How It Works: The Care-Coordination Service Model

Then, Now and Beyond: On its 20th anniversary, a look at how the New Haven Healthy Start program works.

NHHS care coordinators are strategically located at sites where pregnant women are likely to visit. Parnter sites include: Yale New Haven Health; Fair Haven Community Health Center; Cornell Scott-Hill Health Center; and the homeless agencies Christian Community Action and New Reach, Inc.


Every woman who has a reproductive health visit at Yale-New Haven Health or one of the two community health centers is entered into New Haven Healthy Start. Pregnant women are also referred to Healthy Start by primary care providers, the New Haven Health Department, homeless shelters, community agencies, the Housing Authority of New Haven and other community partners.

Universal Risk Assessment

A risk assessment is given to each woman to determine her medical and nonmedical needs so that she is provided with the appropriate level of care and support.

New Haven Healthy Start worked with its various partners to develop and validate a universal intake tool that is used by all providers in the Healthy Start network. Once a participant is in the NHHS program's system, she can see different participating providers without being asked to complete additional forms.

Care Coordination

New Haven Healthy Start care coordinators help participants access resources that will contribute to healthy pregnancies and successful births. This work includes but is not limited to:

  • Referring uninsured women to the New Haven Health Department to sign up for HUSKY, the state Medicaid program for children and parents
  • Helping arrange childcare, transportation and translation services
  • Referrals to specialists or mental health providers
  • Connecting women at risk of homelessness to housing services
  • Screening to ensure qualified benefits are being received

Community Outreach

When a New Haven Healthy Start participant misses a health appointment, a community outreach worker is dispatched reach out to her and help her overcome the barriers that caused her absence. Community outreach workers are hired from within the communities they serve and recruited from local places such as beauty salons, libraries and laundromats. This approach yields results. Ninety-nine percent of women in NHHS have an ongoing source of primary and preventive care services, 96% requiring a referral completed their referral, and 100% received screening for risk factors.

Community Voices

New Haven Healthy Start is guided by the community through the NHHS Consortium, which is unique among all the Healthy Start programs in the country. The Consortium gathers all stakeholders: residents, healthcare providers, mothers, fathers and caregivers. Together, consortium members create a network of community support around the issues of health equity and infant mortality. Monthly meetings are held to discuss barriers to quality healthcare, share resources and advocate for changes to improve the health and wellbeing of our community. In addition to strengthening the local perinatal health system, consortium members also advocate at the national level for continued support for Healthy Start.