Appendix D FORMS - WV DHHR · • To choose the agency which will provide services agreed upon. •...

Appendix D FORMS 101 – Vitamin/Iron Order Form ............................................................................................................... 1 R001A – Client Tracking Sheet ................................................................................................................. 2 R003 – Client Request for Records Release .............................................................................................. 3 R004 – Client Rights and Responsibilities ................................................................................................. 4 R004A – Spanish Client Rights and Responsibilities .................................................................................. 5 R006 – DCC Contact Letter #2 .................................................................................................................. 6 R006 – Spanish DCC Contact Letter #2 ..................................................................................................... 7 R007 – DCC Contact Letter #1 .................................................................................................................. 8 R007 – Spanish DCC Contact Letter #1 ..................................................................................................... 9 R009 – Provider Non-Enrollment Letter ................................................................................................. 10 R010 – Provider Enrollment Letter ......................................................................................................... 11 R011a – Service Care Plan ...................................................................................................................... 12 R011c – Service Care Plan Blank Form ................................................................................................... 13 R015 – Progress Notes ........................................................................................................................... 14 R019 – Alternate Entry Referral OF Infants/Prenatals to RFTS ................................................................ 15 R022 – Outcome Measures At Case Closure........................................................................................... 16 R025 – RFTS/WIC Participant Request for Information ........................................................................... 17 R036a – Initial Client Assessment – Prenatal .......................................................................................... 18 R036b – Initial Client Assessment – Infant ............................................................................................. 19 R038A – High Birth Score Referral and Tracking Form ............................................................................ 20 R039 – Provider Letter ........................................................................................................................... 21 R040 – Quality Assurance Report ........................................................................................................... 22 R041A – Regional Care Coordinators Time Sheet ................................................................................... 23 R041B – Regional Clerk Time Sheet ........................................................................................................ 24 R042 – DCC Contact Letter #3 ................................................................................................................ 25 R042 – Spanish DCC Contact Letter #3 ................................................................................................... 26 R060 – Enhanced Services Education Report.......................................................................................... 27 R065 – Edinburgh Postnatal Depression Scale ........................................................................................ 28 TS001 – Tobacco Screening Form .......................................................................................................... 29 TS002 – Tobacco Follow-up Form .......................................................................................................... 30 TS006 – SCRIPT Intervention Form ......................................................................................................... 31 Part A Designated Care Coordinators and Enhanced Services Providers ................................................. 32 Part B DCC Agency Caseload Projection ................................................................................................. 33 Infant Anticipatory Guidelines ............................................................................................................... 34 Prenatal Anticipatory Guidelines ........................................................................................................... 35 WV Birth Score – Development Risk Screen and Newborn Hearing Screen ............................................. 36 WV Prenatal Risk Screening Instrument ................................................................................................. 37 NICU Care Coordination Referral form ................................................................................................... 38 Designated Care Coordinator Training Certification ............................................................................... 39

DHHR/BPH/OMCFH/RFTS/101 Revised 8/2010

VITAMIN/IRON ORDER FORM Please forward orders to: Office of Maternal, Child and Family Health Right From The Start Program MATERIALS MANAGEMENT OFFICE 900 Bullitt Street Charleston, West Virginia 25301 (304) 558-3417 TOLL FREE: 1-800-642-8522 FAX: (304) 558-1524

ATTENTION

Orders are shipped via UPS. Street address is required. ALLOW NO LESS THAN A 2 WEEK LEAD TIME FOR PROCESSING AND DELIVERY OF YOUR ORDER. For inventory maintenance purposes, all orders must be submitted on form OMCFH/RFTS/101. NO EXCEPTIONS.

Provider Name: ___________________________________________ Provider Number: 5050__________________ STREET ADDRESS: ______________________________________________________________________________ _______________________________________________________________________________________________ Contact Person: __________________________________________ Telephone: _____________________________ Date: ______________________________ RFTS/101 Vitamin Request Forms: ________________ (Amount Requested)

