Current through Register Vol. 56, No. 6, March 18, 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.
