Promising Practices: Peds in MAMA’s at Harbor-UCLA Medical Center – California

From Whole Person to Whole Child/Whole Family Services

Peds in MAMAs fosters parental resiliency and capacity by offering ongoing guidance and support, identifying and addressing specific family needs through a psychosocial model of service delivery. Created in 2014 under a “Whole Person Care” framework, MAMA’s Neighborhood improves birth outcomes by providing interdisciplinary psychosocial care to pregnant people within Los Angeles County clinics. The goal was not just to provide a medical home, but a “patient-centered neighborhood.” Similarly, peds in MAMA’s—a program focused on the pregnant person, the unborn baby, and their family—extends the concept beyond that of a “Whole Child” to a “Whole Family Wellness” model. Peds in MAMAs’ robust pediatric approach incorporates the eco-biological systems framework – recognizing that children grow best when their “caregivers have the internal and external resources to give them safe and loving care.” (Alicia Lieberman, PhD)

Supporting Care Transitions into Parenthood

Newborn care and post-partum obstetrics providers reported challenges in patient care related to a break of trust experienced between parents and providers after birth in some of the families at highest risk, often due to inconsistent messaging about newborn care expectations. Peds in MAMA’s was developed to help bridge that transition, offering pediatric consultation to families prenatally regarding postnatal expectations. Once a pregnant person consents to participate in MAMA’s Neighborhood, a non-health-trained care coordinator conducts a comprehensive intake interview to gather information and assess the family’s risk. The interview integrates validated screeners and gathers information about mental health, substance use, housing, food, transportation, domestic violence, trauma history and other risk factors. Families may then be linked to material needs and supports (food, clothing, shelter), legal aid, mental health services and pregnancy and breastfeeding classes as part of an individualized care plan.

Expectant parents assessed to be at higher risk (per both psychosocial and medical intakes) are then offered support by peds in MAMA’s. Many of the parents served by the program thus far have histories of mental health diagnoses (depression, anxiety, post-traumatic stress disorder, bipolar disorder, schizophrenia) and/or display symptoms of possible mental health concerns.

Since parental mental health strongly impacts optimal infant attunement and the formation of secure attachment, peds in MAMA’s begins to address family systems needs prenatally and provides ongoing support postnatally in the pediatric medical home.

The peds in MAMA’s team meets with referred parents during the third trimester to identify any significant health risks and/or psychosocial stressors requiring continued attention after delivery. Care coordination (detailed below) promotes consistent messaging and warm handoffs across services and care transitions. Additionally, by applying prenatal attachment theories, visits address prenatal parenting milestones and provide anticipatory guidance related to fetal and newborn development, emphasizing the primary importance of the parent as the child’s foundation for feeling safe. After birth, the pediatric licensed clinical social worker (LCSW) continues to see the family in the pediatric medical home, offering continued support for parenting transitions and developing secure attachment.

Relationship-Based Services

The pediatrics team begins connecting with families utilizing information gathered through chart review and interdisciplinary consultation. More information about the pregnant person and their context is learned through clinical interview, and specific interventions and services offered based on family goals, strengths and needs.

Focusing on family strengths is foundational to the peds in MAMA’s program. Using an open-ended, curious approach, the pediatrics team first seeks to meet families where they are and understand strengths and concerns through the family’s perspective. Even the delivery of the American Academy of Pediatrics (AAP) Bright Futures-recommended anticipatory guidance is adapted to the emotional readiness of the expectant parent. Appointments are often scheduled around obstetrical visits and telehealth is offered to additionally meet family needs.

Care Coordination to Support Psychosocial Health Services

Care coordination begins with interdisciplinary conversations and meetings between medical personnel, mental health providers, care coordinators and other professionals—not only to share information, but also problem solve together. The pediatrics team routinely consults with the obstetrics mental health clinician and care coordinators to better understand patient context, needs and existing services. With identified health concerns, the pediatric team may also consult with other specialists (eg, maternal fetal medicine, hematology, genetics, etc) to ensure accurate understanding and consistent messaging across providers. Pregnancy can be a time of great anxiety, often exacerbated by medical challenges, possible fetal abnormalities and psychosocial stressors. Therefore, the pediatric LCSW routinely explores causes of anxiety and coping strategies for the pregnant patient. The pediatric team can then provide linkages to mental health agencies within the hospital system, community clinics, and/or refer the patient to the obstetrics mental health clinician. 

Salient issues requiring continued attention are communicated via warm handoff to the inpatient multidisciplinary teams. This includes medical issues, information regarding high social risk situations, and past traumatic experiences that may be triggered by the birthing process. Embedding the peds in MAMA’s LCSW in the pediatric primary care clinic additionally ensures a smooth transition into ongoing pediatric care. If the family chooses a different medical home, another warm handoff to the community provider is initiated. Seamless care coordination is essential in not only ensuring that patient and family needs are continuously addressed, but also in promoting trust between families and the healthcare system. 

Lessons Learned

Pushing beyond the boundaries of siloed care and partnering with obstetricians is a core feature of peds in MAMA’s. Connecting with pregnant parents before birth creates smoother transitions during the pre-, peri- and post-natal periods. Working in an interdisciplinary team offers many lessons to collaboratively think through service delivery for families. Creating relationships with other professionals working with the same families can make a significant difference in outcomes, particularly for parents at high risk for perinatal mental health challenges and their newborns. Thinking of innovative ways to work across disciplines and streamline physical health, mental health and social services can reduce stressors, treat mental health needs and set the stage for optimal child development.