State/Jurisdiction: North Carolina
Population: Families & Caregivers Infant
Topic Area: Safe and Connected Communities Care Coordination
NPMs: NPM 11: Medical Home
The Family Connects model is available free-of-charge to every family with a newborn in a participating community or service area. Families are typically engaged and recruited in birthing hospitals. All families that schedule a visit receive one to three home visits from a registered nurse. At the home visits, nurses work with the family to assess the health of the caregiver and infant, discuss supportive guidance, and provide comprehensive connections to community resources that support the long-term well-being of the entire family. The goal of our program is to support newborns and their families by linking parents to the individual community resources they need, ultimately improving health outcomes at the population level. The core components of this program include program availability to all families with newborns residing within a defined service area, a comprehensive in-home visit conducted by a registered nurse, assessment of family need using the Family Connects Family Support Matrix, short-term intervention or referrals to community resources when family needs are identified, alignment of community services with identified vulnerabilities and family needs, and documentation of all family encounters through an integrated data system.
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