In this article, M. Rebecca Kilburn and Jill S. Cannon report on First Born, a targeted universal home visiting program operating in over half of New Mexico counties. Created in a small town in response to a lack of support for pregnant women and new parents, First Born adapts features of other home visiting programs, responding to conditions common to high-need, lowresource communities. As its name suggests, First Born enrolls first-time families. A team of home visitors, including a registered nurse or other licensed health care professional and a paraprofessional parent educator, offers 40 weekly home visits during the child's first year; the frequency of visits diminishes during the child's second and third year. The nurse visits the home both before and after the child's birth, and also when medical issues are the focus of visit. Because nurses are in short supply in many communities, however, most of the home visits are made by parent educators, who coordinate with the nurse visitor. To promote early childhood health and development, First Born educates parents and helps them access community resources, using a three-pronged approach: helping the family to develop life and social skills, such as decision-making, crisis intervention, and knowledge of child development; using screening tools to identify problems (for example, substance dependency or developmental delays) and referring families to the appropriate sources of help; and promoting effective coordination among community resources. Based on First Born's scale-up experience, Kilburn and Cannon outline several lessons for other universal programs, including the pros and cons of universal services, the expectation that universal programs will have population-level impact, and barriers to innovation.