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:
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- Provide case management services to 90% 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 at a level and frequency determined by the standards set forth based on the type of client.
- Enrolled families in case management with one or more children under 12 months of age shall receive home visits.
- Assure enrolled infants receive an objective developmental screening within the first 12 months of life utilizing an 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 and integration, to maximize care coordination.
- Assure enrolled families are not active with more than one Provider, except in situations where the client would benefit from dual services and / or an inter-program transitional period.
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. Denial by the Illinois Health Insurance Exchange or client refusal to apply should be documented on the "Determining Financial Eligibility for FCM Primary Care" form.
If approved by the Department, FCM funding may be used to pay for the following services: prenatal healthcare office visits, infants or children under 2 years of age with > 30% developmental delays per Early Intervention (EI) global assessment who need periodic developmental screening; immunization administration on FCM clients; sickle cell testing; parasite testing; vision screening and, or glasses; hearing screening; periodic lead screening or follow up on FCM clients; pregnancy testing; head-to-toe physical assessment (EPSDT visit) on FCM clients; routine and medically indicated dental services for FCM infants, children 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 High Risk Infant Follow-Up Program Handbook and the Maternal and Child Health Services Code, Title 77 Part 630.
- Collaborate with other service providers in the community including primary care physicians and Medicaid managed care entities for service development and integration, and to maximize care coordination.
- Assure that all birth mothers of enrolled high-risk infants are screened for and educated on perinatal mood disorders and referred to services as appropriate.
- Assure enrolled infants receive developmental screening within the first 12 months of life utilizing a standardized screening tool.
- Provide HRIF infants who are also DCFS youth in care with home visits according to the standards set by the Department's most recent High Risk Infant Follow-Up Program Handbook rather than according to the home visit standards set by HealthWorks.
- Ensure the appropriate HealthWorks Lead Agency is notified when youth in care is closed out of High-Risk Infant Follow-Up services program.
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 HealthWorks program standards.
- Obtain previous health care histories on each assigned child in the care and custody of the DCFS.
- Ensure that children receive preventive health care services.
- Ensure that children are connected to a Primary Care Provider.
- Ensure that follow-up health care services are received as medically appropriate.
- Ensure children receive Medical Case Management services after High Risk Infant Follow-Up services are closed.
- Meet with the HealthWorks of Illinois Lead Agency at least quarterly to monitor, review and discuss the contractor's compliance with the performance standards.
- Follow the DCFS statewide Medical Protocol for Drug Endangered Children (DEC) and the related outline for role and responsibilities of the HealthWorks Lead Agency and Medical Case Management Agencies.
- Input medical case management data and medical information using the Department's Cornerstone information system.
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.
- Women will receive a minimum of one contact per month of enrollment in the program alternating between home visit, face-to-face and other two-way communication with respect to the care plan.
- Communicate directly with the MMCO on behalf of the client to assist in arranging transportation when necessary.
D. BEST PRACTICES IN INTER-CONCEPTION HEALTH (BPIH)
Services to be provided include, but are not limited to:
- Deliver interconception-focused case management services that are directed at delaying the onset of subsequent pregnancy to the target population of postpartum women.
- Enroll, and case manage women at high-risk of subsequent pregnancy loss referred from the FIMR program; postpartum women at increased risk of a short pregnancy interval referred from Better Birth Outcomes programs.
- Conduct initial visit in the home within forty-five (45) days of receipt of referral, regardless of source of referral.
- Complete comprehensive needs assessment and care plan development within forty-five (45) calendar days of enrollment.
- Complete a minimum of one contact per month of enrollment in services, which can be completed through a face-to-face visit or two-way communication (phone, text or email).
- Screen for perinatal mood disorders at least one time in the postpartum period.
- Develop and maintain linkage agreements with Better Birth Outcomes agencies identified as referral sources for postpartum women.
- Assist women in accessing needed services based upon results of screening and assessment and client's medical-social history.
- Update the care plan a minimum of once per quarter of enrollment for all case managed women, including periodic reassessment of women as indicated.
- Complete an initial Reproductive Life Plan within ninety (90) days of enrollment into services and complete referrals as necessary.
- Provide grief support materials and referrals to bereavement support counseling and/or perinatal support group as appropriate.
- Arrange for client transportation for medical care visits and appointments, specific to the woman's individual health needs and outlined in her plan of care as needed.
E. PERINATAL DEPRESSION
- 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 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 for evaluation for all clients referred who agree to further evaluation within 10 working days of initial contact.
- Deliver treatment and follow-up to all clients referred, who are assessed as being in need of services for perinatal depression.
- Submit a quarterly report to the Department on the 30th day of the month following the end of each quarter, indicating outcomes associated with initial contact, evaluations and treatment to all referred clients.
F. 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 DHS 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 resources for linking moms with opioid use disorder to Medication Assisted Treatment (MAT)