CODE ITEM AMOUNT PER CASE CASES ON HAND

CASES ORDERED

QUANTITY APPROVED

M100 Prenatal Vitamins w/ Folic Acid

12 bottles/case 100 tablets/bottle

M150 Prenatal Iron 12 bottles/case

100 tablets/bottle

NOTE: We reserve the right to alter your request based on current inventory. Requested by: _____________________________________ Approved by: __________________________________ (County Health Office or Clinic Physician) (OMCFH) Please check expiration date on vitamins presently in stock. We recommend vitamin and iron supplies be rotated with attention to the date of expiration. Expired vitamins and iron should be returned to the Materials Management Warehouse. The Medicaid Program Regulation MA-91-07, issued July 1, 1991, allows for the coverage of the purchase of non-prescription prenatal vitamins and ferrous sulfate, gluconate, and fumarate. Under this allowance, a recipient of WV Medicaid card may receive vitamins and/or iron tablets from a pharmacy with a written prescription from their physician/provider. The policy of Right From The Start Maternity Services for the distribution of vitamins/iron is as follows: Give one bottle at the time of positive pregnancy determination or first OB visit to: 1) minors (19 years of age and under) 2) non-citizens 3) clients who have not yet applied for or been approved for Medicaid 4) clients denied Medicaid and not yet approved for Right From The Start Maternity Services As soon as a patient is enrolled in: Medicaid - provide her with a prescription for future vitamin/iron needs OMCFH - provide her with two (2) additional bottles of vitamins.

PLEASE RESERVE RIGHT FROM THE START MATERNITY SERVICES

SUPPLIES FOR THESE CATEGORIES OF OB PATIENTS ONLY!

OFFICE OF MATERNAL, CHILD AND FAMILY HEALTH RIGHT FROM THE START PROGRAM

CLIENT TRACKING SHEET

WVDHHR/BPH/OMCFBH/DPWH/PP/RFTS/ROO1A//6-2012

Enhanced Services Only Prenatal Infant Birth Score ID:

Name: Name: Last Name First Name (MI) Last Name First Name (MI) Name Change: Name Change: Last Name First Name

(MI) Last Name First Name (MI)

Prenatal SS#: SS#: Birthdate: Birthdate: EDC: Guardian’s Name: Change in EDC: Delivery Date: Guardian’s SS#:

Medicaid #: RFTS Maternity Services #: HMO Name: HMO #: Service Date: Face to Face: Yes No Place: Home Office Clinic Other:

S5190HD ASSESSMENT/SERVICE CARE PLAN Prenatal Only - 1 Per Case

T1016HD CARE COORDINATION (#15 Minute Units) Infant ( PHB Curriculum addressed)

Prenatal ( PHB Curriculum addressed) First 6 Months Months 7-12 1st Trimester Mo. 4 Mo. 5 Mo. 6 Mo. 7 Mo. 8 Mo. 9 1 2 3 4 5 6 7 8 9 10 11 12

Referrals to: Care Coordination:

A01 DHHR A14 Health Check C Monitoring Q Environment: Infant Stimulation A02 HUD A15 Birth to Three E Revise Plan/Assessment R Environment: Safety A03 WIC A16 Children’s Specialty Care F Birth Score S Well Child Care A04 Parenting Education A17 Family Planning G Advocacy T Acute Care For Infants A05 Preventive Self Care Ed A18 Genetics H Transportation U Newborn Hearing Screening A06 Childbirth Education A19 Nutrition J Financial: Infant Care Items V Baby Bottle Tooth Decay/Oral Health A07 Community Agency A21 Systems Point of Entry K Financial: Access to Phone W Tobacco Dependence Treatment A09 Medical Provider A22 CHIP L Financial: Utilities X Developmental Progress A10 Child Care A23 Other M Financial: Money Management Y Nutrition Assessment A11 School A24 WV Quitline N Environment: Adequate Housing Z Day One A12 Clergy BN F/U Missed Appointment O Environment: Safe Drinking Water AA Depression Screening A13 Law Enforcement BY F/U Kept Appointment P Environment: Electrical Circuitry AB Family Planning Education

ENHANCED SERVICES – PRENATALS ONLY – 1 SESSION PER DAY Progress Notes: Time: In Out

S9442HD CHILDBIRTH CLASSES A Maternal/Infant Development D Relaxation/Breathing Tech. B Nutrition/Fitness/Drugs E Postpatum/FamilyPlanning C Physiology of Labor/Delivery F Newborn Care/ Breastfeeding

S9444HD PARENTING EDUCATION

A Infant Care D Child Safety B Preventive Care E Newborn Development C S/S Acute Illness

S9445HD PREVENTIVE SELF CARE EDUCATION

A Physical/Emotional Changes E Breastfeeding B Warning Signs in Pregnancy F Contraceptive Care C Healthful Behaviors H Smoking Assessment D Eating Habits I Safety/Domestic Violence

S9452HD NUTRITIONAL EVALUATION/COUNSELING (RD only)

"I received a home visit by the DCC today." Client Signature:

DCC Signature:

Agency:

County:

A - COMPLETED PROGRAM

B-INCOMPLETE

B1. Spontaneous Abortion B9. Lost to Follow-up B2. Induced Abortion B10. Transferred Within Region B3. Moved Out-of-State B11. Did Not Meet Program Protocol B4. Transferred Out-Of-Region B13. Pre-term Delivery B8. Death B15. Closed by RCC

