Community Partners

Gadsden County has a variety of home visiting/case management programs for pregnant and parenting women and infants. With several home visiting agencies serving the population in Gadsden, it was important to bring each group together on a consistent basis to address system issues. The Collaborative Management Team (CMT), envisioned by the Center, was created for this purpose. The CMT represents the Gadsden (State) Healthy Start Program, the Center’s Federal Healthy Start Gadsden Woman to Woman Project, Gadsden Healthy Families, and FSU Early Head Start as the core home visiting partners. Other service providers including Gadsden’s Federally Qualified Health Center (Jessie Furlow Medical Center), WIC, School Health, and the Department of Children and Families and Juvenile Justice also participate. Monthly CMT meetings allow each of the agencies/programs to plan and implement programs collaboratively thereby avoiding duplication of services, preventing consumers from falling through the cracks, and assuring a seamless system of care. A Memorandum of Agreement was also signed by each of the core home visiting partners in 2007. A Home Visiting Partnership Service Matrix was created to educate the community about the different services offered, as seen below:

Service Info. AreaGadsden Woman-to- Woman Federal Healthy StartGadsden Healthy StartHealthy Families GadsdenFSU Early Head Start
Funding SourceFederalState General Revenue (annual Florida legislature appropriation)State General Revenue (annual Florida legislature appropriation)Federal (annual allocation)
Target PopulationAfrican American women of childbearing age (pregnant and non-pregnant) at risk for poor health and birth outcomesPregnant woman and infants screened at risk for poor birth outcomesPregnant women and families whose babies are under 3 mos. at intake determined most at risk for abuse/neglectLow-income pregnant women/families with infants & toddlers, birth-to-three
(focused on child development)
Program Goals• Improve birth outcomes for African American women
• Reduce the number of African American infant deaths
• Improve the overall health of African American pre- and interconceptional women,
14-44 yrs.
• Reduce infant mortality
• Reduce the number of low birth weight babies
• Improve health and developmental outcomes
• Create stable & nurturing family environments
• Promote child health and development
• Aid in developing positive parent-child relationships
• Ensure that families’ social and medical needs are met
• Provide abuse/neglect prevention education
• Enhance child health, growth, and development
• Support and enhance parent-child relationships
• Strengthen parents as primary nurturers of their children
• Support attainment of family goals for education, literacy, employment and independence
Potential Length of Program EnrollmentUp to 3 yearsUp to 3 years3 to 5 yearsPrenatal until child’s 3rd birth date
Annual Funded Enrollment• 100+ women and their families in case coordination
• 100 -200 in peer support & education groups
• All pregnant women and infants birth-to-three in Gadsden • 87 families • 52 slots for pregnant women and children in home-based
• 16 slots for children in center-based child care
Eligibility for Services• For Peer Support Groups:
African American women pregnant and non-pregnant 14-44.
• For Case Management:
African American women pregnant and non-pregnant with any of the following health conditions:
∙ diabetes
∙ high blood pressure
∙ obesity
∙ substance abuse (including alcohol & tobacco)
∙ mental health (stress, anxiety, depression, etc.)
∙ domestic violence
∙ previous miscarriage, infant loss at birth & up to year 1
∙ previous LBW infant
∙ previous premature birth & other special health needs
• Pregnant woman or newborn infant determined to be at-risk based on results of Healthy Start risk screening.
• Referrals can come from outside agencies, within the health department or self-referrals
• Pregnant woman or family identified within three months of the birth of the baby, scores positive on the HS/HFF screening and assessment tools and does not have an open confirmed case with Child Protective Services at time of assessment. • Pregnant women and families with children birth-to-three that meet Federal poverty guidelines and risks for poor child health and developmental outcomes.
• Infants and toddlers with disabilities and developmental delays.
• Infants and toddlers who are homeless or are involved with the Child Welfare system are categorically eligible
Methods of Service Delivery• Peer support/education groups
• Home visitation
• Office visits
• Home visitation
• Office visits
• Home visitation• Home visitation w/socialization groups twice monthly
• Center-based/child care for working parents
Services Provided• Peer support groups/health education specialist
• Case coordination
• Parenting education
• Child Developmental screenings (ASQ)
• Linkages/referrals to primary care provider and community resources
• Mental Health Counseling
• Stress/Depression screenings
• Health literacy
• Nutrition Counseling
• Health and Fitness Exercise
• Acute Medical Assessments and referrals
• Food Bank
• Case management
• Parenting support & education
• Breastfeeding support & education
• Childbirth education classes
• Mental Health Counseling
• Smoking cessation
• Other case management services
• Linkages/referrals to community resources
• A continuum of support and prevention services, both prenatal & postnatal
• Parenting education
• Child development education and screening
• Linkages/referrals to community resources
• Identification of parental & child medical home
• Self-sufficiency education
• Prenatal education and postpartum support
• Parenting education and parent-child activities
• Early childhood development & child care
• Developmental screening and ongoing assessment
• Health, nutrition, oral health, infant mental health services, mental health counseling, and family health education
• Family goal setting and empowerment
• Linkages/referrals to community resources
Determination of Home Visitation IntensityLeveling system:
• 3b = weekly visits
• 3a = every other week
• 2 = monthly
• 1 = quarterly
Leveling system:
• 3 = 2x per month
• 2 = monthly
• 1 = every other month
Leveling system:
• 1P (Prenatal) = 1 to 4 x per mo. (depends on need)
• 1SS = 2 x per wk. or extended visit
• 1E = Face-to-face visits every other week
• 2 = every other week
• 3 = monthly
• 4 = quarterly
• Level X = Outreach
No leveling system.
• Federal standards require weekly home visits of 1.5 hrs. conducted year-round, for the duration of the child/family’s enrollment; children served in the child care option receive at least 2 home visits annually.
Staffing Composition And Qualifications• Director, Ph.D.
• Clinical Supervisor, LCSW
• Program Coord., LCSW
• 4 Family Health Advocates (3 MSWs, 1 BSW)
• 1 Admin. Assistant
• 1 Nurse, RN
• 1 Nutrition Educator, BS
• 1 Health Educator/Exercise Consultant, MPH
• Program Manager, BSW, MPA
• 2 Nurse Case Managers, RN
• 2 Case Managers (1 MSW, 1 BSW)
• 1 Family Support Worker, CNA
• 1 LPN
• 1 MomCare worker
• Prog. Manager, MSW
• 1 Clinical Supervisor, BS
• .5 Assessment Worker
• 3.5 Family Support Workers
• Director, M.Ed.
• Health Services Coord., MSW
• Home-based Services Coord./Mental Health Specialist, LCSW
• 4 Home Visitors, MSW, BS, BS, AS
• Education Coord., M.Ed.
• Family/Community Partnerships Coord., MS
• Nutrition Consultant, RDL
Staffing ModelProfessionalProfessional/ParaProfessional/ParaProfessional
Average Caseloads25 Families per Case Manager40-5015-25
Depending on Service Levels
Up to 12 Families per
Home Visitor
Staff Training Requirements• Pre-service
• Continuous ongoing
• Pre-service
• Continuous ongoing
• Pre-service
• Continuous ongoing
• Pre-service
• Continuous ongoing
Staff Supervision Frequency• Weekly clinical & reflective supervision
• Monthly interdisciplinary team staffing
• Monthly QA Data Reviews
• Quarterly Team QA Peer Reviews
Weekly staffing of cases• Weekly clinical supervision
• Monthly supervision for supervisors
• Monthly QA Data Review
• Bi-Annual shadowing supervision
• Weekly clinical supervision
• Biweekly reflective supervision
• Quarterly family progress case/QI reviews