BMCH Program Briefing Question and Answer

3/2/25

The Illinois Department of Human Services, Office of Family Wellness Program Briefing included an overview of the program changes to maternal and child health programs in FY26. The Q&A addresses inquiry related to the MCH program evolution - BBO Comprehensive (BBO-C), BBO Navigation (BBO-N), High-Risk Family Case Management Pilot (HRFCM), and Chicago Family Connects investments.

  1. Is BBO-C only available outside of Chicago? or could a Chicago based entity apply for this as well?
    • Answer: Better Birth Outcomes - Comprehensive will only be offered outside of the City of Chicago. Agencies within Chicago willing to offer services in Cook County may apply.
  2. Will Winnebago County be required to apply for the 2nd cohort programming?
    • Answer: The 2nd Cohort of the HRFCM Pilot will be offered as a Notice of Funding Opportunity (NOFO) in the Spring of 2025 for any interested applicants. Current providers are not required to apply but are encouraged to do so if they are interested.
  3. Could you go back to your slide where the current FCM is merging with another program?
    • Answer: Please see slides 18 and 20 of presentation.
  4. Will there be any prenatal aspect to Family Connect?
    • Answer: The Family Connects program is an evidenced-based model serving postpartum persons and their infants. There are no plans to add a prenatal component at this time.
  5. Will the APORS program remain the same? / What will this mean for APORS? / How is HRIF and APORS defined with the changes to the program?
    • Answer: The Adverse Pregnancy Outcomes Reporting System (APORS) will not be changed. Infants with an APORS diagnoses will now be referred to the BBO-C provider locally or the Chicago Family Connects program within the City of Chicago.
  6. How will this affect the rural areas of our state?
    • Answer: BBO-C is designed to offer a RN assessment in all counties of the state. For rural areas, this should ensure a RN is available locally when physicians/medical centers may be further away.
  7. What programs will cover non-Chicago Cook County areas and where specifically will they cover?
    • Answer: See slide 22 of presentation.
  8. The name of the program, home visits, and the length of following up with children is changing. Will there be any other requirements that are changing?
    • Answer: Yes, this is a program redesign based on the listening sessions with providers and participants, review of the data and to better align with other programs across State agencies.
  9. Is there an alternative plan for if the new system does not work?
    • Answer: The Department feels this new system will be successful and staff plan to monitor and adjust as needed.

