Accompany, Don’t Refer: How Pediatrics Northwest stopped handing families a list and started walking alongside them.
From Conversation to Action
On the Thrive Together podcast, we sit down with founders, builders, researchers, practitioners, and leaders who are working to improve the wellbeing of children, families, and communities.
But great conversations create the most impact when they lead to action.
That’s why we’ve created the Thrive Founder Playbook series. Each Playbook distills a key insight, strategy, decision, or lesson from a podcast episode into practical guidance that others can adapt in their own work. Rather than summarizing the conversation, these Playbooks identify the specific choices, experiments, and approaches that helped a leader move an idea from concept to impact.
Whether you’re building a nonprofit, launching a startup, leading change within an institution, or exploring a new solution to an old problem, we hope these Playbooks offer actionable ideas you can borrow, test, and improve upon.
This Playbook is inspired by a conversation with Dr. Mary Ann Woodruff and Rachel Lettieri of Pediatrics Northwest and highlights practical lessons from their journey.
Accompany, Don’t Refer: How Pediatrics Northwest stopped handing families a list and started walking alongside them.
When Rachel Lettieri became Pediatrics Northwest’s first community health worker, the team believed what most of healthcare believes: if families aren’t getting connected to help, the referral pathway must be broken. They decided if they fixed referrals, this would surely lead to better lists, cleaner handoffs, and stronger contacts in the community.
Then Rachel watched what actually happened after a referral. A family would leave the visit clutching the right phone number for early intervention or behavioral health, and months later still nothing. Rachel knew this wasn’t due to a lack of care but the opposite: families trying hard, up against applications, waitlists, phone trees, and a system that was never built to be walked through alone.
So Pediatrics Northwest changed their assumption instead of the pathway. The community health worker’s job stopped being “connect the family to the resource” and became “stay with the family until the resource is actually serving the family.” Community Health Workers would help make the first call together, fill out the application, follow up, and check in. They could even work with families to build the confidence to engage with resources at all.
What Rachel and team learned is that referrals and hope don’t work. Accompaniment does.
The Challenge
Pediatrics Northwest serves 46,000 children and families. These families kept showing up with needs that weren’t purely about medicine, but ranged from food insecurity to caregiver stress or childcare.
There was a maze of systems nobody had taken the time to explain, and none of which fit into a 15-minute visit. Every referral sent out had a way of quietly dying somewhere between the printed list and the family’s actual life.
The Play
1. Follow the handoff home.
Pediatrics Northwest assumed better referral pathways would fix access, until they actually tracked what happened after the referral went out. You don’t know a handoff lands until you follow it home to the family it should be serving.
2. Reassign the failure.
Families who didn’t make it to their reference weren’t failing to try. They were up against fragmented systems that would grind anyone down, yet the chart still called those waitlists and application attempts “failed”. Whose failure you write down determines what you go on to build next.
3. Assign a person, not a pathway.
The community health worker walks alongside the family: first calls, applications, follow-ups. The basis of the model is a relationship, not information transfer.
4. Meet families at a door they already trust.
Almost every child sees a pediatrician in the early years, even when parents skip their own checkups. So instead of asking families to find a new door, Pediatrics Northwest put the help behind the door families already walk through.
5. Let the job include confidence building.
Sometimes the work is helping a parent believe the first call is safe to make. This first step, confidence building and advocating, is important as it is the step everything else waits on.
What It Cost
Accompaniment is slow by design, and it caps the number of families each community health worker can work with compared to a referral desk. Pediatrics Northwest had to retrofit their model to a payment system never built for team-based care. They carried this model for years before Washington’s Medicaid CHW reimbursement caught up in 2025. This approach valued depth over volume.
What It Produced
The model grew from one community health worker (Rachel herself) into a full CHW division inside one of Washington’s largest independent pediatric groups. Pediatrics Northwest is now one of five Pediatrics Supporting Parents communities nationally with ZERO TO THREE, and the pilot’s arc helped make CHW services billable to Washington Medicaid as of July 1, 2025.
Mary Ann now says the practice has moved from “reimagining” to reimagined: team-based care that is efficacious, feasible, and scalable, “and we have data to support it.”
Try This If…
✓ Your service ends at a referral, and you have never measured what happens after this step.
✓ The people you serve are navigating two or more systems that don’t talk to each other.
✓ You have a front door people trust and show up to, where the help could live.
✓ You can fund at least one navigator role whose job is built on connection, not throughput.
Skip This If…
✕ Your bottleneck genuinely is information, and your users reliably self-navigate once pointed the right way.
✕ You need volume economics right now and cannot carry a slow, relational cost center until funding catches up.
✕ You would staff the navigator role similarly to a call center. The model should be a person families come to trust, not a follow-up queue.
✕ You are not ready to change who you assign the referral failure to.
Guest bio: Rachel Lettieri and Mary Ann Woodruff, MD, FAAP Organization: Pediatrics Northwest
In their own words from the Thrive Together podcast conversation:
“What we quickly learned is that referrals alone are rarely enough. You can’t just, as Mary Ann says, fingers crossed, hope you get connected.” (00:23:12) “Families weren’t failing to follow through on different resources that I was providing them because they didn’t care. They were actually trying really hard.” (00:10:05) “We really needed to help families navigate the systems, reduce stressors, and strengthen relationships, because those are the conditions that allow kids and youth to thrive developmentally.” (00:10:05)