Agency Name:



|1. Number of Active Charts Randomly Selected |Assigned |Active | | |

|for Review: |Caseload = |Caseload = | | |

| | | |Woman |Total |

| |Performance |# of Charts |Number |# Done |% Compliance |Quarterly Data from Cornerstone |

| |Standard |Reviewed |Expected | | |Report % |

|Risk Assessment (707G) |100% | | | | | |

|Assessments 700, 701, 703, 704, 705, 706, |90% | | | | | |

|707D, 710 | | | | | | |

|Individual Care Plan |90% | | | | | |

|Home Visit |75% | | | | | |

|PNC Visits: Adequacy of Prenatal Care & | T1 75% | | | | | |

|trimester prenatal care began |90% T2 15% | | | | | |

| |T3 10% | | | | | |

|8. Face-to-Face (2/month) |100% | | | | | |

|9. Started HEALTHY START 1st Trimester |75% | | | | | |

|10. Immunizations |90% | | | | | |

|I. 630.20e Monitoring: At least annually, appropriate health care personnel of the Division and its consultants shall review each project for appropriateness of services and quality of care |

|furnished to recipients in accordance with the project plan. |

|I. Agency Requirements and Provider Qualifications |

|A. The provider provides intensive case management |Contract: |Assessment tool | | | | |

|services to pregnant women meeting specific Department |Attachment | | | | | |

|criteria. |Scope of | | | | | |

| |Services Section | | | | | |

| The agency must agree to help |Section |All Kids log | | | | |

|program participant apply for |Code: |Case Notes | | | | |

|benefits under the All Kids Health |630.220B2 | | | | | |

|Insurance Program or refer them to |Contract | | | | | |

|the closest application agent. | | | | | | |

| | | | | | | |

|Staff employed to provide Healthy |Contract: |Proof license | | | | |

|Start are registered nurses who either |Attachment |Educational | | | | |

|have a B.S.N. with an emphasis on |Scope of Services |qualifications; Degrees| | | | |

|maternal-child health, community |Section | | | | | |

|health nursing, or public health, or a |MCH Code 630.220 |Policy/Procedure | | | | |

|Master of Social Work with emphasis | |Interview with manager | | | | |

|on services for women and children; | |DHS Waiver letter for | | | | |

|and experience in working with | |exceptions | | | | |

|young women and children. | | | | | | |

|Social worker check for staff | | | | | | |

|requirement | | | | | | |

|Case loads for Healthy Start do not |Contract Attachment |Cornerstone | | | | |

|exceed 40 clients per case manager. |Scope of Services |Caseload Reports | | | | |

|(If exceeds 40, explain in |Section |HSPR0202; | | | | |

|“Comments” Section. | |Participant Events: | | | | |

| | |HSPR0604 | | | | |

| | |Policy/Procedure | | | | |

|II. Clinical Record: The participant’s medical record shall contain but not be limited to: |

|General Case Management Activities: |

|A. Documentation of: | | | | | | |

|Missed appointments and attempts to follow-up on missed | |Policy/Procedure | | | | |

|appointments of those participants the case manager or | |Manual | | | | |

|physician have identified as non-compliant. | |Chart Review | | | | |

| | |All Kids Log | | | | |

| | |(optional) | | | | |

|Each service rendered by the case |Code: |Cornerstone Screens: | | | | |

|manager |630.220d |Enrollment (PA03) | | | | |

| |Cornerstone |Program Info (PA15) | | | | |

| |Manual |Medicaid screen (PA05) | | | | |

| | |Most recent Cornerstone| | | | |

| | |Quarterly Reports | | | | |

|Release of information to providers of necessary |Code: |Release of Information | | | | |

