happy children, mother and child, and expecting mother and father

Funded Projects

Grant Status: Completed

Grant Title: Medical Care Management for Complex Prenatal Patients

Web Site: St. John's Well Child and Family Center, Inc. Project Exit Disclaimer

Project Director(s):

Aela Paiz
St. John's Well Child and Family Center, Inc.
Los Angeles, CA  90037
Phone: (323) 541-1600
Email: apaiz@wellchild.org


SJWCFC will provide coordinated medical care management to complex and high risk prenatal patients to improve care coordination of hospital and clinic-based care and address poor perinatal health outcomes for women and children in South L.A.

Goals and Objectives:

Goal 1: Improve health outcomes for low-income mothers and their children in South L.A. Objective 1: Between 3/1/13 and 2/28/18, the RN Care Manager will provide care management services to a minimum of 250 prenatal patients with complex medical needs, annually (Baseline: 0). Objective 2: By the end of Year 1, (2/28/14) St. John's care management will increase the proportion of healthy newborns born to mothers who received prenatal medical care management at St. John's, who are seen for their first well baby visit at St. John's within four weeks after delivery from 0% to 80%. Objective 3: By the end of Year 1 (2/28/14), increase from 72% to 78% the proportion of patients seen at St. John's with a positive pregnancy diagnosis who initiate prenatal care in their first trimester. Goal 2: Improve health outcomes for low-income mothers and their children in South L.A. Objective 1: By the end of year 1 (2//28/14), St. John's care management will increase 6-month exclusive post-partum breastfeeding rates among patients who received prenatal medical care management from 0% to 25%. Objective 2: By the end of year 1, (2/28/14), increase the percentage of pregnant women seen by the RN Care Manager who received counseling and education by the 28th-week from 0% to 90%.


For the proposed MCMCPP project, a bilingual RN Care Manager (RNCM) will provide individually tailored medical care management and coordination for perinatal patients with complex medical needs as well as linkage of their newborns to a pediatric provider. Activities include: outreach and education in order to inform the target population; stratification and enrollment of prenatal patients in the program according to their medical risk; intensive care management and education provided by the RNCM; patient and newborn linked to a medical home for follow up care post-delivery; ongoing training of the providers and staff in cultural competency.


St. Francis Medical Center: SJWCFC will coordinate a referral process which would also link mothers seen for prenatal care at a community health centers to deliver locally at St. Francis. After delivery, patients who received prenatal care at a SJWCFC health center will be referred back to St. John's family and pediatric providers for continued health care for both the mother and newborn.


The evaluation will be descriptive, formative, and summative. The descriptive evaluation will describe activities, outputs, and outcomes of the project. The formative evaluation involves data collection to collect, analyze and track data to measure process and outcomes. The summative evaluation will assess the immediate, short-, and long-term outcomes and the MCMCPP's project contribution to these outcomes.

Experience to Date:

In the last year, we have continued our progress with the Healthy Tomorrows project. One of the biggest accomplishments of the past year has been an effective collaboration between our Medical Care Manager (MCM) and our newly hired Family Specialist (FS) through Project DULCE. SJWCFC was chosen as one of five testing sites nationally for implementation of Project DULCE, (Developmental Understanding & Legal Collaboration for Everyone) a program developed by pediatricians at Boston Medical Center. DULCE provides families with support for age-related information on child development and help with unmet legal needs, in addition to ongoing support from the FS, who partners with parents of newborns with the dual goals of improving child development and reducing toxic stress for the entire family. Families meet with the FS at all routine visits, with home visits and telephone check-ins as optional further contact, depending on the families' preferences. The MCM has been able to refer families to the FS for ongoing holistic support and external referrals that pertain to the family as a whole, parental needs, or the needs of older children. In referring to the FS, the MCM has been able to ensure that high risk mothers, who already have an inordinate amount of toxic stress, have added support to pressure of additional stressors. This relationship has enhanced both Project DULCE and Healthy Tomorrows in the information and support the FS and MCM have been able to share.

Back To Top ↑

Title V in Your State