Maternal & Infant Health Program Manual

Helping Families. Supporting Communities. Empowering Individuals.

Bureau of Maternal and Infant Health
Program Manual

I. Introduction, Programs and Definitions

A. Introduction

Case Management (CM) Programs provide outreach and coordination of medical and oral (dental) health, and social services for low-income families (below 200% of the federal poverty level) with a pregnant woman, infant, or child with special needs (medical, social, psychological, environmental). The focus is on pregnant women in order to impact birth outcomes with the primary goals to decrease infant morbidity and mortality, decrease prematurity and very low birth rates, and assure access to appropriate medical and dental care and other needed community services to eligible families in the State of Illinois.

The mission of the case management programs is to improve the health status of women via appropriate pre-conception, inter-conception, prenatal and postpartum care; thereby, improving the incidence of infant morbidity and mortality, premature births and low birth weight, and to aid in the medical care, and growth and development of infants and children.

The programs in general serve income-eligible pregnant and postpartum women, and infants and children up to two years of age who are at risk due to poverty or eligible medical conditions. High Risk Infant Follow-up (HRIF)/APORS targets infants and children up to two years of age who meet eligible medical criteria/diagnoses. HealthWorks of Illinois focuses on medical care for wards of the Illinois Department of Children and Family Services (DCFS) birth through age 5 years, pregnant wards, and infants and children of DCFS wards.

The programs work in collaboration and cooperation with local public health departments, not-for-profit health and social service agencies, Federally Qualified Health Centers, county boards of health and numerous other organizations, such as the Maternal and Child Health Advisory Council, the March of Dimes, Illinois Public Health Association, Illinois Department of Public Health, EverThrive Illinois and Illinois Department of Healthcare and Family Services.

B. Programs

Better Birth Outcomes - Better Birth Outcomes is an intensive prenatal case management program that provides standardized prenatal health education, linkage and coordination of care with primary and specialty medical care and other social services, referrals to childbirth education and parenting classes, inter-conception health education that includes assistance in accessing contraceptive services and overall care coordination to pregnant women with risk factors that research shows contribute to poor birth outcomes. Identified through administration of a standardized risk assessment tool, risk criteria include, but are not limited to, previous pre-term birth, tobacco use continuing during pregnancy, pre-pregnancy BMI equal to/greater than 30; alcohol/substance abuse during pregnancy, medical conditions that affect pregnancy, homelessness, low educational attainment, presence of domestic violence and presence of a mental health diagnosis. Case managers, who are RN's, MSW's, Licensed Professional Counselors, Licensed Clinical Professional Counselors, Master's in Counseling Psychology and Human Services and Counseling, utilize standardized assessment tools to develop and implement individualized plans of care for enrolled women. BBO services are available in targeted communities of the State with higher than average Medicaid costs associated with poor birth outcomes and higher than average numbers of women delivering premature infants. Goals of the program are to: 1) decrease the incidence of infant mortality and morbidity resulting from lack of adequate prenatal care; 2) improve pregnancy outcomes; and 3) reduce the incidence of prematurity and low birth weight.

Family Case Management - The program provides access to medical care, pediatric health education and counseling, developmental screening, and referrals to other community services as needed. The target population for this program is pregnant women and infants. The program serves special populations, such as incarcerated pregnant women of the Cook County Department of Corrections via Cermak Health Services and an inter-conceptional case management program for women referred through the Fetal Infant Mortality Review program.

DCFS wards and high-risk infants are case managed through two initiatives that are components of Family Case Management:

  • Medical Case Management of DCFS Wards:  The program provides medical case management services to all Wards in the legal care and custody of DCFS and placed in substitute care from birth through age five (5) years, and pregnant DCFS Wards and children of parenting DCFS Wards. Medical case management refers to medically-related services provided by a person trained or experienced in medical or social services as described in 77 Ill. Adm. Code 630.220.
  • HealthWorks of Illinois: works in collaboration and cooperation with DCFS and others such as medical and social service providers to assure that the ward receives all services needed to promote health and well-being.
  • APORS/High Risk Infant Follow-up:  High Risk Infant Follow-Up (HRIF) is funded by Case Management General Revenue Funds (GRF) and some Federal Title XX Health Support Services funds, to provide case management services to families with high-risk infants identified by the Adverse Pregnancy Outcomes Reporting System (APORS); infants diagnosed with a high risk condition after newborn hospital discharge; and/or infants and children at medical and/or environmental risk because of an adolescent parent, drug-abusing parent or high-risk situation identified by the public health nurses. Services are available to infants regardless of the family's income level. The goals of HRIF services are: promotion of optimal growth and development; teach the family care of the high-risk infant; prevent complications; decrease morbidity and mortality; decrease stress and the potential for abuse; and ensure early identification and referral for further treatment and evaluation.