Original: DCC Copy: RCC Copy: Billing

OMCFH/RFTS-R003 White: DCC Revised: 8/2010 Yellow: RCC Pink: Client

WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES BUREAU FOR PUBLIC HEALTH


350 Capitol Street, Room 427 Charleston, West Virginia 25301-3714

Toll Free in WV: 1-800-642-8522

CLIENT REQUEST FOR RECORD RELEASE I, ____________________________________________________ do hereby request:

(Client’s Name)

To review my Right From The Start Program case record. A copy of my Right From The Start Program case record. A copy of my Right From The Start Program case record be released to:

___________________________________________________________ __________________________________ ___________________________________ Signature of Client Date Witness Date ______________________________________________ Title/Agency

OMCFH/RFTS-R004 White: DCC Revised:8/2010 Yellow:

RCC Pink: Client

Goldenrod: Medical Provider

RIGHT FROM THE START PROGRAM CLIENT RIGHTS AND RESPONSIBILITIES

NAME: ________________________________________ SSN: ______________________________________________ (Last) (First) (MI)

RIGHTS RESPONSIBILITIES • To receive professional treatment and consideration. • To participate in development of the care plan and

selection of services. • To choose the agency which will provide services

agreed upon. • To question any planned action. • To decline any or all services offered. • To withdraw from care coordination at any time without

penalty or loss of any other program eligibility. • To review or receive a copy of your RFTS records. • To participate in RFTS any time during the eligibility

period even if services have previously been refused.

• To keep all medical appointments. • To keep all appointments for other services identified in

the care plan and agreed upon by the client. • To obtain all medically-ordered laboratory procedures. • To report any change in address or telephone number. • To report any changes in health condition. • To report any changes in home environment which

affect health condition. • To provide Care Coordinator with a safe environment for

visits.

TO REPORT ANY PROBLEMS OR CHANGES, PLEASE CALL: _________________________________________________

If you believe you have been denied any of the above rights, you may contact the Right From The Start Program by phone at 1-800-642-8522 or mail at 350 Capitol Street, Room 427, Charleston, West Virginia 25301-3714.

CLIENT: I have read and understand my responsibilities and rights and do hereby give permission for my/my infant’s RFTS record to be

released by the Care Coordinator to agencies participating in my care. I also give my permission for agencies participating in

my/my infant’s care to release information to the RFTS staff.

______________________________________________________________________________________________________(Signature) (Date) DESIGNATED CARE COORDINATOR: I have reviewed the rights and responsibilities with this client.

______________________________________________________________________________________________________ (Signature) (Date) CAREGIVER PERMISSION I, ___________________________________________Parent/Guardian of _________________________________________

(Infant) give permission to ____________________________________________ to discuss and plan care for my infant in my absence (Designated Care Coordinator) with _________________________________________________. (Caregiver) ________________________________________________________________________________________ (Parent/Guardian Signature) (Date) ________________________________________________________________________________________ (Designated Care Coordinator Signature) (Date) COMMENTS:___________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

*Please identify additional person/persons who may be caregivers.

WVDHHR/BPH/OMCFH/RFTS-R004-A Blanco: DCC

Revisado: 11/08 Amarillo: RCC Rosa: Client

Oro: el Proveedor Médico

PROYECTO DERECHO DESDE EL PRINCIPIO WEST VIRGINIA DEPARTAMENTO DE SALUD Y RECURSOS HUMANOS

DERECHOS Y RESPONSABILIDADES DE LA CLIENTE

NOMBRE: SSN: ________________________________________________ (Last) (First) (MI)

DERECHOS

RESPONSABILIDADES Recibir tratamiento y consideración profesionales. Participar en el desarrollo del plan de cuidado y en la

selección de servicios. Elegir la agencia que proveerá los servicios seleccionados. Dudar de cualquier acción planificada. Rechazar todo o cualquier servicio. Quitar la coordinación de cuidado a toda hora sin pena y sin

perder elegibilidad de cualquier otro programa. Rever or recibir una copia de sus récords. Participar a toda hora durante el período elegible aunque haya

rechazado los servicios de antes.

Quedarse con toda cita médica. Quedarse con toda cita por otros servicios identificados en el

plan de cuidado y seleccionados por la cliente. Obtener todas las pruebas médicas pedidas. Informarnos de cualquier cambio de señas o de número de

teléfono. Informarnos de cualquier cambio en su condición médica. Informarnos de cualquier cambio en su ambiente casera que

afecte su condición médica. Para proveerie a la trabajadora – Care Coordinator – un

ambiente seguro para las visitas.

