Current through Register Vol. 35, No. 18, September 24, 2024
A. A plan of
care with services is to be offered prior to a newborn's discharge from the
hospital when substance exposure has been identified.
B. The purpose of POC is to ensure continuity
and engagement of support services for the newborn and caregivers. A POC is the
document completed by a healthcare professional with the family or designated
caregiver(s) of the newborn when substance exposure has been identified. POCs
are jointly created by the healthcare professional and the family to support
them to obtain resources and services that sustain family relationships and
support the health and well-being of the infant and family members. The
implementation of services in the POC shall be modified and updated as often as
required to address changes in the needs and circumstances of the family. All
services in the plan are voluntary and at the option of the family. All POC's
must include the following information:
(1)
The newborn's birth information: This shall include date of hospital admission,
birth date, discharge date, and name of infant.
(2) The identified key household members: All
key household members over 18 years of age shall be documented in the POC and
offered supportive services listed in the plan of care.
(3) The discharge address for the family: The
discharge address shall be the physical address of the caregiver who will be
taking the newborn home. This may include, but is not limited to:
(a) parents;
(b) relatives or fictive kin; or
(c) resource family.
(4) In-utero exposures: If a newborn is
exposed to any substances during pregnancy, all exposures shall be documented
in the POC and on the notification of CARA newborn status form when applicable.
Documentation of exposures include exposures occurring during the timeframe in
which the mother may not have known she was pregnant, and all substance
exposures, including, but not limited to illicit and prescription drugs,
alcohol, marijuana (medical or recreational), and medication assisted therapy
such as methadone and buprenorphine.
(5) Substance use assessment: The parents,
domestic partners and key household members shall also be assessed for
substance use disorders. If it is determined they have a substance use
disorder, it shall be documented in the POC. If there is substance use present,
the parents, domestic partners and key household members shall be offered
services to address treatment and recovery goals of each individual. A copy of
the POC will be provided to individuals for whom such referrals are
made.
(6) Services and referrals:
The POC shall also include the services for which the family agrees to be
referred as well as services the family is already participating in. If the
family declines services in their community, the healthcare professional
clearly documents this within the POC. Families shall be informed that they may
request a referral for services at a later time, even if they have declined
these services during the initial development of the POC, by communicating with
their health insurance care coordinator or the CARA navigator(s) whose contact
information shall be included on the POC.
(7) Health insurance and care coordinator
information: The POC shall identify the managed care organization (MCO) or
private insurer that the mother is enrolled with and include contact
information for the assigned care coordinator (CC) when known at the initial
creation of the POC. The initial POC shall specify if a CC has not yet been
assigned or if the family has declined care coordination with their MCO or
private insurer. children's medical services (CMS) shall serve as the care
coordinator for the newborn if the newborn is uninsured, fee for service exempt
(Medicaid), or military if care coordination is unavailable.
(8) Release of information: The POC shall
include a release of information that includes an explanation of the entities
with whom the information in the plan may be shared. The parent or designated
caregiver completing the initial POC shall sign the document to indicate
informed consent for the release of information and referrals included in the
plan. A POC shall be considered inactive until it has been signed by the parent
or designated caregiver. The individual completing the POC shall document that
they reviewed the release of information with the caregivers. Any person or
agency receiving information from the POC shall be directed to treat it as a
confidential document and only to be used for the purpose of collaboration on
this POC. The release of information is valid for two years.
(9) Caregiver acknowledgment of notification
to CARA program: The POC shall be submitted to the CARA program at New Mexico
children youth and families department and New Mexico department of health per
the requirement of the CARA Statute, this includes a POC that is unsigned by
the caregiver. The health care provider who completes the form with the
caregiver shall inform the caregiver of this requirement.
C. When a POC should be completed by and sent
to the CARA Navigators: A POC shall be completed by the hospital staff with the
parent or designated caregiver prior to the newborn's discharge from the
hospital. In the case of births that occur without hospital admission, or when
substance exposure has been identified after the newborn's discharge from the
hospital, a POC may be created with the parent or designated caregiver by the
infant's healthcare provider, or by the assigned insurance care coordinator or
the CARA navigator. The POC shall be considered active upon the date of
signature of the parent/designated caregiver. The individual who creates the
plan with the family shall also sign and date the POC. Once the POC has been
signed it shall be sent to the CARA navigators at CYFD and NMDOH by secure
transmission or submitted through the CARA portal at New Mexico healthy
families by the provider who has initiated the POC.
D. Unknown information: If the individual
completing the POC does not have specific information necessary to complete the
POC, they shall fill it out to the best of their ability and write unknown
where the information is not known. The assigned care coordinator (CC) is
responsible for completing the missing information once they receive the POC.
If a caregiver declines care coordination, then a provider working with the
family will complete the missing information.
E. Who receives copies of the POC: The
caregiver, relative, guardian, fictive kin or resource family of the newborn,
the parents, designated CARA navigators at department of health (DOH) and
children, youth and families department (CYFD), the care coordinator (CC), the
newborn's primary care provider (PCP), and the referred supportive service
providers will each receive a copy of the completed POC.
