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Community Intensive Pilot Projects

About the Community Intensive Pilot Projects

Amended Substitute House Bill 49 of the 132nd General Assembly allocated funding to facilitate a multi-pronged population health, community intensive approach to reducing infant mortality and disparities in maternal and infant health. The Ohio Department of Health solicited proposals that would produce direct, measurable improvements in local birth outcomes and/or inequities in birth outcomes, including addressing known drivers of inequities.

Effective infant mortality reduction strategies are often implemented at the local level. Each community has a unique set of characteristics that impact birth outcomes. Working with local partners to identify those characteristics and implementing the right combination of evidence-based strategies provides the greatest opportunity to improve birth outcomes.

The 2016 state health assessment describes the status of health and wellbeing in Ohio and highlights the state’s many opportunities to improve health outcomes, reduce disparities and control healthcare spending. In the assessment, maternal and infant health was identified as one of Ohio’s greatest health challenges.


In this project, a subrecipient will develop a community intensive pilot project, or place-based initiative, designed to improve birth outcomes and reduce disparities in birth outcomes. Each project will implement a community-driven approach to address infant mortality rates by reducing maternal behavioral and medical risk factors, thereby improving healthy birth outcomes for women and infants. The initiative shall focus in a priority community, defined by the community’s infant mortality rate, preterm birth rate, low birth weight rate and disparity rate between black and white infant deaths, and reduce the impacts of social determinants on pregnant women and infants. This work shall promote a healthy environment and educate the community on healthy practices. In addition, the project should encourage and communicate the importance of addressing individual needs and the support for individuals to make choices in their own best interest.


Cincinnati Children’s Hospital Medical Center/Cradle Cincinnati

Cradle Cincinnati incorporates a collective impact framework and place-based interventions dedicated to elimination of infant death in Hamilton County.  Our unique multi-disciplinary teams include community health workers, nurse case managers and social workers that partners with local health care centers, public health agencies and community-based resources to support Mom in addressing issues and delivering tangible resources. The goal is to put Mom in the center of care, provide consistency and sustained authentic connection, which empowers her to more fully participate in her medical and community experiences.

Every identified mom will be supported by a Community Health Worker working hand-in-hand with a social worker and additional support team that includes a nurse case manager. The teams will provide home-based support that is directly connected to mom’s prenatal care and will also work with the community to develop neighborhood specific solutions.

The teams will build authentic relationships driven by a uniform commitment to solve patient problems, whether directly pertinent to their prenatal care or relevant as social determinants of health. Execution is simply characterized as a willingness on the part of the health care team to always say “yes.” Even if a mother is unable to appear for scheduled care, or does not respond to communication requests, care teams will not end the relationship. Teams will further commit to prompt follow through with a stated goal to always solve problems, using Mom’s self-identified needs as a framework for prioritization. These relationships will be built through continued collaboration and cross talk between the community-based teams and the clinical teams.

We have rallied around three areas of focus in order to make measurable impact: safe spacing between pregnancies in order to lower the risk of pre-term birth, helping mom quit smoking during pregnancy, and promoting safe sleep for infants. Working together with stakeholders, medical professionals and neighborhood residents, we aim to create a community that offers stability for Mom and enhances her potential for a healthy pregnancy and a safe, caring environment for her baby. 

Hospital Council of Northwest Ohio

The Ohio Department of Health investment into a Healthy Lucas County project to combat infant mortality in Toledo’s central city area neighborhoods includes working with residents to determine what they need to improve health and well-being. The project also involves recruiting 150 pregnant women who live in seven census tracts in the 43604, 43608, 43609, 43611 and 43620 ZIP codes into home-visiting programs to support women in delivering healthy babies. These women also are eligible for rental assistance for up to 12 months and up to $500 for transportation, car care and utilities.

As part of the project, four AmeriCorps service members are being hired to help work with central city area residents to determine what they need to improve health and well-being. The project is utilizing the Best Babies Zone approach to reduce racial inequities in infant mortality by mobilizing residents and organizational partners to address the social, structural and economic determinants of health and promote health equity.

The grant was awarded to the Hospital Council of Northwest Ohio, which coordinates the project and the Healthy Lucas County coalition of community health improvement organizations. Mercy Health, Neighborhood Health Association, ProMedica and Toledo-Lucas County Health Department are anchor institutions for the project, which includes their home-visiting programs and the Northwest Ohio Pathways HUB care coordination system. For more information, please visit http://www.healthylucascounty.org/combating-infant-mortality/

Ohio University

Ohio University’s Heritage College of Osteopathic Medicine has provided intensive navigation services in Athens County since 2012 through the Family Navigator Program housed within its Community Health Programs. Through the Ohio Department of Health’s Infant Vitality Community Intensive Pilot Project, Community Health Programs has expanded the Family Navigator Program to Scioto, Jackson, Pike, and Morgan Counties in Southeast Ohio. This expansion provides navigation services that target Medicaid-eligible high-risk pregnant women. The navigation services are provided by registered nurses who work across agencies to ensure that the basic needs of pregnant women are met, and to address social determinants of health which may interfere with a healthy birth outcome. The nurse navigators in the expansion counties are placed in Community Action Agencies where they are best positioned to identify clients and connect them to a wide variety of community resources. Family navigators provide tobacco cessation education through the Baby & Me Tobacco Free program, safe sleep education and resources through the Cribs for Kids program, and ensure access to health care services.