Current through Register Vol. 56, No. 18, September 16, 2024
(a) Case coordination services shall facilitate the delivery of continuous, coordinated and comprehensive services for each patient in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers," as follows:
1. A permanent case coordinator shall be assigned to each patient no later than two weeks after the HealthStart enrollment visit.
2. Prenatal case coordination responsibilities shall be clearly defined and shall include the accountability of the case coordinator for the provision of all services. These responsibilities shall include, but not be limited to, the following:
i. Orienting the patient to all services;
ii. Developing, maintaining and coordinating the Plan of Care in consultation with the patient and appropriate medical practitioners;
iii. Coordinating and monitoring the delivery of all services and referrals;
iv. Monitoring and facilitating the patient entry into and continuation with maternity services;
v. Facilitating and providing advocacy for obtaining referral services;
vi. Reinforcing health teachings and providing support;
vii. Providing vigorous follow-up for missed appointments and referrals;
viii. Arranging home visits;
ix. Meeting with the patient and coordinating patient care conferences;
x. Reviewing, monitoring and updating the patient's complete record;
xi. Vigorous follow-up for referrals; and
xii. Vigorous follow-up for final Medicaid eligibility determination.
3. Postpartum case coordination activities shall include, but not be limited to, the following:
i. Arranging and coordinating the postpartum visit and any home visit;
ii. Arranging with the obstetrical care provider to obtain the labor, delivery and postpartum hospital summary record information no later than two weeks after delivery;
iii. Linking the patient to appropriate service agencies including: the Special Supplemental Food Program for Woman, Infants and Children Program (WIC), pediatric care (preferably with a HealthStart Pediatric Care provider), future family planning, Special Child Health Services County Case Management Unit and other health and social agencies, if needed;
iv. Arranging for the transfer of pertinent information and records to the pediatric care and/or future family planning service providers when authorized by the patient;
v. Coordinating referrals and following up on missed appointments and referrals; and
vi. Reinforcing health instruction for mother and baby.
4. The case coordinator shall complete at the time of the termination of services and submit a Maternity Services Summary Data form to the New Jersey State Department of Health and Senior Services, HealthStart Program, per beneficiary for each pregnancy. Copies of this form are available from the New Jersey State Department of Health and Senior Services, HealthStart Program.
(b) Nutrition assessment and basic guidance services shall be provided to orient and educate patients to nutritional needs during pregnancy and to educate patient to good dietary practices during pregnancy, at least initially, and at intervals of each trimester and postpartum. The results of the nutritional assessment and basic guidance services shall be integrated into the Plan of Care. Specialized nutrition assessment and counseling shall be provided to women with additional needs. Services shall be provided as follows:
1. Initial assessment services which shall include, but are not limited to, the following:
i. Review of patient's chart and plotting of the weight;
ii. Identification of dental problems which may interfere with nutrition;
iii. Nutrition history;
iv. Current nutritional status;
v. Determination of participation in the Special Supplement Food Program for Women, Infants and Children (WIC) or other food supplement programs;
vi. Provision of, or arrangement for, specialized nutrition counseling and intervention services identified through assessment; and
vii. Development of the nutrition component of the Plan of Care.
2. Subsequent nutrition assessment which shall include, but not be limited to, the following:
i. Monitoring and plotting of weight gain/loss;
ii. Identification of special dietary needs;
iii. Identification of need for specialized nutrition counseling services; and
iv. Integration of the nutritional component into the Plan of Care.
3. Prenatal nutrition basic guidance which shall include, but not be limited to, the following:
i. Basic instruction on nutritional needs during pregnancy including balanced diet, vitamins and recommended daily allowances;
ii. Review and reinforcement of other nutrition and dietary counseling services the patient may be receiving;
iii. Instruction on food purchase, storage and preparation;
iv. Instruction on food substitutions, as indicated;
v. Discussion of infant feeding and nutritional needs; and
vi. Referral to food supplementation programs through the case coordinator.
4. Specialized nutrition assessment and counseling which shall be provided to those women with additional needs.
5. Referral for extensive specialized nutritional services which shall be initiated by the medical care provider or the nutritionist under the supervision of the medical care provider in coordination with the case coordinator; and
6. Postpartum nutrition assessment and basic guidance services which shall include, but not be limited to, the following:
i. Review and reinforcement of good dietary practices;
ii. Review of instruction on dietary requirement changes; and,
iii. Instruction on breast feeding and/or formula preparation and feeding.
