Skagit County population-health trust reports CHA progress; newborn outreach pilot shows early uptake

Skagit County Public Health and the Population Health Trust updated the Board of Health on a 2025 community health assessment (CHA) refresh and on a newborn outreach pilot that connects families to services before hospital discharge.

Kristin Ekstrand, Population Health Trust staff, said the CHA is a targeted refresh of the trust's 2020 priorities with three goals: infuse health equity and disaggregated data into the assessment, synthesize existing partner assessments to avoid over-surveying the community, and build on prior community health improvement work to identify upstream, actionable strategies. Ekstrand said the trust is reviewing about 150 indicators (an updated scorecard of roughly 125 indicators with about 25 likely additions), and noted special attention to youth populations including Hispanic/Latino, LGBTQ+, and migrant youth.

As part of the CHA process, Ekstrand said the trust has completed multiple focus groups and one-on-one interviews with youth-serving organizations, and has performed a deep-dive on access to care, including qualitative focus groups with Spanish speakers and quantitative data from area health systems. A Board of Health retreat/data carousel is planned for June to review and prioritize indicators with commissioners.

The meeting also featured an evaluation of the Help Me Grow Newborn Outreach pilot, the program that places a newborn-outreach navigator in the Skagit Valley Hospital postpartum unit to welcome families, provide a welcome bag and short education, and connect them to county navigation and community resources. Lindy Simmons (United General District 304) described the Help Me Grow system and said the newborn outreach program launched in May 2024 to reach families during or shortly before discharge.

Liz Cooksey, newborn outreach worker, and Rose (Rosa) (promotora) provide bedside visits at Skagit Valley Hospital, and staff said the program to date has reached 383 families since May 2024; Cooksey visits three days a week in a part-time role. Public Health reported that over 30% of visited families received at least one referral to services (Help Me Grow navigation, the Family Resource Center, or partner organizations such as Parents as Teachers, WIC, early head start and maternity support services).

Erin York Bannon, a University of Washington nurse-practitioner student who developed an evaluation for the pilot as a doctoral project, presented survey results: 12 patient responses (27% response rate) and 19 hospital-staff responses (28% response rate). York Bannon said “the feedback that we received was very positive,” reporting that respondents said the program introduced them to helpful community organizations, helped them feel welcomed and supported, and provided educational resources many found useful. She highlighted that all patient respondents reported intent to attend a postpartum provider visit, a notable point given national postpartum visit gaps.

Hospital staff commentary in the evaluation praised the program as “incredibly valuable for families, especially those with limited resources,” and asked that the program be expanded to serve patients from surrounding counties who deliver at Skagit Valley Hospital. York Bannon cited Family Connects-style multi-contact models and literature showing community perinatal programs can improve neonatal outcomes, increase breastfeeding, reduce postpartum depression, and in some trials provide net health-cost savings (she cited a $3.17 savings in emergency medical costs per dollar invested for a Family Connects randomized trial).

Program staff noted interest and early collaboration from Island and San Juan counties, and that Island Health and other regional partners have begun producing compatible welcome bags; staff are pursuing further county and regional partnerships to expand coverage for non-Skagit residents who deliver at Skagit Valley Hospital. Commissioners and staff discussed linking newborn outreach with existing programs such as Nurse-Family Partnership and with hospital social work when housing instability is discovered at bedside.

Votes at a glance

- The board approved the minutes for the Board of Health meetings on Feb. 11, March 10 and March 31 as presented; the motion was moved and seconded and the chair declared the vote unanimous (see Actions section for details).