The Meadowlark Initiative System of Care
A simple team-based system of prenatal care can improve perinatal outcomes and strengthen families. In the Meadowlark Initiative System of Care, a Clinical Team and Community Team collaborate to provide integrated prenatal and behavioral health care, and to coordinate community-based supports and services that families need. This simple system has been shown to reduce newborn drug exposure, improve maternal and neonatal outcomes, and reduce the need for foster care placement.
The Clinical Team
Mothers and their families receive care from prenatal and behavioral health providers with support from a care coordinator. These three make up the core of the Clinical Team.
- The Prenatal Care Provider screens all incoming prenatal patients for SUDs and mental illness using a validated written or verbal screening tool. Patients who screen positive receive a same visit “warm hand-off” to the behavioral health provider for evaluation.
- The Behavioral Health Provider (LCSW, LAC/LCSW, or LCPC) assesses the patient and provides a brief counseling intervention, outpatient therapy, or an appropriate referral to higher-level care.
- The Care Coordinator works with each patient to ensure they receive the right care at the right time by coordinating services and referrals and tracking clinical outcomes. The care coordinator also works with patients to identify social factors that may impede their treatment (like insecure or unsafe housing, lack of transportation, or food insecurity) and helps navigate the patient and family toward community resources that can help address those factors.
The Community Team
The Community Team consists of a group of agencies and organizations that can provide critically needed support for pregnant and postpartum women and their families. The Community Team may include social service providers, home visiting programs, child protective services, public health departments, and housing and other agencies. The Care Coordinator helps build and coordinate the Community Team.
The Clinical Team and Community Team work collaboratively to form a support system for the patient and their family.