Chapter 16 Healthy Families Illinois (HFI)

16.0 INTRODUCTION
16.1 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR ADULT PARTICIPANT (HFIE, HFCO, HFIP, HFI1, HFI2, HFI3, HFI4, HFSS, SUSP, G)
16.2 IF A SUCCESSFUL HOME VISIT HAS OCCURRED FOR A PREGNANT WOMAN:
16.3 IF A SUCCESSFUL HOME VISIT HAS OCCURRED FOR A GUARDIAN
16.4 IF A SUCCESSFUL HOME VISIT HAS NOT OCCURRED FOR EITHER A PREGNANT WOMAN OR A GUARDIAN
16.5 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR INFANT OR CHILD PARTICIPANT (I, C)
16.6 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR TERMINATION (Pregnant Mother, Guardian, Infant/Child)

16.0 INTRODUCTION

When serving a family in HFI, most information is tracked under the adult participant who has been designated as the Group Head. Information specific to the infant or child, such as immunizations and well child visits, is tracked under the child participant.

The Healthy Families Illinois chapter is organized in the following manner:

Section 16.1 describes the screens used for adults (pregnant women and guardians)
Section 16.2 describes the screens used for pregnant women with successful home visits
Section 16.3 describes the screens used for guardians with successful home visits
Section 16.4 describes the screens used for pregnant women and guardians with unsuccessful home visits
Section 16.5 describes the screens used for infants and children
Section 16.6 describes the screens used for termination (pregnant woman, guardians, infants and children)

16.1 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR ADULT PARTICIPANT (HFIE, HFCO, HFIP, HFI1, HFI2, HFI3, HFI4, HFSS, SUSP, G)

Please refer to the following screen flows displayed in Appendix A:

"Cornerstone HFI Screen Flow - Pregnant Woman (HFI(A))"
"Cornerstone HFI Screen Flow - Guardian of Infant or Child (HFI(B))"

Recording information in Cornerstone for an adult participant in HFI involves the use of several screens for recording demographic information and the initial assessment, and several screens for recording family support activities and outcome data.

The following screens are used to record demographic information and the initial assessment for an adult participant:

The Participant Look-up (PA01) screen is used to ensure that information about the participant is entered in Cornerstone under only one statewide identification number.
The Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant after the Participant Look-up Screen (PA01)has been utilized.
The Participant Enrollment (PA03) screen is used to assign a statewide identification number and to record demographic information.
The Assessment (AS07) screen is utilized to conduct an abbreviated assessment of new and expectant parent's risk for child abuse and/or neglect.
The Activity Entry (SV02) screen is used to record the occurrence of the assessment.
Case Notes (CM04) may be used by the Family Assessment Worker to record additional information about the assessment interview.

Local HFI projects may record information in Cornerstone about every assessment conducted by the Family Assessment Worker. At a minimum, assessment information must be recorded for every participant who becomes an "active case" (i.e., each family who accepts HFI services and receives at least one home visit for family support).

Following entry of the demographic information and the initial assessment, the following screens are used to enroll an adult participant in HFI. These screens should be completed when the participant agrees to accept HFI services:

The Program Information (PA15) screen is used to identify the participant as actively receiving HFI services and to assign the family (the Group Head) to a level of service intensity. Participants should be categorized as HFIE - HFI Enrollment until a successful home visit has occurred. At that point, the HFIE record should be terminated and a new PA15 record added with the appropriate category (HFIP, HFI1, HFI2, HFI3, HFI4, HFSS, G).
The Participant Group Relationships (PA06) screen is used to link individual participant records into a family group.
The Household Members (PA16) screen is used to record a minimal amount of information about other family or household members who are not directly participating in HFI.
The Caseload Reassignment (AD17) screen is used to assign a Family Support Worker to the family. This screen is also used to change a family's Family Support Worker.
The Activity Entry (SV02) screen is used to record creative outreach activities (activity code "132").
The Participant Goals (CM02) screen is used to identify "strengthen parent-child bond" as a care plan goal.
The Planned Services (CM03) screen is used to identify HFI services as the strategy for strengthening family functioning.
Reports can be utilized as needed.

After a family has agreed to accept HFI services, the following screens are used to record on-going family support (home visiting) activities:

The Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant.
The Program Information (PA15) screen is used to change a family's level of service intensity.
The Activity Entry (SV02) screen is used to record the occurrence of each home visit or other type of contact with an active participant (activity code "130").
The Case Notes (CM04) screen may be used by the Family Support Worker to record additional information about each contact with the participant.

The following screens are used to record information on the beginning and end of pregnancy for women who participate in HFI while pregnant:

The Initial Prenatal Visit (PA07) and the Postpartum Data (PA10) medical screens are used to record the beginning and end of pregnancy.

The following is information on the entry of data into the Cornerstone system for an adult participant in HFI.

SEQUENCE OF SCREENS

When fast path keys are not available at the bottom of the screen, easy access to various screens is available by pressing the CTRL and F9 keys simultaneously. Please refer to Chapter 2 "System Environment" under "2.4.3 Other Features" for more information.

PARTICIPANT LOOK-UP (PA01)

Prior to registration into the Cornerstone system, the Participant Look-up is used to verify the existence of a participant ID number by searching the Master Index to find a participant who may have previously been enrolled in Cornerstone.

The screen is used to copy minimal demographic information on a participant who is already enrolled in the Cornerstone system to the local computer files. A "copy-in" of this data is necessary prior to performing a shared data Wide Area Network (WAN) look-up.

