3.3 - Content

3.3.1 - Frequency (revised October 2022)

The case management agency must have face-to-face contact with the client as specified below and have as much additional contact as necessary to facilitate the family's access to services. Each contact must include the activities described for the client type. Whenever possible, the face-to-face contact should be made by the assigned case manager.

  • For infants, face-to-face contact at birth through the end of 1 month, 2 through the end of 5 months, 6 through the end of 9 months, and 10 through the end of 12 months. The category for infant is I.
  • For pregnant individuals, face-to-face contact once each trimester of pregnancy. The category for pregnant is P.
  • For postpartum individuals, face to face contact during the first 42 postpartum days and in month 6-9 after delivery. An individual can be enrolled in the FCM program at any time up to 9 months after the date of delivery. The category is D for Individual Delivered.

Case management activities shall be conducted in the client's home as presented below.

  • At least once prenatally. 
  • At least once during infancy from birth through the end of 4 months of the infant's life.

3.3.2 - Process- Pregnant & Postpartum Individuals and Infants (revised October 2022)

Outlined below are the guidelines for the full case management process. Agencies with a Family Case Management contract are expected to perform the following processes at a minimum to comply with the performance requirements of the grant.

The agency is expected to provide case management services to a caseload of pregnant & postpartum individuals and infants that is representative of the community served per the contract exhibits.

Agencies are expected to do the following: 

  1. Provide culturally responsive case management services that impact racial disparities in outcomes to 85% of assigned caseload of pregnant, postpartum, and infants.
  2. 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.
  3. Clients will be assigned to a case manager continuously within 30 days of enrollment and must be reassigned if staffing changes occur. Measured through Cornerstone on PA02 (Participant Profile), through Chart Review.
  4. Collaborate and link clients to other culturally responsive service providers in the community including Primary Care Provider (PCP) as documented on PA03 (Participant Enrollment) in the Cornerstone and measured through Chart Review; and Medicaid managed entities for service development to maximize care coordination.
  5. Support the health and well-being of individuals and infants through a Department approved plan for community control of the COVID 19 pandemic by prevention education, contact tracing, and vaccine distribution activities.
  6. All Infants must be grouped with the parent or guardian (if parent is not the guardian) as documented on PA06 (Participant Group Relationships) in Cornerstone and measured through Chart Review.
  7. The agency will complete comprehensive needs assessments and develop individualized care plans in person with the client within forty-five (45) calendar days of initial successful client contact.
    1. The agency will complete the following Cornerstone Assessments:
      1. 701 - Other Service Barriers,
      2. 711 - Prenatal Risk or 712 - Infant Risk as appropriate
    2. Clients are to be referred to the available program most appropriate to their risk level (HRIF or BBO).
      1. If an agency does not offer the program for which the client is most eligible, but another agency in the geographic vicinity does, it is expected that the client be referred to the most appropriate program for the client's needs.

3.3.3 - Pregnant Individuals (revised October 2022)

It is expected that agencies will provide a minimum of the following services as measured through Cornerstone chart review and performance reports to all Pregnant Individuals enrolled in Family Case Management.

The following information is to be obtained and documented in Cornerstone as appropriate:

The following information is to be obtained and documented in Cornerstone as appropriate:

