Skagit County’s community health assessment advances; newborn outreach pilot links nearly 400 families to services

Skagit County public-health officials updated the Board of Health on April 15 about a community health assessment (CHA) refresh focused on health equity and youth, and they reported early results from a Help Me Grow newborn outreach pilot that began in May 2024 and has connected families before hospital discharge.

Kristin Ekstrand, who represents the Population Health Trust’s public-health work, said the 2025 CHA is a refresh of the 2020 assessment and emphasizes disaggregated data to center health equity for populations including youth, Hispanic/Latino residents, LGBTQ+ and migrant communities. “We are looking at disaggregated data in any way and any place that we can,” Ekstrand said.

Ekstrand described a multi-step process: updating a scorecard of key indicators; incorporating recent community assessments (for example, the PeaceHealth community health needs assessment); identifying data gaps; conducting qualitative work (focus groups and interviews); and testing interpretations with community members. Staff said they are reviewing roughly 50 indicators, including measures tied to first thousand days, opioids, housing and food security.

Public-health staff described a targeted qualitative and quantitative push around youth and access to care. They conducted three focus groups to date, with more planned, and have done five Spanish-language focus groups to study how Spanish speakers find health information and access care. Ekstrand said the CHA team is convening a board retreat/data carousel in June to work with the Board of Health on interpreting the data and shaping priorities.

Separately, officials described the Help Me Grow newborn outreach pilot that began in May 2024 at Skagit Valley Hospital. Lindy Simmons, Help Me Grow coordinator with United General (District 304), and Jennifer Sathwaltin, Prevention and Community Health Division Manager for Skagit County Public Health, described a program that aims to “meet families where they are” by connecting them to community resources before hospital discharge.

Liz Cooksey, a home-visiting nurse now operating the newborn outreach visits at Skagit Valley Hospital, said she visits the postpartum unit, meets Skagit County families during their inpatient stay, provides brief education, connects families to local navigation services and resource supports, and gives a welcome bag of items and information. Cooksey and staff reported that from the program launch in May 2024 through early 2025 they have seen about 383 families; Cooksey currently visits part time (three days per week) and estimated that her visits reach roughly one-third of births at the hospital on the days she is present.

Help Me Grow staff said over 30% of families visited received at least one referral to services (Help Me Grow navigation, the Family Resource Center or community programs such as Parents as Teachers, maternity support services and WIC). The preferred languages of families reached include English, Spanish, Mixteco and Russian.

As part of an evaluation developed by University of Washington DNP student Erin York Bannon, the pilot distributed short surveys. The patient survey received 12 responses (about a 27% response rate) and showed strong agreement that the outreach introduced helpful community organizations, helped families feel welcomed and supported, and provided useful educational resources. A hospital-staff survey (19 responses, about a 28% response rate) showed 84% of respondents rated the newborn outreach nurse’s supports as very or extremely helpful; staff asked the county to sustain and expand the program to reach more patients who deliver at Skagit Valley Hospital but live in surrounding counties.

Erin York Bannon summarized evidence that community-based perinatal educational interventions can reduce neonatal mortality, increase breastfeeding rates and reduce postpartum depression. She also cited the Family Connects model’s randomized-trial evidence on multiple contacts and noted community cost-savings reported in that literature.

Board members praised the program and asked about gaps and next steps. Commissioners and staff discussed connections to prenatal clinics, the potential to enroll more families earlier (for example, in the third trimester) to increase Nurse-Family Partnership referrals, and housing or social-work referrals when families face instability. Staff noted that Skagit Valley Hospital now has an on-site social worker in the birth center and that the program is working on partnerships so families receive services even if they ultimately deliver outside their home county.

Ending: Staff said the CHA refresh will proceed with further data analysis, community testing, and a June data-focused board retreat. The newborn outreach pilot will continue and staff are exploring expansion options, additional funding and partnerships with neighboring counties and prenatal clinics.