Referrals and Hope Are Not a Strategy (with Dr. Mary Ann Woodruff & Rachel Lettieri)

In this video episode of Thrive Together, hosts Maya Smith and Jason Lehmbeck speak with Dr.Mary Ann Woodruff and Rachel Lettieri, LCSW, of Pediatrics Northwest, a pediatric group thathas served families in the South Sound region of Washington for more than 50 years.Mary Ann is a general pediatrician who saw patients for 36 years and is now the MedicalDirector of Care Transformation as well as the Washington Medical Director for Reach Out andRead.Rachel directs Care Transformation and built the practice’s community health worker division.Both were fellows in the Thrive Center’s Innovation Hub.Pediatrics Northwest treats the pediatric medical home as a universal touchpoint, the one placenearly every family returns to with their child, and uses it to bridge physical health, behavioralhealth, and unmet social needs.Community health workers from the community accompany families: they help navigatesystems like early intervention and behavioral health, reduce stressors, and build the confidenceto make a first call. The team has protected one non-billable day a week for community healthworkers to be out building relationships with the resources they connect families to, a choicethey have held for four years even while billing Medicaid for those services. Their work grewfrom a Medicaid waiver grant for collaborative care and behavioral health integration in 2018and 2019, and it is part of Pediatrics Supporting Parents, a five-community national initiativewith Zero to Three to strengthen early relational health in well-child visits.The through-line, in Mary Ann’s words: children’s brains develop in relationships, not systems,and so our systems have to catch up with that science.