  1. The following information is to be obtained and documented in Cornerstone as appropriate:
    1. Completion of the PA07 (Initial Prenatal Data) screen in Cornerstone with provision of the following:
      1. Estimated Date of Confinement (EDC
      2. Month when Prenatal Care Bega
      3. Number of Prenatal Medical visits prior to enrollment
    2. Completion of the PA10 (Postpartum Data) screen in Cornerstone with provision of the following at the Postpartum visit:
      1. Date of Deliver
      2. Number of Prenatal Medical visits completed
  2. Ensure that the following assessments and education are provided, and appropriate educational materials are distributed to pregnant and postpartum individuals to supplement the education topics discussed.
    1. Home Visit
      1. Complete the assessment AS01:706 - Home Assessment at the Home Visit
    2. Assure that all enrolled pregnant individuals are educated on and screened for perinatal mood disorders and referred to services as appropriate
      1. Screenings shall use a Medicaid-approved perinatal depression screening tool as indicated on the Department of Healthcare and Family Services website. The screening is to be completed during a face-to-face visit with the case manager and entered as a service entry (SV01: 825 - Depression Screening). This does not have to be repeated if there is documentation on the Service Entry Screen (SV01:825) that one was completed and confirmed by communication with the Primary Care or Obstetrical Care Provider along with a Case Note (CM04) detailing that verification has been obtained with the Provider.
      2. Licensed health care workers providing Family Case Management, prenatal care, to individuals shall screen pregnant individuals for perinatal mood disorder symptoms at a prenatal check-up visit on or after 20-weeks gestation or provide documentation that screening was completed and confirmed by communication with the Primary Care or Obstetrical Care Provider.
      3. FCM licensed health care workers providing prenatal and postnatal care to an individual shall include fathers and other family members, as appropriate, in both the education and treatment processes to help them better understand the nature and causes of postpartum mood disorders. This is to be documented through Cornerstone Case Notes and will be reviewed in chart audits.
      4. In accordance with the Perinatal Mental Health Disorders Prevention and Treatment Act (PMD), all reproductive-age individuals will receive information on postpartum mood disorders, including the Department's Postpartum Depression brochure pdf   and contact information for the Perinatal Depression Hotline.
  3. Evidence of medical care coordination in accordance with the HFS vs. Memisovski Consent Decree from 1992 shall be expected to include the following:
    1. Adequacy of prenatal care as measured by the Kotelchuck Index
    2. Linkage with a Primary Care Provider
    3. All referrals (specialty care, mental health, housing, etc.) as documented on the Cornerstone system Service Provider Selection (RF01). Minimal documentation will include the reason for referral and documentation if follow-up has occurred.
      1. Clients are to be given a copy of the referral.
  4. Pregnant individuals enrolled in the program are to receive at minimum the following services:
    1. Adequate prenatal care visits throughout pregnancy as measured by daily entry of client data into Cornerstone Data Entry Screens: PA07 (Initial Prenatal); PA10 (Postpartum); PA15 (Program Information); SV01:802 - Prenatal Care (Service Entry).
    2. Education about Reproductive Well Being with a hard copy in the client record as measured by timely entry of client data into Cornerstone Data Entry Screens: SV01:941 - Prenatal Reproductive Life Plan (Service Entry).
    3. At least one (1) Depression Screening completed on or greater than 20 weeks of gestation with a hard copy in the client record or documentation of PCP acknowledgement of completion as measured by timely entry of client data into Cornerstone Data Entry Screens: SV01:825 (Service Entry) with SV01:940 - Postpartum Depression Brochure (Service Entry) in accordance with the Perinatal Mental Health Disorders Prevention and Treatment Act (PMD).
    4. A minimum of one (1) prenatal face-to-face contact per trimester active in FCM as measured by timely entry of client data into Cornerstone Data Entry Screens: SV02 (Activity Entry). The home visit completed in any trimester is considered as a face-to-face in the indicated trimester.
    5. Prenatal Health Education provided at each face-to-face as measured by timely entry of data into Cornerstone Data Entry Screens: SV02 (Activity Entry) and CM04 (Case Note).
  5. Collaborate and link clients to other service Agencies in the community including primary care physicians and Medicaid managed care entities for service development and integration to maximize care coordination.

3.3.4 - Postpartum individuals (revised October 2022)

It is expected that agencies will provide a minimum of the following services as measured through Cornerstone chart review and performance reports to all Postpartum Women enrolled in Family Case Management.

  1. The following information is to be obtained and documented in Cornerstone as appropriate:
    1. Completion of the PA07 (Initial Prenatal Data) screen in Cornerstone with the provision of the following: The completion of PA07 is a history collection of data for clients who were not enrolled in the FCM program during pregnancy.
      1. Estimated Date of Confinement (EDC)
      2. Month when Prenatal Care Began
      3. Number of Prenatal Medical visits prior to enrollment
    2. Completion of the PA10 (Postpartum Data) screen in Cornerstone with provision of the following at the Postpartum visit:
      1. Date of Delivery
      2. Number of Prenatal Medical visits completed
  2. Postpartum Women enrolled in the program are to receive at minimum the following services within 42 calendar days of delivery to include:
    1. Postpartum Medical Follow-up Visit completed as measured by timely entry of client data into Cornerstone Data Entry Screens: SV01:820 - Postpartum Medical Follow-Up (Service Entry), with a hard copy of the Post-Birth Warning Signs given to client and blood pressure measurement recorded by the case manager. If the case manager is unable to obtain a blood pressure a documentation from PCP, or a client verification of the reading should be obtained.
    2. At least one (1) Depression Screening completed with a hard copy in the client record or documentation of PCP acknowledgement as measured by timely entry of client data into Cornerstone Data Entry Screens: SV01:825 - Depression Screening (Service Entry) with SV01:940 - Postpartum Depression Brochure (Service Entry) as evidence of providing the mother the brochure and focusing on resources identified in the brochure.
    3. Reproductive Life Plan with a hard copy in the client record as measured by timely entry of client data into Cornerstone Data Entry Screens: SV01:942 - Postpartum Reproductive Life Plan (Service Entry).
    4. Interconception health education as measured by timely entry of data into Cornerstone Data Entry Screens: SV01:PEWW - Well Women's Health Education (Service Entry).
    5. Collaborate and link clients to other service Agencies in the community including primary care physicians and Medicaid managed care entities for service development and integration to maximize care coordination.
  3. Postpartum women enrolled in the program are to receive at least one (1) Postpartum Health Education completed at 6-9 postpartum months with documentation of identified risk and/or complications specific to the mother under the service entry and/or case note (CM04) as measured by a timely entry of client data into Cornerstone Data Entry Screens: SV01:PPED - Postpartum Education (Service Entry) and SV02 (Activity Entry).
  4. Postpartum women enrolled in the program who experienced loss are to receive postpartum bereavement services from trained staff and/or are connected to trained professionals and/or support groups as measured by timely entry of client data into Cornerstone Data Entry Screens (PA10 (Postpartum Data - Outcome), SV02 (Activity Entry), RF01 (Service Provider Selection and CM04 (Case Note).