PARA INFORMARNOS DE PROBLEMA O CAMBIO, POR FAVOR LLAME: ____________________________________________ Si cree que se le ha negado cualquier de estos derechos, puede hablar con el Proyecto Derecho Desde El Principio por teléfono a 1-800-642-8522 o por correo a 350 Capitol Street, Room 427, Charleston, West Virginia 25301-3714.

CLIENTE: He leído y entiendo mis responsabilidades y derechos y desde ahora permito que mi récord de Derecho Desde El Principio o el récord de mi niño sea mandado por el Coordenador de Cuidado a las agencias que particpan en mi cuidado. __________________________________________________________________________________________________________ (Firma) (Fecha) COORDENADOR DE CUIDADO DESIGNADO: He revisto los derechos y responsabilidades con esta cliente. __________________________________________________________________________________________________________

(Firma) (Fecha)

PERMISO PARA CUIDANIÑOS Yo, ______________________________________________ Padre/Guardian de ___________________________________________,

(Niño)

permito que ____________________________________________________________ hable de y planifique el cuidado de mi niño en (Coordenador de Cuidado Designado)

WVDHHR/BPH/OMCFH/RFTS-R004-A Blanco: DCC

Revisado: 11/08 Amarillo: RCC Rosa: Client

Oro: el Proveedor Médico

mi ausencia con ___________________________________________. (Cuidaniños)

__________________________________________________________________________________________________________ (Firma de Padre/Guardian de) (Fecha) ________________________________________________________________________________________________________________________ (Firma de Coordenador de Cuidado Designado) (Fecha)

COMMENTS: *

________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

________________________________________________________________________________

*Por favor identifique otra(s) persona(s) que le(s) permite ser cuidaniños.

OMCFH/RFTS-R006-DCC Contact Letter #2 White: Client Revised: 6/2011 Yellow: DCC

Earl Ray Tomblin Governor

Michael J. Lewis, M.D. Ph.D. Cabinet Secretary

STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES

RIGHT FROM THE START PROGRAM

______________________________ (Date) Dear ________________________________: You recently received a letter about the Right From The Start Program’s free services for you and your baby. Social workers and nurses from the Right From The Start Program can offer pregnant women and their babies resources and services to help keep them healthy. Right From The Start may be able to assist you with housing needs, transportation to doctor’s appointments, health care, items for your baby and WIC (Women’s, Infants and Children Program) benefits. The Right From the Start Program has information about:

• how being pregnant may make you feel bad • how your body changes when you’re pregnant • things that shouldn’t happen during pregnancy (like having contractions before your due date) • baby blues • how to tell when things are not normal • how to tell if your baby is sick • easy ways to take care of your baby • colic • how to tell if your baby has a fever • when to call your or your baby’s doctor

All Right From The Start Program services are free and offered in your home or at some other place of your choosing. Pregnant women and new moms decide the services they want. There is also information available for dads. Having a baby can be a happy event. But at times, taking care of a baby can be very hard. Having someone to talk with and to offer ideas may make things easier. Please call or email me to let me know if you would like services from the Right From The Start Program. Sincerely, Designated Care Coordinator

________________________________ DCC Name (Please Print)

________________________________ Agency

________________________________ Agency Address

________________________________

________________________________ Telephone/Email

OFFICE OF MATERNAL, CHILD AND FAMILY HEALTH Bureau for Public Health

350 Capitol Street, Room 427 Charleston, WV 25301-3714

Phone: (304) 558-5388 Toll-Free (in WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-7164

OMCFH/RFTS-R006-DCC Contact Letter #2 White : Client Revised: 6-2011 Yellow: DCC



ESTADO DE WEST VIRGINIA EL DEPARTAMENTO DE SALUD Y LOS RECURSOS HUMANOS

PROGRAMA DESDE EL PRINCIPIO

______________________________ (Fecha/Date) Estimada ________________________________: Recientemente le mande una carta sobre el program Desde el Principio y come puede obtener ayuda valde para usted y su Bebé. West Virginia tiene asistentes sociales y enfermeras que pueden ofrecer a las mujeres embarazadas y a sus bebés ayuda en mantenerlos sanos. Estas enfermeras y asistentes sociales pueden asistir en encontrar cosas que usted puede necesitar como WIC, un lugar para vivir, maneras para conseguir al doctor, cosas para su bebé y cuidado médico. Pueden ayudarle a aprender:

• cómo estando embarazada puede hacerle sentir mal • cómo su cuerpo cambia cuando usted está embarazada • cosas que no deben suceder durante el embarazo (como tener contracciones antes de su fecha debida) • depresión postparto • sabiendo cuándo las cosas no son normales • sabiendo si su bebé esta enfermo • maneras fáciles de tomar cuidado de su bebé • colico • cómo saber si su bebé tiene una fiebre • cuándo debe de llamar al medico

