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Prenatal Care Coordination Services Handbook
Appendix 7

Medicaid Guidelines and Performance Measurements for Prenatal Care Coordination

The following pages provide guidelines with which prenatal care coordination (PNCC) agencies are required to comply when providing PNCC services. The document is divided into seven sections:

  1. Prenatal Care Coordination Administration.
  2. Pregnancy Questionnaire Administration.
  3. Care Plan Development.
  4. Ongoing Prenatal Care Coordination and Monitoring.
  5. Nutrition Counseling.
  6. Basic Health Information and Health Education.
  7. Postpartum Services.

Benefit guidelines are listed in the left-hand column of each page, while performance measurements are in the right-hand column. Wisconsin Medicaid uses the performance measurements to determine if the provider is complying with the benefit guidelines. If a guideline is not met, the provider is required to have written documentation that it has a reasonable alternative in place.

I. Prenatal Care Coordination Administration

Guideline
The provider must:		 Performance Measurement
I.A. Develop a plan which addresses the hiring and ongoing support and training of staff who can provide quality services that are family-centered and culturally appropriate. I.A. The provider's plan to hire, support, and train staff to provide services that are family-centered and culturally appropriate must be documented and available for review.

Documentation of staff training includes the name of the employee, date of training, and the employee's signature
I.B

Develop and implement an outreach plan to inform potentially eligible pregnant women about the availability of PNCC services. At a minimum, the plan must:

  • Identify the provider’s target population (for example, teens only, all eligible recipients in the county, recipients in specific ZIP codes).
  • Outline the strategies that will be used to inform eligible recipients, the local community, social service providers, schools, local health care providers, and other appropriate agencies and organizations about the availability of PNCC services.

Outreach efforts could also include community presentations, informational brochures, posters, billboards, television ads, or newspaper articles.

 I.B The provider is required to have an outreach plan available for review. The plan also must be specific to the target population and address strategies to inform eligible pregnant women about PNCC services.
I.C Establish written procedures to ensure that care coordinators include recipients, to the full extent of their ability, in all decisions regarding appropriate services and providers. I.C Written procedures that meet the stated guidelines are available for review.
I.D. Develop and implement internal policies and procedures for ensuring that quality services are provided in accordance with Medicaid rules. At a minimum, these policies and procedures address:
  • Patient confidentiality. These policies must include clear statements regarding the type of information that can be released, the time period for which the authorization is valid, and the agencies or individuals to whom the information can be released.
  • Accuracy, legibility, and completeness of records (for example, the accurate scoring of Pregnancy Questionnaires, the legibility of care plans and other written information, and documentation of all contacts with, or on behalf of, a recipient).
  • Procedures to ensure that priorities established in individual care plans are addressed in a timely manner.
  • Procedures to ensure that recipients are offered services that are sufficient in intensity. The procedures must include well-defined criteria for increasing or decreasing the intensity of services.
  • Procedures to ensure that timely and appropriate referrals are made and there is follow up on all referrals. Unless otherwise stated, follow up on referrals must be made within two weeks of the referral.
  • Ongoing staff training and support, including adequate supervision and support of paraprofessionals. Provide face-to-face supervision of paraprofessionals every 30 days, at a minimum.
  • Appropriate staff-to-client ratio. Ensure that care coordinators have an adequate amount of time to spend with each recipient. The number of clients per care coordinator will vary depending on the needs of the recipients on their caseload.
  • The provision of services by culturally competent staff.
  • The provision of services that are family centered.
  • Procedures to ensure that staff are following the provider’s policies and procedures for the provision of services.



The policies and procedures must clearly identify:

  • The staff responsible for oversight of the policies and procedures.
  • Steps for prioritizing, monitoring, and correcting problem areas.
 I.D.

Written policies and procedures that meet the stated guidelines are available for review. Documentation of all activities that meet the stated guidelines is also available for review. Provider records indicate paraprofessional supervision every 30 days, at a minimum.
I.E. Establish written procedures to ensure that a qualified professional reviews and signs all assessments completed by paraprofessional staff. I.E. The provider has written procedures requiring the review by and signature of qualified professionals of all Pregnancy Questionnaires completed by paraprofessionals.
I.F.

Develop a written plan for providing timely, non-disruptive, translator services for recipients who are hearing impaired and for recipients who do not speak or understand English.

If the provider does not have an interpreter on staff, the provider must maintain a current list of interpreters who are "on call" to provide interpreter services.

Do not use family members as interpreters when administering Pregnancy Questionnaires (PDF, 119 KB) or for the initial care plan development. Do not use children as interpreters.

 I.F. The provider has a written plan that meets the stated guidelines available for review. If the interpreter is not a staff member, the provider has a current list of "on call" interpreters available for review.
I.G. Develop written procedures for scheduling recipients for the initial assessment, initial care plan development, ongoing care coordination and monitoring services, and health and nutrition education, if appropriate. The schedule should allow adequate time with each individual to address her problems, develop a plan of action, and provide adequate education. If possible, schedule the initial assessment within 10 working days after the request for a service by a pregnant woman, or after receiving a referral.