F. Duration and Monitoring of Plans of Care:
Once the CC has been assigned and has met with the family, the CC shall contact
the newborn's primary care provider (PCP) and other referred providers to
ensure that referrals have been received; to provide support for family
engagement with the services on the POC; and to ensure that providers have
received a copy of the POC as permitted by the release of information (ROI) and
informed consent signed by the caregiver. The POC shall remain in place for at
least the first year of the child's life and shall remain active if continued
services are needed for the child or caregivers after the first year. The
implementation of services on the POC shall by monitored by the CC assigned
under the newborn's MCO or private insurer; CMS when an infant lacks health
insurance or is not eligible for CC; or by a designated CARA navigator or by a
designated provider. The delivery of services and family engagement shall be
monitored at the frequency and intensity needed to ensure the safety and
well-being of the infant, and to support progress toward achieving the parents'
or designated caregivers' expressed objectives for their POC. At one year from
the child's birth, a re-assessment of the POC with the family by the assigned
CC shall occur and, if necessary, the POC may be extended for a period of time
to be determined jointly by the family and assigned CC, by a designated
provider, or CARA navigator.
G.
Plan of care modifications: A POC may be modified in the following situations,
including but not limited to when:
(1) there
is a change in caregivers during the active POC, the plan shall be adjusted, as
needed, based on the new caregivers' location, and identified needs;
(2) a caregiver moves to a different city or
town in the state of New Mexico;
(3) reunification of the child with their
parents occurs during the first year, the POC shall remain active and can be
modified if needed;
(4) the needs
of the child have changed;
(5) a
child comes into CYFD custody, and the caregiver needs to continue following
the POC; or
(6) the needs of the
caregiver change.
H.
Notice of transfer of newborn between medical facilities:
(1) If a newborn is born outside of New
Mexico and is a New Mexico resident, and an agreement has been made with that
birthing hospital, then the out-of-state hospital shall complete a notification
of CARA newborn status to alert the CARA navigators at DOH and CYFD.
(2) If a New Mexico hospital is transferring
a newborn to another facility either in-state or out of state, the notification
of CARA newborn status shall be sent to the receiving hospital/facility and the
CARA Navigators.
(3) For in-state
hospital transfers of a newborn, the receiving hospital shall create the POC
and should be notified by the transferring hospital.
I. Late identification of substance
use/exposure: Late identification is when substance use or newborn exposure to
substances is not known or identified until the newborn has already been
discharged. If late identification occurs:
(1)
The notification of CARA newborn status shall be utilized to notify the CARA
CYFD and DOH navigators. If the hospital notifies the caregiver of the positive
result on the newborn, the hospital shall explain that the CARA navigators
shall be notified, and that a CARA navigator shall contact the caregiver to
offer a POC for their newborn.
(2)
If the CC or another healthcare provider is informed of an exposure following
the newborn's discharge from the hospital or birthing facility, they shall
inquire if the caregiver has a POC. If not, they shall inform the caregiver of
the newborn that the CARA navigators may be notified using the notification of
CARA newborn status and may be contacting the caregiver to offer a POC for the
child.
J. Open CYFD case
or case needs to be opened:
(1) When hospital
staff or other providers who are involved in creating a POC with the family
have concerns about the safety of the newborn upon discharge, the individual
shall make a report to CYFD statewide central intake (SCI). The referral to SCI
shall be indicated on the POC when known by the professional completing the
POC. Upon receipt of a POC, the CYFD CARA navigator shall review if there is
current involvement of CYFD protective services with the parent or designated
caregiver of the newborn. The CARA navigator shall provide a copy of the POC to
assigned CYFD worker when CYFD involvement has been identified. The CARA
navigator shall also notify the designated CC of the newborn when there is an
investigation involving the caregiver(s) of the newborn. If the CC has concerns
around the safety of the newborn, they shall contact the CYFD worker and the
CARA navigators. If the CC or other providers have immediate concerns they
shall immediately make a report to the CYFD SCI and notify this is a family
that has an active POC.
(2) If a
newborn enters CYFD custody after a POC has been created, the POC shall be
modified by the CC or the CARA navigator to address the needs of the infant in
the new setting. The new POC shall contain the resource family's information
and shall be re-sent to all entities required to receive copies of the
POC.
K. Implementation of
the plan of care: Once the CC has been assigned and has met with the family,
the CC shall contact the newborn's primary care provider (PCP) and other
referred providers to ensure that referrals have been received and that the
provider has a copy of the POC as permitted by the release of information (ROI)
and informed consent signed by the caregiver. The CC shall periodically
communicate with the family and review the family's engagement with the
services on the POC. If the CC is unable to connect with the family and is not
able to confirm the newborn is established with a PCP, along with other
services, they will inform the CARA navigator, and follow an internal process
(within their MCO/agency) for potentially calling in a report to CYFD
SCI.
