Helping Families Succeed Through Holistic Support

PHHI Doctor Visit

Co-located within the pediatric clinic at Winston-Salem’s Downtown Health Plaza, Maria Stockton is in constant motion, connecting families with low incomes—often families of color or non–English-speaking families—to services they need. Working as a liaison to pediatricians, Maria helps parents promote their childrens’ health and readiness to succeed in school. On any given day, she might help translate between a Spanish-speaking family and their doctor, work one-on-one with a family in their home, or coach a new mom on breastfeeding in her office at the clinic.

Maria is a family educator at Imprints Cares, a community-based organization supporting parents and children in Forsyth County. Her role is part of the Pediatric Holistic Health Initiative (PHHI), a new model piloted by Imprints Cares that integrates a holistic set of services into pediatric clinics to expand access and improve quality.

PHHI is supported in part through a grant from Great Expectations, the Kate B. Reynolds Charitable Trust’s early childhood initiative. Funding this program is part of the Trust’s strategy to improve coordination among health care and other providers and families, as a way of ensuring equitable access to high-quality health care.

Giving families access to coaching and care—on their terms

The PHHI model provides connected services addressing a wide range of needs that occur between pregnancy and the age of five: breastfeeding support, coaching for first-time parents, screening and assessment for children with behavioral or developmental issues, connections to social services, and many others. The program fills the gap between these highly needed services and parents who don’t always know how to access them—or have support to do so.

“Through Trust listening and learning efforts like Forsyth Family Voices and the Family, Friends and Neighbor research, we learned that families want better access to services they need,” says Joe Crocker, Local Impact and Great Expectations program officer for the Trust. “PHHI does just that, connecting families to the right kinds of support and ensuring their success.”

Family educators like Maria serve as connectors

Maria is a nexus between families, schools, and the clinic. She’s the first person that parents see after a referral, and a stable point of contact as the family moves through the journey from pregnancy to kindergarten. She has access to the clinic’s electronic medical records system, which allows her team to track referrals and keep up with their clients’ health status.

Maria and a team of family educators translate pediatricians’ directives for the day-to-day realities of their clients. Advice as simple as “put peanut butter in your daughter’s lunchbox” can help parents act on instructions like “feed your child more protein.” And it works two ways, with Maria giving pediatricians a window into the lives of the families they see only in an office setting.

Downtown Health Plaza is a training clinic, with a mix of teaching pediatricians and residents. That’s another opportunity for the Imprints Care team. They teach providers how and when to make referrals to needed services and, in turn, join training sessions on issues like birth control counseling. It’s an atmosphere of open learning—seeding a next generation of integrated, family-driven care for Forsyth County.

Long-term engagement makes a big difference

When seventeen-year-old Alicia* came to Downtown Health Plaza with a stomachache, the last thing she expected was to discover she was pregnant. Her mother was furious, and her stepfather and sister refused to speak to her. She was very much alone.

Maria began attending prenatal visits with Alicia, then incorporated home visits into the mix, encouraging Alicia to maintain prenatal care and facilitating family conversations to ease the pressure on Alicia during the pregnancy and give her the best chance for a healthy delivery and a healthy child. After Alicia gave birth to a healthy, full-term baby boy, Maria continued to work with the new mother, coaching her on parenting and assessing her son’s development.

With ongoing support from the PHHI program, Alicia was able to improve her housing situation, graduate from high school, and secure her first job. These milestones allow her to provide a stable environment in which her son can thrive.

Expanding a model that works

By deeply integrating services and allowing close engagement with families over time, PHHI is amplifying the impact of existing resources—pediatric care, home visiting, a successful early learning program. PHHI puts the family, not the service, at the center. That’s why it was a natural fit for the Kate B. Reynolds Charitable Trust, which places a high priority on strategies guided by listening to and learning from the community.

Support from the Trust funded Maria’s position and a full-time mental health counselor provided by Family Services, a partner in the initiative, at the Wake Forest Baptist Health – Downtown Health Plaza. Now Imprints Cares is assessing the successful model, to define the key factors and conditions that would allow successful adoption of the integrated model by other facilities in Forsyth County.

“When we partner together,” said Maria Stockton, “we can help families in Forsyth make changes for their children that last a lifetime.”


*To protect the privacy of the families involved in the PHHI program, real names have been withheld.