EMBARK: In-Home Care Coordination for Pregnant Mothers
A Community Model That Grew From One Café to Five Kentucky Counties
EMBARK supports pregnant and parenting mothers with opioid use disorder by pairing each family with a dedicated Family Care Coordinator who connects them to obstetric care, substance use treatment, pediatric services, and practical supports such as rent, utilities, cribs, and diapers so mothers and babies can remain safely together and avoid child welfare involvement.
The Challenge They Were Addressing
Kentucky has been among the states hit hardest by the opioid epidemic, and Appalachia has suffered a disproportionate share of the harm. Infants affected by substance exposure are placed in foster care at disproportionately high rates. At the same time, Kentucky's Child Fatality Review has consistently identified substance use as a contributing factor in a substantial proportion of child fatalities. The average child in Kentucky foster care costs the state more than $65,000 per average stay, and outcomes for children who enter the system are generally worse than for children who remain safely with a parent.
For years, KVC's family preservation and reunification teams watched the pattern unfold: mothers with untreated or insufficiently supported opioid use disorder (OUD) often came to the attention of the child welfare system only after giving birth, when a positive toxicology screen prompted an investigation. By then, families were frequently in crisis, and infants had already entered temporary care. The traditional service system had no organized pathway to reach a pregnant mother with OUD early, surround them with the supports needed for recovery and family stability, and reduce the likelihood of child removal.
Compounding this challenge was a fragmented service system in which critical supports were spread across multiple providers, agencies, and payers. Obstetric care, medication-assisted and other substance use treatment, pediatric care, behavioral health services, and practical supports for housing and family stability often operated independently. Mothers who most needed integrated care were often the least equipped to navigate multiple intake processes while also confronting stigma, transportation barriers, and the fear that seeking help could result in losing their child. When Kentucky's opioid abatement commission opened its grant process, KVC saw an opportunity to close this gap by building the proactive, coordinated model that families and the field had been missing.
What They Built
At the center of EMBARK is a Family Care Coordinator who maintains a small caseload of pregnant and parenting mothers, providing intensive, in-home and community-based support beginning as early in pregnancy as possible and continuing through the first 6 months of the child's life. Referrals come from obstetric practices, MAT providers, Quick Response Teams, hospital labor and delivery units, drug courts, and Kentucky's Department for Community Based Services (DCBS). The program accepts women at any stage of pregnancy, including at delivery with no prior prenatal care, and works with program partners to coordinate care and add adjacent counties when a mother in need lives just over the line.
The Family Care Coordinator begins with a comprehensive needs assessment and develops an individualized plan that connects each family with the services and supports they need. Depending on the family, this may include obstetric and gynecologic care, medication-assisted treatment (MAT), primary and pediatric care, behavioral health services, parenting education through KVC's Nurturing Parenting curriculum, and referrals to KVC's substance use treatment or evidence-based mental health services.
The coordinator meets mothers at MAT appointments, in their homes, at the hospital, and throughout the community. Early visits focus on meeting immediate needs, such as providing diapers, wipes, and other essentials, and building trust to create a foundation for mothers to engage more fully in the services and supports available to them.
Contingency management is a core operational feature. To qualify for a monthly gift card incentive, mothers must meet a defined threshold for kept appointments, including both prenatal and treatment visits. The design deliberately links physical health and substance use treatment engagement and provides the coordinator with a structured, non-judgmental way to reinforce consistent care during a high-risk period.
Flexible funding is the second operational feature. EMBARK holds settlement-funded dollars that the coordinator can use to address the concrete barriers that would otherwise pull a family apart: a rent payment, a utility shutoff, a crib, a car seat, diapers, or help paying for a move into stable housing before delivery. KVC learned from decades of family strengthening work that these dollars often decide whether a mother can safely bring her baby home.
Key Program Components
Who You Need at the Table
What made a willing partner essential vs. optional?
The required partners are those without which the program couldn't exist, including critical funding sources and agencies that provide specialized care that the mother cannot get directly from EMBARK. Each generates the trusted referrals the program depends on. The MAT/SUD provider delivers the treatment. The obstetric practice delivers the medical care. The FQHC or hospital delivers the birth. The Kentucky Opioid Abatement Advisory Commission, along with the Department of Medicaid Services and the Managed Care Organizations (MCOs), provides funding and, critically, the flexibility that allows EMBARK to follow the family throughout treatment. Without any one of these partners, the coordinator would be linking mothers to services that do not exist.
Helpful partners expand reach and improve outcomes without being essential to day-one operations. DCBS referrals during investigations allow EMBARK to intervene when a family is in crisis. Drug court and labor and delivery referrals catch mothers who did not enter care through the standard OB or MAT pathway. Each additional partner tightens the net, but the core model runs on the required set.
