5.3 - Content

5.3.1 - Frequency

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.

  • minimum of one face-to-face contact must be completed as a home visit every trimester the client is active in the program.
  • 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

5.3.2 - Process (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 Better Birth Outcomes up to the 42 postpartum days.

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 Began (i.e., month of pregnancy and not calendar month)
    3. Number of Prenatal Medical visits
  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

Pregnant individuals enrolled in the program up to 42 postpartum calendar days 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 (Service Entry).
  2. Ensure that all enrolled individuals receive the following assessments and education with appropriate education materials provided to clients.
    1. 707G Presence of = 2 risk factors & identify (if 1 RF, must include MCH Nurse Consultant approval)
    2. 700: 1-40 General
    3. 701: Other Service Barrier
    4. 703: Psychosocial Stress
    5. 704: Alcohol / Substance Abuse
    6. 705: Violence
    7. 706: Home Visiting
  3. Education about a Reproductive Well Being during pregnancy as measured by timely entry of client data into Cornerstone Service Entry Screens: SV01:941 with a hard copy in the client record.
  4. Education about Reproductive Well Being within 42 postpartum days as measured by timely entry of client data intro Cornerstone Service Entry: SV01:942 with a hard copy in the client record.
  5. At least one (1) Prenatal Depression Screening completed on or greater than 20 weeks of gestation and one (1) within 42 postpartum calendar days 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 accordance with the Perinatal Mental Health Disorders Prevention and Treatment Act (PMD).
    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). 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.
    2. Licensed health care workers providing BBO Case Management, prenatal care, and postnatal care to individuals shall screen new gestational parents 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.
    3. BBO 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 individuals will receive information on postpartum mood disorders, including the Department's Postpartum Depression brochure and contact information for the Perinatal Depression Hotline.
  6. 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.
    1. Delivery of the Department's standardized BBO Curriculum in its provision of prenatal education to all enrolled individuals according to the BBO Curriculum Guide with service codes entered in Cornerstone for all education modules provided.
  7.  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.
  8. Provide the curriculum on Initiation of Breastfeeding or referral to a lactation specialist as documented in SV01: PEBF or RF01.
  9. Refer all BBO individuals and infants born to BBO individuals who may be income-eligible to the WIC program.
  10. Communicate directly with the Medicaid Managed Care Organization (MMCO) on behalf of the client to assist in arranging transportation when necessary.
  11. Ensure the documentation of the postpartum medical follow-up as documented in SV01: 820 (Service Entry), with recommendation of providing a hard copy of the (AWHONN) 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.
  1. Education about a Reproductive Life Plan during pregnancy as measured by timely entry of client data into Cornerstone Service Entry Screens: SV01:941 with a hard copy in the client record.
  2. Education about Reproductive Life Plan within 42 postpartum days as measured by timely entry of client data intro Cornerstone Service Entry: SV01:942 with a hard copy in the client record.
  3. Prenatal education/preconception & inter-conception health education during pregnancy and within 42 postpartum days as measured by timely entry of data into Cornerstone Service Entry Screens: SV01: PEWW through the Well Women education.
  4. Provision of service or referral for childbirth education SV01:922 or RF01.
  5. Provision of service or referral to parenting classes SV01:918 or RF01.
  6. At least one (1) Prenatal Depression Screening completed on or greater than 20 weeks of gestation and one (1) within 42 postpartum calendar days 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 accordance with the Perinatal Mental Health Disorders Prevention and Treatment Act (PMD).

5.3.3 - Better Birth Outcomes Curriculum (revised October 2022)

GUIDELINES FOR USE

While the original curriculum is divided into a series of sessions structured by trimester, the Department 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 most, if not all 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, and the required documentation into the Cornerstone system on every face to face. Supporting Materials and Cornerstone Documentation listed below may be repeated for more than one trimester.

Addendum 5.3.3 Better Birth Outcomes Curriculum

5.3.4 - Cornerstone Workflow Sheets (revised October 2022)

Pregnant Cornerstone Workflow - Addendum 05.03.04 BBO Pregnant

Postpartum Cornerstone Workflow - Addendum 05.03.04 BBO Postpartum

5.3.5 - 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 (Service Provider Selection) 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.

5.3.6 - 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.