Embedding social care in community college settings through a mental health navigator program

Background: Central Brooklyn, which has a high concentration of immigrants and Blacks, is considered the epicenter of NYC's maternal health crisis because of its high severe maternal morbidity (SMM) rates.Objective: We present formative data on a novel community health worker (CHW)-led intervention called We Care About Brooklyn (WeCAB), which addresses fundamental system-level drivers of maternal death and morbidity in NYC: fragmented care and unmet social needs.Methods: Funded by the National Institute of Nursing Research, and in partnership with the Arthur Ashe Institute for Urban Health, we conducted community-engaged mixed methods research to design an intervention prototype and evaluate preliminary efficacy.Methods include a document review of commonly used health-related social need (HRSN) screening tools (N = 8 tools), qualitative interviews with community partners (N = 18) and a pilot RCT trial (N = 62).Pregnant women were recruited in a clinic serving Central Brooklyn.Data collection on immigrant experiences, perceived stress (Cohen's Scale), perinatal mental health (Edinburgh Postnatal Depression Scale), and postpartum care is ongoing.Results: Core intervention components include urgent warning signs education (CDC "Hear Her" campaign), CHW schedules for client check-ins based on gestational age and social risk, and a digital 'closed-loop' care navigation platform called Unite Us that employs a 40-item WeCAB screener to address HRSNs of pregnant persons.Among WeCAB participants, 100% screened positive for at least one need (N = 36).Most identified