Maternal & Infant Health Program Manual

Helping Families. Supporting Communities. Empowering Individuals.
  1. Introduction/Definition

    1. Introduction

      • This document establishes minimum procedures for all Community Service Provider Agreements with the Illinois Department of Human Services, Division of Family and Community Services - Bureau of Maternal and Child Health (BMCH), and is used in conjunction with specific program policy and procedure manuals when applicable. The BMCH oversees provision of maternal and child health programs as defined below
    2. Program Definitions:

      1. Family Case Management (FCM)

        • The FCM program is offered statewide providing 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, infants and a small number of high risk children. Children in the care of DCFS 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.
          • Adverse Pregnancy Outcomes Reporting System (APORS)/High Risk Infant Follow-up (HRIF): APORS/HRIF is offered statewide and 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.
      2. Better Birth Outcomes (BBO)

        • BBO services are targeted to areas of Illinois with higher than average Medicaid costs associated with poor birth outcomes, and with higher than average numbers of women delivering premature infants. The BBO program provides comprehensive case management services, including care plan development and care coordination with the woman's obstetrical care provider and other social services providers, delivery of a standardized prenatal education curriculum, education on pre-and inter-conception health and adequate spacing of pregnancies, childbirth and parenting classes to high-risk pregnant women through the duration of pregnancy and up to six weeks postpartum. Eligibility for BBO services is determined by the presence of two or more risk factors as identified via the administration of a standardized assessment instrument
        • Providers are responsible for early identification and enrollment of high risk pregnant women during the first trimester of pregnancy, completion of required assessments in the Cornerstone management information system to determine eligibility, assessment of client needs and care plan development and implementation, provision of a standardized prenatal education curriculum throughout the pregnancy, linkage to and coordination of care with primary care, obstetrical care and any appropriate specialty care, education and referral regarding contraceptive care, referral for childbirth education and parenting classes, and coordination of care with other needed social services
      3. Bureau of Maternal and Child Health Special Project

        1. Fetal and Infant Mortality Review (FIMR)
          • The FIMR provider operates in cooperation and collaboration with the Department, developing a strategic plan to decrease infant mortality in targeted communities. As a part of this effort a system of review of fetal and neonatal deaths within the metropolitan Chicago area is conducted. 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
        2. Family Case Management Best Practices for Pregnant and Post-Partum Incarcerated Women (BPPPIW)
          • BPPPIW Family Case Management is offered in Cook County only. It is designed to provide case management services to 100% of pregnant and postpartum women who are incarcerated in the Cook County jail to decrease infant mortality and morbidity and improve pregnancy outcomes. The provider is responsible for assessment of client needs, linkages with Medicaid and primary medical care, referral for assistance with identified social needs, and coordination of care. Women who remain incarcerated after delivery receive services up to six weeks postpartum, after which they are referred at release for continued inter-conception health education and case management to the Department's Best Practices in Inter-Conception Health program. In addition, women who are released from incarceration while still pregnant are referred to service providers of the Department's Better Birth Outcomes or Family Case Management programs
        3. Best Practices in Inter-Conception Health (BPIH)
          • BPIH is a pilot project designed to provide inter-conception case management services to women in one of the following categories: previous fetal or neonatal loss referred from the FIMR project; postpartum teens; selected Better Birth Outcomes agencies in Chicago who are in greatest need of education; or postpartum women released from the Best Practices for Pregnant and Post-Partum Incarcerated Women (BPPPIW) who delivered while incarcerated in the Cook County Jail. Inter-conception case management services will be provided related to Reproductive Life Planning and adequate spacing of pregnancies based upon risk factors associated with poor pregnancy outcomes
        4. Perinatal Hotline
          • Ensure 24/7 telephone-accessible consultation for crisis intervention specific to peri-partum depression by Masters and/or Doctoral-level mental health professionals credentialed to provide crisis intervention. Provide crisis intervention services to women referred from the DHS Family Case Management program (who have screened positive on a perinatal depression screening). Link and refer women who have screened positive for symptoms of perinatal depression to appropriate resources in their community. Improve the ability of maternal and child health programs to respond to pregnant women with emotional or behavioral problems through updates of training materials and resources, publications, etc. These screenings are program requirements of all Illinois Department of Human Services (IDHS) case management and home visiting programs. Assist Illinois Department of Human Services (IDHS) Healthy Families Illinois, Family Case Management and Better Birth Outcomes, and ALL KIDS program providers in meeting the program requirements through the referrals of pregnant and parenting women who have screened positive for symptoms of perinatal depression.
        5. Perinatal Depression
          • Targets postpartum women in the Chicago area served by the Family Case Management and/or Healthy Families Illinois programs. Women referred from DHS Family Case Management and Healthy Families Illinois programs receive a complete postpartum depression screening, assessment, treatment and psychiatric services to postpartum. The Perinatal Mental Health Act (SB0015 Postpartum Mood Disorder Prevention Act) became law in Illinois in January 2008; it requires that licensed healthcare providers offer screening and education concerning perinatal depression to pregnant and postpartum women and their families to increase knowledge of the signs, symptoms and treatment of perinatal mood disorders through training to community agencies and medical provider
    3. Definitions of Commonly Used Terms and Acronyms