Special Projects

Fetal and Infant Mortality Review -

In cooperation and collaboration with the Department, the contractor develops a strategic plan to decrease infant mortality in targeted communities. As a part of this effort, the University develops and implements a system of review of fetal and neonatal deaths within the metropolitan Chicago area. Cases are referred through the statewide APORS reporting system. Activities specific to this project include establishment of a system to maintain confidentiality of persons who have experienced a perinatal loss, identifying cases appropriate for contact and interview, conducting home interviews when agreed upon by referred women, staffing a community case review team that meets quarterly, and extracting data from medical records to determine possible impacts on fetal or neonatal loss.

Findings of the review, the quarterly team review meetings and the chart extractions are compiled into an annual report that is shared with community leaders and others who have the ability to impact change in communities and provider settings. Women who agree to voluntary enrollment in a case management program are then referred for inter-conception care case management to help reduce the likelihood of a subsequent poor birth outcome. Additionally the University participates in the activities of the Perinatal Care Statewide Quality Council.

Best Practices in Interconception Health -Provides inter-conception case management services to a target population of women who have experienced a fetal or neonatal loss referred from the FIMR project; postpartum teens; and postpartum women released from Cermak Health Services who delivered while incarcerated in the Cook County Jail. Continuing in FY17 as a pilot project inter-conception case management services will be provided to postpartum women referred from selected Better Birth Outcomes agencies in Chicago who are in greatest need of education related to Reproductive Life Planning and adequate spacing of pregnancies based upon risk factors associated with poor pregnancy outcomes.

Bureau of Maternal and Infant Health Special Projects

The Division of Family & Community Services may have many Special Projects with individual agencies, the details of which are on file. These projects are generally operated by a small number of providers and are often supported by short-term federal grants.

The Department will designate the scope of services for the special project that the Provider is authorized to conduct by means of a letter. If the Provider is funded for more than one special project, the letter will detail the scope of services by special project.

C. Definitions

See the Appendix for the definitions of commonly used terms and acronyms by the case management programs.

II. Policies & Procedures 

A. Policies

  1. The Department's policies for contractual programs are contained within the Community Services Agreement, the Bureau of Maternal and Infant Health Attachment U and the Program Manual.
  2. Providers who receive funds for program administration are required to submit an annual program budget.
  3. The Department will communicate changes and/or clarifications of policy during Provider meetings and/or in writing.

B. Procedures

  1. The Department's procedures for contractual programs are outlined in the Program Manual. Instructions for submitting billings and completing forms are provided at the beginning of the contract period.
  2. The Department will communicate changes and/or clarifications of procedures during Provider meetings and/or in writing.

III. Contract/Amendment Process

A. Contract

The contract between the Department and the Provider consists of several parts:

  1. Community Service Agreement containing the standard contract language used for all Department contracts;
  2. Community Service Agreement Attachment U containing contract language specific to the Bureau of Maternal and Infant Health;
  3. Exhibit C and D showing the contact information, program type, methods of payment and reconciliation, and the estimated funding amount;
  4. Exhibit B an Addendum further detailing services to be provided, due dates, and payment information;
  5. this Program Manual and links containing the program service provisions, forms and instructions for submitting and completing billing, and other forms; and
  6. the Provider's approved request for funding and budget, if applicable.
  7. The Department will initiate the contract, send it to the Provider for review and signature, obtain the Secretary's signature and return a copy of the executed contract to the Provider.

B. Amendment Process

  1. The Department will initiate a two party signed amendment when Attachment U is being added to an existing contract.
  2. The Department will modify the contract by letter notification when it:
    1. extends the contract beyond the original expiration date; and/or
    2. revises the services purchased as shown on Exhibit B and Exhibit C; and/or
    3. increases or decreases the estimated funding amount; and/or
    4. revises the Program Manual due to a change in federal or state law or other reason of substance, when warranted.

IV. Exhibit B/Exhibit C - Deliverables/Costs/Payments

A. Exhibit B - Deliverables:

The program services, number of individuals to be served, and outcomes are detailed in Exhibit B.

B. Exhibit C- Costs/Payment:

The funding level for each program is based upon a Department approved budget for the services detailed in the Program Manual and/or the Provider's request for funding, when applicable. The funding level for each program is shown in Exhibit C.

The Department will utilize one (1) of the methods of payment and reconciliation specified in Exhibit C.

