Description

The American Academy of Pediatrics (AAP) recommends screening the birth parent for depression during the 1-, 2-, 4-, and 6-month well-child visits.

In alignment with these guidelines, SUNY Upstate implemented a structured workflow for maternal depression screening and expanded its integrated behavioral health program to include direct maternal therapy services. PSP funding supported specialized training for an integrated clinical social worker in perinatal depression treatment, allowing mothers who screen positive during pediatric visits to access therapy in the same building where their child receives care. This model promotes timely support, continuity of care, and reduced stigma around seeking maternal mental health services.  

Need / Problem Statement

While maternal depression screening was already part of clinic practice, there was a persistent gap between identification and treatment.

Previously, mothers who screened positive were given phone numbers for outside providers, often without follow-up or feedback from the agencies involved. Many families lacked transportation, faced scheduling barriers, or felt unwelcome in external care settings. Existing pediatric relationships presented an opportunity for better access and trust. This innovation also aimed to:

• Eliminate barriers to maternal mental health treatment by co-locating services
• Establish closed-loop communication between pediatricians and behavioral health providers
• Offer care in a familiar, accessible environment to improve follow-up and engagement

Process

This innovation built upon an existing integrated care infrastructure at the clinic.

Integrated behavioral health leadership guided workflow design and referral protocols, and a Licensed Clinical Social Worker (LCSW) completed PSP-funded perinatal mental health training and began providing therapy. The design-to-implementation period was approximately 6–12 months. Together, team members: 

• Identified a maternal mental healthcare gap through family discussions and staff observations
• Supported providers in completing perinatal mental health training and certification
• Developed and approved an internal referral process modeled on existing integrated care workflows
• Introduced the service during team huddles and ongoing provider communication

Partnership

Community and family input directly influenced the innovation’s design. As examples:

• Families consistently expressed frustration that maternal mental health programs were inaccessible or unwelcoming.
• Leadership sought to ensure access to care in a trusted, familiar pediatric setting.
• Ongoing engagement with families helped shape the structure and tone of the service, emphasizing comfort, inclusion, and ease of access.
• Community feedback validated the need for a model that met mothers where they already receive care—the pediatric clinic.

Implementation

Implementation followed a structured but flexible rollout process that identified needs through family and provider discussions.

After selecting and training a qualified LCSW in perinatal mental health care, leadership and staff developed a workflow collaboratively. Logistical challenges around scheduling and locations were addressed. Staff and residents were integrated around internal referral steps, and appointment availability gradually expanded as patient load increased. Additional integration strategies include:

• Clerical staff trained to schedule efficiently
• Regular reminders in team huddles to sustain awareness
• Close collaboration between pediatricians and behavioral health providers to ensure closed-loop communication

Changes & Outcomes

Since implementation, families have shown strong interest and appreciation for the service.

Mothers can now access therapy “in the moment” when a need is identified during a pediatric visit. Even mothers who decline or miss appointments benefit from quick follow-up, reducing the risk of being lost to care, and many continue therapy since it’s in a setting where they already feel comfortable and supported. Additional system and workflow outcomes include:

• Seamless communication between pediatricians and therapists ensures more coordinated care.
• Pediatric providers report improved satisfaction knowing they can offer concrete, immediate help.
• Reduction of referral gaps and missed opportunities for intervention.

Measurement for Success

• Tracking of internal referrals and appointment completions serves as the primary success metric.

• Early data focuses on the number of referrals made, the rate of appointment follow-through, and ongoing engagement in therapy.

• Qualitative indicators include provider and parent feedback on accessibility and trust.

• Formal data collection and analysis will continue through 2025 and 2026 to evaluate sustainability and outcomes over time.

Payment & Funding

• Funding type: Supported through sustainable reimbursement mechanisms and philanthropic funds used for provider training and initial implementation. This innovation will be financially self-sustaining once integrated into standard care workflows 
• Anticipated gains: Improved family access and reduced no-show rates due to co-location and strengthened interdisciplinary collaboration within the pediatric medical home

Resources

• Facilitating Attuned Relationships (FAN)
• IPFCC Checklist for Attitudes
• Promoting First Relationships
• Promotion and Prevention Reflection
• Resilient Attitudes and Living for Professionals
• The Reflective Practitioner

To learn more about this innovation please email Dr. Jenica O’Malley, Pediatrician at SUNY Upstate ([email protected]) or Summer Merrick, Director of Help Me Grow ([email protected])