Badgercare clients who are pregnant will be referred to PNCC.
Reproductive health clients with a positive pregnancy test will be referred to PNCC.
PNCC information will be sent to school nurses, counselors, and health care providers annually.
Guidelines outlined in the Prenatal Care Coordination Services Handbook provided by Medicaid will be used when providing PNCC services.
Referrals are received from various sources. A public health nurse (PHN) will contact the individual within 10 working days of receipt of a referral for PNCC services.
The PHN will verify whether the individual has MA, is eligible for and can apply for MA, or if the individual should receive PNCC services under the Maternal and Child Health grant.
The PHN will assist the individual as needed to complete the Pregnancy Questionnaire. The questionnaire is then scored by the PHN. Clients with a score of 4 or more risk factors will be admitted to the PNCC program. If the client scores under 4 risk factors , the service cannot be paid for my MA. However, if an individual with MA scores under 4 risk factors and has PNCC related needs, the individual may be admitted to PNCC and provided PNCC services under the Maternal and Child Health grant.
The PHN will complete an individualized care plan with the client using the Prenatal Nursing Care Plan form. Clients are expected to participate in the development of the care plans. The care plan will include:
Identification and prioritization of all risks found during the assessment;
Identification and prioritization of all services to be arranged for the client;
A description of the recipient’s informal support system, including collaterals and any activities planned to strengthen it;
Identification of individuals who participated in the development of the care plan;
Arrangements for, referrals for, and frequency of various services available to the recipient and the expected outcome for each service component;
Documentation of unmet needs and gaps in service (for example, indicate that the service needed is not available in the area); and
The recipient’s responsibilities in the plan’s implementation.
Once the care plan is developed, the client will sign and date it.
The client will be asked to sign a release of information form for the health care provider. This form is combined with a letter to the health care provider to notify him or her that the client will be receiving PNCC services from the health department.
Client contact visits (face-to-face or collateral) will be made no less than every 30 days. Documentation of all visits will be made on the PNCC Flow Sheet, PNCC Progress Notes, and the PNCC Time Log. Such visits include:
Face-to-face and telephone contacts with the client;
Face-to-face and telephone contacts with collaterals;
Record keeping (documenting the pregnancy statement from a physician or family planning clinic; updating care plans; documenting care management activities; documenting all contacts with the recipient and collaterals).
During the initial client visit, a full assessment will be completed. Abbreviated risk assessments will be done at each subsequent visit.
The care plan will be reviewed and updated with the client at a minimum of every 60 days. This will be documented on the care plan.
Missed or canceled visits will be documented in the progress notes. The reason for the missed appointment will be documented, along with the date of the next scheduled appointment.
Health education may be provided to the client to overcome her individual risk factors by strengthening her knowledge for ex: Smoking cessation, Alcohol consumption, Use of elicit or street drugs, Safer sexual practices, Use of over-the-counter and prescription medications, Environmental/occupational hazards related to pregnancy, Lifestyle management, Reproductive health, Parenting skills.
Nutrition counseling may be provided if the medical need for it is identified in the risk assessment and the strategies and goals for it are part of the care plan. Nutrition counseling can be provided on an individual or group basis. The counseling is intended to assist a pregnant woman to overcome her individual nutrition-related risk factors by strengthening her knowledge and helping her change her behavior.
Reproductive Health Services will be provided as follows:
Reproductive life plan discussions will be initiated in the third trimester or prior.
Post-partum contraceptive plans will be developed in the third trimester or prior.
Contraceptive supplies, including a standard dual protection kit, or arrangements for contraceptive supplies will be in place prior to delivery.
On-site pregnancy testing will be available.
All referrals and follow up on all referrals will be documented. A written release of information will be signed as indicated.
PNCC services will continue during the first 60 days postpartum. The delivery date and follow up visits will be documented by the PHN.
At least one contact with the client will be made during the 60-day postpartum period.
HealthCheck and reproductive health services will be explained and offered to the client prior to discharge from the PNCC program.
