Citizen Portal
Sign In

HRSA‑funded integrated maternal health pilot links clinic screening to a community Pathways hub and care‑coordination network

Joint Interim Standing Committee on Health and Human Services · February 17, 2026

Get AI-powered insights, summaries, and transcripts

Subscribe
AI-Generated Content: All content on this page was generated by AI to highlight key points from the meeting. For complete details and context, we recommend watching the full video. so we can fix them.

Summary

A HRSA grant-backed pilot integrates standardized SDOH screening in a maternity medical home with a Pathways Community Hub to connect pregnant people to community health workers and community care agencies; the pilot completed 500+ risk assessments and enrolled many clients into multiple verified pathways (housing, transportation, postpartum care).

Representatives of the HRSA Integrated Maternal Health Services (IMHS) grant—Dr. Nadia Gomez, Amy Schmidt (Comagine Health) and Gabriela Bucchini (UNLV evaluation lead)—described a pilot that integrates in‑clinic SDOH screening with the Pathways Community Hub model to address social drivers of adverse birth outcomes.

Clinic workflows embed an 11‑domain screening tool in the electronic health record; community health workers administer the screening early in pregnancy (ideally first trimester) and either deliver interventions or open standardized "pathways" in the certified hub. The hub contracts with community care agencies (Dignity Health, Southern Nevada Health District, Nevada Health Centers) that employ CHWs to resolve pathways (housing, food security, transportation, prenatal access). The pilot team reported 500+ completed risk assessments with 191 referrals accepted by the hub and 93 enrollments to date; demographic data show a majority Hispanic cohort followed by Black/African American participants.

IMHS implements maternity medical home elements (integrated clinical teams, whole‑person orientation) plus hub care coordination to close referral loops. Early results included high pathway completion rates in prenatal care access, housing stability and food security. Presenters said they have generated roughly $1.8M per year in grant funding for five years and are planning scale‑up, sustainable payment pilots (PCAI outcome‑based unit rate) and further partnership with Nevada Medicaid to test outcome‑based reimbursement.

Committee members asked about capacity and the need to expand CHW staffing; presenters said more CHWs are required and that training pipelines and certification efforts are in progress. The agencies committed to provide cost‑per‑participant figures as pilot data matures.