Budget Breakdown
What is the minimum viable budget to replicate this?
About $75,000 a year is enough. That figure works when the program is housed within an organization that already provides clinical services, because the settlement dollars can pay for the coordinator, incentives, and flexible spending. Clinical infrastructure is already in place. The coordinator role can sit inside an existing targeted case management or substance use treatment team. Contingency management incentives and a modest flex pool for rent, utilities, and infant supplies can be added without new infrastructure, and they often deliver the highest per-dollar return of any line in the budget.
What Worked and Why
Specific decisions or design features that drove success
Building on KVC's existing infrastructure enabled EMBARK to launch quickly and efficiently. KVC drew Family Care Coordinators and administrative support from its established family strengthening teams, which meant EMBARK opened with staff who already understood motivational interviewing, wraparound service delivery, and the culture of the communities they served. The first client enrolled in March 2024, roughly two months after funding began, a feat that would have been difficult to achieve if the program had been built from the ground up.
Partnering with a local FQHC gave EMBARK a strong starting point. The FQHC shared patient data that helped KVC estimate demand, determine initial staffing needs, and adjust as referral patterns became clearer. Communities looking to replicate EMBARK should identify a similar healthcare partner early to help guide staffing and budget decisions.
EMBARK's braided funding model helps each settlement dollar go further. Medicaid covers eligible clinical, case management, and care coordination services, while opioid settlement funds support parenting education, incentives, and practical needs that traditional payers do not cover. Although this approach requires careful tracking of each funding source, it allows EMBARK to serve more families with the available settlement funds.
Flexible eligibility, both clinically and geographically, keeps the door open for the mothers who need the model most. EMBARK has served mothers referred at 37 weeks with no prior prenatal care, mothers with mental health diagnoses in remission from substance use who ask for support to stay sober through the pregnancy, and mothers who live one county over from an approved footprint. Each of those decisions required a small amount of internal flexibility from KVC and from the state opioid abatement commission, and each one converted a likely removal into a family that stayed together.
A strong presence in the recovery community drives EMBARK's referrals. EMBARK staff regularly participate in Quick Response Team meetings, ASAP and UNITE meetings, drug courts, and community events to connect with pregnant mothers who may need support. EMBARK builds relationships and reaches families through trusted community partners.
Early outcomes and data
Expansion from an initial four counties to 17 counties in two years, with adjacent-county service permitted on a case-by-case basis.
First client enrolled roughly two months after funding began and was staffed by existing KVC family strengthening team members.
Referral pipelines established with FQHCs, hospital labor and delivery units, MAT providers, drug courts, DCBS, and Quick Response Team situation tables.
Mothers stabilized in housing and connected to consistent prenatal, MAT, and pediatric care before delivery, including several who entered the program at 37 or more weeks of pregnancy.
Contingency management incentives are operational and linked to keeping appointments for both prenatal and treatment visits.
Flexible spending is regularly used for rent, utilities, cribs, and other concrete needs that keep the highest-risk families together.
Second successful funding cycle secured: $325,000 per year for FY27 and FY28.
Lessons Learned
Build the program on existing family strengthening infrastructure when possible. EMBARK moved fast because the coordinators, supervisors, and clinical practices already existed inside KVC. A new grantee without that infrastructure should either partner with an established family strengthening or targeted case management provider or plan for a longer ramp before the first mother enrolls.
The right staff is more decisive than any curriculum. Mothers with OUD have often had judgmental experiences in professional settings and arrive guarded. Coordinators who are patient, non-judgmental, and comfortable in homes and clinics generate the trust that gets a mother to answer the phone the second time. Hiring for that posture is worth more than any single evidence-based practice.
Flexible concrete supports are the wraparound feature that changes outcomes. The rent payment that keeps a family housed the week before delivery, the crib that arrives before the baby, and the utility payment that keeps the lights on are the interventions that most often decide whether a mother can bring her baby home. Traditional funding will not cover these; opioid settlement dollars can and should.
Follow the mother across county lines. Rigid county-of-residence rules will filter out families the program was built to serve. Negotiate up front with the funder for the flexibility to serve mothers in adjacent counties when the need is clear, and document the case-by-case decisions to support renewal.
Plan for a slow ramp in year one, and expect stigma to suppress early demand. The first year is a build year. Referral partnerships take time to mature, and mothers who fear that asking for help will trigger a child welfare investigation may take multiple contacts before they engage. Build a realistic year-one plan that funds the coordinator position through the ramp.
Track both individual outcomes and system-level savings. Individual outcomes tell the mother-and-baby story. System-level tracking of prevented removals, avoided foster care days, and downstream Medicaid costs tells the funder's story. Kentucky's more than $65,000-per-average-stay cost of a child in foster care is the number that makes prevention math work; capture it from day one.