4.3 - Content

4.3.1 - Frequency (revised October 2022)

All APORS referred clients must receive their first contact from the agency within seven (7) business days of referral.

A minimum of 6 face-to-face visits shall be made by the nurse case manager at the following intervals for all clients:

  1. within fourteen (14) business days of newborn hospital discharge (birth through the end of 1 month),
  2. a 4-month visit (between chronological 2 months through the end of 5 months),
  3. a 6-month visit (between chronological 6 months through the end of 9 months),
  4. a 12-month visit (between chronological 10 months through the end of 15 months),
  5. an 18-month visit (between chronological 16 months through the end of 21 months),
  6. a 24-month visit (between chronological 22 months through the end of 24 months).

Infants and their families having actual or potential health problems identified by the nurse shall be visited more frequently for health monitoring, teaching, counseling, and/or referral for appropriate services. Occasionally, when an infant is receiving services at the Local Health Department, a follow-up visit may be conducted by the nurse at that time.

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

  • At least once during infancy from birth through the end of 4 months of the infant's life
  • For complex APORS conditions, three to four home visits may be needed. If the APORS condition is non-complex and the family is mobile, additional home visits will be based upon the professional judgement of the nurse case manager. The nurse should document evidence of contact and location on the SV02 (Activity Entry) screen in Cornerstone for each contact.

4.3.2 - Process (revised October 2022)

Outlined below are the guidelines for the high-risk follow-up case management process. Agencies with a High-Risk Infant Follow-up contract are expected to perform the following processes to comply with the performance requirements of the grant.

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:
    1. Birthweight of the baby on PA11 (Birth Data) screen in Cornerstone:
    2. With written confirmation (e.g., birth certificate, crib sheet, etc.)
    3. With verbal confirmation from the parent or guardian, and/or a verification from the PCP
    4. APORS box should be "Y" after receiving the APORS report
  2. Completion of the PA15 (Program Information) screen in Cornerstone as applicable at the initial infant visit:
    1. APOR for APORS with IDR
    2. HRIF for High-Risk Infant Follow-up without IDR
    3. Family Case Management program for Infant/Child

The physical assessment is to be completed by a registered nurse. The physical assessment will be documented in Cornerstone: AS01:708 questions 27-52 - Pediatric Primary Care Assessment. Each physical assessment should be documented by the nurse at each face-to-face visit under the Cornerstone Data Screen SV02 (Activity Entry). A Maternal Child Health (MCH) Nurse Consultant will review the documentation of physical assessments during program review.

The RN Case Manager is required to complete the additional assessments within the following timeline:

  1. 45 calendar days of program enrollment
    1. General Assessment (AS01:700), Q43-51
    2. Other Barriers (AS01:701),
  2. Birth through the end of 4 months
  • Home Assessment (AS01:706).

The Infant Risk Assessment (AS01:712) should not be completed on known HRIF or APORS referred clients.

The Case Note (CM04) documentation is required after providing a pediatric health education.

Developmental Assessments are to be completed by a registered nurse who has training in administering any of the developmental screening tool approved by Department of Healthcare and Family Services (HFS). A developmental assessment will be completed during face-to-face visit schedule starting from 6 to 24 month visit frequency and a hard copy of each scheduled screening tool used will be placed in the client's file/record.

The purpose of the Primary Care Physician (PCP) Notification Form pdf is to inform the PCP of any abnormal/unusual or questionable findings resulting from the assessment of the infant by the public health nurse. It is not required that this form be sent to the primary physician after each assessment. The use of the PCP Notification Form is based on the professional judgment of the Case Manager. All pertinent information should be shared between the local public health nurse and primary care physician. However, the primary physician should be notified that the infant/child is active in HRIF program services.

Services to be provided include, but are not limited to:

  • Provide services with a focus on a racial equity and the reduction of racial/ethnic disparities to 90% of assigned caseload of children.
  • Ensure that all clients have an assigned Primary Care Provider, and this provider is known to the client.
  • Complete needs assessment and develop an individualized care plan
  • Update the Individualized Care Plan at least quarterly based on assessments and current client needs.
  • Deliver all age-based assessments, screenings, and services to high-risk infants in accordance with the provisions of the current Department's Program Policy Manual.
  • Collaborate with other service Agencies in the community including primary care physicians and Medicaid managed care entities for service development and integration and to maximize care coordination.
  • Ensure enrolled infants receive developmental screening per schedule utilizing a standardized screening tool.
  • Ensure children in DCFS investigations and/or custody are eligible for HRIF program to receive services.
  • Ensure that all children receive a Well Child /EPSDT Exams at each face to face completed at birth to the end of 1 month, 2 months through the end of 5 months, 6 months through the end of 9 months, 10 months through the end of 15 months, 16 months through the end of 21 months, and 22 months through the end of 24 months and documented in Cornerstone Data Entry Screen: SV01:806 - Well Child/EPSDT (Service Entry).
  • Initial Face-to-Face contact with infants (0-12 months) is to be made within fourteen (14) business days of APORS referral as measured through chart review of the printed Infant Discharge Record (IDR) and the Cornerstone Data Entry Screen: SV02 (Activity Entry).
  • Subsequent Face-to-Face Visits with age-based assessments are to be completed at birth to the end of 1 month, 2 months through the end of 5 months, 6 months through the end of 9 months, 10 months through the end of 15 months, 16 months through the end of 21 months, and 22 months through the end of 24 months as measured by timely entry of client data into Cornerstone Data Entry Screen SV02 (Activity Entry), AS01:708 - Pediatric Primary Care questions 27-52 - Physical Assessment, AS01:708A-I (Assessments).
  • Ensure completion of Developmental Screenings per schedule completed at 6 months through the end of 9 months, 10 months through the end of 15 months, 16 months through the end of 21 months, and 22 months through the end of 24 months as measured by timely entry of client data into Cornerstone Data Entry Screen SV01:824 - Developmental Screening (Service Entry). Evidence of developmental screening can be collected through agency administration or documented confirmation completed from another service provider with date screening completion.
  • 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 at birth to the end of 1 month, 2 months through the end of 5 months, 6 months through the end of 9 months, 10 months through the end of 15 months, 16 months through the end of 21 months, and 22 months through the end of 24 months.
  • Infants are to receive a Home Visit with completed Home Assessment and Safe Sleep Health Education at birth to the end of 4 months as measured by timely entry of client data into Cornerstone Data Entry Screen AS01:706 Home Assessment (Assessment), SV01:SSED - Safe Sleep Education (Service Entry) and SV02 (Activity Entry). The content of home visits will be measured through annual electronic chart review during the scheduled review visit. At least 75% of infants are to receive the Home Visit and Safe Sleep Health Education.
  • Referrals are completed based on assessments and care plan as documented on the Cornerstone Data Entry Screen RF01 (Service Provider Selection).

4.3.3 - 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 necessary services such as, but not limited to:

  • Early Intervention (EI) services based on the Developmental Screening
  • WIC services, if not enrolled in the program

will be referred and documented in the Cornerstone System Referral Screen RF01 (Service Provider Selection) with the reason for the referral. A follow-up documentation and status of the referral is required. Clients are to be given a hard copy of the referral.

4.3.4 - 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.

4.3.5 - Cornerstone Workflow Sheets (revised October 2022)

Infant/Child Cornerstone Workflow - Addendum 04.03.05 Infant/Child