Revised October 2019
Case Managers must, at minimum, have a Face-to-Face contact with the client every month they are enrolled in the program. Each Face-to-Face contact should be documented in Cornerstone with the appropriate SV02 activity code.
A minimum of one face-to-face contact must be completed as a home visit every trimester the client is active in the program.
A minimum of one face-to-face contact must be completed during the postpartum period as documented in Cornerstone with the appropriate SV02 activity code.
Best practices are to follow the schedule identified below in the ideal situation a client is enrolled for the full pregnancy:
- Month 1 Face-to-face in clinic
- Month 2 Home visit
- Month 3 Face-to-face in clinic
- Month 4 Face-to- face in clinic
- Month 5 Home visit
- Month 6 Face-to- face in clinic
- Month 7 Face-to- face in clinic
- Month 8 Home Visit
- Month 9 Face-to- face in clinic
- Postpartum Face-to- face in clinic
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 Women enrolled in Better Birth Outcomes.
The following information is to be obtained and documented in Cornerstone as appropriate:
- Completion of the PA07 (Initial Prenatal Data) screen in Cornerstone with provision of the following:
- Estimated Date of Confinement (EDC) Date
- Month when Prenatal Care Began
- Number of Prenatal Medical visits
- Completion of the PA10 (Postpartum Data) screen in Cornerstone with provision of the following at the Postpartum visit:
- Number of Prenatal Medical visits completed
- Birth weight of the baby on PA11 (Birth Data) screen in Cornerstone (with written confirmation, e.g. birth certificate, crib sheet, etc.) If verbal only, enter "9999" in this section, and the appropriate weight should be documented after receipt of proper documentation with birth weight.
Pregnant women enrolled in the program are to receive at minimum the following services:
- 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 (Service Entry).
- Ensure that all women receive the following assessments and education with appropriate education materials provided to clients.
- 707G Presence of = 2 risk factors & identify (if 1 RF, must include MCH Nurse Consultant approval)
- 700: 1-40 General
- 701: Other Service Barrier
- 703: Psychosocial Stress
- 704: Alcohol / Substance Abuse
- 705: Violence
- 706: Home Visiting
- 707D: Women Nutrition
- Education about a Reproductive Life Plan as measured by timely entry of client data into Cornerstone Service Entry Screens: SV01:941 with a hard copy in the client record.
- Prenatal education/preconception & inter-conception health education as measured by timely entry of data into Cornerstone Service Entry Screens: SV01: PEWW through the Well Women education.
- Provision of service or referral for childbirth education SV01:922 or RF01.
- Provision of service or referral to parenting classes SV01:918 or RF01.
- At least one (1) Prenatal Depression Screening completed at =20 weeks of gestation as measured by timely entry of client data into Cornerstone Data Entry Screens: SV01-825 (Service Entry) with SV01-940 Postpartum Depression Brochure given in cases of a score over ten (10) as determined during the Depression Screening.
- 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). 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 or a Case Note (CM04) detailing that verification has been obtained with the Provider.
- Licensed health care workers providing BBO Case Management, prenatal care, and postnatal care to women shall screen new mothers for perinatal mood disorder symptoms at a prenatal check-up visit on or after 20 weeks gestation and at the time of a postnatal check-up in the 42 days postpartum, or provide documentation that screening was completed and confirmed by communication with the Primary Care or Obstetrical Care Provider.
- BBO licensed health care workers providing prenatal and postnatal care to a woman 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.
- In accordance with the Perinatal Mental Health Disorders Prevention and Treatment Act (PMD), all women will receive information on postpartum mood disorders, including the Department's Postpartum Depression brochure and contact information for the Perinatal Depression Hotline.
- 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.
- Delivery of the Department's standardized BBO Health Education Curriculum in its provision of prenatal education to all enrolled women according to the BBO Prenatal Education Curriculum Guide with service codes entered in Cornerstone for all education modules provided.
- Provide a comprehensive needs assessment and have a case management care plan developed within forty-five (45) calendar days of enrollment with appropriate referrals and updated as necessary throughout participation in the BBO program.
- Provide the curriculum on Initiation of Breastfeeding or referral to a lactation specialist as documented in SV01:PEBF or RF01.
- Refer all BBO women and infants born to BBO women who may be income-eligible to the WIC program.
- Refer postpartum women in the Chicago area to the Best Practices in Inter-Conception Health (BPIH) program at the University of Chicago as indicated.
- Communicate directly with the Medicaid Managed Care Organization (MMCO) on behalf of the client to assist in arranging transportation when necessary.
6.3.3 PRENATAL HEALTH EDUCATION CURRICULUM
GUIDELINES FOR USE
While the original curriculum is divided into a series of sessions structured by trimester, the workgroup recommends that case managers should discuss the individual topics based upon the client's knowledge and needs during any given point in time. Client needs should drive the education delivered with all, if not most of the content / topics listed over the course of the potential ten to eleven contacts made with the client. The curriculum should be administered with fidelity based upon client engagement & relationship building using a client centered approach and motivational interviewing techniques. Supporting Materials and Cornerstone Documentation listed below may be repeated for more than one trimester.
