Co-Scheduling Visits and Reducing Care Burden
Families are referred to UI Health Two-Gen via multiple pathways including through other providers (often OB-GYNs or NICU providers) as well as self-referrals. An intake worker reviews all incoming referrals and contacts potential patients to confirm interest and schedule a dyad appointment. Families may join UI Health Two-Gen immediately after birth or anytime during the first 12 months postpartum. Currently, UI Health Two-Gen does not restrict the number of days or months postpartum that families are eligible for services although due to resource limitations, there is a plan to transition families to usual care after 1 year postpartum.
Dyad clinic visits for mothers and infants are co-scheduled (back-to-back) and co-located (in the same facility), at least for the first visit. After that, the cadence at which mothers and infants may need care or services often naturally becomes staggered, although dyadic visits are available throughout the care period.
Note: The American Academy of Pediatrics periodicity schedule recommends preventive infant health care at 3–5 days post-hospital discharge and then at 1, 2, 4, 6, 9, and 12 months of age. This is the baseline schedule followed in a two-generation care model. While expected care for postpartum mothers typically occurs less frequently, providing care to a mother or just a check-in during the infant’s well-child visit is well-aligned with the provision of postpartum and primary care for mothers after delivery, particularly for those with complex mental and physical health needs.
Various means of patient referral into a Two-Gen program can be arranged by healthcare organizations, including direct provider referrals or patient-led requests.
After the initial dyad visit, visits for mothers and infants may not always naturally align, and strong communication is needed to ensure mothers continue receiving the care they need. However, co-scheduling visits whenever possible can reduce the care burden on families and help ensure mothers receive postpartum and primary care. Well-child visits, whether co-scheduled or not, are always an opportunity to check in on mothers when they are already on site.
When possible, any needed behavioral and social support services should also be offered to mothers during well-child visits to maximize services provided per visit. Behavioral health visits and care management may be offered virtually to increase access for patients.
How are postpartum mothers and their infants referred to your organization now? What referral pathways might be needed to better meet the needs of postpartum families?
Does your organization have the scheduling capability to co-schedule visits for mothers and infants, either with the same provider or different providers?
Does your organization have the capacity to schedule visits with families at the recommended pediatric well-child cadence? If not, for how many months might this be feasible?
How might your organization integrate behavioral health services and/or support for social needs immediately before or after primary care visits?
If your organization provides behavioral health services, which services are offered in a virtual format? Can other services be offered virtually to reduce care burden for families?