3.3.5 - Infants (revised October 2022)

It is expected that agencies will provide a minimum of the following services as measured through Cornerstone chart review and performance reports to all Infants enrolled in Family Case Management.

  1. The following information is to be obtained and documented in Cornerstone as appropriate:
    1. Completion of the PA11 (Birth Data) screen in Cornerstone with provision of the following at the first Infant visit:
      1. Birth weight of the baby:
        1. with written confirmation (e.g., birth certificate, crib sheet, etc.)
        2. with verification from the PCP
        3. a verbal confirmation, if unable to obtain weight information
  2. B. Infants enrolled in the program are to receive, at minimum, the following services:
    1. Face-to-Face Visits with age-based assessments completed at birth through the end of 1 month, 2 through the end of 5 months, 6 through the end of 9 months, and 10 through the end of 12 months as measured by timely entry of client data into Cornerstone Data Entry Screens: SV02 (Activity Entry) and completed AS01: 708A- F (Assessments).
    2. A minimum of one of each assessment completed as measured by timely entry of client data into Cornerstone Data Entry Screens: AS01:712 - Infant Risk Assessment and AS01:701 - Other Service Barriers (Assessment) within 45 calendar days of activation in the program.
    3. At least one home visit from birth through the end of 4 months as measured by AS01:706 Home Assessment (Assessment), SV01: SSED - Safe Sleep Education (Service Entry) and SV02 (Activity Entry).
    4. Completion of Immunization Education based on current CDC Guidelines as documented in Cornerstone Data Entry Screen: SV01: IMED - Immunization Education (Service Entry) at each Face-to-Face contact.
    5. Developmental Screening completed per schedule as measured by timely entry of client data into Cornerstone Data Entry Screens: SV01:824 - Developmental Screening (Service Entry). Evidence of an objective developmental screening approved by the Illinois Department of Healthcare and Family Services (HFS) Medicaid completed through agency administration or documentation completed by another service provider, including date of screening completion recommended within 6-12 months age range.
    6. A minimum of one (1) required age-based well child visit completed at birth through the end of 1 month, 2 through the end of 5 months, 6 through the end of 9 months, and 10 through the end of 12 months as measured by timely entry of client data into Cornerstone Data Entry Screens: PA03 (Participant Enrollment) and SV01:806 - Well Child/EPSDT Visit (Service Entry). A minimum of three (3) well child visits is required within the first year of life.
  3. Educational materials discussed and given for infant as measured by timely entry of data into Cornerstone Service Entry Screens CM04 (Case Notes) with topics related to assessment or client needs. Collaborate and link clients to other service Agencies in the community including primary care physicians and Medicaid managed care entities for service development and integration to maximize care coordination.
  4. Evidence of medical care coordination in accordance with the HFS vs. Memisovski Consent Decree from 1992 shall be expected to include the following:
    1. Education on the importance of childhood immunizations
    2. EPSDT participation at age one year
    3. Linkage with a Primary Care Provider
    4. All referrals (Early Intervention (EI), specialty care, mental health, housing, etc.) as documented on the Cornerstone system Service Provider Selection (RF01). Minimal documentation will include the reason for referral, and documentation status or follow-up has occurred.
      1. Clients are to be given a copy of the referral.

3.3.6 - Referral and Advocacy (revised October 2022)

The case manager shall assure that any necessary referrals are made and advocate as necessary on the client's behalf for services identified in the individual care plan. The case manager will ensure that all infants in need of Early Intervention (EI) services based on the Developmental Screening will be referred to the necessary services, and documentation will be made in the Cornerstone System on the Referral Screen RF01 (Service Provider Selection) with the reason for the referral and documentation that follow-up has occurred.

Minimal documentation requirements for all referrals on the RF01 screen in Cornerstone will include the reason for referral and documentation that follow-up has occurred.

Clients are to be given a hard copy of the referral.

3.3.7 - Follow-Up and Reassessment

Subsequent case management activities shall include, as necessary, a review of the implementation of the individualized care plan to date. The case manager should update the individual care plan using any additional information received from the physician or other service Agencies. These updates should occur at a quarterly minimum.

3.3.8 - Cornerstone Workflow Sheets (revised October 2022)

Pregnant Individual Cornerstone Workflow - Addendum 03.03.10 Pregnant

Postpartum Individual Cornerstone Workflow - Addendum 03.03.10 Postpartum

Infant Cornerstone Workflow - Addendum 03.03.10 Infant