Use of the Participant Look-up reduces duplicate entry of participants. For this reason, the Participant Look-up must be performed before a new participant can be enrolled into the Cornerstone system.

Please refer to Chapter 3 "Participant Screens" under "3.1 Participant Look-up (PA01)" for more information.

For information about resolving duplicate participants in Cornerstone, please refer to Chapter 3 "Participant Screens" under "3.21 Participant Duplicate Browse (PA21)."

PARTICIPANT PROFILE (PA02) OR INQUIRE BY PARTICIPANT NAME/SSN (PA20)

After utilizing the Participant Look-up (PA01) screen, the Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant.

For more information about the Participant Profile (PA02) or Inquire by Participant Name/SSN (PA20) screens, please refer to Chapter 3 "Participant Screens" under "3.2 Participant Profile (PA02)" or "3.20 Inquire by Participant Name/SSN (PA20)."

PARTICIPANT ENROLLMENT (PA03) - add/edit Address as needed

This screen is used to enroll a new participant into the Cornerstone system and to capture demographic information for a new participant. If the participant is already enrolled in Cornerstone, this screen is used to view and update demographic information.

The Participant Enrollment (PA03) screen is completed only once for each person participating in Cornerstone programs, but can be edited thereafter. Participants may be made active in several programs from the same enrollment record.

The processing within this screen includes checking for duplicate enrollment; assigning a unique, permanent statewide participant ID number (when enrolling a participant for the first time in the Cornerstone system); assessing potential eligibility for Cornerstone programs; and recording a participant's date of death.

The user then selects the Wide Area Network (WAN) look-up by pressing the F2 shared data key. This will copy-in and add to the local data any additional information found in the statewide search of the participant look-up function.

NOTE: The WAN should be reviewed on a regular basis in order to obtain the most current participant information.

From this screen, the "Address" pop-up window is used to record address and telephone information by pressing F9.

Please refer to Chapter 3 "Participant Screens" under "3.3 Participant Enrollment (PA03)" for more information.

ASSESSMENT (AS07)

This screen is used for the abbreviated assessment of new and expectant parent's risk for child abuse and/or neglect; it is not completed for a successful Home Visit. This screen is used to record an initial assessment. The Assessment (AS07) screen is a feature of the Cornerstone system that is available for the use of all program areas.

Please refer to Chapter 7 "Assessment Screens" under "7.7 Healthy Families Illinois Eligibility Tool (AS07)" for more information.

NOTE: The user must be enrolled into the Cornerstone system in order use this assessment screen.

ACTIVITY ENTRY (SV02) - participant related

The following activity code is used to record the occurrence of the assessment:

131 - HFI Assessment

Please refer to Chapter 4 "Service/Activity Screens" under "4.2 Activity Entry (SV02)" for more information.

CASE NOTES (CM04)

This screen is optional and may be used at any time. This screen is used to enter and view case notes for participants that are related to an assessment or family support activity. Specifically, it is used to document the Family Assessment Worker's (FAW's) activities during the initial assessment and the Family Support Worker's (FSW's) activities during creative outreach and family support services.

This screen is available for use in all Cornerstone programs. Case notes are available to other users in the local agency who have security access to this screen, unless the note is marked confidential. If marked "confidential", only the user who entered the case note and their supervisor will be able to view the notes.

The case notes must be written in a clear and focused manner. Notes are free-form and may be used to record information about the activity conducted with the family. There is no limit to the number of notes that may be entered.

NOTE: Once case notes have been saved they can not be edited or deleted. If errors occur, new case notes must be entered in order to correct the errors.

Please refer to Chapter 6 "Case Management Screens" under "6.4 Case Notes (CM04)" for more information.

Following entry of the demographic information and the initial assessment, the following screens are used to enroll an adult participant. These screens should be completed when the participant agrees to accept HFI services

PROGRAM INFORMATION (PA15)

This screen is completed at the time of enrollment, to change the family's level of service intensity, and at case closure.

Each active family in HFI must be assigned to one of the following category codes for HFI levels of service intensity. This is done by assigning the Group Head to one of the following categories:

HFIE - HFI ENROLLMENT - Participants should be categorized as HFIE - HFI Enrollment until a successful home visit has occurred. At that point, the HFIE record should be terminated and a new PA15 record added with the appropriate category (HFIP, HFI1, HFI2, HFI3, HFI4, HFSS, G). Families may not remain in the HFI Enrollment category longer than three consecutive months.
HFCO - HFI CREATIVE OUTREACH - This code is to be used for families who were previously engaged in the program but are now the recipients of outreach efforts. Families may not remain on Creative Outreach status for longer than three consecutive months.
SUSP - HFI SUSPENSION - This category will allow programs to temporarily suspend participants when services must be interrupted because the family will not be available for a specified period of time. The suspension period should be more than one month but not exceed three consecutive months. Suspended participants will be considered Eligible but not Active and their case will have no weighted value. Participants assigned to this category will be automatically terminated after three consecutive months in suspension (participants may only be suspended for three months in any twelve month period).

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.1 General Information and Enrollment" for more information.

PARTICIPANT GROUP RELATIONSHIPS (PA06)

This screen is to be completed at the time of enrollment. This screen is used to establish and display group relationships among Cornerstone participants in the Cornerstone system.

To establish a group, all participants must be enrolled in the Cornerstone system (i.e., must have had the Participant Enrollment (PA03) screen completed).

The screen is used to add, update, end, or delete group relationships. The screen establishes family linkages necessary for HFI program reporting in order for the reports to accurately count families.

