The Department will identify key lead measures that are targeted toward highlighting and reducing key factors identified in infant and maternal morbidity and mortality statistics across the state. Agencies will be asked to provide services specified towards these key lead measures as communicated by the Department in addition to the specific program responsibilities highlighted below.
A. FAMILY CASE MANAGEMENT
Services to be provided include, but are not limited to:
- Provide case management services to 85% of assigned caseload of pregnant women and infants.
- Conduct case finding from a weekly list of newly enrolled Medicaid clients by contacting and encouraging clients not currently active in case management to participate and enroll in the FCM program.
- Target all pregnant women as the priority population to be served followed by infants in descending order.
- Assign a case manager to participants continuously within 30 days of enrollment and must be reassigned if staffing changes occur.
- Complete comprehensive needs assessments and develop individualized care plans within forty-five (45) calendar days of successful client contact.
- Assure that all enrolled pregnant and postpartum women are educated on and screened for perinatal mood disorders and referred to services as appropriate.
- Conduct face-to-face contacts and home visits with all clients as prescribed in the current Program Policy Manual.
- Assure enrolled infants receive an objective developmental screening within the first 12 months of life utilizing current Illinois Department of Healthcare and Family Services Medicaid-approved screening tool.
- Collaborate and link clients to other service providers in the community including primary care physicians and Medicaid managed care entities for service development, to maximize care coordination.
i. Primary Care
In specific circumstances determined and approved by the Department, FCM funds may be used to pay for Primary Care if there is no other source of payment. It is expected that all Medicaid-eligible families are offered and provided assistance in applying for coverage. It is expected that all non-Medicaid eligible families receive information and assistance regarding enrollment in the Illinois Health Insurance Exchange as directed by the Department. Client refusal to apply should be documented on the "Determining Financial Eligibility for FCM Primary Care" form in cases where cultural or religious beliefs may prohibit them from applying.
If approved by the Department, FCM funding may be used to pay for the following services: prenatal healthcare office visits, periodic developmental screenings for infants or children under 2 years of age with > 30% developmental delays per Early Intervention (EI) global assessment; immunization administration on FCM clients; sickle cell testing; parasite testing; vision screening and, or glasses; hearing screening; periodic lead screening; pregnancy testing; head-to-toe physical assessment (EPSDT visit) on FCM clients; routine and medically indicated dental services for FCM infants or pregnant women.
B. HIGH RISK INFANT FOLLOW-UP / HEALTHWORKS
Services to be provided include, but are not limited to:
i. HRIF
- Complete needs assessment and develop an individualized care plan.
- Deliver all services to high-risk infants in accordance with the provisions of the current Department's Program Policy Manual.
- Collaborate with other service providers in the community including primary care physicians and Medicaid managed care entities for service development to maximize care coordination.
- Assure enrolled infants receive developmental screening within the first 12 months of life utilizing a standardized screening tool.
- Provide HRIF infants with face to face contact and home visits according to the Program Policy Manual.
- Ensure children in DCFS custody who are eligible for HRIF, are offered HRIF program services, and are referred back to HWIL program once they are no longer requiring HRIF services .
ii. HWIL
- Complete the comprehensive needs assessment on successful contact with the development of an individualized care plan.
- Provide medical case management services to all children, in accordance with the HealthWorks program Policy Manual.
- Obtain previous health care histories on each assigned child in the care and custody of DCFS.
- Ensure that children are connected to a Primary Care Provider for preventive health care & follow-up services as medically appropriate.
- Document all medical case management information using the Department's Cornerstone information system as specified in the Program Policy Manual .
C. BETTER BIRTH OUTCOMES (BBO)
Services to be provided include, but are not limited to:
- Provide intensive case management services to 90% of assigned caseload of high-risk pregnant women.
- Deliver the Department's standardized Prenatal Health Education Curriculum in its provision of prenatal education to all enrolled women according to the BBO Prenatal Education Curriculum Guide.
- Provide services to clients who reside in the targeted geographic area designated by the Department.
- Provide a comprehensive needs assessment and have a case management care plan developed within forty-five (45) calendar days of enrollment with appropriate referrals.
- Refer all BBO women and infants born to BBO women who may be income-eligible to the WIC program.
- Provide one home visit per trimester of pregnancy that they are active in the program.
- Provide a minimum of one face-to-face contact per month of enrollment in the program.
- Communicate directly with the MMCO on behalf of the client to assist in arranging transportation when necessary.
D. PERINATAL DEPRESSION
Any agency contracted with the Perinatal Depression program at DHS will be expected to perform the following deliverables and meet the performance standards identified in Exhibit F as well as adhere to the treatment guidelines set forth in 77 Ill. Adm. Code 2110 as they pertain to the population served under the Perinatal Depression Program.
Services to be provided include, but are not limited to:
- Provide postpartum depression screening, assessment, treatment, and psychiatric care to a minimum of 200 women referred by the FCM and the HFI Programs and the Perinatal Depression Hotline in the Chicago area who are suffering from prenatal and, or PPD.
- Maintain consistent staffing including therapists, psychologists and case managers who understand perinatal depression and are well-versed in treatment.
- Ensure treatment will consist of psychiatric evaluation, psychotherapy, and follow-up care.
- Deliver in-service trainings on the administering, scoring, and general interpretation of the Edinburgh Postnatal Depression Scale (EPDS) to community agencies and HFI workers.
- Deliver educational trainings/presentations on PPD for case managers / case workers, mental health practitioners, public health staff, RNs, and social workers, as well as new or soon-to-be new mothers.
- Ensure trainings focus on the identification of symptoms, the difference between the "baby blues" and postpartum depression (PPD), addressing immediate safety concerns, contributing risk factors, and available treatment options.
- Produce quarterly reports measured through provider's data management systems to account for billable services provided, direct-service case management / case coordination sessions, psychiatric sessions, individual therapy sessions and group therapy sessions.
- Contact 100% of clients referred for evaluation and treatment of perinatal depression from area FCM and HFI providers within one week of referral.
- Schedule an appointment with all referred clients who agree to assessment and further evaluation within 10 working days of initial contact.
- Deliver perinatal depression treatment and follow-up services to all clients referred .
E. ILLINOIS PERINATAL QUALITY COLLABORATIVE (ILPQC)
Services to be provided include, but are not limited to:
- Facilitate in-person collaborative learning opportunities for ILPQC Hospital Teams including local provider network of Maternal Child Nurse Consultants.
- Establish distance learning opportunities (webinar) for FCM program providers statewide.
- Facilitate implementation of and stakeholder input on Mothers and Newborns affected by Opioids (MNO) - OB and Neonatal initiatives through OB and Neonatal Advisory Calls and Leadership calls to which DHS and/or FCM staff are invited.
- Facilitate training and capacity building to expand network resources for linking moms with opioid use disorder to Medication Assisted Treatment (MAT)