      1. APORS - Adverse Pregnancy Outcomes Reporting System.
      2. ASQ3 - Ages and Stages Developmental Screening Tool
      3. BBO - Better Birth Outcomes
      4. BMCH- Bureau of Maternal and Child Health
      5. BPPPIW - Best Practices in Family Case Management for Pregnant and Post-Partum Incarcerated Women
      6. CBO - Community-Based Organization
      7. CSA - Community Service Agreement
      8. DCFS - Department of Children and Family Services
      9. DFCS - Division of Family and Community Services (within DHS)
      10. DHS - Department of Human Services
      11. EPDS - Edinburgh Postnatal Depression Screening
      12. 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.
      13. EI - Early Intervention
      14. FCM - Family Case Management
      15. FIMR - Fetal Infant Mortality Review
      16. FQHCs - Federally Qualified Health Centers
      17. HFI - Healthy Families Illinois, an intensive home visiting program to prevent child abuse in designated eligible families.
      18. FS - Illinois Department of Healthcare and Family Services
      19. HWIL - HealthWorks of Illinois, Medical Case Management for DCFS Wards Program
      20. HRIF - High Risk Infant Follow-up; sometimes used interchangeably with APORS.
      21. IDPH - Illinois Department of Public Health
      22. IPHA - Illinois Public Health Association
      23. IDR - Infant Discharge Record from birth hospital or perinatal center
      24. IMZ - Immunizations
      25. MCH - Maternal Child Health
      26. MCM - Medical Case Management for DCFS Wards
      27. MEDI - Medicaid Assistance Information for Medicaid Providers, operated by HFS
      28. MIECHV - Maternal and Infant Early Childhood Home Visiting Program, an intensive home visiting program for eligible designated clients.
      29. NFP - Nurse Family Partnership, an intensive home visiting program for eligible families where all home visits are made by registered nurses.
      30. PHQ-9 - Patient Health Questionnaire
      31. PPMD - Postpartum Mood Disorders
      32. QA - Quality Assurance; a Continuous Quality Improvement (CQI) program.
      33. WIC - Special Supplemental Nutrition Program for Women, Infants and Children
  2. Policies & Procedures

    1. Policies

      1. The Provider will provide the services detailed in this Program Manual and will agree to act in accordance with all state and federal statutes and administrative rules applicable to the provision of services pursuant to this Agreement (see Attachment U).
  3. Deliverables/Costs /Payments

    1. Deliverables

      1. The program services, number of individuals to be served, and outcomes are detailed in Exhibit B
      2. Costs/Payments: 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.
        • Payments to the Provider are scheduled on a monthly basis.
        • All payments will be reconciled based on submitted documentation.
        • Failure of the Provider to submit documentation may result in a reduction to the total award. In the case of special circumstances, please contact the Department for consideration.
        • The final payment from the Department under this Agreement shall be made upon the Department's determination that all requirements under this Agreement have been completed, which determination shall not be unreasonably withheld. Such final payment will be subject to adjustment after the completion of a review of the Provider's records as provided in the Agreement.
  4. Provider Responsibilities

    • Refer to Attachment U for a listing of the applicable Rules and Statutes for this program.
    • See contract Exhibits for detailed program information.
  5. Department Responsibilities

    • The Department will provide technical assistance and monitoring for all programs operated under 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.
  6. 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
    • Other related social service agencies Please refer to the program-specific Exhibits for additional requirements
  7. 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 forms and supporting documentation by e-mail to or the following Program(s) by the 15th of each month following the month of service:
    • Family Case Management (includes HealthWorks MCM and APORS/HRIF)

      • EDF: FY18FCMExpenditureDocumentFormEDF (xlsx)
      • EDF Instructions:FY18FCMEDFInstructions (pdf)
    • Better Birth Outcomes

      • EDF: FY18BBOExpenditureDocumentationFormExcel (xlsx)
      • EDF Instructions: FY18BBOEDFInstructions (pdf)
    • Bureau of Maternal and Child Health Special Projects

      • Adverse Pregnancy Outcomes Reporting System (APORS) (as a separate contract from FCM)

        • EDF: FY18APORSExpenditureDocumentFormEDF (xlsx)
        • EDF Instructions: FY18APORSEDFInstructions (pdf)
      • Best Practices in Family Case Management for Pregnant & Post-Partum Incarcerated Women (BPPPIW)

        • EDF: FY18BPPPIWExpenditureDocumentFormEDF (xlsx)
        • EDF Instructions: FY18BPPPIWEDFInstructions (pdf)
      • Better Practices in Interconception Health (BPIH)

        • EDF: FY18BPIHExpenditureDocumentFormEDF (xlsx)
        • EDF Instructions: FY18BPIHEDFInstructions (pdf)
      • Fetal & Infant Mortality Review (FIMR)

        • EDF: FY18FIMRExpenditureDocumentFormEDF (xlsx)
        • EDF Instructions: FY18FIMREDFInstructions (pdf)
      • Perinatal Depression & Perinatal Hotline

        • EDF: FY18PerinatalExpenditureDocumentFormEDF (xlsx)
        • EDF Instructions: FY18PERINATALEDFInstructions (pdf)
  8. Program Monitoring

  9. Program Budget

    • Providers agree to establish and utilize a budget approved by the Provider's Board of Directors.
    • This budget must be submitted through the Illinois Department of Human Services Community Service Agreement (CSA) Tracking System.