Participation/Programming

  1. Will you define "high risk?" / If there is no medical risk, will the client still be eligible for services? / What will be the patient eligibility criteria for the different programs a part of this new model (BBO Comprehensive & BBO Navigation)? / How will a "High Risk" prenatal client be defined? / What will determine eligibility for services? / Will the BBO-C be for all pregnant and postpartum or will there still be requirements to be part of the program?
    • Answer: A vulnerability index which includes medical and social risk factors will be used to screen families for eligibility.
  2. What is the plan for the current FCM participants? / What should we be saying to current clients that we are enrolling? / When can we expect to see a transition plan for current FCM and BBO patients? / How will the department be guiding grantees on ramping down enrollment and transitioning of current FCM and BBO patients (especially in the City of Chicago where there will not be a Comprehensive BBO model)? / How will the department be guiding grantees on ramping down enrollment and transitioning of current FCM and BBO patients (especially in the City of Chicago where there will not be a Comprehensive BBO model)?  
    • Answer: A communications plan will be developed in the coming months to aid current agencies in transferring/discharging families which should begin in April/May/June.
  3. Roughly 80% of our HRIF/APORS are not eligible for FCM and we do not see them during their pregnancy. We open these families upon newborn discharge from the hospital. Will we continue to see them for 2 years? Will eligibility change? When opening these cases during the next few months, what should we be telling families? Currently, we offer 2 years of follow up. How will the HRIF/APORS program merge with BBO's if we have not opened them during pregnancy? or did you mean the At-Risk infants in FCM will merge with BBO rather than the HRIF infants?
    • Answer: Although currently eligible for up to 2 years after birth, the average length of time clients choose to stay enrolled in the program is currently 6 months or less. For FY26, dyads will be offered services throughout pregnancy and up to 6 months after birth. Dyads requesting support after this time may be served on a case-by-case basis with pre-approval from the Department.
  4. If the nurse determines medical risk on the first assessment, will subsequent visits be required by a nurse vs a CHS? How often will medical assessments be required? /How many visits per client and how many of them will be medical assessments. / Will there be a minimum number of visits in BBO comprehensive?
    • Answer: Providers will be expected to use professional judgement to determine who and how often, subsequent visits should be completed after the first assessment. This should be based on clinical need and with input from the family.
  5. What entity will act a coordinating entity?
    • Answer: Agencies will be asked to work together to support families. Those engaged with BBO-N prenatally would learn about Family Connects to prepare them for contact from that program after delivery. If a family accepts Family Connects the staff from that program should engage with the BBO-N provider following their assessment to ensure continuity of care.
  6. How will the BBO navigators "find" the pregnant people?
    • Answer: BBO-N cases can be identified prenatally through partnerships with FQHCs, WIC, MIECHV etc. The Chicago Family Connects program can assist with referrals of the dyad in the postnatal period.
  7. What will be the method of information sharing between the BBO navigators, Family Connects and MCO navigators be?
    • Answer: At this time there is not a plan for a shared data system for these groups thus traditional communications will be needed- phone, fax etc. ensuring confidentiality of participant information.
  8. What will the role of MCO's be with BBO navigators?
    • Answer: Agencies are expected to coordinate with MCOs and assist clients in awareness and access to services provided through their MCO.
  9. Will we still receive a case finding list?
    • Answer: It isn't clear yet if/when a case finding list will be available but is certainly a goal. In the meantime, BBO-C cases can be identified through partnerships with FQHCs, WIC, MIECHV etc.
  10. We appreciate the flexibility provided by the new model, if BBO Navigation organizations were interested in retaining a component of home visits for some patients would that be feasible?
    • Answer: Home Visits are not required in BBO-N but may be done if client requests a home-visit.
  11. Will Cornerstone still be used and where will referrals come from? / Does IDHS plan to continue using Cornerstone for documentation?  
    • Answer: No final decisions have been made, but IDHS notes feedback shared about the aging platform and is exploring viability of transitioning out of using it for the new programs.
  12. What is the requirement for collaboration between BBO Navigation, Family Connects, and the high-risk pilot in the City?
    • Answer: All agencies are expected to coordinate with MCOs and assist clients in awareness and access to services provided through their MCO. Agencies will be asked to work together to support families. BBO-N staff should educate pregnant persons about Family Connects to prepare them for contact from that program if they will be delivering at a participating hospital. If a family accepts Family Connects the staff from that program should engage with the BBO-N provider following their assessment to ensure continuity of care. The HRFCM staff should be communicating with BBO-N and Family Connects Teams.
  13. We greatly appreciate the flexibility emphasized in the new model to allow us to meet patient needs. What will be the flex components of each program?
    • Answer: Details of the program will be provided in the NOFO. Generally speaking, the new programs are expected to be more participant centered with the program staff and family deciding the frequency of visits, where visits take place and when program services should end.
  14. Will there be transportation funding for BBO-C where MCO's are not effective?
    • Answer: No. Providers are expected to help clients access the transportation benefits through their MCO. DHS will be working with HFS to ensure this is effective.
  15. Will our caseload increase since under the new changes the program follows children for up to 6 months? A lot of current participants in the past 6 months will be terminated.
    • Answer: Children will not be served in this new model. Pregnant persons, postpartum persons and infants up to 6 months of age will make up the majority if the caseload with allowances to continue engagement with some dyads on a case-by-case basis.
  16. Will required contacts change from current requirement (1 face to face per trimester, 3 total for pregnant)? And how often will staff have to see infants for the 6 months' timeframe?
    • Answer: Yes, this is a program redesign. The NOFO will provide details on the performance measures and program deliverables.
  17. Pregnant clients are going from having BBO Intensive Prenatal Case Management to what?
    • Answer: The High-Risk Family Case Management pilots will provide intensive prenatal services where they are offered. Downstate the BBO-C program will be providing prenatal services. Within the City of Chicago BBO-N staff will be engaging to ensure the pregnant person is accessing needed services including a medical home.
  18. Will you still keep track of Face-to-face contacts, ASQ, depression screenings, well child visits, prenatal visits, --in relations to the Quarterly Report?
    • Answer: Providers will be asked to keep track of participant contacts. The NOFO will provide details on the performance measures and program deliverables.

Staffing/Training

  1. Will we get reimbursed for individuals such as a Community Health worker with the new system setup? Or only for the nurse?
    • Answer: A multi-disciplinary team may work in BBO-C as long as a nurse completes the initial assessment.
  2. Since caseload will be capped, is it possible for a nurse to do the initial assessment and a community health specialist (CHS) to do all subsequent visits? Will there be a cap to each nurse's caseload or to the agency's overall caseload? / What will caseload numbers be and how will they be determined? Will it be per nurse? Per agency?
    • Answer: Yes, a multi-disciplinary team is encouraged. The RN caseload will have a range including a maximum of dyads to be served.
  3. Will there be any educational requirements for nurses? BSN? AD? LPN?
    • Answer: Active unencumbered IL Professional Registered Nursing License or Advanced Practice Nursing License
  4. For BBO Navigation what is the staffing education/ credential requirements for the CHW role? / What are the training/ credential requirements for staff on navigation grant?
    • Answer: For BBO-N the navigator staff do not have to be CHWs. Staff working in BBO-N will be expected to have a bachelor's degree, preferably in a health-related field, or be certified as a Community Health Worker (CHW) with a maternal child health focus.
  5. Will there be a standard curriculum for BBO-C?
    • Answer: A resource guide will be provided, but services are expected to be tailored to meet the needs of the family.
  6. Will there be special training to do for those of us that have only been FCM?
    • Answer: Yes, training will be offered closer to July after Notices of Award are released.
  7. What are the credentials and ratios for BBO Navigation? What qualifies BBO Navigators to have the title of case manager?
    • Answer: BBO Navigators will be expected to have a bachelor's degree, preferably in a health-related field, or be certified as a Community Health Worker (CHW) with a maternal child health focus. There are no plans to set a staff to participant ratio for Navigators. BBO Navigators will not have the title of case manager, they will be navigators.
  8. Can we have an updated guide to this new system?
    • Answer: Training materials, policies etc. will all be provided.
  9. Will the Regional Meetings continue and who will attend: BBO-Navigation, High Risk Infant, and Family Connect?
    • Answer: DHS intends to hold quarterly MCH meetings throughout SFY26.
  10. Do you have a plan to support displaced workers, as a result of cutting prenatal care services?
    • Answer: The Department does not consider this to be a cut in prenatal services but rather a shift in the service delivery model based on input from the field, data and knowledge of other programs offered within the State. The new program design is flexible and in and of itself should not result in worker displacement.

