4.3 Content

Revised October 2019

4.3.1 FREQUENCY

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 follow-up nurse at the following intervals for all clients:

  1. within fourteen (14) business days of newborn hospital discharge,
  2. a 4-month visit (between chronological months 2 - 5),
  3. a 6-month visit (between chronological months 6 - 9),
  4. a 12-month visit (between chronological months 10 - 15),
  5. a 18-month visit (between chronological months 16 - 21),
  6. a 24-month visit (between chronological months 22 - 25).

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 in months 2 - 4 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 case manager. The nurse should document evidence of contact and location on the SV02 screen in Cornerstone for each contact.

4.3.2 PROCESS

Physical Assessment - to be completed by a registered nurse. The physical assessment will be documented in Cornerstone: AS01:708, questions 27-52. Each physical assessment should be documented by the nurse in the SV02 Cornerstone screen. A Maternal Child Health Nurse (MCH) will review documentation of physical assessments during program review.

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

  • General Assessment (AS01:700),
  • Other Barriers (AS01:701),
  • Nutrition Assessment (AS01:708) Q81 if WIC active or Q 81-90 if not WIC active,
  • Home Assessment (AS01:706).

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

Developmental Assessments are to be completed by a registered nurse who has training in administering any of the Department of Healthcare and Family Services (HFS) approved developmental assessment tools. A developmental assessment will be completed at the 6-month visit and again at 12-, 18- and 24-month visits. The nurse shall document these developmental assessments in Cornerstone on the SV01:824 screen and a hard copy of the screening tool used will be placed in the client's file/record. Additional assessments may be completed and documented as necessary.

The purpose of the Primary Care Physician (PCP) Notification form (Addendum) 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:

  • 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 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 within the first 12 months of life utilizing a standardized screening tool.
  • Ensure children in DCFS custody who are eligible for HRIF receive HRIF and are referred back to HWIL once they are no longer eligible for HRIF.
  • Ensure that all children receive a Well Child /EPSDT Exams at minimum at the 4, 6, 12, 18- and 24-month visits and document these visits in Cornerstone Data Entry screens SV01:806.
  • Initial Face-to-Face contact with infants (0-12 months) is to be made within fourteen (14) days of APORS referral as measured through chart review of the printed Infant Discharge Record (IDR) and the Cornerstone entry of SV02.
  • Subsequent Face-to-Face Visits with age-based assessments are to be completed at 2-5 months, 6-9 months, 10-15 months, 16-21 months, and 22-25 months as measured by daily entry of client data into Cornerstone Data Entry Screen SV02.
  • Infants are to receive a completed Home Visit and SIDS education at age 2 - 4 months as measured by AS01:706 Assessment, SV01:SSED and SV02. The content of home visits will be measured through annual electronic chart review during the scheduled review visit.
  • Completion of Immunization Education based on current CDC Guidelines as documented in Cornerstone Data Entry Screen SV01:IMED at each Face-to-Face contact.
  • Referrals are completed based on assessments and care plan as documented on the Cornerstone system referral screens (RF01).

4.3.3 REFERRAL AND ADVOCACY

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) 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.

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

Infant/Child Cornerstone Workflow