Maternal, Infant, and Early Childhood Home Visiting Program - Project Title: Delaware MIECHV-SSDOH Project Applicant Name: State of Delaware Division of Public Health Address: 1351 West North Street; Dover, Delaware 19904 Project Director Name: Crystal Sherman Phone Numbers (Voice, Fax): 302.608.5742 Office, 302.739.6653 Fax E-Mail Address: crystal.sherman@delaware.gov Website Address: http://www.dhss.delaware.gov/dhss/dph/index.html Track One, no collaboration across multiple MIECHV recipients. Annotation: Both MIECHV-enrolled and MIECHV-eligible individuals and families statewide who have unmet adverse social and structural determinants of health (SSDOH) serve as the population that will be addressed through this innovation. Comprehensively speaking, the innovation comprises of four methods that will help build a two-way, collaborative system that will ultimately better integrate MIECHV with community health worker agencies within the State of Delaware. Problem: The project helps to bolster “Concrete Support in Times of Need”, one of the five Protective Factors of the Strengthening Families Approach embodied in the maternal and child health programming within the state. This factor, which comprises of SSDOH needs such as inadequate housing and food insecurity, greatly affects MIECHV-enrolled families yet may not be readily addressed by evidence-based home visiting programs. Purpose: This innovation will strengthen the referral linkages across evidence-based home visiting programs and community health worker agencies. In doing so, families currently enrolled in evidence-based home visiting programs who have unmet adverse SSDOH that cannot be readily nor robustly addressed by home visitors will be referred to community health workers who have the capacity and capability to assist these families. Correspondingly, families who have worked with community health worker agencies and who are eligible yet not enrolled in evidence-based home visiting due to limited familiarity of such programs will be referred to such programs by their respective community health worker agency. Goal(s) And Objectives: The Delaware MIECHV-SSDOH Project features two goals: (1) increase the recruitment of MIECHV-eligible families who are historically unserved by home visiting or who face disproportionate barriers to accessing or participating in services and (2) advance the overall population health and improvement in health equity within the State of Delaware. Objectives include the development of MOUs for data sharing across home visiting programs and community health agencies, the inclusion of MIECHV-eligible criteria in community health worker forms, the inclusion of community health worker referral notation in MIECHV intake and post-enrollment forms, the creation of quarterly dashboards, and the carrying out of continuous quality improvement efforts. Methodology: This innovation consists of four methods, namely (1) the inclusion of community health worker referral notation in MIECHV intake and post-enrollment forms; (2) the development of dashboard that crosslink SSDOH indicators with MIECHV performance measures; (3). the inclusion of MIECHV eligibility criteria into community health worker program participation forms; and (4) the creation of ongoing evaluation reports that detail successes and areas for improvement.