NOTES:

The Group Head must be classified in one of the seven HFI level categories (HFCO, HFI Levels 1 through 4, HFIP or HFSS).
The program staff may use their best judgment as to who should be the Group Head. It is typically the mother or the family member with whom the agency will have the most ongoing contact.
All active infants and children must be grouped with an adult participant who is classified in an HFI level category. An infant or child can not be a Group Head.
If a family has an older child (a child who is too old to be eligible for HFI) at the time the family is first accessed for HFI, the child should be identified as a household member, rather than as a member of the group. Additional children who are born to an active family (i.e., woman and child who have been accepting services) should be included as group members.
The immunization status and use of well child care will be measured for children who are included in the Cornerstone group, but not for household members.

Please refer to Chapter 3 "Participant Screens" under "3.6 Participant Group Relationships (PA06)" for more information.

HOUSEHOLD MEMBERS (PA16)

This screen is completed at the time of enrollment and is used to associate other household members with the Group Head. This screen is not required.

This screen is used to record the names and relationships of other members of the participant's household. This links household members who are not enrolled in Cornerstone to an existing participant. These household members need not be biologically or legally related to the participant. The screen should not be used to enter into a household those individuals who have been linked through a group relationship.

Please refer to Chapter 3 "Participant Screens" under "3.16 Household Members (PA16)" for more information.

CASELOAD REASSIGNMENT (AD17)

The Caseload Reassignment (AD17) screen is used to assign the Group Head to a Family Support Worker. Other members of the group will be automatically assigned to the Family Support Worker at the same time. This screen is also used to change a family's Family Support Worker.

Please refer to Chapter 9 "Administrative Screens" under "9.17 Caseload Reassignment (AD17)" for more information.

16.2 IF A SUCCESSFUL HOME VISIT HAS OCCURRED FOR A PREGNANT WOMAN:

Please refer to the following screen flows displayed in Appendix A:

Cornerstone HFI Screen Flow - Pregnant Woman - Successful Home Visit - HFI(A - 1)

SEQUENCE OF SCREENS

ACTIVITY ENTRY (SV02) - participant related

The Activity Entry (SV02) screen is used to record the occurrence of each home visit or other type of contact with an active participant. These activity records should be entered under the Group Head's participant ID number.

130 - Family Support

Please refer to Chapter 4 "Service/Activity Screens" under "4.2 Activity Entry (SV02)" for more information.

PARTICIPANT PROGRAM (PA15)

This screen is completed at the time of enrollment, to change the family's level of service intensity, and at case closure.

F6 Edit and terminate the current HFIE - HFI Enrollment record with a Termination Reason of "55 - Active in HFI". F5 Add a NEW PA15 record with one of the following category codes for HFI levels of service intensity. This is done by assigning the Group Head to one of the following categories:

HFCO - HFI CREATIVE OUTREACH - This code is to be used for families who were previously engaged in the program but are now the recipients of outreach efforts. Families may not remain on Creative Outreach status for longer than three consecutive months.
HFI1 - HFI LEVEL 1 - This code is to be used when the service intensity level calls for weekly home visits.
HFI2 - HFI LEVEL 2 - This code is to be used when the service intensity level calls for bi-weekly home visits.
HFI3 - HFI LEVEL 3 - This code is to be used when the service intensity level calls for monthly home visits.
HFI4 - HFI LEVEL 4 - This code is to be used when the service intensity level calls for quarterly home visits.
HFIP - HFI PRENATAL - This code is to be used during the prenatal period. Individual programs' practices may vary in terms of when in pregnancy families are enrolled and how frequently they are visited. Families at this level, however, should receive a minimum of two home visits per month.
NOTE: If a woman who has been a Group Head becomes pregnant, users should "keep" or select the category code that reflects the level of service intensity that the family requires. Example: If the family was at level HFI1 when the Group Head became pregnant, it would not be necessary to change the category code to HFIP solely because the participant is pregnant. Instead, the family should be left at level HFI1 until their progress warrants changing the level of service intensity.
HFSS - HFI SPECIAL SERVICES - This code may be used when service intensity calls for more than one home visit per week.
SUSP - HFI SUSPENSION - This category will allow programs to temporarily suspend participants when services must be interrupted because the family will not be available for a specified period of time. The suspension period should be more than one month but not exceed three consecutive months. Suspended participants will be considered eligible but not active and their case will have no weighted value. Participants assigned to this category will be automatically terminated after three consecutive months in suspension (participants may only be suspended for three months in any twelve month period).
OVFL - HFI OVERFLOW - This code is used to store demographic information on Group Heads who have been referred to the HFI program but cannot be served because the program is at full capacity. Group Heads activated in the OVFL category will remain "eligible" for HFI in Cornerstone until their OVFL program record is terminated locally. (NOTE: Group Heads assigned to the OVFL category will not be considered active in HFI.) Group Heads should be terminated from the OVFL category on the Program Information (PA15) screen when either the family is being enrolled/activated in HFI or the participant is no longer eligible for HFI. The following Termination Reasons have been developed for use with the OVFL category:

54 - NOT ELIG FOR ENROLLMENT IN HFI

55 - TERM OVFL - ALLOW ACTIVE IN HFI

More than 1 guardian can be enrolled in a group (i.e. both parents can be enrolled as guardians, as well as other individuals who care for the child). All assessment data must be entered under the correct participant ID.

Participant category "G" is not limited to a child's legal guardian.

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.1 General Information and Enrollment" for more information.

