NOURISH – A Partnership between NYU and God’s Love We Deliver

This partnership was not just established, but it was forged on the knowledge that community-based organizations (CBOs) like God’s Love We Deliver (GLWD) have successfully integrated innovation into sustainable collaborative models. These models, which can work alongside clinical innovation and research, can be effective in improving outcomes for our shared clients, patients, and community members.

Community-based organizations operate with inherent values that have built trust in the communities and the distinct ability to implement direct client feedback. Through this partnership and a generous gift by the Batty Family Foundation, which formalized NOURISH in 2023, Dr. Ortiz and God’s Love We Deliver have worked with NYU Brooklyn and stakeholders at the Beyond Bridges Initiative to address adverse maternal health outcomes for pregnant people diagnosed with Gestational Diabetes (GDM) through our groundbreaking “Healthy Starts” Intervention. In the last year, GLWD expanded our eligibility criteria to include other high-risk pregnancy outcomes and rebranded our program to “Pregnancy and Post Partum Health” to encompass the preventative nature of this intervention.

Our partnership began by documenting a recurring issue: a low number of timely referrals to our GDM program, despite the need and positive feedback from referring partners during initial outreach activities in 2022. We also partnered to implement a pilot data-collection effort for clients who are caregivers with dependents living in the home to identify additional opportunities for community-to-clinic referral pathways. In the coming months, we realized we needed to expand on this critical work through funding opportunities to increase our capacity and resources and expand our efforts. Our primary goal was to address inefficiencies in the referral pathway, ensure enrollment was completed during the critical window of 20-30 weeks of gestation before partum, and implement a direct referral pathway to increase and streamline clinician referrals. We thus began referrals through our traditional pathway in 2023. Our first referrals with our new electronic health record system were in 2024.

As part of this partnership, we designed and launched two implementation strategies including a direct electronic health record referral pathway (a SmartSet) that now encompasses GDM and pre-existing type 1 and 2 diabetes, and the addition of a dedicated community health worker (CHW) to the NOURISH team who builds relationships with clients/patients while serving as a critical liaison between the clinical team at NYU and client services team at God’s Love to expedite and facilitate referrals. Through this work, a few additional team members were added to help increase our capacity, including two research data associates, one of whom came into a novel hybrid role working on site at both NYUGSoM and GLWD, and a research scientist to enhance data collection and analysis to inform the growth of the program and expansion to inform other related work even beyond the boarders of New York City.