Addendum 6.3.3 Better Birth Outcomes Curriculum
6.3.4 CORNERSTONE WORKFLOW SHEETS
6.3.5 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.
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.
The Referral is documented as an initiation of the referral, the update on status of the referral, or the completion or refusal of the referral by the client.
6.3.6 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 quarterly.
- Agencies are expected to assist clients in arranging for client transportation as necessary for prenatal care visits and appointments, visits for specialty medical care and/or other appointments specific to the woman's individual health needs and outlined in the plan of care.
- Agencies must work closely with MMCOs to utilize transportation services provided.
- Transportation costs that are incurred due to inability or lack of availability of MMCO transportation services or for clients not enrolled in Medicaid or a MMCO, may be documented for reimbursement on a monthly basis.
- Agencies are expected to be able to provide proof of attempts to use other means of transportation for clients whenever possible.
- The number of Gas Cards / Public Transportation Tokens purchased for clients should not exceed monthly assigned caseload without prior written approval from the Department.
- Transportation costs may be documented on monthly Periodic Financial Reports (PFRs) for reimbursement if they have been documented in the budget under line item 15 known as the Grant Exclusives Line Item.
- Costs for Transportation may not exceed 10% of the overall grant amount.
"Outreach" means any activity to find and inform potential program clients of available services. The primary objective of outreach activities is to inform potential program clients of available services, eligibility criteria, and method of accessing services (for example, the name, address and phone number of the Agency). This is not to preclude the use of nontraditional methods of outreach that may be necessary to identify potential participants in hard-to-reach populations, such as persons who abuse substances or engage in prostitution. Acceptable Outreach methods are outlined in Section 6.3.9 of the Program Policy Manual.
The primary purposes of outreach are the following:
- Build and maintain strong relationships, including execution of Linkage Agreements, with primary care medical providers, including but not limited to physicians, certified nurse midwives, nurse practitioners, physician assistants, and hospital labor and delivery and emergency room personnel.
- Establishment of a working relationship between the BBO Agency and Medicaid Managed Care Organizations serving women within the Agency's service area, as directed by the Department of Human Services.
Costs for outreach may be documented on monthly PFRs for reimbursement if they have been documented in the approved budget under line item 15 known as the Grant Exclusives Line Item.
Costs for Outreach may not exceed 10% of the overall grant amount.
6.3.9 ALLOWABLE COST FOR OUTREACH AND CASE MANAGEMENT ACTIVITIES
- Costs incurred for outreach activities as defined in section 6.3.8 of the Policy & Procedure Manual are allowed. However, health, general education, or other social service activities may not be included as outreach.
- Salary and other expenses for staff conducting outreach and case management activities must be supported by documentation. Expenses incurred for the provision of any other direct service (including Client teaching) by staff conducting outreach and case management activities must be excluded. If program staff provide other direct services in addition to outreach and case management, the grantee's time and activity reporting system must distinguish between allowable and excluded costs.
- Outreach can include community campaigns such as door-to-door canvassing, production and distribution of handbills, design and publication of newspaper announcements, and production and broadcast of public service announcements or paid advertising on radio or television.
- Outreach efforts can be used to establish and maintain Linkage Agreements with social services agencies and other community-based organizations, including WIC agencies and local Public Health Departments (if the BBO Agency is an FQHC or other community-based organization), for purposes of early identification and referral of potentially eligible pregnant women and for overall coordination of care for enrolled women.
- The Agency is expected to pursue partnerships with various community sectors that can provide additional support and services that enhance outreach efforts.
- The Agency is responsible for identifying more global strategies emphasizing a community-wide approach for all reproductive-age women in the targeted services area with an emphasis on the importance of a healthy lifestyle and habits before, during and after pregnancy; the importance of early prenatal care; and preconception/inter-conception health education.
- Agency will evaluate outreach activities annually for effectiveness
- Appropriate approved billable Outreach includes, but is not limited to
- Printing and distribution costs associated with distribution of pamphlets, brochures, flyers, posters, tear-off info posters & similar printed materials about the case management program.
- Printed materials may be given to local entities such as schools, churches, social service agencies & local area service providers.
- attendance at health fairs promoting contact information and program services, speaking engagements with facilities and their staff as listed above
- Costs associated with the purchase & distribution of the paperback "What to Expect When You're Expecting" to OB-GYN offices to make available to potential pregnant clients with non-removable attached program contact information
- Costs associated with dissemination of information about the program services through channels such as local community news articles, on the local radio station or TV channel
- Outreach expenditures should be concentrated on activities which access and activate eligible clients to BBO program services.
- Written approval must be obtained from the Department for awareness campaigns / promotions, and billboards prior to purchase and/or implementation.
- Raffles are not allowable as a means of outreach.