The Cumberland County Department of Social Services (DSS) and the Cumberland County Department of Public Health (CCDPH) have received funding to implement an initiative which focuses on primary prevention by utilizing a whole person/family approach and addressing social determinants of health (SDOH). The initiative includes multi-disciplinary Case Management and Care Coordination teams responsive to community referrals to provide care coordination and case management services to address social determinants of health, address social needs, improve health behaviors and health outcomes, improve health equity, and reduce health disparities, reduce preventable hospital stays, and prevent and reduce child abuse and neglect.   The Nutritionist II is an in-home and commu