V. Provider Responsibilities

The Provider will provide the program(s) specified in Exhibit B and Exhibit D in accordance with the following provisions. Exceptions to these provisions must have the written approval of the Department.

Better Birth Outcomes - Services to be provided include, but are not limited to:

  1. The Provider will target pregnant women who are within a specific Illinois geographic area defined by the Department and who have risk factors associated with adverse birth outcomes as identified through administration of a standardized assessment process or who are members of a designated population with a common special need, including but not limited to incarcerated populations, women with developmental disabilities, and women temporarily residing in domestic violence shelter or homeless shelters as defined in the BBO Outreach Policy.
  2. The Provider will build and maintain strong relationships with the medical community, including OB/GYN medical practice physicians and hospital emergency room and labor and delivery personnel, for both enhanced care coordination and for early identification and referral of pregnant women to services.
  3. The Provider will conduct mandatory outreach activities, so as to identify, recruit and enroll pregnant women into services within the first trimester of pregnancy.
  4. The Provider will build and maintain strong working relationships with community-based social services agencies also serving pregnant women and is required to enter into Linkage Agreements with medical care providers, WIC agencies, local health departments, and other social service organizations serving pregnant women within their service area.
  5. The Provider will deliver a standardized Prenatal Health Education curriculum as designated by the Department.
  6. All women are to receive education and support around family spacing, reproductive life planning, maintenance of a healthy lifestyle, education regarding contraceptive methods and linkage with contraceptive services as needed.
  7. The Provider will promote and support the Illinois WIC program breastfeeding philosophy through the provision of educational materials and information about breastfeeding.
  8. The Provider will make reasonable efforts to assure Medicaid/insurance status of all BBO clients, providing information on Medicaid enrollment and enrollment with the Illinois Health Insurance Exchange.

Family Case Management - Services to be provided include, but are not limited to:

  1. Provide case management services to an assigned caseload of pregnant women and infants and high-risk children. The assigned caseload is set yearly and derived from a portion of the total grant.
  2. Provide services to clients in the catchment areas designated by the Department. When enrolling in Family Case Management the provider needs to be mindful of the program requirements of the Better Birth Outcomes program, and of any applicable regional, county or city transfer policies.
  3. Providers will make reasonable efforts to assure that infants of enrolled pregnant women are appropriately immunized, receive well-baby services (EPSDT) and developmental screenings at designated periodic intervals.
  4. Use the Cornerstone system to record Family Case Management client services and staff activities.
  5. Providers will establish and maintain Policies and Procedures related to the Family Case Management Program, which will include quality improvement indicators.
  6. Providers will perform and document Outreach efforts to build and maintain their caseload.
  7. Providers will be expected to attend staff development and training that is required by the Program or the Department of Human Services.
  8. Providers will be expected to meet and maintain the standards for program certification.
  9. Engage in Outreach efforts to locate eligible high-risk clients within their assigned geographic area, with priority given to locating and enrolling Medicaid-eligible pregnant women.
  10. Collaborate with other service providers in the community for service development and integration.

For providers who have HealthWorks Medical Case Management and/or the APORS/High-Risk Infant Follow-Up components of Family Case Management:

    Medical Case Management of DCFS Wards - Services to be provided include, but are not limited to:

    1. Provision of medical case management services to all DCFS Wards, birth through age five (5) years, and pregnant DCFS Wards and children of parenting DCFS Wards, residing in the Provider's service area. The Provider will obtain previous health care histories on each DCFS Ward in the care and custody of the Illinois Department of Children and Family Services at the time of the execution of this Agreement and are assigned to the Provider for medical case management services; ensure that DCFS Wards receive preventive health care services; ensure that DCFS Wards select a Primary Care Provider; develop health care plans for inclusion in each DCFS Ward's service plan; and ensure that follow-up health care services are received as medically appropriate.
    2. The Provider shall meet with the Lead Agency at least quarterly to monitor, review and discuss the provider's compliance with the performance standards specified on page 15 in DCFS HealthWorks Lead Agency Program Manual HealthWorks of Illinois.
    3. The Provider shall follow the DCFS Statewide Medical Protocol for Drug Endangered Children (DEC) in illegal methamphetamine labs and the related outline for role and responsibilities of the HealthWorks Lead Agency and Medical Case Management Agencies. The DEC Protocol addresses the medical needs of the children living in homes where methamphetamine and/or illegal drugs are being manufactured. This protocol is in conjunction with the Statewide Operational Agreement between DCFS and Illinois Law Enforcement agencies for responding to families involved in drug manufacturing where children are expected to be present or found in the home.
    4. DCFS Wards assigned to the Provider must remain active cases while the DCFS Ward is in the care and custody of the Department of Children and Family Services and resides in the Provider's service area. Case management activities must be terminated when the DCFS Ward leaves the care and custody of the Department of Children and Family Services or when the DCFS Ward reaches six (6) years of age, (except for pregnant DCFS Wards, who should remain as active cases) or when the DCFS ward moves out of the Provider's service area.
    5. Provider shall provide the DCFS wards' infant and/or children case management activities while the ward is in custody.
    6. Provider shall maintain a strong working relationship with the appropriate APORS/High Risk Infant Follow-up provider while ward is receiving APORS/HRIF services.