The procedures must also include guidelines for staff regarding the time frame within which the initial contact must be scheduled after the Pregnancy Questionnaire and care plan are completed.		 I.G. Written procedures that clearly outline the provider’s plans for scheduling the initial assessment, the initial care plan development, and ongoing care coordination and monitoring services must be available for review.
I.H. Develop written procedures for following up with recipients who fail to keep appointments (care coordination, social service, prenatal or other appointments). Include time frames within which the recipient must be contacted and the steps designed to help the recipient keep future appointments. I.H.

Written procedures that meet the stated guidelines are available for review.
I.I.

Maintain a current list of appropriate community resources (for referral purposes). The list includes, but is not limited to, the following services and agencies:

  • Adoption.
  • AIDS/HIV.
  • Adult protective services.
  • Alcohol, tobacco, and other drug abuse.
  • Child welfare services.
  • Children with special health care needs program.
  • Day care centers.
  • Domestic/family violence.
  • Early childhood intervention programs (for example, Head Start, Birth to 3).
  • Education.
  • Employment/job training.
  • Family planning.
  • Food pantries/other food services.
  • Special Supplemental Food Program for Women, Infants, and Children (WIC) programs.
  • Housing and shelters for the homeless.
  • Legal assistance.
  • Social services (e.g., family/marriage counseling, family support services, clothing for newborns).
  • Parenting education (including fathers).
  • Perinatal loss/grief counseling.
  • Respite/family resource centers.
  • Transportation.



The list(s) must include the description of services offered, name of agency, address, telephone number, contact person, and any costs associated with the services.

 I.I. A current list of appropriate community resources - including, but not limited to, the services and agencies stated in the guidelines - and addresses, telephone numbers, and any associated costs is on file.
I.J. Establish working relationships (for the purpose of referrals) with key community agencies, social services providers, HMOs, and Medicaid primary care providers. If possible, develop written agreements that address the specific procedures to be followed for making referrals and for obtaining information on the outcome of the referrals from these agencies and providers. Ensure that staff are aware of these agreements.

Medicaid HMOs are required to sign a Memorandum of Understanding (MOU) with all PNCC providers in their service area.		 I.J. The provider’s file includes written agreements or documentation that show that the provider has made good faith efforts to develop effective working relationships with key health and social services providers. The provider has on file a current MOU with each HMO in the county.
I.K. Establish written procedures regarding the release of recipient-specific information. Recipients may sign a general release of information. However, providers must obtain specific approval to release sensitive information about the recipient.      I.K. The provider has written policies regarding the release of recipient-specific information. The policies specifically address the release of sensitive information.

II. Pregnancy Questionnaire Administration

The provider must administer the Medicaid-approved assessment tool (the Pregnancy Questionnaire) to determine eligibility for the benefit. The assessment tool is designed to identify the recipient’s strengths and needs. In addition to the Pregnancy Questionnaire, the provider may use any commercial or self-designed form to conduct a more detailed assessment.

Providers may consult the Guidance Manual for Administering the Prenatal Care Coordination Pregnancy Questionnaire for detailed information on administering the questionnaire. Refer to Appendix 16 for information on obtaining the Guidance Manual for the Pregnancy Questionnaire.

All recipients must have a completed copy of the Pregnancy Questionnaire in their file.

Note: The Pregnancy Questionnaire includes several questions to which the recipient may object. Prior to administering the Pregnancy Questionnaire, explain the assessment and care planning process, acknowledge the intrusiveness of some of the questions and explain why you need to ask the questions. If necessary, share your agency’s confidentiality policies with the recipient, including who will have access to the information provided.

Guideline
The provider must:		 Performance Measurement
II.A. Administer and score the Pregnancy Questionnaire in its entirety unless the recipient objects to a particular question or section, or the information is unavailable. II.A. The recipient’s file includes a completed and scored Pregnancy Questionnaire. If the questionnaire is not completed in its entirety, there is documentation that explains why.
II.B. Review and finalize the Pregnancy Questionnaire in a face-to-face meeting with the recipient. The staff completing the Pregnancy Questionnaire must sign and date it. A qualified professional must review and sign all Pregnancy Questionnaires completed by paraprofessional staff. II.B. The recipient’s file includes documentation that the Pregnancy Questionnaire was reviewed and finalized in a face-to-face visit. The Pregnancy Questionnaire is signed and dated. The recipient’s file also includes documentation that a qualified professional reviewed and signed all Pregnancy Questionnaires completed by paraprofessional staff.
II.C. Inform recipients who score 40 or more points on the Pregnancy Questionnaire that they are eligible to receive PNCC services.

