The Collaborative Management Team (CMT) includes the four Maternal and Child Health home visiting programs of Gadsden County including: 1)The Federal Healthy Start (Gadsden Woman to Woman (GWTW)) Project, administered by the Center for Health Equity, Inc., 2)Healthy Families Gadsden, 3)The FSU Early Head Start program and 4)The state’s Healthy Start program which is administered through the local health department.

The primary reason for this original collaboration was to begin building a seamless system of care for women and children and to eliminate duplication of limited services so often found in rural communities. When the CMT was first implemented the focus was on creating a comprehensive referral system among MCH home visiting programs. This was eventually articulated in a formal Memorandum of Agreement among the four home visiting agencies which follows the Life Course model with prenatal care, infant care, and pre-interconceptional care for women. These linkages are strengthened by monthly meetings of all program directors to review the system of care as well as a monthly meeting of program mangers to staff women and families appropriately so that consumers receive risk appropriate services based on screening and assessment.

The Gadsden Woman-to-Woman Project (GWTW), administered by the Center for Health Equity, Inc. is a voluntary federal program whose goals are to improve African American birth outcomes, reduce the number of African American infant deaths and to improve the overall health of African American women in Gadsden County. The program strategies for reaching these goals are provided to pregnant and non pregnant women (14-44) through case/care coordination that includes but is not limited to: outreach, educational, peer support groups, health assessment and screening, nutritional assessment and education, mental health counseling and case management. The services components of case/care coordination are as follows:

Outreach services are those that include door-to-door canvassing, as well as, community health programs, health fairs and events to recruit childbearing age, pregnant, and parenting women into the program. These services also include community education and awareness of the risks associated with infant mortality and prematurity.

Peer Support groups meet weekly for eight weeks or more to provide a support system for pregnant and parenting women and to discuss educational topics in the areas of health, stress, body image, needs, family, community, environment, etc.

Basic primary care nursing assessments are provided to pre-interconceptional African American women and their children in case management and ongoing follow-up for high risk consumers such as those with a chronic medical condition; consumers are also linked with a primary care provider to assure a medical home for women and children.

Nutrition assessments are provided for all case managed consumers including nutritional education and follow-up for high risk consumers.

Mental health counseling is provided to consumers who have been screened for depression and stress and have been identified as having a high level of either. Mental health counseling is also provided to consumers whose care coordinators have identified as needing mental health services.

Gadsden Woman-to-Woman Project is funded to serve approximately 200 African American women of childbearing age, their children and families each year during the pre and interconceptional period, to 2 years after a birth, infant death or fetal demise. The project also provides peer support and education groups to approximately 150 women annually.

The Healthy Families Gadsden Program (HFG) is a long-term 3–5 year voluntary program that provides pregnant or parenting families, with an infant under three months of age, at intake, services through home visitation. The goals of HFG are: 1)Create stable and nurturing family environments; 2)Promote child health and development; 3)Aid in developing positive parent-child relationships; 4)Ensure that families’ social and medical needs are met; 5)Provide abuse/neglect prevention education; and 6)Ensure families are satisfied with project. Services provided include the following:

• 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.

Healthy Families Gadsden is funded to serve a total of 75 women annually.

The Gadsden Healthy Start Program (GHS) is a legislatively mandated program. Florida statute (F.S. 381.14) requires that Healthy Start risk screening is offered to all pregnant women at their first prenatal visit by their prenatal health care provider. In addition, Florida Statute requires that Healthy Start Infant risk screening is offered by the birthing facility to parents or guardians of all infants born in Florida before leaving the facility. Women and infants who receive a positive screening score, or who are referred for other risk factors other than score, are encouraged to participate in Healthy Start services.

The Gadsden County Healthy Start program, in keeping with the goals of Healthy Start to reduce infant mortality, reduce the number of low birth weight babies, and improve health and development outcomes offers the following services:

• Outreach
• Care coordination
• Childbirth education
• Parenting education & support
• Nutrition counseling
• Psychosocial counseling
• Tobacco education and cessation counseling
• Breastfeeding education and support
• Interconceptional education and counseling

The FSU Early Head Start Program (EHS) is a Federally-funded program serving low-income pregnant women, infants, and toddlers, birth to age three, and their families. Eligibility is based upon Federal poverty guidelines and criteria that put families at risk for poor child development outcomes. The program also serves families of infants and toddlers with disabilities. The goal of the program is to build children’s competence and readiness for future learning through comprehensive services focused on the healthy cognitive, physical, and social-emotional development of infants and toddlers. Services provided include the following:

• Prenatal and postpartum education and support
• Parenting education and parent-child activities
• Child development screening and ongoing assessment, early care and education
• Health, nutrition, dental, and mental health services
• High quality child care
• Linkages, referrals, and follow-up with community resources

Early Head Start services are provided through a home-based model which serves expectant and parenting families in their home, and includes parenting education, play and early development activities for children, along with socialization and educational support groups twice monthly. FSU Early Head Start Program is funded for a total of 68 enrollment slots (52 in home-based; 16 in center-based). Pregnant women are served through the home-based option and are counted as one enrollment slot until giving birth, at which point the newborn takes the enrollment slot thereby ensuring service continuity.