1. Sarah A. Redding, MD, MPH Executive Director Community Health Access Project Mansfield, Ohio

2. Target Population Engage those at greatest risk Confirm connection to evidence-based intervention Measure the Outcome

3. HealthSocial From the client’s perspective, social issues are as important as health issues. Both must be addressed.

4. Identify/ enroll at risk Care Coordination Evidence - based Intervention Measureable Outcome $ $ $ Initiation Step Defined “at risk” pregnant women engaged and enrolled in care coordination Determine and document barriers: 1.Insurance Status 2.Transportation 3.Prenatal Care Prenatal care provider established First and ongoing prenatal visits confirmed Completion Step Healthy baby > 5 pounds, 8 ounces (2500 grams)

5. Community HUB Primary Health Home State- funded outreach program State- funded outreach program Schools Health Department County agency Mental Health Hospital Community - based agency One Care Coordinator  One Outcome (Pathway) No duplication Measurable results, tied to funding Central Registration – Agencies as a Team

6. Albuquerque, New Mexico Central Oregon Dallas, Texas Indianapolis, Indiana Ohio: Cincinnati Mansfield Toledo