Medical Screens

The following screens are used to record information on the beginning and end of pregnancy for women who participate in HFI while pregnant:

No medical screens are completed for Guardians ("G" category code). Medical screens are completed only if a woman is active in Healthy Families Illinois during her pregnancy.

By the end of the quarter that a baby is born, the Family Support Worker (FSW) should ask if the mother has ever breastfed her baby. If she tried (even if it was only once in the hospital), the FSW should enter code '935 - Breastfeeding Initiation' on the Service Entry (SV01) screen. Please refer to Chapter 4 "Service/Activity screens" under "4.1 Service Entry (SV01)" for more information.

The appropriate medical screens may be completed as needed. Because the medical screens are not program specific, they already may have been completed for the participant through another program in the agency and do not need to be done again.

The Initial Prenatal Data (PA07) screen is the screen that will be completed near the beginning of pregnancy. The Postpartum Data (PA10) screen will be completed after the woman has delivered her child. The required medical screens for pregnant women in these programs are:

PA07 Initial Prenatal Data
PA10 Postpartum Data

INITIAL PRENATAL DATA (PA07)

This screen is used to add, update, or inquire about a participant's prenatal health visit information. This screen must be completed for all pregnant women. Only one record per pregnancy may be entered. If the Initial Prenatal Data screen (PA07) has already been completed for the current pregnancy, no future work on this screen is necessary.

NOTE: HFI is only required to record the pre-pregnancy weight, EDC date, and complete the smoke/drink questions.

Please refer to Chapter 3 "Participant Screens" under "3.7 Initial Prenatal Data (PA07)" for more information.

ASSESSMENT (AS01)

This screen is used for the initial assessment; it is not completed for infants or children. This screen is used to record the results of the Family Stress Checklist. The Assessment (AS01) screen is a feature of the Cornerstone system that is available for the use of all program areas.

Please refer to Chapter 7 "Assessment Screens" under "7.1 Assessment (AS01)" for more information.

The following assessment is required for an adult participant in HFI:

FSC - Family Stress Checklist - Questions 1-11

NOTE: Assessment screens are associated with an individual participant. When two adults (both parents) participate in the assessment, a participant enrollment record should be created for each person and their assessment scores should be recorded separately.

NOTE: The user must enter the total assessment score. Cornerstone does not automatically add their sub-scale scores to calculate the total score.

PARTICIPANT GOALS (CM02) - (Edit as needed)

This screen displays system-generated goals selected for the care plan, as well as a status and priority for each goal. The goals are generated as a result of the answers to assessment questions. The goals should be used as a guide in formulating the participant's individual care plan.

Goals may be added or changed from the standard list of goals, and the user may update goal detail information. Goals should not be deleted, per program policy. All goals should be addressed.

FSC (Family Stress Checklist) total score of 25 or greater for a participant will automatically select "Strengthen Parent-Child Bond" as the care plan goal in HFI. Most Cornerstone care plan goals pertain to service coordination rather than parent/child interaction. Goals related to the development of parenting skills should be recorded manually (on paper) in the family's service plan.
minimum of one goal must be generated or developed for each participant. If all assessment questions were answered with the "norm," then no goals or services will be system-generated; therefore, the user will have to develop a goal.

Please refer to Chapter 6 "Case Management Screens" under "6.2 Participant Goals (CM02)" for steps on how to develop a goal and for more information.

PLANNED SERVICES/CARE PLAN (CM03)

This screen displays system-generated services that are appropriate to the achievement of participant goals. As with goals, planned services are generated as a result of answers to assessment questions. Specifically, the screen is used:

To view the services recommended for a participant based upon the goals that have been generated from the answers to assessment questions.
To add or delete services as needed.
To update the status and/or the planned completion date for a service.

Additional information on participant planned services is as follows:

The planned services list only occurs as a result of conducting assessments. If the user adds to this list, it will be necessary to manually add services for the goals. Manually added goals and services will also be displayed on this screen.
The FSW must select at least one planned service for each goal established for the participant.
The order in which the services are to be addressed depends on the planned completion date.

A FSC (Family Stress Checklist) total score of 25 or greater for a participant will automatically select "Offer HFI Services" as the planned service for HFI. Most Cornerstone care plan goals and services pertain to service coordination rather than parent/child interaction. Services related to the development of parenting skills should be recorded manually (on paper) in the family's service plan.

Please refer to Chapter 6 "Case Management Screens" under "6.3 Planned Services/Care Plan (CM03)" for more information.

ACTIVITY ENTRY (SV02) - participant related

130 - Family Support

Please refer to Chapter 4 "Service/Activity Screens" under "4.2 Activity Entry (SV02)" for more information.

REPORTS (as needed)

Please refer to Chapter 10 "Report Screens" for information on how to run a report.

Please refer to Chapter 11 "Reports" for more information about a specific report.

After a participant has been made active in HFI, the following screens are used to record on-going family support (home visiting) activities:

***AFTER DELIVERY BY ENROLLED PRENATAL participant***

PARTICIPANT PROFILE (PA02) OR INQUIRE BY PARTICIPANT NAME/SSN (PA20)

The Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant.

For more information about the Participant Profile (PA02) or Inquire by Participant Name/SSN (PA20) screens, please refer to Chapter 3 "Participant Screens" under "3.2 Participant Profile (PA02)" or "3.20 Inquire by Participant Name/SSN (PA20)."

POSTPARTUM DATA (PA10)

This screen is used to add, edit, or inquire about a participant's postpartum information. For each pregnancy, there must be one Initial Prenatal Data (PA07) screen and one Postpartum Data (PA10) screen completed. These screens are "linked" by certain information that is entered (for example, the EDC fields).

