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 N.J.A.C. 10:54-6
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 activities shall include, but not be limited to:
i. Orienting the patient to all
services;
ii. Developing,
maintaining and coordinating the care plan in consultation with the
patient;
iii. Coordinating and
monitoring the delivery of all services and referrals;
iv. Monitoring and facilitating the patient's
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; and
x. Reviewing, monitoring and updating the
patient's complete record.
3. Postpartum care coordination activities
shall include, but not be limited to:
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 Women,
Infants and Children (WIC), pediatric care (preferably with a HealthStart
pediatric care provider), future family planning, Special Child Health Services
County Case Management Unit, early intervention services for infants with
disabilities, and other health and social agencies, if needed;
iv. Arranging for the transfer of pertinent
information or records to the pediatric care and/or future family planning
service providers;
v. Coordinating
referrals and following up on missed appointments and referrals; and
vi. Reinforcing health instructions for
mother and baby.
(b) Nutrition assessment and basic guidance
services shall be provided to orient and educate all patients to nutritional
needs during pregnancy and educate the patient to good dietary practices in
accordance with N.J.A.C. 10:54-6. Specialized nutrition assessment and
counseling must be provided to those women with additional needs. Services
shall be provided as follows:
1. Initial
assessment services, which shall include, but not be limited to:
i. Review of the patient's chart;
ii. Identification of dental problems which
may interfere with nutrition;
iii.
Nutritional history;
iv. Current
nutritional status;
v.
Determination of participation in WIC or other food supplement programs;
and
vi. Identification of need for
specialized nutritional counseling;
2. Subsequent nutritional assessment, which
shall include, but not be limited to:
i.
Monitoring of weight gain/loss;
ii.
Identification of special dietary needs; and
iii. Identification of need for specialized
nutritional counseling services;
3. Prenatal nutritional guidance, which shall
include, but not be limited to:
i. Basic
instruction on nutritional needs during pregnancy including balanced diet,
vitamins and recommended daily allowances;
ii. Review and reinforcement of other
nutritional 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 nutritional assessment and
basic guidance services which shall include, but not be limited to:
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 to assist the patient in
resolving social-psychological needs, in accordance with N.J.A.C. 10:54-6.
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 not be limited to:
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. Identification of 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:
i. Determination of patient's
reaction to pregnancy;
ii.
Ascertaining the reaction of family, friends and actual support person to the
pregnancy;
iii. Identification of
the need for social service interventions and advocacy; and
iv. Identification of 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:
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 medical care provider or by the social worker under the supervision of
the medical care provider and in coordination with the case coordinator;
and
6. Postpartum
social-psychological assessment and guidance which shall include, but not be
limited to:
i. Review of prenatal, labor,
delivery and postpartum course;
ii.
Assessment of the patient's current social-psychological status, including
mother and infant bonding and the acceptance of the infant by the father and/or
family, 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; and
vi.
Counseling regarding school/employment planning.
(d) Health education assessment
and instruction shall be provided to all patients at intervals throughout the
pregnancy, based on the patient's needs and in accordance with N.J.A.C.
10:54-6. Services shall be provided as follows:
1. Initial assessment of health educational
needs, which shall include, but not be limited to:
i. Identification of general educational
background;
ii. Patient's health
education needs; and
iii. 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. Childbirth preparation, including
management of labor and delivery;
vii. Preparation for hospital
admission;
viii. Substance,
occupational and 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; and
4. Postpartum assessment of health education
needs shall be conducted.
(e) One face-to-face preventive health care
contact must be provided or arranged for during the time after hospital
discharge and prior to the required medical postpartum visit. This requirement
is in accordance with N.J.A.C. 10:54-6, as follows:
1. This contact shall include, but not be
limited to:
i. Review of the mother's health
status;
ii. Review of the infant's
health status;
iii. Review of
mother/infant interaction;
iv.
Revision of the care plan; and
v.
Provision of additional services, as indicated; and
2. The provider shall provide or arrange for
one or more home visits for each high risk patient in accordance with N.J.A.C.
10:54-6.
(f) HealthStart
maternity care providers shall utilize existing community services to enhance
the maternity care services.
(g)
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 procedures shall include but are not limited to:
nutritional 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.
