Back to audience

Best practice №25

Identify community care resources for the mother and newborn

by Jadene Wong, Katherine Weiss

Last updated October 7th, 2020

Download Best Practice as PDF
Download as PowerPoint Presentation


Identify community care resources for the mother and newborn and appropriate partner agencies and services in the community. 

Why we are recommending this best practice

Providing adequate transitions of care pre- and postnatally that include outpatient support structures with expertise in addressing the needs of both mothers with opioid use disorder (OUD) or substance use disorder (SUD) and their exposed newborns can improve outcomes and support the development of protective factors that reduce or mitigate the effects of adverse life experiences for children and their families. Early interventions like home visits are a prime example of this.

Strategies for implementation

  • Involve the mother and newborn in outpatient support programs as early as possible, ideally prenatally for the mother. Descriptions of evidence-based programs can be found below. 

  • Each unit should maintain an updated list of outpatient resources (federal, state, and local) that families can access. 

  • Arrange a system to refer the mother and newborn to outpatient OUD/SUD treatment and recovery programs. The system should clarify who refers (physician, social worker, etc.) and when to refer (upon admission or discharge). Consider a default referral on admit orders.

  • Inform and educate mothers on these referrals and highlight the benefits of these programs.

  • Potential short-term and long-term neurodevelopmental delays exist for these infants. Early intervention programs, child protective services, and/or health care services are recommended to cover neurodevelopmental, psycho-behavioral, growth and nutrition, ophthalmologic, and family support assessments. Refer to Best Practices #31 and #32 for additional information on these topics.

  • The identification of key community care resources and supports for mom and baby should be incorporated into the Plan of Safe Care as described in Best Practice #29.

Pre-, Peri-, and Postnatal Programs: The programs described below begin services during pregnancy and cover the mother/baby dyad. Most pre-, peri-, and postnatal programs are federally funded. In California, many of these programs are also funded by local First 5 Commissions, which use money from a state excise tax on cigarettes and other tobacco products to fund programs from birth (i.e., during pregnancy) to five years of age. In addition to the ones listed in this toolkit, other evidence-based pre-, peri-, and postnatal programs can be found in the Resources section of this Best Practice. 

  • California Home Visiting Program (CHVP): CHVP oversees implementation of various evidence-based home visiting programs throughout California, including the Nurse-Family Partnership (NFP) and Healthy Families America (HFA), and currently 23 California counties have these evidence-based programs. State-level agency workgroups conduct needs assessments to determine the greatest need for and potential impact from these programs based on factors such as poverty rates, rates of child abuse and neglect, and the ability to find and enroll at-risk parents in particular areas.
    • NFP: Geared towards low income, first-time pregnant women. Care starts in pregnancy and follows the dyad until the child reaches two years of age.  The mother must be referred before 28 weeks of pregnancy.
    • HFA: Geared towards low-income, at-risk families from birth to a minimum of three years.

  • Early Head Start: Early Head Start provides preschool and home visiting services geared towards low-income, at risk families. This is one of the few programs that can be started either during pregnancy or after delivery and follows the dyad until the child reaches three years of age. 

  • CalWORKS:  CalWORKS offers a new three-year home visiting pilot initiative that began in January 2019. It is supported by both state General Fund and federal Temporary Assistance for Needy Families dollars. The program provides up to 24 months of home visiting for pregnant and parenting people, families, and infants born into poverty. 

  • Healthy Start: Healthy start targets communities with infant mortality rates that are at least one and a half times the U.S. national average. Women and their families can be enrolled into Healthy Start at various stages of pregnancy, including pre- inter-, and post-conception. Each family that enrolls receives a standardized, comprehensive assessment. 

Postnatal Programs: These programs are primarily geared towards infants and can be implemented in the postnatal period.

  • Early Start: Early Start is California’s early intervention program (i.e., Part C of the Individuals with Disability Education Act), providing early intervention services to at-risk infants and children less than three years of age who meet eligibility criteria based on the presence or risk of developmental disability. Services include infant education, occupational therapy, physical therapy, and speech therapy.  Referrals can be made from the NICU or newborn nursery and are often coordinated by a social worker, although anyone can make a referral, including parents, medical providers, neighbors, family members, foster parents, and day care providers.

  • Home Health Visits: A number of public and commercial insurance companies offer home health visits, usually in response to a medical need. If the patient does not have insurance, or if the patient’s insurance declines to cover the home health visit, the county often will provide a public health nurse. Some counties or local areas have established their own system (e.g,. Palomar Home Health Services).



  • Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547-561.
  • McQueen K, Murphy-Oikonen J. Neonatal abstinence syndrome. N Eng J Med. 2016;375(25):2468-2479.

Jadene Wong


Dr. Jadene Wong is Clinical Associate Professor of Pediatrics at Stanford University School of Medicine. She has practiced as a neonatal hospitalist at Lucile Packard Children’s Hospital Stanford for more than 10 years, and practiced in primary care outpatient community settings for more than 20 years.  She is a member of the task force for the joint CMQCC/CPQCC Mother & Baby Substance Exposure Initiative. She is also the Newborn Clinical Lead for this project and mentors Central California hospitals participating in the initiative.

Katherine Weiss


Dr. Katherine Weiss is a neonatologist at Rady Children's Hospital-San Diego and an assistant professor of pediatrics at UC San Diego. Previously, she was a clinical assistant professor of pediatrics for the University of Arizona.

Her areas of interest are in quality improvement, education and international health.