This is the Story of a medically complex family that was served by two parent educators, Connie and Bobbi (our RN parent educator), and how they tirelessly worked to find the family, engage them, and provide the services they needed.

This is the story of Sara and her baby. Sara was originally referred to us prenatally. Connie tried diligently to find her but was unsuccessful and the referral was closed. A few months later the referral was sent back to us through the hospital with information that the baby had been born and the mother would like services.

Connie was now assigned to the new referral and that she sought out to engage the mother. After several attempts, Connie was almost ready to close the referral when she was able to locate the mother. The mother finally signed with our program and is now receiving much needed help. Because the mom and the baby had many health challenges, Connie had Bobbi, our nurse parent educator, engage with this family. Here is her back story.

Sara was homeless and living in a downtown Salvation Army shelter. She delivered at one of the main maternity hospitals with what seemed to be a normal labor and delivery. The mother began to hemorrhage and in order to save her life – the obstetrician had to do an emergency hysterectomy. The placenta had grown into and attached itself to the wall of the uterus which upon delivery caused the hemorrhage. Sara was now in critical condition and the baby was transferred to All Children’s NICU due to NAS. Sara was in the hospital for about 2 weeks and was discharged. Baby came home soon after to the homeless shelter. Sara began to feel ill and returned to the emergency room a week from her discharge and was septic. She was told that she had an abscess at the site of the original surgery. She had to face surgery again to save her life. The baby was with the father at the shelter.

The baby was born with a club foot and also had to have surgery a week after Sara got out of the hospital from her second surgery. The baby although healthy and well, required many doctor visits and special care regarding his castings and appointments. Sara was able to attend to the needs of the baby through so many obstacles.

Connie was able to engage the family and keep them in services through all of the many, many barriers that happened upon the family. Sara is on a managed does of methadone. Baby had the surgery and is casted and Sara is doing very well in getting the baby to and from all appointments. Sara, however, is neglecting herself a bit and so Bobbi was able to speak with the mom about the importance of her own health and well-being. She helped Sara find a medical home, make an appointment for dental care she desperately needed, and attend her post-natal visit. Bobbi continues to be involved to help monitor the families many medical needs.

The family is connected to many resources and they are on a steady road to financial and health stability. Our team meets with them weekly and has developed a strong trusting relationship with the · family.