Estos servicios, llamados “Desde el Principio,” son gratis y pueden visitarle en su hogar o en otro lugar. Las mujeres embarazadas y las nuevas mamás consiguen eligenlos servicios que ellas quieren. Hasta hay información disponible para los papás. Me gustaría hablar con usted del programa Desde el Principio. Tener un bebé puede ser un tiempo muy feliz, pero puede ser realmente duro. Tener a alguien con quien hablar y para ofrecer ideas puede a veces hacer cosas más fáciles. Por favor llámeme o envíe por correo electrónico y déjeme saber independientemente si usted quiere usar el programa Desde el Principio. Sinceramente, ________________________________ Designated Care Coordinator


________________________________ Agency

________________________________ Agency Address

________________________________ Telephone/Email

OFICINA DE LA SALUD MATERNAL, DEL NIÑO Y DE LA FAMILIA

Oficina para la salud pública 350 Capitol Street, Room 427 Charleston, WV 25301-3714

Telephono: (304) 558-5388 Gratis (en WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-7164






________________________________

(Date) Dear : Having a baby can be a very happy time, but can also be really hard. Having someone to talk to and offer ideas can sometimes make things easier. West Virginia has social workers and nurses who can offer pregnant women and their babies help to keep them healthy. These nurses and social workers can help you find things you may need like WIC, a place to live, a way to get to the doctor, things for your baby and health care. They can help you learn about:

• how being pregnant may make you feel bad • how your body changes when you’re pregnant • things that shouldn’t happen during pregnancy (like having contractions before your due date) • baby blues • how to tell when things are not normal • how to tell if your baby is sick • easy ways to take care of your baby • colic • how to tell if your baby has a fever • when to call your or your baby’s doctor

These services, called Right From The Start, are free and can be held in your home or at some other place. Pregnant women and new moms get to choose which services they want. There is even information available for dads. Helping West Virginia’s pregnant women and babies stay healthy is our goal. We hope to hear from you so we can talk about what services you may like to have. Please call or email me to let me know whether or not you want Right From The Start. Sincerely, Designated Care Coordinator

_________________________________ DCC Name (Please Print)

______________________________________ Agency

______________________________________ Agency Address

______________________________________

______________________________________ Telephone/Email

OFFICE OF MATERNAL, CHILD AND FAMILY HEALTH Bureau for Public Health

350 Capitol Street, Room 427 Charleston, WV 25301-3714


OMCFH/RFTS-R007-DCC Contact Letter #1 White: Client Revised: 6-2011 Yellow: DCC





________________________________

(Fecha/Date) Estimada : Tener un bebé puede ser un tiempo muy feliz, pero puede también ser realmente duro. Tener alguien con quien hablar y que le ofrezca ideas puede a veces hacer cosas más fáciles. West Virginia tiene asistentes sociales y enfermeras que pueden ofrecer a las mujeres embarazadas y a sus bebés ayuda en mantenerlos sanos. Estas enfermeras y asistentes sociales pueden asistir en encontrar cosas que usted puede necesitar como WIC, un lugar para vivir, maneras para conseguir al doctor, cosas para su bebé y cuidado médico. Pueden ayudarle a aprender:

• cómo estando embarazada puede hacerle sentir mal • cómo su cuerpo cambia cuando usted está embarazada • cosas que no deben suceder durante el embarazo (como tener contracciones antes de su fecha debida) • depresión postparto • sabiendo cuándo las cosas no son normales • sabiendo si su bebé esta enfermo • maneras fáciles de tomar cuidado de su bebé • colico • cómo saber si su bebé tiene una fiebre • cuándo debe de llamar al medico

Estos servicios, llamados “Desde el Principio,” son gratis y pueden visitarle en su hogar o en otro lugar. Las mujeres embarazadas y las nuevas mamás eligen los servicios que ellas quieren. Hasta hay información disponible para los papás. Ayudando Las mujeres embarazadas y los bebés de West Virginia quedarse sanos es nuestra meta. Esperamos oír de usted para hablar de qué servicios usted puede usar. Llámeme o envíe por correo electrónico por favor dejerme saber independientemente si usted quiere usar el programa Desde el Principio. Sinceramente, ________________________________ Designated Care Coordinator


________________________________ Agency

________________________________ Agency Address

________________________________ Telephone/Email

OFICINA DE LA SALUD MATERNAL, DEL NIÑO Y DE LA FAMILIA

Oficina para la salud pública 350 Capitol Street, Room 427 Charleston, WV 25301-3714


OFFICE OF MATERNAL, CHILD AND FAMILY HEALTH

Bureau for Public Health 350 Capitol Street, Room 427 Charleston, WV 25301-3714

Phone: (304) 558-5388 Toll-Free (in WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-7164 OMCFH/RFTS-R009-Provider Non-Enrollment Letter White: Provider Revised: 6/2011 Yellow: RCC




RIGHT FROM THE START PROGRAM _______________________________ (Date) Dear Provider:

This is to inform you that your client, _________________________________________

will not be receiving care coordination at this time for the following reason(s):

∼ Does not meet eligibility requirements.

