Culture of Data 2025

This presentation will feature Family Connects; an evidence-based postpartum nurse home visiting program that has been implemented in several counties across Colorado. During the visit, nurses conduct an assessment of families’ strengths and needs and connect them to appropriate community-based resources. Because the program is universal rather than targeted, and aims to serve 60% of the eligible population, we have a unique opportunity to gather data around the support needs of our perinatal community and their ability to successfully connect to community-based resources to meet those needs. Specifically, participant data collected includes demographic data such as caregiver and infant race and ethnicity, caregiver education level, primary language spoken, and caregiver and infant insurance type. Additionally, participants’ strengths and needs are assessed in 12 domains and assigned a matrix score of 1-4 depending on risk-level. Participants are referred to community-based resources and supports for any matrix ratings of 3 or 4, signifying high need or risk for the family. Participants receive a follow-up call 30 days after their visit, and data is collected on whether or not the participant successfully connected to community resources. This data is being used to identify systems-level gaps in services and improve community alignment efforts across systems of service. Specifically, this presentation will present data from Denver and Jefferson counties. Denver county launched their program in late 2024 and Jefferson County launched their program in 2023. As both programs move through the implantation phase, they are serving approximately 17% and 11% of the eligible birthing population, respectively.
Through this presentation, the audience will better understand the current needs of families with young children in Denver and Jefferson counties and how well the counties’ systems are supporting families through available resources. It will also provide an example of how to use programmatic data to identify areas that need system level improvement. The presentation will feature intentional strategies for engaging community voice in program implementation and data interpretation in order to reduce disparities among marginalized communities and improve health equity.