If the recipient is not interested in receiving services, try to determine the reason. Give the recipient a written copy of the agency’s address and telephone number and ask the recipient to call or stop by if she changes her mind.		 II.C. The recipient’s file documents that the recipient was offered PNCC services.

If the recipient is not interested in receiving services, the reason is documented. The file includes documentation that the recipient received a written copy of the provider’s address and telephone number and was asked to call if she changes her mind about receiving services.
II.D. Inform recipients who score less than 40 points on the Pregnancy Questionnaire that they are not eligible to receive PNCC services.

Based on the recipient’s identified needs, refer her to other community resources as appropriate. Give the recipient a written copy of the agency’s telephone number and ask her to call or stop by if she has a significant negative change in her family, medical, social, or economic status while she is still pregnant.

Also, the provider may reassess the recipient if someone, such as a health care professional, a school, or a social worker, refers her back to the provider.

The provider may use the same Pregnancy Questionnaire if the reassessment or update is within 12 months of the initial assessment. Changes to the Pregnancy Questionnaire must be clearly identified (for example, use a different color of ink, cross out old response). Do not erase or totally obliterate the original response.

Re-sign and date the Pregnancy Questionnaire.		 II.D .  The recipient’s file includes documentation that the recipient was referred to other community resources as appropriate. The file also documents that the recipient was asked to contact the provider if she has a significant negative change in her family, medical, social, or economic status while she is still pregnant.

Changes to the Pregnancy Questionnaire are legible and clearly identified. The Pregnancy Questionnaire is signed and dated.
II.E. Use a new Pregnancy Questionnaire for assessments administered after 12 months of the initial assessment. II.E.  The recipient’s file includes a new Pregnancy Questionnaire if more than 12 months have elapsed since the initial assessment.

III. Care Plan Development

The Pregnancy Questionnaire must be completed prior to the development of the care plan. The provider is not required to use a specific care plan format. However, the care plan must be based on the results of the Pregnancy Questionnaire.

 
Guideline
The provider must:		 Performance Measurement
III.A. Develop a written individualized care plan for each recipient scoring 40 or more points on the Pregnancy Questionnaire. Develop only one care plan for each recipient. III.A. The recipient’s file includes an individualized care plan if the recipient scored 40 or more points on the Pregnancy Questionnaire.
III.B. Include the recipient in the development and any subsequent revisions of the care plan. Include family members and other supportive persons as appropriate.

The recipient and provider who developed the care plan must sign and date the plan.		 III.B. The recipient’s file includes documentation that the recipient and, when appropriate, the recipient’s family and other supportive persons actively participated in the development of the care plan.

The recipient and the provider have signed and dated the care plan.
III.C. Inform the recipient that the care plan can be changed at any time, and as often as necessary. Provide the recipient with information on how to request changes to the care plan, including the name and telephone number of the person to contact to initiate the change. III.C. The recipient’s file includes documentation of the stated guideline.
III.D. Ensure that the care plan includes the following:
  • Identification and prioritization of all strengths and problems identified during the initial assessment, including those related to health and nutrition education.
  • Identification and prioritization of all services to be arranged with the recipient, including the names of the service providers (including health care providers).
  • A description of the recipient’s informal support system, including collaterals, and activities planned to strengthen it if necessary.
  • Appropriate referrals and planned follow up.
  • Expected outcome of each referral.
  • Progress or resolution of identified priorities.
  • Documentation of unmet needs and gaps in service.
  • Planned frequency, time, and place of contacts with the recipient.
  • Identification of individuals who participated in the care plan development.
  • The recipient’s responsibility in the plan’s implementation.

If there are other care coordinators involved with the recipient, the care plan must address any needed collaboration or coordination. This requirement applies whether or not Medicaid covers the other care coordinators’ services. The recipient’s preferences concerning which care coordinator should provide services must be considered when the care coordinators’ roles overlap.

 III.D. The recipient’s file includes a care plan that meets the stated guidelines.
III.E. At a minimum, review and update the recipient’s care plan every 60 days or sooner if the recipient’s needs change. If necessary, update the recipient’s care plan during each visit.

All updates to the care plan must be signed or initialed and dated by the provider and the recipient.		 III.E. The recipient’s file includes documentation that the care plan was updated at least every 60 days. All updates to the care plan are signed or initialed and dated by the provider and the recipient.
III.F. Provide the recipient with the written name and telephone number of:
  • The person who will provide the ongoing care coordination services. If necessary, introduce the recipient to the care coordinator if he or she is different from the person who administered the assessment and developed the care plan.
  • The person to contact in urgent situations or as backup when the care coordinator is unavailable.
 III.F. The recipient’s file includes a copy of, or documentation stating that the provider gave to the recipient, written information identifying the name and telephone number of the care coordinator and of the person to contact as back-up.

Appendix 7 (more on next page)

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