Only one postpartum data record per pregnancy is allowed, even if the pregnancy results in a multiple birth. This screen must be completed within six weeks of delivery. Once a pregnancy has been "closed" through the completion of the Postpartum Data (PA10) screen, some of the information on the Initial Prenatal Data (PA07) screen cannot be edited.

NOTE: HFI is only required to record the date of delivery, weight at delivery, prenatal EDC, number of males/females, pregnancy outcome, and complete the smoke/drink questions.

Please refer to Chapter 3 "Participant Screens" under "3.10 Postpartum Data (PA10)" for more information.

SERVICE ENTRY (SV01)

If the participant has ever breastfed, add a new SV01 record with the type of "935 - BCAH - Breastfeeding Initiation".

Please refer to Chapter 4 "Service/Activity Screens" under "4.1 Service Entry (SV01)" for more information.

PROGRAM INFORMATION (PA15)

The Program Information (PA15) screen is used to change a family's level of service intensity. This is accomplished by selecting the current program information screen for the Group Head, pressing F6 Edit to edit the record, manually entering the new category code, and then saving the record.

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under the "To Edit a Record" section in "12.1 General Information and Enrollment" for more information.

ACTIVITY ENTRY (SV02) - (Participant related)

130 - Family Support

Please refer to Chapter 4 "Service/Activity Screens" under "4.2 Activity Entry (SV02)" for more information

16.3 IF A SUCCESSFUL HOME VISIT HAS OCCURRED FOR A GUARDIAN

Please refer to the following screen flows displayed in Appendix A:

Cornerstone HFI Screen Flow - Guardian of Infant or Child - Successful Home Visit - HFI(B - 1)

SEQUENCE OF SCREENS

ACTIVITY ENTRY (SV02) - participant related

130 - Family Support

Please refer to Chapter 4 "Service/Activity Screens" under "4.2 Activity Entry (SV02)" for more information.

PARTICIPANT PROGRAM (PA15)

This screen is completed at the time of enrollment, to change the family's level of service intensity, and at case closure.

F6 Edit and terminate the current HFIE - HFI Enrollment record with a Termination Reason of "55 - Active in HFI". F5 Add a NEW PA15 record with one of the following category codes for HFI levels of service intensity. This is done by assigning the Group Head to one of the following categories:

HFCO - HFI CREATIVE OUTREACH - This code is to be used for families who were previously engaged in the program but are now the recipients of outreach efforts. Families may not remain on Creative Outreach status for longer than three consecutive months.
HFI1 - HFI LEVEL 1 - This code is to be used when the service intensity level calls for weekly home visits.
HFI2 - HFI LEVEL 2 - This code is to be used when the service intensity level calls for bi-weekly home visits.
HFI3 - HFI LEVEL 3 - This code is to be used when the service intensity level calls for monthly home visits.
HFI4 - HFI LEVEL 4 - This code is to be used when the service intensity level calls for quarterly home visits.
HFIP - HFI PRENATAL - This code is to be used during the prenatal period. Individual programs' practices may vary in terms of when in pregnancy families are enrolled and how frequently they are visited. Families at this level, however, should receive a minimum of two home visits per month.
NOTE: If a woman who has been a Group Head becomes pregnant, users should "keep" or select the category code that reflects the level of service intensity that the family requires. Example: If the family was at level HFI1 when the Group Head became pregnant, it would not be necessary to change the category code to HFIP solely because the participant is pregnant. Instead, the family should be left at level HFI1 until their progress warrants changing the level of service intensity.
HFSS - HFI SPECIAL SERVICES - This code may be used when service intensity calls for more than one home visit per week.
SUSP - HFI SUSPENSION - This category will allow programs to temporarily suspend participants when services must be interrupted because the family will not be available for a specified period of time. The suspension period should be more than one month but not exceed three consecutive months. Suspended participants will be considered Eligible but not Active and their case will have no weighted value. Participants assigned to this category will be automatically terminated after three consecutive months in suspension (Participants may only be suspended for three months in any twelve month period).
OVFL - HFI OVERFLOW - This code is used to store demographic information on Group Heads who have been referred to the HFI program but can not be served because the program is at full capacity. Group Heads activated in the OVFL category will remain "eligible" for HFI in Cornerstone until their OVFL program record is terminated locally. (NOTE: Group Heads assigned to the OVFL category will not be considered active in HFI.) Group Heads should be terminated from the OVFL category on the Program Information (PA15) screen when either the family is being enrolled/activated in HFI or the participant is no longer eligible for HFI. The following Termination Reasons have been developed for use with the OVFL category:

54 - NOT ELIG FOR ENROLLMENT IN HFI

55 - TERM OVFL - ALLOW ACTIVE IN HFI

Participant category "G" is not limited to a child's legal guardian.

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.1 General Information and Enrollment" for more information.

ASSESSMENT (AS01)

Please refer to Chapter 7 "Assessment Screens" under "7.1 Assessment (AS01)" for more information.

The following assessment is required for an adult participant in HFI:

FSC - Family Stress Checklist - Questions 1-11

NOTE: The user must enter the total assessment score. Cornerstone does not automatically add their sub-scale scores to calculate the total score.

PARTICIPANT GOALS (CM02) - (Edit as needed)

Goals may be added or changed from the standard list of goals, and the user may update goal detail information. Goals should not be deleted, per program policy. All goals should be addressed.