(c) Social-psychological assessment and basic guidance services shall be provided to all patients, initially, each trimester, and postpartum, and the results shall be integrated into the Plan of Care to assist the patient in resolving social-psychological needs, in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers." Specialized social-psychological assessment and short-term counseling shall be provided to those women with additional needs. Services shall be provided as follows:
1. Initial social-psychological assessment services which shall include, but are not limited to, the following:
i. Determining financial resources and living conditions;
ii. Determining the patient's personal support system;
iii. Determining the patient's attitudes and concerns regarding the pregnancy;
iv. Ascertaining present and prior involvement by the patient with other social programs or agencies and current social service needs;
v. Ascertaining educational and/or employment status and needs; and
vi. Identifying the need for specialized social-psychological and/or mental health evaluation and counseling services.
2. Subsequent social-psychological assessment services which shall include, but not be limited to the following:
i. Determining patient's reaction to pregnancy;
ii. Ascertaining the reaction of family, friend and actual support person(s) to the pregnancy;
iii. Identifying the need for social service interventions and advocacy; and
iv. Identifying the need for specialized social-psychological and/or mental health evaluation and counseling.
3. Basic social-psychological guidance which shall include, but not be limited to, the following:
i. Orientation and information on available community resources;
ii. Orientation regarding stress and stress reduction during pregnancy; and
iii. Assistance with arrangements for transportation, child care and financial needs.
4. Specialized, short-term social-psychological counseling, which shall be provided to women who are identified through assessment or basic counseling as having need for more intense service.
5. Referral for extensive specialized social-psychological services, which shall be initiated by the maternity medical care provider or by the social worker under the supervision of the maternity medical care provider and in coordination with the case coordinator.
6. Postpartum social-psychological assessment and guidance, which shall include, but not be limited to, the following:
i. Review of prenatal, labor, delivery and postpartum course;
ii. Assessment of patient's current social-psychological status, including mother and infant bonding and father/family acceptance of the infant, as applicable;
iii. Identification of the need for additional social-psychological services;
iv. Review of available community resources for mother and infant, as applicable;
v. Counseling regarding fetal loss or infant death, if applicable;
vi. Counseling regarding school and employment planning.
(d) Health education assessment and instruction shall be provided to all patients at intervals throughout the pregnancy, based on patients needs and as described in the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers." Services shall be provided as follows:
1. Initial assessment of health educational needs, which shall include, but not be limited to, the following:
i. Identification of general educational background;
ii. Identification of patient's health education needs; and,
iii. Identification of previous education and experience concerning pregnancy, birth and infant care.
2. Health education instruction, which shall be provided for all patients based on their identified health education needs shall include at least, the following:
i. Normal course of pregnancy;
ii. Fetal growth and development;
iii. Warning signs, such as signs of pre-term labor, and identification of emergency situations;
iv. Personal hygiene;
v. Exercise and activity;
vi. Child birth preparation, including management of labor and delivery;
vii. Preparation for hospital admission;
viii. Substance/occupational/environmental hazards;
ix. Need for continuing medical and dental care;
x. Future family planning;
xi. Parenting, basic infant care and development;
xii. Availability of pediatric and family medical care in the community; and,
xiii. Normal postpartum physical and emotional changes.
3. Health education services, which shall include guidance in decision making and in the implementation of decisions concerning pregnancy, birth and infant care.
4. Postpartum assessment of health education needs shall be conducted.
(e) Providers shall provide, or arrange for, one or more home visits for each high risk patient, as described in the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers" (N.J.A.C. 10:66-3).
(f) One face-to-face preventive health care contact shall be provided or arranged for during the time after hospital discharge and prior to the required medical postpartum visit in accordance with the "New Jersey State Department of Health and Senior Services Guidelines for HealthStart Maternity Care Providers," as follows:
1. This contact shall include, but not be limited to, the following:
i. Review of the mother's health status;
ii. Review of the infant's health status;
iii. Review of mother and infant interaction;
iv. Status of the basic nutrition of mother and infant;
v. An assessment of social-psychological and counseling services for referral;
vi. Revision of the Plan of Care; and
vii. Provision of additional services, including referrals, indicated.
(g) HealthStart Maternity Care providers must utilize existing community services to enhance the maternity care services.
(h) HealthStart Maternity Care Providers shall have written procedures which identify specific agencies or practitioners and criteria for referral of patients requiring services which are extensive, complex or expected to extend beyond the pregnancy. These shall include but are not limited to: nutrition and food supplementation services, substance abuse treatment facilities, mental health services, county/local social and welfare agencies, parenting and child care educational programs, future family planning services, fetal alcohol syndrome and AIDS counseling services.