|services |630.220d |Consent | | | | |

| |Cornerstone | | | | | |

| |Manual | | | | | |

| |Code: |Case Notes CM04 | | | | |

|4. Coordination of care |630.220d |Service Entry SV01 | | | | |

| |Cornerstone |Activity EntrySV02 | | | | |

| |Manual |RF01/03 | | | | |

| | | | | | | |

| | | | | | | |

| The provider uses the Cornerstone |Healthy Start |Policy/Procedure: | | | | |

|Management Information System to |Contract Agreement |C-Stone Screens | | | | |

|Record demographic health status |Attachment Section A 2nd|PA01 | | | | |

|and service delivery information |paragraph |PA02, PA03 | | | | |

|about each client receiving | |PA15, PA05 | | | | |

|Healthy Start services. | |PA06, SV01, | | | | |

| | |PA07, PA08, | | | | |

| | |PA10; | | | | |

| | |Assessments | | | | |

| | |700-General | | | | |

| | |(questions 1-40) | | | | |

| | |701-Other Service | | | | |

| | |Barriers | | | | |

| | |703 Psychosocial Stress| | | | |

| | |Mgt., | | | | |

| | |704-Alcohol and | | | | |

| | |Substance Abuse, | | | | |

| | |705-Violence | | | | |

| | |706-Home | | | | |

| | |707D-Prenatal Nutrition| | | | |

| | |707G-Risk Factors | | | | |

| | |SV01-Service Entry | | | | |

| | |SV04-Time Entry | | | | |

| | |708-Assessment | | | | |

| | |710- | | | | |

|Outreach efforts are conducted to |MCH Code |CM04-Case Notes, | | | | |

|identify and recruit high-risk pregnant |630-220b5 |CM02-Participant | | | | |

|women to participate |Contract attachment 13 |Goals, CM03 – | | | | |

| |paragraph |Planned Service | | | | |

|* Outreach includes assigned | |Summary, RF01-Referrals| | | | |

|community areas, assigned CA | | | | | | |

|participants | |Discussion with | | | | |

| | |manager/staff; | | | | |

| | |policy/procedure | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|III. 630.220c1 and 630.220.131 Case Management Process |

|A. Assessment of needed health and social |Code: 630.220e1a & |Policy & Procedures | | | | |

|services assessment(s) to determine need |630.220e1e |Assessments: | | | | |

|for health, mental health, educational, |Performance Standard 90%|(AS01) | | | | |

|vocational, substance abuse treatment, |Contract |General: 700 | | | | |

|child care, transportation, oral health, |Healthy Start |(questions: 1-40) | | | | |

|prenatal and postpartum depression |Contract |701-Other service | | | | |

|screening and other services (must |Attachment |barriers | | | | |

|include: risk assessment) |Paragraph 2 C-Stone |703 Psychosocial/ | | | | |

| |Healthy Start Flow Chart|Stress Mgt. | | | | |

| | |704-Alcohol/ | | | | |

| | |Substance Abuse | | | | |

| | |705 Violence | | | | |

| | |706 Home | | | | |

| | |707D Prenatal Nutrition| | | | |

| | |707G Risk | | | | |

| | |708 Prenatal Educ. | | | | |

| | |PA11 Birth Data | | | | |

| | |SV01 | | | | |

|Healthy Start clients are entered in |Healthy Start |C-Stone Program | | | | |

|the “Targeted Intensive Prenatal Case |Contract |Information Screen | | | | |

|Program” on the Program |Attachment |(PA15) | | | | |

|Information Screen (PA15) in the |Healthy Start | | | | | |

|Cornerstone Information System: |C-Stone Flow Chart | | | | | |

|(The client is active in two programs, | | | | | | |

|Healthy Start and Family Case | | | | | | |

|Management) | | | | | | |

|Frequency of Contacts: |Healthy Start |C-Stone: Case Notes | | | | |

|A minimum of two face-to-face |Contract |(CM04) Service Entry | | | | |

|contacts with each client each month |Attachment |Screen (SV01) Activity | | | | |

|(from enrollment to termination of the |Paragraph 1 |Entry Screen (SV02) | | | | |