    APORS/High Risk Infant Follow-Up - Services to be provided include, but are not limited to

    1. The Provider will follow-up on all referrals initiated by regional perinatal centers or the IDPH Adverse Pregnancy Outcomes Reporting System.
    2. The Provider will conduct face-to-face follow-up with all infants who are referred with an Infant Discharge Record within two weeks of receipt of the IDR.
    3. A minimum of six (6) visits should be made by the follow-up nurse at intervals determined by the infant's chronological age of four, six, 12, 18 and 24 months.
    4. The Provider is expected to have referral relationships with other programs having a direct connection to high-risk follow-up, including, but not limited to, WIC; Primary Care, and Early Intervention.
    5. The Provider who is not a local public health department will maintain a strong working relationship with the local health department within their service delivery area.
    6. The Provider will conduct home visits to high-risk pregnant and postpartum women in order to assess the woman and the family environment and facilitate the early intervention for identified problems.
    7. Home visits for the high-risk infant are conducted in order to identify as early as possible those conditions requiring further evaluation, diagnosis and treatment; and assure an environment that promotes the infant's optimal growth and development.
    8. Provider shall provide the DCFS ward's infant and/or children APORS/HRIF and other case management activities while parenting ward is in DCFS custody.
    9. Provider shall maintain a strong working relationship with the appropriate HealthWorks Lead Agency while ward is receiving APORS/HRIF services.

     Bureau of Maternal and Infant Health Special Projects - The Department will designate the scope of services for the special project that the Provider is authorized to conduct by means of a contract exhibits or a letter. If the Provider is funded for more than one special project, the letter will detail the scope of services by special project.

    VI. Department Responsibilities

    The Department will provide technical assistance and monitoring for all programs operated under the Division of Family and Community Services.

    The Department will monitor the delivery of case management services through the certification review process and site visits, and review of the Department's Cornerstone reporting system data and other documentation as required by the Maternal and Child Health Services Code and the respective program Exhibits.

    VII. Support Services

    It shall be the responsibility of each local agency provider to coordinate the services provided through the CM programs with other sources of care in the community, such as:

    1. Local Health Departments
    2. Neighborhood Health Centers
    3. Federally Qualified Health Centers
    4. Local Child Development Clinics
    5. Division of Specialized Care for Children
    6. Local Child Care Centers, Early Head Start, Head Start and Preschool for All
    7. Local Hospitals
    8. Local Physicians and Physician Groups
    9. Local Children and Family Services Programs
    10. Community-Based Organizations providing substance abuse treatment and mental health services
    11. Regional Perinatal Centers
    12. Local Early Intervention Programs for Infants and Toddlers with disabilities
    13. Home visiting programs such as Healthy Families Illinois, Nurse Family Partnership, Parents as Teachers, Maternal and Infant Early Childhood Home Visiting
    14. Medicaid Managed Care Entities, such as Accountable Care Entities (ACE's), Coordinated Care Entities (CCE's), Managed Care Organizations (MCO's), Managed Care Community Networks (MCCN's), and others
    15. Other related social service agencies

    Please refer to the program-specific Exhibits for additional requirements

    VIII. Billing Instructions

    Providers shall use the following methodology to document the use of these funds:

    1. The Provider shall provide summary documentation by line item of actual expenditures incurred for the purchase of goods and services necessary for conducting program activities. The Provider shall use generally accepted accounting practices to record expenditures and revenues as outlined in DHS Rule 509, Fiscal Administrative Recordkeeping and Requirements.
    2. Program requirements may differ regarding expenditure documentation. Providers will be provided with the specific expenditure documentation forms and instructions to meet those requirements.
    3. Expenditures shall be recorded in the Provider's records in such a manner as to establish an audit trail for future verification of appropriate use of Agreement funds.
    4. Expenditure documentation must be submitted in the format defined by the Division of Family and Community Services. Expenditures must be received by the Department no later than the 15th day of the month following the month of service. Any change in this schedule must be submitted in writing to the Department. Final billings must be received by the 15th day of the month following the end of the Agreement period.
    5. All financial record keeping on the part of the Provider shall be in accordance with generally accepted accounting principles consistently applied.
    6. The Provider shall allocate and report all related program expenditures. This is a requirement of the federal award.

