Programs for Pregnant Woman and Young Families

Zuckerberg San Francisco General and local community organizations currently provide multiple programs to help pregnant women and young families address non-medical, social and psychological determinants of health. Solid Start aims to identify these programs and work to increase collaboration so that every door becomes an open door to the network of social and mental health services that can work together to support vulnerable families.

 

The table below outlines a number of programs, the services they provide, referral processes and points of contact. For additional information on programs listed  here, please contact joanie.rothstein@ucsf.edu.

 

ZSFG BASED PROGRAMS

Project Name

What are the services provided by the program?

Target Population

Eligibility Criteria

How is client referred?

For more info contact:

Centering Pregnancy

Centering Pregnancy is an enhanced model of prenatal care, which includes medical aspects, as well as empowerment and self care skills. It is a group based model, co-led by an SFGH midwife and Homeless Prenatal Program staff person. There are 10 women per group, all due same time. The initial prenatal visits are individual, then at about 4 months the groups began.

There are ten 2-hour sessions over pregnancy. Groups include self care activities (weight urine, bp), individual time with midwife and approx 75 minutes. one hour and quarter group time of facilitated discussions.

Pregnant Women Almost everyone is offered the option of participating. (A small number are not eligible due to medical conditions). Prenatal intake nurse can refer to program.

Margy Hutchison, Leadership Council Chair, Nurse-Midwives of SFGH

margy.hutchison@ucsf.edu

 415-206-4202

Child and Adolescent Services The Child and Adolescent Services program provides intensive psychotherapy for children 0 -18. Because most younger kids go to the Infant Parent Program or Child Trauma Research Program, the average client is over 5 years. Children 6-18 Child must be a resident of San Francisco and on Medi-Cal or Healthy Kids. There must be a medical necessity for enrollment, such as an impairment of functioning.

The program receives referrals from pediatrics providers, outside agencies and self referral.

Referrals can be made through e-referral, fax or phone.

Marisol Romero, UCSF/SFGH Infant Child Adolescent Psychiatry

marisol.romero@ucsf.edu 415-206-9687

Kempe Behavioral Health Partnership Adult Psychiatric consultation to the Pediatric High Risk Clinic ('Kempe Clinic'). The psychiatrist is co-located in the Kempe clinic and sees parents of children enrolled in the clinic who have mental health needs. The parents seen are not receiving psychiatric services elsewhere in the community. The psychiatrist also provides consultation to the pediatric team for cases in which the mother or father is suffering from mental illness but does not wish to receive mental health treatment. Parents The Kempe clinic provides comprehensive, multidisciplinary services to families who have experienced significant social risk factors such as teenage pregnancy, substance use, foster care, and significant parental mental illness. Children must meet this criteria to be enrolled in Kempe. The only criteria for the parents seen by the adult psychiatrist is for their children to be enrolled in the clinic. Referrals can be made by providers by phone, email or in-person

Melissa Nau, Physician Champion

melissa.nau@ucsf.edu 415-206-5978 (o)/

415-314-1840 (c)

High Risk Obstetrics Psychiatry (HROB) Mental Health services (MD, PhD) to pregnant and newly postpartum (up to 6 weeks postpartum) women in the SFGH network. Main services are medication management and therapy. Pregnant women For the mothers - must be a patient at SFGH or DPH either with HROB, Family Health Center, or a community primary care clinic. Referrals come through e-referrals from CNMs , PCPs, NPs and OBs.

Melissa Nau, Physician Champion

melissa.nau@ucsf.edu 415-206-5978 (o)/

415-314-1840 (c)

UCSF  HIVE HIVE Clinic provides multidisciplinary preconception, prenatal, gynecologic and sexual health care to women living with HIV as well as HIV-affected couples including serodifferent couples (when one partner is HIV+ and the other is HIV- Women living with or affected by HIV who are pregnant or desire to be pregnant. Woman must be living with HIV and/or have a sexual partner living with HIV, and are pregnant or desire pregnancy. Call HIVE social worker Becca Schwartz at 415-206-4240, or e-mail Monica Hahn (monica.hahn@ucsf.edu) or request through e-referral.