∼ Past EDC

∼ No Care Coordination Provider available. (Will assign as provider becomes

available.)

∼ Refused

Please call if you have questions or concerns.

Sincerely,

___________________________________

Regional Care Coordinator Agency Name: __________________________

Address: _______________________________

______________________________________

Agency Telephone: ______________________



Phone: (304) 558-5388 Toll-Free (in WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-7164 OMCFH/RFTS-R010-Provider Enrollment Letter White: Provider Revised: 9-2011 Yellow: DCC





___________________________________________ (Date)

RE: ____________________________________ (Client Name)

____________________________________

(Social Security Number)

Dear Provider:

The State of West Virginia provides money so that social workers and nurses from local health departments, community health centers and other community agencies can offer pregnant women and their newborns support services to improve well-being. These nurses and social workers are knowledgeable on how to locate community resources, depending on the need, such as WIC, housing assistance, transportation to doctor appointments, infant care items and the availability of medical care. They offer information on pregnancy discomforts and body changes that occur during pregnancy. They can help the pregnant woman learn to recognize warning signs of such complications as preterm labor, postpartum blues and when to call their doctor. The nurses and social workers also offer parenting support and information on baby care such as colic, dealing with a fever and how to determine if the baby is sick.

These services, called Right From The Start, are provided at no cost to the family and are offered

in the family’s home or other setting. Pregnant women or new moms who participate in Right From The Start choose which services they want. There is even information available for dads.

The above referenced client has been evaluated and is eligible for Right From The Start services. With the assistance of the client, a service plan has been developed for management of the client’s needs. Should you wish to recommend any modifications to the service plan at any time, please call me at the number listed below. Sincerely,

Designated Care Coordinator

____________________________________ Phone Number

____________________________________ Agency Name

____________________________________ Address

____________________________________ City, State & Zip

Enclosure

OMCFH/RFTS-R011A White: DCC Revised: 12-2011 Pink: RCC Yellow Client Goldenrod: Provider


SERVICE CARE PLAN

Closure Date: Closure Code: A

B

CLIENT NAME MEDICAID NO. SOC. SECURITY # PRENATAL (Last) (First) (MI)

INFANT

IDENTIFIED NEEDS Prenatal DCC Client Infant DCC Client

Childbirth education Parenting education Obstetrical care Pediatric care Parenting education Nutrition WIC Anticipatory guidance Anticipatory guidance Safety Safety DCC/guardian trusting relationship DCC/Client trusting relationship Coordination of services Coordination of services Transportation to medical appointments Transportation to medical appointments Infant care items Choose method of infant feeding Please List Others Infant care items

Please list others:

GOALS TO BE COMPLETED TO MEET IDENTIFIED NEEDS TARGET DATE

COMPLETED DATE Prenatal Infant

To have a full term, healthy pregnancy To promote optimal infant health to age one year To choose a family planning method To ensure safety To provide parenting education To educate on coping skills To provide anticipatory guidance To educate about sign/symptoms of maternal depression To obtain postpartum care To provide parenting education To assist with locating resources To provide anticipatory guidance To provide benefits of breast vs. bottle feeding To assist with locating resources To establish trusting DCC/client relationship To establish trusting DCC/guardian relationship

Please list others: Please list others

ACTIVITIES TO BE COMPLETED TO MEET GOALS TARGET DATE

COMPLETED DATE Prenatal Infant

Client will: Client will: Keep all doctor appointments Choose a doctor and keep appointments Keep all WIC appointments Keep all WIC appointments Eat a nutritious diet recommended for pregnancy Get all immunizations according to schedule Remain tobacco, alcohol and drug free Maintain diet recommended for age Maintain a smoke free environment Provide a smoke free environment Recognize signs/ symptoms of pre-term labor Practice safe sleeping Maintain safe environment Provide safe care during feeding, changing and transportation Report any health concerns to DCC and physician Bond with infant and provide adequate stimulation for growth and development Keep Medicaid card and HMO current Recognize signs/symptoms of illness and seek medical care