FSC (Family Stress Checklist) total score of 25 or greater for a participant will automatically select "Strengthen Parent-Child Bond" as the care plan goal in HFI. Most Cornerstone care plan goals pertain to service coordination rather than parent/child interaction. Goals related to the development of parenting skills should be recorded manually (on paper) in the family's service plan.
minimum of one goal must be generated or developed for each participant. If all assessment questions were answered with the "norm," then no goals or services will be system-generated; therefore, the user will have to develop a goal.

Please refer to Chapter 6 "Case Management Screens" under "6.2 Participant Goals (CM02)" for steps on how to develop a goal and for more information.

PLANNED SERVICES/CARE PLAN (CM03)

To view the services recommended for a participant based upon the goals that have been generated from the answers to assessment questions.
To add or delete services as needed.
To update the status and/or the planned completion date for a service.

Additional information on participant planned services is as follows:

The planned services list only occurs as a result of conducting assessments. If the user adds to this list, it will be necessary to manually add services for the goals. Manually added goals and services will also be displayed on this screen.
The FSW must select at least one planned service for each goal established for the participant.
The order in which the services are to be addressed depends on the planned completion date.

Please refer to Chapter 6 "Case Management Screens" under "6.3 Planned Services/Care Plan (CM03)" for more information.

ACTIVITY ENTRY (SV02) - participant related

130 - Family Support

Please refer to Chapter 4 "Service/Activity Screens" under "4.2 Activity Entry (SV02)" for more information.

PROGRAM INFORMATION (PA15)

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under the "To Edit a Record" section in "12.1 General Information and Enrollment" for more information.

CASE NOTES (CM04)

Case Notes (CM04) may be used by the Family Support Worker to record additional information about each contact with the participant.

NOTE: (If the Family Support Worker does not record progress notes in Cornerstone, then notes must be maintained on paper.)

Please refer to Chapter 6 "Case Management Screens" under "6.4 Case Notes (CM04)" for more information.

REPORTS (as needed)

Please refer to Chapter 10 "Report Screens" for information on how to run a report.

Please refer to Chapter 11 "Reports" for more information about a specific report.

PARTICIPANT PROFILE (PA02) OR INQUIRE BY PARTICIPANT NAME/SSN (PA20)

16.4 IF A SUCCESSFUL HOME VISIT HAS NOT OCCURRED FOR EITHER A PREGNANT WOMAN OR A GUARDIAN

Please refer to the following screen flows displayed in Appendix A:

Cornerstone HFI Screen Flow - Pregnant Woman - Unsuccessful Home Visit - HFI(A - 2)
Cornerstone HFI Screen Flow - Guardian of Infant or Child - Unsuccessful Home Visit - HFI(B - 2)

SEQUENCES OF SCREENS

NOTE: A Family Support Worker (FSW) has a minimum of 30 days and a maximum of 90 days to successfully contact the family and have a home visit. If a successful home visit has not occurred after 90 days, the case should be Terminated on the Program Information (PA15) screen.

ACTIVITY ENTRY (SV02) - Participant related

The following activity code (132) is used to record attempts to engage a family in either of the following two scenarios:

The family has accepted the program but not yet completed a home visit (HFI Enrollment category)
A Family Support Worker is no longer able to successfully engage a family who had been enrolled in the program and previously assigned to a home visiting level.
- 132 - Creative Outreach

Please refer to Chapter 4 "Service/Activity Screens" under "4.2 Activity Entry (SV02)" for more information.

16.5 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR INFANT OR CHILD PARTICIPANT (I, C)

Please refer to the following screen flow displayed in Appendix A:

"Cornerstone HFI Screen Flow - Infant or Child (HFI(C))"

Recording information in Cornerstone for an infant or child in HFI involves the use of several screens for recording demographic information and several screens for recording outcome data. The sequence of screens for these purposes is presented on the screen flow diagrams in Appendix A.

The following screens are used to record demographic information for an infant or child participant. These screens should be completed when the parent agrees to accept HFI services.

The Participant Look-up (PA01) screen is used to ensure that information about the participant is entered in Cornerstone under only one statewide identification number.
The Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant.
The Participant Enrollment (PA03) screen is used to assign a statewide identification number and to record demographic information.
The Program Information (PA15) screen is used to identify the infant as actively receiving HFI services.
The Participant Group Relationships (PA06) screen is used to link individual participant records into a family group.
The Birth Data (PA11) screen is used to record birth information for each infant or child.

Five screens are used to record outcome data for an infant or child in the HFI program:

The Service Entry (SV01) screen is used to record the occurrence of well-child visits and developmental delay screens.
The Well Child Visit Summary (SV11) is used to determine what date the child should receive their next well child visit.
The Immunizations (PA12) screen, Immunization History (PA13) screen, and the Future Immunizations (PA14) screen are used to record or view immunization data.
The Multiple Immunization Entry (PA23) screen is used to enter current or past multiple immunizations for the same participant at one time, rather than entering the immunizations individually using the Immunizations (PA12) screen.
Reports are utilized as needed.

All information except the infant or child participant's immunizations and well-child visits is recorded under the Cornerstone participant ID of the Group Head.

The following is information about the entry of data into the Cornerstone system for an infant or child participant in HFI.

SEQUENCE OF SCREENS

PARTICIPANT LOOK-UP (PA01)

Prior to registration into the Cornerstone system, the Statewide Look-up is used to verify the existence of a participant ID number by searching the Master Index to find a participant who may have previously been enrolled in Cornerstone.

Use of the Statewide Look-up reduces duplicate entry of participants. For this reason, the Statewide Look-up must be performed before a new participant can be enrolled into the Cornerstone system.