Karishma Oza, MPH

HIVE Program Coordinator

Karishma.Oza@ucsf.edu

 

Phone: (415) 206-8919

 

UCSF  Infant Parent Program

IPP is San Francisco’s pioneering infant mental health program specializing in serving children birth to five years of age with a particular commitment to underserved, vulnerable and at risk populations. Services provided to this population include outpatient, usually home based, infant-parent psychotherapy (birth -3 years of age), perinatal mental health services , and community and hospital based infant and early childhood mental health consultation. Additionally therapeutic shadowing and developmental therapeutic playgroups are offered in conjuction with, and at some sites where, consultation is being provided.

Children 0-5; pregnant women; parents

For families who are referred to the Infant-Parent Program for psychotherapy services, the parent and or infant/ child must meet medical necessity for a mental health diagnosis. In the majority of families, it is the parent who has a significant enough psychiatric concern to warrant a diagnosis but occasionally the child’s symptomatology will rise to the level of a diagnosis. Both partners in a dyad do not have to have to be diagnosable but at least one must be and that person must have full scope Medi- Cal. All other services are grant funded and do not require patient eligibility.

Referrals to the Infant-Parent Program for mental health treatment are made by phone. The number is 415-206-5270 . It is a two part process. The first contact is administrative. The referring party is asked to provide basic demographic information about the parents and child. The second phone encounter is with the intake psychologist. The referring party is asked about the reason for referral,presenting relational concerns and development / medical information about the pregnant woman and/or the child. Referrals are from several sources including SFGH prenatal and pediatric providers, Child Protective Services , Foster Care Mental Health and community based providers.

.

Kadija Johntson, Director U.C.S.F. Infant-Parent Program/Daycare Consultants 

kadija.johnston@ucsf.edu

415-206-5082

UCSF Child Trauma Research Program

A clinical research program providing services (child/parent psychotherapy) for children 0-5. Also serve pregnant women in conflicted relationships or history of trauma. Serves children who have experienced a traumatic event - abuse, neglect, witnessing domestic violence, community violence, loss of loved one, medical trauma. Service provision is 6 - 8 months of weekly psychotherapy sessions.

Children 0-5; pregnant women; parents

Need to have experienced traumatic event and be under six years old.

Anyone can make referral including self-referrals. Preferred method is a call to the referral intake line: 415-206-5311. 

Maria Torres, UCSF Department of Psychiatry

maria.torres@ucsf.edu 415-206-5311

Multi Disciplinary Assessment Center The purpose of the MDAC is to provide family-centered assessment services, diagnosis, service linkages, short term intervention and case management to children and families needing neurological, psychological, and medical assessment for suspected/actual developmental delay.

Children 0-5;

Children 6-18

Any child under 6 years, regardless of insurance status is eligible. If child is over 6 yrs the child must be Medi-Cal AND a part of the SFHN.

Appropriate referrals include:

• Assistance with diagnosis of autism

• Mental health concerns (eg ADHD, depression, anxiety) in a child with developmental delay.

• Behavioral concerns beyond scope of primary care counseling in areas of toilet training, sleep, aggression, hyperactivity < 6 years of age

• Delays/concerns in more than one area: eg speech/language delay with motor delay, sensory sensitivities

• Children > 3 years old, but not yet in school, with concern for delay on developmental screen

• Neurocognitive testing following traumatic brain injury

• Pts rejected by GGRC/SFUSD but whom you still have concerns about

•Concerns that an IEP (individualized education plan) and/or GGRC plan of services does not fit the needs of a child.
Referrals from SFGH and outside agencies can be made through e-referral or a referral form can be faxed in. For questions call (415) 206-6129.

