New Partnership Aids At-Risk Moms, Young Kids


A young mother diagnosed with post-partum depression. A diabetic pregnant woman unable to access a medical home. A family with young children struggling with behavioral health and financial concerns.

These are just a few examples of the at-risk women and their children up to age 5 that will benefit from a new partnership between the San Diego County Health and Human Services Agency (HHSA) and home visitation programs that serve South County.

The new South Region Referral Pathway was developed specifically for at-risk families. The referral pathway will help community partners find the appropriate services and programs for these moms and moms-to-be. This “no wrong door” approach will make sure moms are referred to the most appropriate services from the first point of contact. 

Through a strong partnership with 211, the pathway tool has a digital home enabling the collaborative agencies to update program information real time.  Medical providers, community partners and clients can access the database at County residents who call 211 are able to speak to Health Care Navigators trained to use the tool to provide the best first referral.

“These pathway tools will avoid duplication of services, expand service capacity and improve health outcomes for South Bay families,” said Barbara Jiménez, Health and Human Services Agency South Regional General Manager. “This will also make it easier for families to find a patient-centered medical home.”

The Referral Pathway Collaborative is led by Paulina Bobenrieth, Public Health Nurse Manager at HHSA’s South Region Public Health Center and her team.  “Working with amazing partners who serve South Region is critical” said Bobenrieth. “We want to be able to help this at-risk population in the most efficient way possible.”

Creating an improved delivery system for home visitation programs is aligned with Live Well, San Diego! Collaborating agencies include HHSA, First 5 San Diego, American Academy of Pediatrics, 211 San Diego, Nurse Family Partnership, Maternal Child Public Health Nursing, Black Infant Health, Project Concern International/CA Border Healthy Start, Early Start/San Diego Regional Center, Healthy Developmental Services/South Bay Community Services, Family Violence Support Services, Vista Hill ParentCare Perinatal Case Management and San Diego Adolescent Pregnancy and Parenting Program.