Please refer to Chapter 3 "Participant Screens" under "3.1 Participant Look-up (PA01)" for more information.

For information about resolving duplicate participants in Cornerstone, please refer to Chapter 3 "Participant Screens" under "3.21 Participant Duplicate Browse (PA21)."

PARTICIPANT PROFILE (PA02) OR INQUIRE BY PARTICIPANT NAME/SSN (PA20)

The Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant.

PARTICIPANT ENROLLMENT (PA03) - add/edit Address as needed

NOTE: The WAN should be reviewed on a regular basis in order to obtain the most current participant information.

From this screen, the "Address" pop-up window is used to record address and telephone information by pressing F9.

Please refer to Chapter 3 "Participant Screens" under "3.3 Participant Enrollment (PA03)" for more information.

PROGRAM INFORMATION (PA15)

This screen is completed at the time of case opening, at the child's first birthday, and at the time of case closure.

The Program Information (PA15) screen is used to record program eligibility. The screen is used to enroll a participant in HFI. Listed below is a description of the category codes for an infant or child:

I - An infant is classified as a child 12 months of age or younger.
C - A child is classified as older than one year of age.

NOTE: When an infant reaches one year of age, the category code will automatically change from "I" to "C."

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.1 General Information and Enrollment" for more information.

PARTICIPANT GROUP RELATIONSHIPS (PA06)

This screen is to be completed at the time of case opening. This screen is used to establish and display group relationships among Cornerstone participants in the Cornerstone system. To establish a group, all participants must be enrolled in the Cornerstone system (i.e., must have had the Participant Enrollment (PA03) screen completed).

NOTES:

All active infants and children must be grouped with an adult participant. An infant or child can not be a Group Head.
If a family has an older child (a child who is too old to be eligible for HFI) at the time the family is first assessed for HFI, the child should be identified as a household member, rather than as a member of the group. Additional children who are born to an active family (i.e., woman and child who have been accepting services) should be included as group members.
The immunization status and use of well child care will be measured for children who are included in the Cornerstone group, but not for household members.

Please refer to Chapter 3 "Participant Screens" under "3.6 Participant Group Relationships (PA06)" for more information.

BIRTH DATA (PA11)

This screen is completed once shortly after the birth of each child.

This screen is used to record birth information for each infant or child. The Cornerstone system allows entry of only one birth record per participant.

NOTE: HFI is only required to record birth weight and place of birth.

Please refer to Chapter 3 "Participant Screens" under "3.11 Birth Data (PA11)" for more information.

Five screens are used to record outcome data for an infant or child in the HFI program:

SERVICE ENTRY (SV01)

This screen is used for entering the services that the participant has received, regardless of whether the services were delivered at the agency or by an external provider.

HFI requires that the following services be recorded on this screen:

Well Child Visits (806 - Well Child/EPSDT/Healthy Kids) for infants and children
824 - Development Screening (Add when Developmental Screenings have been completed)

Other services can be recorded at the agency's discretion.

The Service Entry (SV01) screen must be completed because performance on the well child visit outcome indicator is measured from this screen.

Please refer to Chapter 4 "Service/Activity Screens" under "4.1 Service Entry (SV01)" for more information.

WELL CHILD VISIT FORECAST (SV11)

The Well Child Visit Forecast screen (SV11) is used to determine when the next EPSDT visits are due to be scheduled for the child.

Please refer to Chapter 4 "Service Activity Screens" under "4.11 Well Child Visit Forecast (SV11)" for more information.

About Medical Screens

The appropriate medical screens may be completed as needed. Because the medical screens are not program specific, they may have already been completed for the participant through another program in the agency and do not need to be done again.

NOTE: In some cases, this screen already may have been completed when services from other Cornerstone programs, such as WIC or FCM, were provided to the participant.

INFANT/CHILD NOTE: The required medical screens for infants and children in the HFI program are:

Immunizations (PA12) screen or Multiple Immunization Entry (PA23) (also includes Immunization History (PA13) and Future Immunizations (PA14)). Immunizations must be recorded because performance on the Immunization Outcome Indicator is measured from these screens.

IMMUNIZATIONS (PA12)

As of March 9, 2005 the Cornerstone Central Office nightly processing downloads new immunization records to the appropriate clinic site via the Beginning of Day process. There must be a Program information (PA15) screen in order for a participant to receive the new immunization record. This has eliminated the need to use the WAN to obtain immunization records. Any questions regarding immunizations and the WAN prior to this date should be addressed by calling the Cornerstone Service Desk.

This screen is used to enter current or past single immunizations for a participant by vaccine type, date, provider, lot number, and place of service. To enter multiple immunizations on a single participant when the same provider gave all of the immunizations on the same date, use the Multiple Immunization Entry screen (PA23). (Please refer to Chapter 3 "Participant Screens" under "3.23 Multiple Immunization Entry (PA23)" for more information.)

The number in the series is automatically calculated. Infant, child, and adult immunizations can be recorded. Immunizations given by the local clinic, as well as those given by outside providers, may be recorded.

The user has the option to select a Wide Area Network (WAN) look-up on this screen by pressing the F2 shared data key, which will copy-in and add any statewide data to the local data.

Please refer to Chapter 3 "Participant Screens" under "3.12 Immunizations (PA12)" for more information.