    The Provider shall submit expenditure documentation by one of the following means for the following Program(s):

    Better Birth Outcomes,  FIMR and FCM

    Helena Hughes-Osby

    815 East Monroe

    Springfield, IL 62701

    Phone: 217-782-7939

    Fax 217- 557-0515


    EDF: FY17BBOExpenditureDocumentationFormExcel (xlsx)

    EDF Instructions:FY17BBOEDFInstructions (docx)

    Family Case Management (includes HealthWorks MCM and APORS/HRIF)

    Helena Hughes-Osby

    815 East Monroe

    Springfield, IL 62701

    Phone: 217-782-7939

    Fax: 217-557-0515


    EDF: FY17FCMExpenditureDocumentFormEDF (xls)

    EDF Instructions:FY17FCMEDFInstructions (docx)

    Bureau of Maternal and Child Health Special Projects

    Helena Hughes-Osby

    815 East Monroe

    Springfield, IL 62701

    Phone: 217-782-7939

    Fax: 217-557-0515



    EDF Instructions

    IX. Program Monitoring

    The Department will monitor program operations in accordance with federal regulations, applicable state statutes, and administrative rules.

    X. Program Budget

    Providers agree to establish and utilize a budget approved by the Provider's Board of Directors.

    Providers will enter Budgets into a web-based system for review and approval by the Bureau Chief, Program administrator or designee. Final Budget Approval is done within the Office of Contract Administration.


    APORS - the Adverse Pregnancy Outcomes Reporting System. High Risk Infant Follow-up Case Management Program for all infants ages birth to two years who meet diagnostic criteria for follow-up.

    ASQ3 - Ages and Stages Developmental Screening Tool

    BBO - the Better Birth Outcomes program

    CBO - Community-Based Organization

    DCFS - Department of Children and Family Services

    DFCS - Division of Family and Community Services (within DHS)

    DHS - Department of Human Services

    EPDS - Edinburgh Postnatal Depression Screening

    EPSDT - Early and Periodic Screening, Diagnostic and Treatment, a preventive child health initiative that provides initial and periodic examinations and medically necessary follow-up care.

    EI - Early Intervention

    FCM - Family Case Management

    FIMR - Fetal Infant Mortality Review

    FQHCs - Federally Qualified Health Centers

    HFI - Healthy Families Illinois, an intensive home visiting program to prevent child abuse in designated eligible families.

    HFS - Illinois Department of Healthcare and Family Services

    HWIL - HealthWorks of Illinois, Medical Case Management for DCFS Wards Program

    HRIF - High Risk Infant Follow-up; sometimes used interchangeably with APORS.

    IDPH - Illinois Department of Public Health

    IPHA - Illinois Public Health Association

    IDR - Infant Discharge Record from birth hospital or perinatal center

    IMZ - Immunizations

    MCH - Maternal Child Health

    MCM - Medical Case Management for DCFS Wards

    MEDI - Medicaid Assistance Information for Medicaid Providers, operated by HFS

    MIECHV - Maternal and Infant Early Childhood Home Visiting Program, an intensive home visiting program for eligible designated clients.

    NFP - Nurse Family Partnership, an intensive home visiting program for eligible families where all home visits are made by registered nurses.

    PHQ-9 - Patient Health Questionnaire

    PPMD - Postpartum Mood Disorders

    QA - Quality Assurance; a Continuous Quality Improvement (CQI) program.

    WIC - Supplemental Nutrition Program for Women, Infants and Children

    State Authoritative Sources:

    As the Provider, in addition to State and Federal rules and regulations governing the programs you deliver, you are responsible for complying with all of the State sources below, if applicable:

    Administrative Orders:

    Contractual Services defined:

    Professional and Artistic Services defined:

    Purchasing, Contracting and Leasing:

    Contract filing and late filing affidavits:

    Lease of office and storage space and facilities:

    Fair Employment Practices:

    Governmental Ethics:

    Expenditure Authority:

    Contract Signatures:

    Payment for Goods and Services:

    State Contracts:

    Human Services Provider Contracts:

    Requirement to Purchase from Department of Corrections:

    Child Care Service Contracts (Only Applicable to Child Care Contracts):

    Purchase of Recyclable Products or Supplies:

    Change Orders in Public Contracts:

    Invoice Voucher Certification Clause: