Reducing Hospital Readmissions for Mothers and Infants with Sarasota Memorial Hospital and First 1,000 Days Suncoast
Harnessing a strong network of community partners through the First 1,000 Days Suncoast initiative, along with Unite Us’ closed-loop referral system, Sarasota Memorial Hospital (SMH) reduced hospital readmissions for mothers and infants. This case study highlights how timely, closed-loop connections to community-based services reduce postpartum and infant readmissions, decrease healthcare costs, and improve overall health outcomes for families.
Key Takeaways
In this case study, you’ll learn how:
Closed-loop referrals to accountable community partners effectively lower hospital readmission rates for mothers and infants.
Unifying key stakeholders on a centralized referral platform drives greater efficiency for providers, reduces administrative burden, and demonstrates measurable ROI.
Prioritizing access to prenatal and postpartum community care leads to healthier downstream outcomes for families.
Key Results
reduction in odds of postpartum-related and all-cause 30-day readmissions for mothers on Medicaid
reduction in odds of all-cause hospital admission up to 3 months post-birth for mothers on Medicaid
reduction in odds of 30-day readmissions for infants
reduction in odds of hospital admission up to 3 months post-birth for infants
Background
Founded in 1925 as one of the largest public health systems in the nation, Sarasota Memorial Hospital (SMH) serves as the safety-net healthcare provider for Sarasota and the southwest Florida region. In 2018, SMH was designated as the “backbone organization” to lead the operations and strategy of First 1,000 Days Suncoast—a regional initiative of 90+ partner organizations established to provide families with wrap-around, foundational support during babies’ critical early years. Through First 1,000 Days Suncoast, Sarasota Memorial partnered with Unite Us to streamline referrals and connect new mothers and infants with community-based services.
See How Sarasota Memorial Hospital Expanded This Work Hospital-Wide
Challenge
SMH serves a high-need population in Southwest Florida and operates as the safety-net hospital system in the region. While consistently ranked among the nation’s top hospitals, SMH remains committed to continuously improving outcomes for patients. Recognizing that non-medical factors such as social, economic, and environmental conditions play a significant role in maternal health outcomes and healthcare utilization, SMH actively seeks opportunities to address these factors and advance high-quality care for its patients. Understanding these non-medical patient challenges, SMH, together with First 1,000 Days Suncoast, began its search for a technology partner to help streamline care coordination, address non-medical needs, track patient and intervention outcomes, and improve post-birth health outcomes for mothers and infants.
Solution
With Unite Us, the staff at SMH has the infrastructure they need to seamlessly coordinate closed-loop referrals for community services, measure and track patient outcomes, and enhance provider efficiency. SMH maternity patients are connected to the support they need through multiple Unite Us solutions:
- Closed-Loop Referrals: Staff at SMH use Unite Us’ closed-loop referral system to connect new mothers and their infants to community services they might need.
- Assistance Request Forms (ARFs): First 1,000 Days Suncoast uses a Unite Us-powered Assistance Request Form to connect pregnant individuals and families with young children to community resources. Requests flow directly into the Unite Us platform, where First 1,000 Days Suncoast family navigators review, triage, and coordinate timely, closed-loop referrals. This service is available post discharge until a child’s third birthday.
“We have an incredible network of community resources and Unite Us has made it so much easier to connect families with the right support. Having our trusted partners in one place, along with the ability to see the outcome of referrals, helps me provide more coordinated, effective care.”
Renee King, Family Navigator, First 1,000 Days Suncoast
Evaluation
To measure how connecting families to community-based services through closed-loop referrals affects health outcomes and healthcare costs, SMH and First 1,000 Days Suncoast partnered with Unite Us to conduct two evaluations:
Maternal Impact: This study assessed the impact of Unite Us implementation on maternal postpartum hospital admissions. The total study sample comprised 1,996 patients, 998 of whom were screened positive for one or more non-medical needs and were referred through Unite Us between August 2020 and January 2023. They were matched with patients who received usual care prior to Unite Us implementation (January 2019-July 2020) based on 19 criteria, including sociodemographic characteristics, comorbid conditions, and insurance status at birth.
Infant Impact: This study assessed the impact of Unite Us implementation on infant hospital admissions in the first 6 months of life. The total matched study sample comprised 2,826 infants, including 1,413 with a Unite Us referral between August 2020 and August 2023. They were matched one-to-one with infants who received usual care prior to Unite Us implementation (January 2019-July 2020) based on 11 maternal, infant, and delivery characteristics.
