When I made the initial home visit after receiving a referral on a pregnant woman, everything seemed routine. There were a few cleanliness and safety issues we would discuss again at a later date. A second visit was planned for the third trimester, but no date set. When I tried to reach her later, I found the number had been disconnected. The "grapevine" had information that the family had moved to a city in another county.

The family never crossed my mind again until spring when a Healthy Start visitor from a neighboring county said she heard that the family had returned to the area and baby wasn't doing well. She wondered if I had been able to make a Healthy Start visit. Phone attempts to reach them were unsuccessful, so I wrote a letter setting up a day and time for a visit and how to contact me if this was not convenient.

Because of the information I had received from the other Healthy Start visitor, I contacted SRS to see if they had any reports on this family or any concerns. They also had received concerns and were going to see the family the next day. They requested I not make a visit until they had contacted the family. The local SRS agency had dealt with the family previously and stated concerns about safety of one person going out alone to what might very well be an unfriendly greeting.

The following morning I received a telephone call from the social worker stating that the baby had been hospitalized and they would like to include Healthy Start in the plan of care when the baby was released from the hospital.

The SRS workers met with the county attorney to prepare a schedule of visits by various agencies that could network together to enable the family to take the baby home instead of being placed in foster care. The plan included Healthy Start making a weekly visit on Mondays to weigh the baby as well as continuing the regular education and support supplied by the Healthy Start program. Parents as Teachers educator would also be making a weekly visit. The family preservation unit would supply two visits per week. The fifth day the family would be required to be seen either by the doctor or take the baby to the health department for another weight check. Release of information forms were signed by the clients so we would be able to discuss the case and progress the family was making. It was also an important consideration that we were not giving conflicting instructions and could reinforce the same information. The baby's weight was a major concern because at six weeks of age she weighed 6#, 9 oz, six ounces less than her birth weight of 6#, 15 oz.

When I made my first required visit, I was met with a less than enthusiastic greeting. Mom, Dad, and older brother, age 4, were all present. Since I had met the family prenatally, I did not feel the need for a second person to be present, but I did, however, have my cell phone handy. The visit went fairly well and the baby was showing a slight weight gain. It took a lot of conversation to convince the parents that all the agencies are not the enemy but were there to help and support them and that everyone has the best interest of the baby as the uppermost concern.

When the Parents as Teachers educator was to make her initial visit, she requested the HealthyStart visitor accompany her. She wanted the support of another person when going out to this rural isolated area to a family who had not requested her visit but were required to have the service.

The baby began to thrive and the workers from all agencies were greeted with smiles and coos from baby. As the weeks went on, all persons involved were able to communicate with one another and were pleased with the progress. The home conditions were improving and baby was gaining steadily, now weighing 14#, 12 oz. The parents have begun the infant on immunizations and Kan-Be-Healthy assessments at the local health department. Parents are more attentive and aware of the needs of baby and importance of maintaining a healthy and safe environment for their family.

Our hard work paid off. After eighteen weeks the Family Preservation Unit, Healthy Start Home Visitor, and Parents as Teachers educator received letters from SRS that services could be discontinued. If the family or the agencies wanted to continue, it would be voluntary and participants were encouraged to do so for on-going support. The family has chosen to continue enrollment in the Parents as Teachers Program and are willing to have further Healthy Start Visits on a less frequent schedule.

With all the agencies networking their services together we have had a positive outcome. No one leg of the system was deemed more important than another and by net-WORK- ing together we have a happy ending to what could have been a very tragic story.