Amy Whittle, Physician Champion

amy.whittle@ucsf.edu

(415) 206-3605

ZSFG Health Advocates The ZSFG Health Advocates is a program designed to improve patient care by bringing volunteers, social workers and legal aid providers together to triage and partner with patients to address social and legal needs that are barriers to good health. The Health Advocates are student and community volunteers that conduct standardized social and legal needs screenings with participating families. This screening includes questions related to food security, housing stability and safety, financial security, and healthcare access. Volunteers then use county-specific resource algorithms, community resource lists, and on-line resources to facilitate applications to existing benefits programs (like CalFresh, California's Supplemental Nutrition Assistance Program) and to connect families with external community organizations like food pantries and workforce development centers. When volunteers encounter more complex issues-like family mental health issues or complicated legal challenges-they connect families with clinical social workers and/or lawyers who provide additional professional advice and support. Pregnant women; parents; families All are eligible Volunteers approach families in clinic to see if assistance would be welcomed. Providers can also fill out a referral form for Health Advocates who then contact the families later by phone.

Anais Amaya, Program Manager

anais.amaya@ucsf.edu

 

Medical-Legal Partnership at the SFGH Family Health Center The SFMLP at the FHC offers full legal representation for eligible clients in areas including: housing and habitability, public benefits, domestic violence issues, consumer rights, and legal barriers to employment.

Other services include: referrals to outside organizations if appropriate, brief advice and counsel, informal consultations with care team, and provider/staff training on legal topics.In conjunction with the Health Advocates program at SFGH, we also offer screening of patients for social-legal health harming needs

Adults; parents, families

Patients with any legal issues can be referred to the MLP at the FHC. The attorney will then perform a further screen to determine if they are eligible for Bay Legal's services. If they are not, MLP attorney will refer them to another legal organization if applicable. On-site referrals on Thursday afternoons: Patients directly referred by provider or Behavioral Health Team (LCSW or BAs) ; Patients identified through health advocate screening.

Offsite referrals: Patients directly referred by provider or Behavioral Health Team (LCSW or BAs) via email, phone, pager, or eReferral

Georgia Sleeth, Project Coordinator

georgia.sleeth@ucsf.edu

415-206-6539

           
 

                                        COMMUNITY PROGRAMS

   

Project Name

What are the services provided by the program? 

Target Population

Eligibility Criteria

How is client referred?

For more info contact:

Black Infant Health Program The mission of the Black Infant Health Program is to close the gap in Black infant and maternal mortality. Prenatal or postpartum support group series (2.5 hours per week for ten weeks) for African American women who are 18 years or older. Postpartum group - for women who have been through prenatal services. Child care onsite. Once postpartum series are complete women can have 60 more days of individual case management/life planning. Pregnant Women; postpartum women Pregnant; identifies as African American Referrals by providers and mental health workers can be faxed or phoned in. Fax to 

415 776 4453, ATTN: Anastasia Gordon.

Anastasia Gordon, Community Outreach Liaison

415-776-4457
Anastasia@sfblackinfanthealth.org

Public Health Nurse Home Visiting Program The Public Health Nurse Home Visiting Program provides visits to high risk prenatal and postpartum women and their newborns. While the Nurse Family Partnership program limits participants to first time mothers, this program is available to any high risk mother in San Francisco, regardless of inurance status. The program currently has 12 nurses, each can handle a caseload of 40. Pregnant Women; Postpartum Women High risk, high need pregnant or post-partum women. Any provider can refer a high need/high risk pregnant or postpartum woman to the program. Many referrals from SFGH, others from other providers throughout city.

Aline Armstrong, Program Coordinator

aline.armstrong@sfdph.org

 

SFDPH Nurse Family Partnership Nurse-Family Partnership's maternal health program introduces vulnerable first-time parents to caring maternal and child health nurses. This program allows nurses to deliver the support first-time moms need to have a healthy pregnancy, become knowledgeable and responsible parents, and provide their babies with the best possible start in life. The relationship between mother and nurse provide. In San Francisco women must enroll by 28 weeks at the latest (the goal is to enroll by 16 weeks). Women stay enrolled in the program until the child turns 2. Visit frequency is not fixed. Generally during pregnancy and infancy it is weekly or bi monthly. As child gets older it visits may happen once a month. This is a relationship based intervention where nurses work with the family for an extended period. Currently there are 9 nurses working for the Nurses Family Partnership. Their max caseload is 25 families.   First time mothers only. Any provider in SF can refer a first time mom to this program.

Diane Beetham, Director of Public Health Nursing

diane.beetham@sfdph.org