Coordinates with other agencies in the community to ensure at-risk-families are receiving as many forms of assistance as possible, such as social, medical and educational services. Community Care Coordinators meet clients in their own homes to assess the family's needs and to establish a care management plan. Targets pregnant women to support throughout their pregnancy to help reduce and eliminate Ohio's Infant Mortality Rate. Offers diapers and wipes to families at all visits by the coordinators.

Provides central intake to women who are pregnant or postpartum to assist in locating resources and coordinate assistance by way of Neighborhood Navigators in the client's preferred setting (home, agency and/or community setting). Performs a detailed screening to identify barriers, needs, and opportunities for women and their families and then a step-by-step approach to action is taken to each item of need. Applies for and/or enrolls individuals in various community programs that the individual qualifies for, such as WIC and Medicaid.

Provides Community Health Workers (CHW) that assist pregnant women throughout their pregnancy and up to their child’s first birthday. CHWs provide outreach, health education, care coordination and advocacy. They bridge the gap between communities and the health and social services system while advocating for individual and community needs. Services are individualized and adjusted for each women's needs.

Offers central intake for expectant women and families to provide resources and coordinate assistance by community health workers (CHW) in the client's preferred setting (home, agency and/or community setting). Performs a detailed screening to identify barriers, needs, and opportunities for women and their families and then a step-by-step approach to action is taken to each item. Applies for and/or enrolls individuals in various community programs that the individual qualifies for, such as WIC and Medicaid. Completes a minimum of three (3) outreach attempts on each person screened to ensure all needs/opportunities have been met.

Offers empowering support to pregnant women, new moms and their babies through the first year. The Community Health Worker assists the pregnant woman in navigating the health care system and social services as well as educational support throughout each trimester of pregnancy. Services are individualized and adjusted for each woman's needs.