1. Introduction/Definitions


The mission of the Bureau of Maternal and Child Health (BMCH) is to:

  • Reduce the incidence of infant mortality, premature births and low birth weight;
  • Promote optimal growth and development of infants; and
  • Promote healthy habits and medical follow-up care to high-risk infants and pregnant women.

BMCH implements several programs throughout the State in partnership with Local Public Health Departments, FQHCs and CBOs throughout the state to provide services at a local level to achieve this mission.

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 the following programs as defined below:

i. Family Case Management (FCM)

Family Case Management (FCM) is a statewide program that provides comprehensive service coordination to improve the health, social, educational, and developmental needs of pregnant women, and infants (0 - 12 months) from low-income families in the communities of Illinois (410 ILCS 212/15). Family Case Management (FCM) aims to "assess current needs within the State and provide goals and objectives for improving the health of mothers, children, and for reducing infant mortality" (77 Ill. Adm Code 630.20).

ii. High Risk Infant Follow-Up / HealthWorks

The IDHS BMCH aims to facilitate case management services to high risk infants and children statewide with the goal of reducing infant mortality and morbidity rates at both the state and local level. Assistance in obtaining health and human services which promote healthy growth and development will be provided to high-risk families as mandated in the Illinois Family Case Management Act through High Risk Infant Follow-Up, HealthWorks and the 0-3 Initiative.

a) High Risk Infant Follow-Up

Infants and children (ages 0 - 2 years old) are referred to the high-risk infant follow up program either through the IDPH Adverse Pregnancy Outcomes Reporting System (APORS) or based on assessments done in the Family Case Management program which determine: that the infant has been diagnosed with a serious medical condition after newborn discharge; when maternal alcohol or drug addiction has been diagnosed; or when child abuse or neglect has been indicated based on investigation by the Illinois Department of Children and Family Services (See 410 ILCS 525/3 and 77 Ill. Adm. Code 840.210).

The primary goals of HRIF are to:

  • Minimize disability in high-risk infants by early identification of possible conditions requiring further evaluation, diagnosis, and treatment
  • Promote optimal growth and development of infants
  • Teach family care of the high-risk infant
  • Decrease stress and potential for abuse

b) HealthWorks of Illinois (HWIL)

Clients are referred to HWIL from DCFS Lead Agencies after the initial 45 days the child is in care. Grantees are expected to provide follow-up services and communicate regularly back to the Lead Agencies regarding issues pertaining to these cases and to maintain complete medical records for the child.

The primary goals of HWIL are to:

  • Ensure that each child receives preventive health care services
  • Ensure that each child in connected with a Primary Care Provider (PCP)
  • Develop health care plans for incorporation into each child's overall DCFS service plan.

c) 0-3 Initiative

DHS has engaged in the development of a collaborative initiative with DCFS to improve the health outcomes of children whose families currently have an "Intact Case" with DCFS. Based on data assessed between the two agencies in the Spring of 2018 over half of families in DCFS intact services are known to Family Case Management or WIC, but only about a third are currently actively engaged in the programs. To improve the outcomes for this vulnerable population, the Department of Human Services (DHS) has embraced a collaborative initiative with the DCFS focusing on measures aimed to prevent further injury, serious harm or death as well as improve the health outcomes for children from birth to three years of age.

iii. Better Birth Outcomes (BBO)

High-risk pregnant women in areas of the state with higher than average Medicaid costs associated with poor birth outcomes and with higher than average numbers of Medicaid women delivering premature infants are enrolled in the BBO program.

BBO offers a standardized prenatal education curriculum that emphasizes the importance of regular prenatal medical care visits, home visits each trimester active in the program, and monthly engagement with the BBO case manager for continued prenatal education; care coordination and communication with the client's prenatal medical provider. The program's emphasis on reproductive life planning and health benefits associated with the delay of subsequent pregnancy impacts Illinois' infant mortality rate and rates of prematurity in Medicaid-eligible pregnant women. Women are enrolled in BBO through the duration of pregnancy up to six weeks postpartum. Because the pregnant women that are the target population for these services are not women who typically tend to seek out early prenatal medical care or other needed services, BBO programs are expected to develop an annual outreach plan.

iv. Best Practices in Inter-Conception Health (BPIH)

BPIH provides inter-conceptional case management services to a target population that includes women who have experienced a pregnancy loss or an infant death before thirty days of life. These women and families are primarily referred from the IDPH Fetal Infant Mortality Review (FIMR) program and select Better Births Outcomes (BBO) programs in Chicago. Women receiving these services have multiple medical and/or social risk factors that put them at increased risk of having less than optimal intervals between subsequent pregnancies which lead to an increased risk of infant mortality or morbidity.

The service objectives of the Best Practices in Interconception Health (BPIH) program are to:

    • Increase intervals between subsequent pregnancies
    • Improve pregnancy outcomes
    • Reduce the incidence of prematurity and very low/low birth weight

v. Perinatal Depression

The Perinatal Depression Treatment program provides the following client services in the Chicago area:

    • Perinatal depression screening
    • Assessments
    • Treatment
    • Psychiatric care to women referred by the Family Case Management (FCM) and Healthy Families Illinois (HFI) programs

vi. Illinois Perinatal Quality Collaborative (ILPQC)

The ILPQC assesses current trends and issues related to negative maternal/infant outcomes and through its collaborative identifies strategies to address them. A partnership between BMCH and ILPQC enhances FCM services by allowing for training and implementation of these strategies statewide though the FCM provider networks.

The ILPQC operates targeted collaborative learning opportunities designed to reduce maternal morbidity in Illinois.


  • APORS - Adverse Pregnancy Outcomes Reporting System
  • BBO - Better Birth Outcomes
  • BMCH - Bureau of Maternal and Child Health
  • BPIH - Best Practices in Inter-Conception Health
  • CBO - Community Based Organization
  • CDC - Centers for Disease Control
  • DCFS - Department of Children and Family Services
  • DHS - Department of Human Services
  • FCM - Family Case Management
  • FIMR - Fetal Infant Mortality Review
  • FQHC - Federally Qualified Health Center
  • GATA - Grants Accountability & Transparency Act
  • HFS - Healthcare and Family Services
  • HRIF - High Risk Infant Follow-up
  • HWIL - HealthWorks of Illinois
  • IDPH - Illinois Department of Public Health
  • ILPQC - Illinois Perinatal Quality Collaborative
  • Intact Case - A DCFS program for families in which the investigation identified areas of concern, but the home environment has enough positive attributes to allow the family to remain "intact" while they are connected to services/treatment to build them up and ensure long term safety for the children. In the first 1-2 months of the case the Intact Caseworker will be in the home weekly to see all of the children.
  • LHD - Local Health Department
  • NICU - Neo-Natal Intensive Care Unit
  • PBC - Procurement Business Case
  • PCP - Primary Care Provider
  • PFR - Periodic Financial Report
  • SSBG - Social Services Block Grant Title 20
  • WIC - Special Supplemental Nutrition Program for Women, Infants & Children