Read More On BMC Pregnancy and Childbirth
Impact
Together, SMH and First 1,000 Days Suncoast have reduced hospital readmissions for both mothers and infants, lowered costs, and improved overall health outcomes.
Maternal Results
*All maternal results are specific to patients with Medicaid coverage.
59%
reduction in odds of postpartum-related and all-cause 30-day readmission for Medicaid patients
57%
reduction in odds of all-cause hospital admission up to 3 months post-birth for Medicaid patients
55%
reduction in odds of postpartum-related hospital admission up to 6 months post-birth for Medicaid patients
Infant Results
*Infant results are not specific to patients with Medicaid coverage.
54%
reduction in odds of 30-day readmissions for infants with Unite Us referrals
43%
reduction in odds of hospital admission up to 3 months post-birth for infants with Unite Us referrals
46%
reduction in odds of hospital admission up to 6 months post-birth for infants with Unite Us referrals
Community Support in Action
Beyond improving readmission rates, Unite Us helped First 1,000 Days Suncoast connect families to the community support they needed most. The most common needs identified included individual and family support, food assistance, benefits navigation, clothing and household goods, and education. More than 60% of referrals were ultimately resolved, helping families access critical services. One family’s experience illustrates this impact. A Spanish-speaking mother reached out through a Unite Us Assistance Request Form because she had received no prenatal care and didn’t know where to turn. First 1,000 Days Suncoast Family Navigators connected her with prenatal care, provided a car seat and infant supplies, and coordinated referrals for food assistance, breastfeeding education, and Healthy Start home visiting.
“I was so scared. I didn’t know what to do. This is my first baby, and everything is really confusing. You have been such a blessing. You always text or call me back, and I know you’ll answer me.”
Parent assisted by First 1,000 Days Suncoast Navigation Service
Broader Systematic Savings: The Downstream Impact
Beyond improving clinical outcomes for postpartum patients and their infants, Sarasota Memorial’s initiative demonstrates how better-connected care can improve efficiency across the healthcare system. By streamlining care coordination and helping patients access appropriate services, the program supports more effective use of healthcare and community resources and can help slow the growth of healthcare spending while strengthening access to coordinated, high-quality care.
Estimated public value includes:
- +1,170 hrs in estimated administrative efficiency gains: Based on previously measured efficiency gains from a longitudinal survey of Unite Us end-users assessing time spent on care coordination activities before and after using Unite Us. The additional efficiency represents an estimated $35,000 in administrative cost savings.
- Reduced hospital utilization among postpartum patients: The observed reduction in six-month postpartum hospital admissions among patients receiving Unite Us referrals, compared with those receiving usual care, represents an estimated $228 per member per month (PMPM) in avoided Medicaid healthcare costs.
- Reduced hospital utilization among infants: Similarly, lower six-month hospital admission rates among infants whose families received Unite Us referrals represent an estimated $69 PMPM in avoided healthcare costs.
While these estimates illustrate the initiative’s potential economic impact, its broader value lies in helping patients connect with needed services, improving care coordination and making more effective use of healthcare resources.
Lessons Learned
By bringing healthcare providers, care coordinators, and community organizations together around a shared goal, SMH and First 1,000 Days Suncoast created a more connected support system for families during one of the most critical periods of life. These results demonstrate that when health care extends beyond hospital walls and into the community, organizations can improve outcomes for families while strengthening overall system performance.
- Closed-Loop Referrals Improve Maternal and Infant Outcomes: Connecting families to community-based services through accountable, closed-loop referrals helps address critical needs and reduce postpartum readmissions among mothers and infants.
- Community Support Is Critical Beyond Hospital Discharge: Streamlining access to community services before and after birth helps address non-medical factors that can affect recovery and improve outcomes for both mothers and infants.
- Coordinated Care Creates Measurable Value: Bringing healthcare providers, community organizations, and care coordinators together on a shared platform provides transparency, increases accountability, and potentially reduces healthcare costs.
First 1,000 Days Suncoast and SMH leaders continue to convene Regional Care Coordination workgroups with healthcare, foundation, and nonprofit partners to review referral trends and real-time case data, including co-occurring needs, top service types, and unresolved or rejected referrals. These collaborative sessions have led to targeted interventions that reduce barriers to care, improve referral resolution, strengthen community partnerships, and expand participation in the Unite Us network.
By using data to continuously refine care coordination and deepen community collaboration, SMH is well-positioned to sustain and scale the impact of whole-person care integration across the health system.
See How Sarasota Memorial Hospital Expanded This Work Hospital-Wide
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.