IMMUNIZATION HISTORY (PA13)

As of March 9, 2005 the Cornerstone Central Office nightly processing downloads new immunization records to the appropriate clinic site via the Beginning of Day process. There must be a Program information screen (PA15) in order for a participant to receive the new immunization record. This has eliminated the need to use the WAN to obtain immunization records. Any questions regarding immunizations and the WAN prior to this date should be addressed by calling the Cornerstone Service Desk.

This screen is used to inquire on the previous immunizations a participant has received in the local clinic, including those previously copied in from the Wide Area Network. The screen shows Series 1 through 6, but only part of the data are visible on the screen. Use <Tab> or the left and right arrow keys to see the data not visible on the screen.

The user has the option to select a Wide Area Network (WAN) look-up on this screen by pressing the F2 shared data key, which will copy-in and add any statewide data to the local data.

Please refer to Chapter 3 "Participant Screens" under "3.13 Immunization History (PA13)" for more information.

FUTURE IMMUNIZATIONS (PA14)

This screen is used to inquire on recommended future immunizations, dose number in series, and recommended date for returning to receive vaccines. The Cornerstone system calculates this information based upon the recommendations of the Advisory Committee for Immunization Practices (ACIP).

Upon entering the screen, the user will have the option of retrieving shared data from the Wide Area Network (WAN), which will copy-in and add any statewide data to the local data or will use local data only.

Please refer to Chapter 3 "Participant Screens" under "3.14 Future Immunizations (PA14)" for more information.

MULTIPLE IMMUNIZATION ENTRY (PA23)

This screen is used to enter current or past multiple immunizations for the same participant at one time, rather than entering the immunizations individually using the Immunizations (PA12) screen. This screen allows greater flexibility in entering multiple immunizations on a single participant, when the same provider gave all of the immunizations on the same date. The number in the series is automatically calculated.

The screen can be used to inquire on prior immunizations, but can not be used to delete immunizations. The Immunizations (PA12) screen can be used for deletions. (Please refer to Chapter 3 "Participant Screens" under "3.12 Immunizations (PA12)" for more information).

Infant, child, and adult immunizations can be recorded. Immunizations given by the local clinic, as well as those given by outside providers, may be recorded.

The user has the option to select a Wide Area Network (WAN) look-up on this screen by pressing the F2 shared data key, which will copy-in and add any statewide data to the local data.

Immunizations must be recorded because performance on the Immunization Outcome Indicator is measured from these screens.

Please refer to Chapter 3 "Participant Screens" under "3.23 Multiple Immunization Entry (PA23)" for more information.

REPORTS (as needed)

Please refer to Chapter 10 "Report Screens" for information on how to run a report.

Please refer to Chapter 11 "Reports" for more information about a specific report.

16.6 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR TERMINATION (Pregnant Mother, Guardian, Infant/Child)

Please refer to the following screen flow displayed in Appendix A:

"Cornerstone HFI Screen Flow - Termination(Pregnant Mother, Guardian, Infant/Child) (HFI(D))"

The following screens are used to close active cases:

The Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant.
The Program Information (PA15) screen is used to close the case.
The Case Notes (CM04) screen is used to enter and view case notes that are related to a service or a case management activity.
The Case Management Assignment History (CM01) screen is used to remove the family from the Family Support Worker's caseload.

SEQUENCE OF SCREENS

PARTICIPANT PROFILE (PA02) OR INQUIRE BY PARTICIPANT NAME/SSN (PA20)

The Participant Profile (PA02) screen or the Inquire by Participant Name/SSN (PA20) screen is used to locate Cornerstone records for the participant.

For more information about the Participant Profile (PA02) or Inquire by Participant Name/SSN (PA20) screens, please refer to Chapter 3 "Participant Screens" under "3.2 Participant Profile (PA02)" or "3.20 Inquire by Participant Name/SSN (PA20)."

PROGRAM INFORMATION (PA15)

This screen is completed at the time of the participant's termination from the program. Change the program status to "T" and enter the appropriate Termination Reason Code.

Please refer to Chapter 12 "Program Information Screen (PA15) for All Programs" under "12.6.2 Manual Termination" for more information.

CASE NOTES (CM04)

This screen is used to enter and view case notes for the participants that are related to a service or family support activity. In this case it will be used to document the reason for the participant's termination and other pertinent information.

Please refer to Chapter 6 "Case Management Screens" under "6.4 Case Notes (CM04)" for more information.

CASE MANAGEMENT ASSIGNMENT HISTORY (CM01)

This screen is used to end an FSW's assignment after a participant has been terminated from Healthy Families Illinois. This is accomplished by completing the "End Date" field on the Case Management Assignment History (CM01) screen.

Please refer to Chapter 6 "Case Management Screens" under "6.1 Case Management Assignment History (CM01)" for more information.

Chapter 16 Healthy Families Illinois (HFI)

Table of Contents

16.0 INTRODUCTION

16.1 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR ADULT PARTICIPANT (HFIE, HFCO, HFIP, HFI1, HFI2, HFI3, HFI4, HFSS, SUSP, G)

16.2 IF A SUCCESSFUL HOME VISIT HAS OCCURRED FOR A PREGNANT WOMAN:

16.3 IF A SUCCESSFUL HOME VISIT HAS OCCURRED FOR A GUARDIAN

16.4 IF A SUCCESSFUL HOME VISIT HAS NOT OCCURRED FOR EITHER A PREGNANT WOMAN OR A GUARDIAN

16.5 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR INFANT OR CHILD PARTICIPANT (I, C)

16.6 HEALTHY FAMILIES ILLINOIS SCREEN FLOW FOR TERMINATION (Pregnant Mother, Guardian, Infant/Child)