The University of Arkansas for Medical Sciences (UAMS) (applicant) and Our House, Inc. (OH) (sub-recipient) will lead the Home Together project to increase the capacity of providers in the Metropolitan Little Rock area to engage with one another and with homeless adult pregnant women and mothers with children ages 0-5 who also have a serious mental illness (MI) or co-occurring MI/Substance Use Disorder (COD) to improve long-term family outcomes. We plan to serve 428 families (1,284 individuals) including Veterans’ families over the five-year project (90 families/270 individuals annually except year 1 with 68 families/ 204 individuals). A large proportion of families are expected to be low income, medically underrepresented minorities. Arkansas (AR) has the fourth worst child and family homelessness problem in the US. At UAMS University Hospital alone, 30 housing-insecure babies are discharged every month—a majority of their mothers suffer from MI/COD. Many of these families become involved with the child welfare system. Compared to top performing US counties in 2017, Pulaski County, where Little Rock is located, has twice the rate of children living in poverty, a SMI rate 24% greater, 12.5X the prevalence of HIV (529), 29% greater adult tobacco use, 67% greater low birthweight, and 45% more unintended injury deaths with 2.5X the rate of alcohol-impaired driving deaths. Our House, an effective provider of services to homeless individuals and families for 30 years, will be the direct services provider. Guided by gaps identified through an existing Homeless Pregnant Woman’s Task Force and lessons learned through OH’s Central Arkansas Family Stability Institute (CAFSI), Our House will expand CAFSI care coordination to serve the families of focus. New staff will include: 3 Family-Community Engagement Navigators (FCENs) and a child and family therapist. New services will include linkage of enrolled families to integrated behavioral health care, prenatal care, and integrated behavioral-primary health care. Specific new interventions will address health disparities including access to primary and behavioral health care, HIV prevention, and tobacco use cessation. OH will work to increase housing availability. FCENs will assist families with motivation and with parenting and injury prevention, employment, and recovery supports as families transition to permanent housing and long-term successful community living. Evidence-based Motivational Interviewing (MI) and evidence based client navigators (training based on effective community health worker model) will guide client-family outreach, engagement and retention, development and implementation of family-driven Family Stability Plans, and access to appropriate and acceptable services. FCENs will coordinate multiple services and multiple “case managers” also “working” with these complex-need families as they learn self-care and chronic disease management. We will offer all project partners annual training in MI, and promising practices of Trauma Informed Approach, and Two Generation Approach as strategies to improve partner abilities to engage client families. Lessons learned will be shared with clients, providers, and policy-makers.