A Coordinated, Relationship-Based Model
Patients in GRACE are supported by a dedicated team consisting of a nurse case manager and a social worker. This dyad model allows the program to address both medical and psychosocial needs at the same time—coordinating prenatal care, treatment for substance use, mental health support, and access to essential resources such as housing and transportation.
Care begins during pregnancy and continues through delivery and the postpartum period. Throughout this time, the care team works closely with obstetric, neonatal, and community partners to ensure that patients remain engaged in treatment and experience a seamless transition across care settings.
Building Trust to Improve Outcomes
A defining feature of GRACE is its emphasis on trust. Patients with substance use disorders often face stigma in healthcare settings, which can create barriers to care. GRACE addresses this through consistent, non-judgmental engagement and trauma-informed approaches that support long-term recovery.
At the same time, the program aligns maternal care with best practices for infants at risk of withdrawal, promoting approaches such as rooming-in, breastfeeding when appropriate, and coordinated discharge planning.
Designed for Scale and Replication
GRACE has served more than 350 women and operates with one nurse case manager and one social worker. Strong partnerships with community organizations and treatment providers extend care beyond the hospital and support long-term recovery.
Originally grant-funded, the program is transitioning to a sustainable model supported by clinical billing and reimbursement, demonstrating its potential for replication in other health systems.