This pilot project will assess whether or not it is effective to provide additional resources to allow Maternal Infant Health Program (MIHP) providers to better serve families with high levels of need. Key outcomes include social determinants of health, specifically: housing stability, reduced food insecurity, education, employment, treatment for substance abuse and addiction, treatment for mental health challenges, parenting support, and access to additional social services. We will recruit and randomize 50 providers (stratified by provider type, geographic location). Twenty-five providers will be assigned to the treatment and 25 to a control condition. MIHP providers in the treatment group will identify ?high risk? participants from the MRI or IRI and will be able to bill for additional services for those ?high risk? participants. There are several new billing codes being considered including: a code to bill for additional time and a set of codes to bill for care coordination. The care coordination codes would include diagnosis codes so that the nature of care coordination activities can be tracked. In addition, the team is considering adding an additional code for a discharge appointment and discharge assessment. A discharge assessment will be required from all participating providers in order to track outcomes. Outcomes will be assessed at enrollment and discharge from the program based on MRI and/or IRI and the discharge assessment, treating the family (maternal-infant dyad) as the unit of interest.