|pregnancy). | | | | | | |

| | | | | | | |

| | | | | | | |

|Half of the face-to-face contacts |Healthy Start |Care Plan: | | | | |

|occur in the client’s home |Contract |Goals (CM02) | | | | |

| |Attachment |Participant Services | | | | |

| |Paragraph 1 |(CM03) | | | | |

| | |Cornerstone: | | | | |

| | |Case notes (CM04) | | | | |

| | |Service Entry Screen | | | | |

| | |(SV01) | | | | |

| | |Activity Entry Screen | | | | |

| | |(SV02) | | | | |

|All prenatal visit dates for each client |Healthy Start |Cornerstone | | | | |

|are recorded on the Cornerstone |Contract |Service Entry Screen | | | | |

|Service Entry Screen (SV01) with |Cornerstone |(SV01) | | | | |

|Code 802. |Flow chart | | | | | |

| | | | | | | |

|EPDA prenatally and postpartum |Perinatal Mental Health |SV01 code 825 | | | | |

|(6 weeks and 6 months) |Disorders Prevention and| | | | | |

| |Treatment Act | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|B. Development of an Individual Care Plan |

|List of all service providers involved |Code: |Policy & Procedures | | | | |

| |630.220e1b & |Chart review | | | | |

| |630.220e2 |Cornerstone screens: | | | | |

| |Performance Standard 90%|Care Plan | | | | |

| | |Goals-CM02 | | | | |

| |Contract |Planned Services-CM03 | | | | |

| | |Case Notes- | | | | |

| | |CM04, RF01, RF03 | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| |CM021 | | | | | |

| |CM03 | | | | | |

| |CM04 | | | | | |

|List of agencies participant referred to | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|Problem list and plans for resolution | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|Includes evidence of review, updated information and | | | | | | |

|follow-up activity | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|Referrals as appropriate documented on the RF01/03 with status of follow-up documented under RF01 comments field: |

|Health |Code: 630.220e1c |Cornerstone screens: | | | | |

|Mental health |Contract |Case Notes— | | | | |

|Substance abuse treatment | |CM04 &/or | | | | |

|Smoking cessation services | |Service Provider | | | | |

|Domestic violence services | |Selection (RF01, 03) | | | | |

|Family planning | |CM02, CM03 | | | | |

|Housing | |RF01 | | | | |

|Educational/vocational | |SV01 | | | | |

|Child care | |Code 813 medically | | | | |

|Transportation | |necessary | | | | |

|Oral health and other services | |transportation | | | | |

|WIC | | | | | | |

|Food bank | | | | | | |

|Clothing | | | | | | |

|Other services | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|D. Client Education |

|Provide Healthy Start/Grow Smart |Contract |Anticipatory Guidance | | | | |

|brochures from HCFS post delivery |Code: |Screens, SV01 Service | | | | |

| |630.210.D |Entry | | | | |

| |630.210.E |Case Notes | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| |PA42/RF01/RF03 | | | | | |

| | | | | | | |

| |SV01 | | | | | |

|Post information on accessing free | | | | | | |

|Transportation | | | | | | |

|All Kids | | | | | | |

|Prenatal Care | | | | | | |

|E. Postpartum Information |

|Each child’s birth data is entered on |SV01 | | | | | |

|the Cornerstone Infant Birth Data |PA10 |PA11 | | | | |

|Screen (PA11) |PA08 |Cornerstone | | | | |

|Dual assignment another agency |C-Stone |Infant Birth Data | | | | |

| |Healthy Start |Screen | | | | |

| |Flowchart | | | | | |

| |Healthy Start Contract | | | | | |

| |Attachment | | | | | |

|After the infant’s birth, the |HEALTHY START Guidelines|Cornerstone Program | | | | |

|Healthy Start Program Record (the | |Information Screen | | | | |

|PA15 is closed on all clients | |(PA15) | | | | |

|Postpartum Medical |SV01 (820) | | | | | |

| |PA10 | | | | | |

|Family Planning Method |SV01-804 | | | | | |

| |PA10 | | | | | |

|Corrective Action Plan |

|Please respond within 20 working days to the following required actions by: _________________________________ |

|(Date) |

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FY12 Healthy Start Case Management Program Clinical Review Tool

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