DCC will: Report any health concerns to DCC and physician Screen for depression and help client recognize signs/symptoms DCC will: Promote oral health Promote oral health Teach about components of adequate prenatal care Promote mother/infant bonding Provide education on labor and delivery Make referrals as needed Provide education on family planning choices Establish trusting DCC/client relationship Make referrals as needed Please list others: Establish trusting DCC/client relationship

Please list others: Copy of completed, signed and dated Service Care Plan to be given to client on the date client signs the plan. __________________________________________________________________________________________________________________________________________ Client Signature Date DCC Signature Date Service Care Plan Revision: __________________________________________________________________________________________________________________________________________ Client Signature Date DCC Signature Date

OMCFH/RFTS-R011C-Blank White: DCC Revised: 12/2011 Pink: RCC Yellow Client Goldenrod: Provider


SERVICE CARE PLAN Closure Date: Closure Code: A B

CLIENT NAME MEDICAID NO. SOC. SECURITY # PRENATAL

(Last) (First) (MI)

INFANT

IDENTIFIED NEEDS

Prenatal DCC Client Infant DCC Client

GOALS TO BE COMPLETED TO MEET IDENTIFIED NEEDS TARGET

DATE COMPLETED

DATE Prenatal Infant

ACTIVITIES TO BE COMPLETED TO MEET GOALS TARGET DATE

COMPLETEDDATE Prenatal Infant

Copy of completed, signed and dated Service Care Plan to be given to client on the date client signs the plan. __________________________________________________________________________________________________________________________________________ Client Signature Date DCC Signature Date Service Care Plan Revision: __________________________________________________________________________________________________________________________________________ Client Signature Date DCC Signature Date

Office of Maternal, Child and Family HealthRIGHT FROM THE START PROGRAM

Progress Notes

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R015-Progress Notes(Savable) Revised 5-12 DCC-Original/RCC-Copy

MI

*DCC Signature required for each entry

Prenatal Infant

Name: DCC:

SSN: Agency:

Date Time In/Out Comments

First TitleLast

*SEPARATE FORMS FOR MULTIPLE BIRTHS White:RCC OMCFH/RFTS-R019 Yellow:DCC Revised 5-2012 (Infants only) Pink:HMO

Goldenrod:RCC

RIGHT FROM THE START PROGRAM ALTERNATE ENTRY REFERRAL OF INFANTS/PRENATALS TO RFTS*

*Infant's Name: _________________________________ (Last) (First) (MI)

SSN: _________________________________________

Birth Score ID #: ____________________________________

Hospital of Delivery:_______________________________________

*Date of Birth: ____/___/_____ Sex: Female Male

Birth Weight: ___________ Birth Score: _____________

*Mother/Guardian Name: _____________________________

Address: __________________________________________

__________________________________________________

Mother/Guardian SSN: _______________________________

Mother/Guardian DOB: __________ County: _____________

Telephone: ________________________________________

Medicaid Number: __________________________________

Child Mother/Guardian Effective Date: ___________

HMO Plan: _________________________________________

HMO No.: __________________________________________

Effective Date: _____________________________________

Name & Address of Physician:________________________

__________________________________________________

__________________________________________________

Telephone: ________________________________________

Concerns: _________________________________________

__________________________________________________

__________________________________________________

Newborn Hearing Screening Pass Fail Unknown

*Prenatal Name: _____________________________________ (Last) (First) (MI)

SSN: ______________________________________________

Address: ___________________________________________

___________________________________________________

Telephone: _________________________________________

*Date of Birth: _____/_____/_____

EDC: ____/______/______

County: ___________________________________________

RFTS Maternity Services Medicaid Insurance

RFTS/Medicaid No.: ________________________________

Effective Date: ______________________________________

HMO Plan: _________________________________________

HMO No.: __________________________________________

Effective Date: ______________________________________

Name & Address of Physician:

___________________________________________________

___________________________________________________

___________________________________________________

Telephone: _________________________________________

Concerns: __________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________ Referral Closure Codes (For DCC Use) Date:______________ B-01 Spontaneous Abortion B-06 Unable to Establish contact B-02 Induced Abortion B-07 Refused Services B-03 Moved out of state B-08 Death B-04 Transferred out of region B-14 Did not meet eligibility

Protective Service Referral: _________________________________ Case Worker: ___________________________________

Referred to RFTS by: ___________________________________________________ Date: ______________________________

Site: _________________________________________________________________ Telephone: _________________________

Date Received: ___________________________________________ Date of Approval: ________________________________

Referred to (DCC Agency): __________________________________________________________________________________

Recommendations: ________________________________________________________________________________________

Signature: _________________________________________________________ Date: ________________________________ (Regional Care Coordinator)

