Best Practices

1. Best Practices Outreach Management Case Management Expenses Management Common Mistakes

2. Outreach – overview • Incoming Referral • Eligibility • Preliminary Risk Assessment • Referrals and Follow ups • Contact Attempts • Initiate a Case

3. Outreach – Incoming Referral • Can be filled in by: • Outreach workers • Community Members • Self • Should have: • Minimum contact information • Preliminary Risk Assessment • Psychosocial • Medical • Preliminary Needs Assessment • Some services related questions

4. Outreach - Referrals • Psychosocial Referrals • Categories of referrals • Providers • Follow ups • Medical Referrals • Categories of referrals • Providers • Follow ups

5. Outreach – Reports • List of all outreach forms by • Outreach worker • Date • Risk Level • Status – Active, Closed with reasons, Initiated Case • Contact Attempts and their outcomes • List of Referrals, their Categories and Providers • List of Closed Referrals, their Categories and Providers with Follow ups • Productivity analyses by Outreach Worker

6. Outreach – Key to success • Small outreach form • Not very long list of Risk line items to screen • Easy to understand questions, so just not only outreach workers, but any community member or even family member should be able to fill it in • Outreach form should be unprotected online form • Record Contact Attempts and Follow ups

7. Case Management • Enrollment • Eligibility • Risk Assessment • Psychosocial • Medical • Needs Assessment • Referrals and Follow ups • Education

8. Case Management - Enrollment • Capture complete past and present contact details • As per the case type, ask questions • Do not ask questions related to Psychosocial and Medical Risk factors • Do not provide any education • Do not assess needs • Do not initiate referrals

9. Case Management – Risk Assessment • Psychosocial Risk line items • Referrals for the high Risk line items • Follow ups for the Referrals • Medical Risk line items • Referrals for the high Risk line items • Follow ups for the Referrals

10. Case Management – Needs Assessment • Family needs supplies, stocks of which are maintained by Healthy Start • Stock management system to effectively manage supplies

11. Case Management – Reports • List of all Cases by • Case Managers • Date • Risk Level • Status – Active, Closed with reasons • Contact Attempts and their outcomes • List of Referrals, their Categories and Providers • List of Closed Referrals, their Categories and Providers with Follow ups • Audit lists by case managers • HRSA – MCHB Reports for any period • Productivity analyses by Case Managers

12. Case Management – Key to success • Long enrollment form to record complete details • Exhaustive Risk Assessment to ascertain Psychological and Medical Risks • Exhaustive Referral and Follow up system integrated within Risk Assessment • Exhaustive Needs Assessment and Follow up system • Check compliance with HRSA – MCHB reports • Check compliance with Objectives • Exhaustive Auditing system • Exhaustive Reporting system • Client satisfaction survey • Employees satisfaction survey • Exhaustive Expenses management system

13. Expenses Management • Record time for every service to effectively measure expenses in providing services • Travel time and distance • Service time • Documentation time • Reports to get total number of hours

15. Case Management – Common Mistakes • While designing forms to collect data, we often forget what is required by HRSA – MCHB reports, however objectives are generally kept in mind. Some of the examples are: • Risk assessment may not cover all the risk line items in “Section B – Risk Reduction and Prevention Services” report • Prenatal care initiated may not get filled in, if there is no provision to collect this information on subsequent home visits

16. Common Mistakes – PM # 17 and 20 • Insurance should not be used to calculate access to Medical Home • A client with no primary insurance, can have access to Medical Home • Medical home should mean access to • OB GYN for Pregnant women • PCP for Interconceptional women • Pediatrician for Infants and babies

17. Common Mistakes – PM # 21 and 38 • When initiation of referrals are not from within Risk assessment tool, then it is possible to forget to refer the client for a high risk line item. • It is important to keep track of every referral and follow it up individually, to close every referral.

18. Common Mistakes – PM # 36 • Most of the times, date PNC initiated is asked at the time of enrolling a Prenatal Client. It is right to do so, but what if she has not started PNC as yet? Make sure to collect this information on subsequent visit(s) or Audit objection should be raised to alert the case managers to fill up this critical information • System should automatically calculate the Trimester PNC initiated from the date PNC Initiated, instead of case managers recording the Trimester PNC initiated to avoid mistakes.

19. Common Mistakes – PM # 39 • Make sure Risk Assessment is performed in the third trimester of pregnancy • If Risk Assessment cannot be done again in the third trimester, then adding a question about smoking in every encounter is a good idea • System should automatically calculate the total number of women, who smoked in the last 3 months of their pregnancy

20. Common Mistakes – PM # 50 - 51 • Birth weight should be part of Pregnancy Outcome (Birth Outcome) Record within a Prenatal Case • For every baby born to a program participant, separate Pregnancy Outcome (Birth Outcome) Record should be filled in

21. Common Mistakes – PM # 52 – 55 • Infant death form should be a separate form, not part of the Birth Outcome Record • Infant death form should be available from Pediatric cases also

22. Common Mistakes – PM # 81 • Breastfeeding question should be part of Pediatric Case encounter form, not Interconceptional case encounter form

23. Common Mistakes – Form 5 • Primary Insurance should be part of Enrollment form for a Case • Special Health Care needs should be assessed for every case type at the time of Enrollment • It is always a good idea to get a satisfaction survey filled in by every community participant

24. Common Mistakes – Section A • Total number of Family Members and Family Income should be recorded in cases, as opposed to in demographics • It should be an audit objection, if date PNC initiated is left blank on Enrollment form • Total number of PNC visits, since the last case manager visit, should be captured on every Prenatal Encounter, and not on Birth Outcome record • To differentiate between singleton and Multiple births, it is very important to record birth information of every baby on a separate birth outcome record • Maternal Death should be recorded on a separate form, and should be part of Interconceptional case

25. Common Mistakes – Section B • Even if screening services for the clinical risk line items are not provided by the case managers, but still it should be asked • Counseling and Money for the treatment are often ignored topics • Most of the times, referrals do not tie up with the risk line items • When for a risk line item, there is a separate screening tool, e.g. depression; it should be integrated within the risk assessment tool or case managers should check mark as an indication it is done. • While designing risk assessment tool, do not ignore local risk line items

26. Common Mistakes – Section C • Direct Health Care Services are generally ignored, as all the programs consider they are not providing it • Most of the line items under Enabling services are not captured, even though services are provided • Population services are often ignored, as programs consider they are not providing these services • Infrastructure Building services are also ignored in the same way as are Population services

27. Common Mistakes – Audit List • Include Audit Objections and Audit Alerts within Audit List • While designing period based audit objections, set the specifications in a way that after some time old objections should get deleted automatically