of program is needed and beneficial within our community/location. Participants attend regularly scheduled sessions in small groups, where they receive clinical monitoring, guided education, and opportunities to build supportive relationships with other mothers experiencing similar life stages.

Program Goals

• • Improve maternal and infant health outcomes
•   Increase postpartum visit adherence and continuity of care
•   Promote early identification of health concerns
•   Enhance participant knowledge of postpartum recovery and infant care
•   Reduce social isolation through peer support
•   Support healthy behaviors and parenting practices
•   Improve mental health and emotional well-being
  

Remote Patient Monitoring Program

This program provides remote blood pressure monitoring for OB patients at risk for, or diagnosed with pre-eclampsia. Patients must be referred to the program by their OB provider and will be followed through their six-week postpartum appointment. 

The goal is to improve outcomes for these patients and their infants by actively managing symptoms and trending blood pressures, intervening sooner for worsening conditions, and making sure they successfully transition to a continuing care provider after delivery. 

Patients receive an automated, blue tooth capable blood pressure cuff and access to a phone app.  Their daily vital signs and health screenings are relayed to a platform monitored by the Community Health Nurse.  Interventions and recommendations provided to the patient will be communicated directly to the provider in the Electronic Health Record.  The RN managing the program can answer questions and assist patients between appointments as needed. 

Sickle Cell Program

The goal of North Central Indiana Sickle Cell Initiative (NCISCI) is to enhance the quality of life for those with Sickle Cell Trait or Disease by advocating, providing resources, and raising awareness about this rare disease. Our team assists patients and families with education, counselling, care coordination, social determinants of health screenings, referrals and advocacy. We serve the northern 31 counties in Indiana and educate our local communities about this rare disease.