The PHN will submit the PNCC Time Logs to the health department secretary for billing purposes.
Agency will perform randomly chosen chart audits to monitor for completeness of Pregnancy Questionnaire/Care Plan and case management for quality assurance.
Standardized Prenatal Care Coordination Quality Assurance Checklist provided by the state will be used for creating chart audits.
Audits will be performed by the PNCC R.N.s at least three times a year.
Written audit reports will be submitted to management on completion.
Documentation of record audits will be filed in the PNCC Coordinator’s office.
Wisconsin Medicaid and Badger Care Information for Provider Handbook, Prenatal Care Coordination Services. (2001).
AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director PURPOSE STATEMENT: This is a general postpartum/newborn follow up policy summarizing the principles and standards of this department.
POLICY: Pepin County Health Department provides numerous services to the maternal and child health population. This agency will assist this population with health-related needs through dissemination of information, making referrals, and providing services directly.
PROCEDURE: Pepin County Health Department will engage in the following functions related to postpartum/newborn follow up:
Review all birth certificates for high-risk newborns or for potential postpartum needs. This includes reviewing birthweight, medical conditions, and psychosocial factors that would suggest the family would benefit from services.
Send an infant packet to all families of newborns in Pepin County to provide information about public health services, child health, and other resources.
Contact referral source discharge planners as needed to discuss direct referrals received.
Provide prenatal care coordination (PNCC) services to MA eligible families to help ensure healthy birth outcomes.
Work collaboratively with the Women, Infants, and Children (WIC) program.
Provide MCH-related services, such as CYSHCN, fluoride supplements, HealthCheck, immunizations, and blood lead screening to facilitate optimal health.
The following list includes examples of high-risk criteria for public health intervention. The list is not intended to be all-inclusive.
Infant Risk Factors
Maternal/Family Risk Factors
Low birthweight (<2500g) or small for gestational age (<10 percentile)
Newborn medical conditions
Hospital referral (medical, social, or other)
Preterm (<37 weeks gestation)
Maternal age <20 and >2 other pregnancies (high parity)
Family economic status (homeless, migrant, <12th grade education)
A basic level of services is offered to families in need of follow up after delivery of a baby. The intensity and length of services is based on need. A PHN will assess the family’s needs, strengths, and resources; provide nursing care and case management as appropriate; and provide health teaching, anticipatory guidance, and care coordination as needed. The following guidelines will be followed:
If a direct referral is received from a health care provider, a PHN will contact the family within 5 working days of receipt of the referral. The purpose of the contact is to offer and arrange a home visit.
Some clients may not be directly referred by a health care provider, but may appear high-risk when reviewing the birth certificate information. These families will also be contacted to offer a PHN home visit.
All families have the right to refuse a home visit or any other public health service.
The PHN may cover any of the following components during one or more home visits with the family:
Environmental assessment and teaching. This includes things like well water testing, indoor air quality, lead poisoning, general safety, pets, housing, and income/financial status of the family.
Psychosocial assessment including: sources of social support, adjustment to having a newborn, ability to communicate, ability to arrange for community resources, coping and/or grief response to newborn’s medical condition/diagnosis, family relationships, and caretaking/parenting skills.
Health teaching and guidance. This includes nutrition and elimination, growth and development, sleep and awake states, infant stimulation and parenting, child care, medications and other treatment procedures, safety, primary care follow up appointments, immunizations, and parent’s understanding and comfort with monitoring equipment.
Care coordination to assure service needs are met.
Postpartum assessment (if applicable), including psychosocial factors (feelings about delivery, adjustment to baby, support systems, postpartum depression, stress, and interaction with the infant), physiological factors (integument, pain, circulation, bowel and genitor-urinary function), and health related behaviors (nutrition, sleep and rest patterns, activity, family planning, substance use, and postpartum check-up).
Home visits are not required. Some families may prefer asking questions and getting information over the telephone. This is up to the client and assistance can be provided in person or over the phone.
The PHN will provide follow up services and referrals as indicated.
Ongoing services are based on the needs of the family.