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How Social Care Improves Maternal Health Outcomes: Learn from Innovators at Sarasota Memorial Health Care System


The U.S. has one of  the highest maternal mortality rates among developed countries, with stark disparities depending on race, ethnicity, geographic region, and other social and economic factors. Medicaid programs, which cover 42% of all births in the U.S., can play a key role in driving innovations and devising new approaches to maternal health.

Person-Centered Maternal Care

The First 1,000 Days Suncoast initiative in Florida, led by Sarasota Memorial Health Care System, shows us a path toward proactive, person-centered maternal care. This pioneering, cross-sector collaboration is focused on supporting pregnant women, new parents, and their families by addressing their unmet social and healthcare needs.  

Together with Unite Us, Sarasota Memorial Health Care System conducted a study demonstrating that addressing unmet social needs may significantly improve maternal outcomes while reducing overall healthcare costs. Results included:

  • A 79% reduction in the odds of postpartum-related readmissions for Medicaid enrollees 
  • Over $350,000 estimated savings for all-cause readmissions per 1,000 deliveries
  • Continued reduction in odds of hospital admission up to 12 months after delivery 

These key factors drove the study’s success:

  • Streamlining collaboration with the community to deliver care outside the hospital’s four walls 
  • Incorporating patients’ lived experiences in program and service design 
  • Using technology to support cross-sector collaboration, securely collect actionable data, streamline care coordination, and measure the impact on people’s lives

The Launch

The Charles & Margery Barancik Foundation launched First 1,000 Days Suncoast in 2018 to improve care coordination and increase access to care for pregnant mothers and families with young children. Composed of more than 85 partner organizations, First 1,000 Days identifies the most pervasive barriers families face and develops innovative solutions to increase connections to help. The philanthropic dedication of numerous foundations and donors, including Sarasota Memorial Healthcare Foundation, support the operations and a dedicated team to lead the work.  

Following the Collective Impact Model, the initiative relies on Sarasota Memorial Health Care System as its backbone organization, which leads the strategy and operations. In 2020, First 1,000 Days turned to Unite Us to provide the technical infrastructure needed to support cross-sector collaboration. 

Screenings and Workflows

As the backbone agency, Sarasota Memorial has implemented various programs to better support families, including universal social drivers of health screenings and a Family Navigation service. 

Every time a maternity patient arrives in the hospital, a staff nurse talks with them about their social support needs. When they identify a need, the nurse notifies a case manager through the electronic health record system. Then the case manager visits the mother or parent to do a more thorough assessment of the whole family’s needs, including those of the parents, any caregivers, and other children in the household. After completing the assessment and gaining the individual’s consent, the case manager then securely sends referrals for needed social services through the Unite Us Platform. 

A First 1,000 Days Family Navigator responds to requests for help that come from mothers and families in the community through a public, Unite Us-powered assistance request form.

A New Maternal Health Ecosystem

top five service typesIn a survey on care experience, local care providers and families in Florida identified “difficulties navigating the healthcare system” as one of their top barriers to better maternal care. 

At a recent webinar, Meeting Mothers Where They Are: A Community and Person-Centered Approach to Care, leaders from Unite Us and Sarasota Memorial discussed both the program’s success and how it addressed challenges.

As Dr. Chelsea Arnold, the First 1,000 Days’ Manager at Sarasota Memorial, puts it, “With First 1,000 Days, we’ve moved from a maze of resources to a coordinated system of care that improves the health and well-being of mothers, families, and children.” 

“Gone are the days of people calling community agencies and hearing, ‘I’m sorry, we don’t know who can help.’ With Unite Us, we now have the resources, tools, and partnerships to connect the whole family to the right support.”


Unite Us’ software allows program leaders to measure the impact of social needs interventions to improve maternal care quality. Presented by Unite Us Director of Research and Evaluation Dr. Amanda Terry and evaluation co-lead Dr. Arnold, the data illustrates that First 1,000 Days’ efforts have made significant improvements in maternal health outcomes at Sarasota Memorial. 

Specifically, when we compare patients receiving closed-loop referrals through Unite Us to matched patients receiving usual care (n=2,456), we saw statistically significant reductions in their odds of hospital readmission 30 days after delivery (p <.05). And the impact on health outcomes continues three, six, and twelve months after delivery. 

impact over time

More details on this research and key metrics are available in this short case study

Key Takeaways

  • The program made interventions easier and more effective. Sarasota Memorial case managers, nurses, and First 1,000 Days’ navigators can quickly and efficiently identify a family’s needs, take action to help them get the right support, and feel confident that any referrals or requests will be followed up. 
  • Another powerful element of the program is its no-wrong-door approach. No matter where a family enters the system—whether through the hospital or one of First 1,000 Days’ partner organizations—they’ll quickly get the support they need. 
  • The program leaders know how important it is to rely on parents’ lived experiences as experts in their own lives. As Dr. Terry stated, “Behind all the data and systems are real people with real stories, and those stories matter. Great care starts by listening closely to people with lived experiences, and incorporating their perspectives into programs designed to serve them.” 
  • Blake Neathery, a one-time program participant who is now a community leader, says, “The best thing you can do is be authentic, honest, and supportive with families without judging them for what they’re going through. A lot of families are experiencing trauma and are really scared to share their challenges, and afraid of entering the system. What you say to them matters. Instead of asking ‘What’s wrong with you?’ we need to say, ‘What happened to you?’ and ‘What support do you need?’” 
  • As mothers and families learn about the resources available to them, more are reaching out for help, knowing they will not be judged or rejected. This work is strengthening families and giving parents confidence in raising their children. 

A Scalable Solution

The success of First 1,000 Days Suncoast demonstrates the power of collaborative efforts that bring parents, community professionals, social services groups, and healthcare organizations together. The Unite Us Platform makes this impactful collaboration possible. 

With the insights Unite Us provides, our partners can identify changes in social services needs, understand inequities, and look at co-occurring needs to make sure they’re connected seamlessly. Working together with partner organizations will continue to expand programs and projects that improve maternal and family health.  

That’s a model that can be scaled and replicated in communities across America. Social services are extremely important for individual and community health, and their impact on health outcomes, costs, and quality of life is transformational. 

More Resources

About Unite Us

Unite Us is the nation’s leading software company bringing sectors together to improve the health and well-being of communities. We drive the collaboration to identify, deliver, and pay for services that impact whole-person health. Through Unite Us’ national network and software, community-based organizations, government agencies, and healthcare organizations are all connected to better collaborate to meet the needs of the individuals in their communities.

Topics: Maternal Health