2 - Service Coordination

  • 2 Service Coordination

  • 2.1 Multiple Program Service Coordination


Department grantees providing HRFCM services should engage in activities (as described below) to coordinate with other agencies in the grantee's service area that provide similar services to the same population as the grantee has agreed to serve (WIC, Early Childhood Home Visiting, Hospital-Provided Case Management, Nurse Home Visiting, etc.). This coordination is intended to avoid duplication of services at the local level and ensure that each client has only one lead RN case manager at any given time.

  1. The HRFCM agency should ensure that every family enrolled in the HRFCM program continues to utilize primary medical care, regardless of the primary case management agency working with the family.
  2. Agencies providing DHS HRFCM services should enter into written agreements with other agencies with the same geographic service area (in whole or in part) who offer similar social or health services to the same population. These agreements must specify, at minimum, each grantee's target group for services, referral procedures, procedures to obtain informed consent for services and protection of client's privacy, and procedures to determine the agency(ies) most appropriate to provide services to meet the needs of the family.
  3. Following the assessment of a client enrolled in multiple programs, the RN Case Manager, RN Program Coordinator, other involved social service or health Agency staff, and the client (and the client's parent(s) or legal guardian(s), depending upon the client's ability to consent for services) should determine the one agency or program most appropriate to take a lead role in providing services if any of the criteria listed below are met. Only those Agencies for which the client has given written consent may participate in the determination. The factors used to determine if services from multiple programs are indicated should include:
    1. the participant's most important problem requires expertise that the agency's staff does not possess; and
    2. the participant's most important problem requires expertise that another agency's staff does possess; and
    3. the participant's problems are so complex as to require the close collaboration of several agencies for the family to successfully meet their health goals and the family requests to be enrolled in multiple programs and understands the services offered at each.

2.2 Client Transfer Policy


Clients may only be enrolled in services at one agency at a time. Based on this, it is essential that all agencies cooperate in adhering to the following client transfer policy to ensure that there is a strong continuity of care for families, and each family is receiving the most appropriate service based on their individual needs. Every agency is expected to follow the policy as it is written unless prior approval has been given and documented by the MCH Nurse Consultant.

Before activating any client, it is imperative that the client meets the eligibility criteria and a lookup in the MIS has been completed of the birthing parent, siblings, and infant name to determine if the family is already enrolled at another agency.

If a referral has been received and an MIS lookup has identified that the birthing parent, any sibling, or the infant is already active at an agency, the HRFCM agency performing the lookup should not reach out to that family and the family should continue to receive services at the agency in which they are already active.

  1. Requests for transfer of clients with an Active program status should only be made for one of the following reasons and the client must agree to the transfer prior to it being completed:
    1. the family's most important problem requires expertise that the grantee's staff does not possess, and the receiving agency has capacity to provide services outside of their usual service area
    2. the family's most important problem requires expertise that another agency's staff does possess, and the receiving agency has capacity to provide the service outside of their usual service area
    3. the family has moved into the receiving agency's service area; or
    4. the family prefers to obtain HRFCM services from another agency and the receiving agency has capacity to provide the service outside of their usual service area
      1. If a parent requests to transfer their family to another agency, the agency should have a conversation with the client emphasizing the importance of continuity of care. If the client still requests to change agencies, the sending agency should verify with the receiving agency that they have the capacity to provide service to the client outside of their usual service area. A detailed Case Note should be documented in the MIS.

If a transfer of an active client is deemed necessary, based on the reasons given above, the agency receiving the client must communicate directly with the agency who is going to be losing the client to inform them of the transfer and request that the record be released in the MIS. A detailed Case Note should be documented in the MIS.

To ensure continuity of care, the birthing parent and infant should be enrolled at the same agency and have the same assigned RN Case Manager as each other, unless:

  1. The birthing parent and infant are not part of the same family (gestational surrogate, adoption, etc.)
  2. The birthing parent does not have a relationship with the infant and the infant has a primary caregiver/guardian who is not the birthing parent
  3. The birthing parent and infant live in 2 separate service areas
  4. The birthing parent requests that the infant be assigned a separate case manager from the birthing parent