PROJECT SUMMARY In the past 20 years, the United States (US) has seen a fourfold increase in the prevalence of maternal substance use disorders during pregnancy. Substance use during pregnancy is associated with adverse maternal and infant health outcomes. Numerous barriers impede the delivery of well-coordinated and high- quality pregnancy and postpartum care for women with substance use disorder: lack of access to obstetrics providers who are comfortable with providing medical care to women with substance use disorders; competing demands from child welfare and necessary medical services; and limited availability of substance use disorder treatment programs that allow children and provide parenting support resources. A coalition of maternity care providers, substance use treatment agencies, state social service agencies, and Medicaid funding partners in Oregon tested a care model called Project Nurture in three clinics in the Portland area in 2015. Project Nurture combines maternity care, substance use disorder treatment, peer/doula support, and case management in a single setting. Access to these services in a single care setting reduces barriers to care and facilitates increased collaboration among providers, which creates a more supportive environment with realistic expectations for mothers. Care is delivered in a non-judgmental and trauma-informed manner, which is important given the high prevalence of stressful life events experienced by women with substance use disorder. A peer-reviewed study found Project Nurture to be associated with reductions in child maltreatment and placement of children in foster care, and increases in prenatal visits. Preliminary data from an independent evaluator also suggest that Project Nurture may reduce preterm births, reduce intensive neonatal care, and increase engagement in substance use disorder treatment. Oregon's Governor is expanding Project Nurture to five rural and underserved counties. The objective of this study is to establish the empirical evidence needed to replicate Project Nurture in other states. While preliminary findings suggest that Project Nurture improves short- and longer-term maternal-infant outcomes, we propose further investigation to answer three critical questions: (1) What are the key elements of Project Nurture associated with improved outcomes; (2) how can these elements be implemented in rural and underserved settings; and (3) what is the effectiveness of Project Nurture in rural regions and when mothers are engaged in methamphetamine and polysubstance use? Thus, this study is designed to accomplish the following four aims: (1) Assess the effects of Project Nurture on pregnancy, birth, neonatal, and child welfare outcomes; (2) Assess the effect of Project Nurture on health care expenditures; (3) Describe implementation of Project Nurture; and (4) Identify critical elements of Project Nurture and support replication and dissemination. This study will provide state, regional and o...