Funding/Caseload/Data

  1. How is this being balanced with the potential Medicaid cuts we are all concerned about? / Is there a contingency plan for Medicaid changes?
    • Answer: Questions regarding Medicaid are best answered by HFS as this is not an area that the Bureau of Maternal and Child Health oversees.
  2. What will caseload numbers be and how will they be determined? Will it be per nurse? Per agency?
    • Answer: Funding and caseload will be assigned to geographic areas with consideration for current numbers served and available birth data and the staffing needed as well as the total funding available.
  3. Do you have anticipated funding availability in each of the options? Particularly for BBO-N or BBO-C / What is the current to future caseload comparison by funding stream and geography?
    • Answer: See slide 23 for percentage estimates. We do not have further detailed information at this time.
  4. How many BBO Comprehensive grantees will there be per geographic region?
    • Answer: At this time, it is expected to have 1 BBO-C grantee per county. For heavily populated areas a grantee may choose to subcontract portions of the work.
  5. How does data capture and reporting get streamlined/ improved through this new model?
    • Answer: Data reports will be developed. Streamlining is a priority as the focus shifts to a more family centered model.
  6. Will current grantees past performance impact their eligibility for these new funding opportunities?
    • Answer: Notice of Funding Opportunities require interested applicants to draft a narrative portion, where applicants will answer questions specific to the proposal and generally share some history of the organization and its capacity to do the work being funded.
  7. How many grants will be offered? Will there be more than one? How much will the grants be?
    • Answer: We anticipate offering more than one BBO-N grant for the City of Chicago. At this time, it is expected to have 1 BBO-C grantee per county. For heavily populated areas a grantee may choose to subcontract portions of the work. Regarding funding, see slide 23 for percentage estimates. We do not currently have further detailed information.
  8. How does the High-Risk Infant follow-up program play into the budget for FCM/BBO agencies that cover these target areas?
    • Answer: In the City of Chicago high risk infants will be enrolled in Chicago Family Connects. In Cook County and the rest of the state the BBO-C program will serve infants with an APORS diagnosis.
  9. How many days of access are envisioned in the programs in the new system?
    • Answer: Families will on average be in the program for 6 months and staff will work with the family to determine the number of contacts per week/month needed to meet their specific needs.

Questions Specific to the HRFCM Pilot and Chicago Family Connects

Chicago Family Connects

  1. What data can you share about family connects?
  2. Can you share and overview of the demographics and risk factors of the Family Connects population?
  3. Is the Family Connect Program going to have any prenatal component in this new model? If not, how will the program be building trust with patients to get them to agree to home visits at time of delivery?
  4. What will the referral reporting and outcomes look like for the Family Connect component? What will be the closed loop process for collaborating agencies?  
    • Is there data showing they reach the patients intended? Our experience is that the approach at time of delivery does not allow for the trust needed to agree to home visits.
    • Answer: Questions specific to the Chicago Family Connects program should be directed to Chicago Department of Public Health. General Information regarding Chicago Family Connects can be found here: https://www.chicago.gov/city/en/sites/onechifam/home/family-wellness/family-connects.html
  6. Can Family Connects curriculum/handouts be shared to model after?

High Risk Family Case Management

  1. How will we learn about the outcome of the pilot - prior presentation had noted they would be shared?
    • Answer: The Department is looking into sharing some learnings from the HRFCM pilot in the coming months. Services began in December 2024.
  2. What have been the successes of the HRFCM pilot sites thus far? What type of reporting can we expect? Our understanding was that there was a commitment to transparency around the performance of the pilot and how it informs future programming.
    • Answer: The Department is looking into sharing some learnings from the HRFCM pilot in the coming months. Services began in December 2024.
  3. What MIS is being used in the HRFCM Pilot?
    • Answer: Each pilot is filling in an Excel provided by Program to capture the basic information. More detailed info may be entered into the agencies' local EMRs or MIS.
  4. What is the Chicago community areas (5-6) HRFCM current case load? And what is the impact so far?
    • Answer: The assigned caseload for the HRFCM pilot in Chicago is: 450 dyads. The Program officially launched with grant execution on December 1, 2024. Participant impact information is not yet available.