DCC is to return a copy of form to RCC with appropriate code checked if unable to complete the Initial Client Assessment (R036) * Required fields

OMCFH/RFTS-R022 White - DCC Revised 6-2012 Yellow - RCC

Pink - Provider


OUTCOME MEASURES AT CASE CLOSURE

__________________________________________________________________________________________________________ *Last Name *First Name (MI)

_________________________________________________ *Birthdate: __________________ *Social Security No. (Mother) *Coverage Type: Medicaid

*Medical Card No.: ______________________________________ RFTS Maternity Services HMO PRENATAL OUTCOME MEASURES AT CASE CLOSURE Closure: Complete Incomplete *PHYSIOLOGY OF LABOR AND DELIVERY Delivery Date: _________ Maternal complications during labor and delivery: Yes No

List:____________________________________________________

If yes, did patient deliver at a Tertiary Care Center? Yes No

*NUTRITION/FITNESS/DRUGS Maternal Alcohol and/or Drug Abuse: Yes No Gestational Diabetes Yes No

Did patient miscarry? Yes No *POSTPARTUM CARE Kept postpartum appointment Yes No Referred: ___________________________________________________

*CONTRACEPTIVE CARE Did the mother start a method of birth control after delivery? Yes No If no, Family Planning Referral: Yes No

Referred to:_________________________________________________

*SMOKING CESSATION (Self reported) Remained quit Yes No ETS exposure at closure Yes No Referred to WV Quitline Yes No

Infant 1 Female Male Infant 2 Female Male Infant 3 Female Male Infant 4 Female Male

Vag C-S VBAC Gest. Age (Wks) Birth Defects Yes No NICU Stay # Days: ______ Infant Death

Vag C-S VBAC Gest. Age ________(Wks) Birth Defects Yes No NICU Stay # Days: ______ Infant Death

Vag C-S VBAC Gest. Age ________(Wks) Birth Defects Yes No NICU Stay # Days: ______ Infant Death

Vag C-S VBAC Gest. Age _______(Wks) Birth Defects Yes No NICU Stay # Days: ______ Infant Death

Did the mother breastfeed at hospital discharge? Yes No Breastfeeding at closure? Yes No Number of weeks breastfed: <1 1-6 7+




Was the infant’s birth weight: Very Low Birth Weight <1500 gm Low Birth Weight 1500-2500 gm

Normal Birth Weight >2500 gm Weight: ______________(lbs/ozs) ______________(Grams)







Type of Infant Risk Score? Low Birth Score < 99 High Birth Score > 100 Developmental Risk Hearing Impairment




Use of safety seat for infant transport: Yes No




INFANT OUTCOME MEASURES AT CASE CLOSURE Closure: Complete Incomplete

*WELL CHILD CARE

Has child kept 5 well child visits with Pediatric Care Provider? Yes No Immunizations up to date: Yes No If no, referred: Yes No CHIP referral Yes No PCP at closure Yes No If no, referred Yes No

*SAFETY Does mother use a child safety seat to transport child? Yes No

*NICU STAY Yes No

Tertiary Care Center: __________________________________________

*BREASTFED Months <1 1-6 7+

DCC Signature: _________________________________________________________________ *Service Date: __________________________ Agency: _______________________________________________________________________ *County: ______________________________ (Do not complete on client transfers – DCC who receives transferred case to complete upon case closure)

* Required Fields

OMCFH/RFTS-R025 White: WIC Revised: 3/2012 Yellow: DCC Pink: RCC

RIGHT FROM THE START PROGRAM RFTS/WIC PARTICIPANT REQUEST FOR INFORMATION

(TO BE COMPLETED BY THE RIGHT FROM THE START DESIGNATED CARE COORDINATOR)

PRENATALS

Participant Name: ____________________________________________ Last Name First Name (MI)

Participant Address: __________________________________________

____________________________________________________________

INFANTS

Parent's Name: ______________________________________________ Last Name First Name (MI)

Parent's Address: ____________________________________________

SPECIFIC INFORMATION REQUESTED

Diet History

24 Hour Recall

Height/Length

Weight

Hemoglobin/Hematocrit

Head Circumference

Birth Weight

Weight Gain During

Pregnancy

Pre-Pregnancy Weight

Verification of Appointments

Current Status as WIC

Participant

Breastfeeding Status

____________________________________________________ ______________________ Signature - RFTS Designated Care Coordinator Date

PLEASE SEND REQUESTED

INFORMATION TO

____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________

(For completion by WIC Staff)

Check if verbal request ______________________________ Date request received

____________________________________________ ______________________________

Signature of WIC Staff Date responded to request

WVDHHR/BPH/OMCFH/DPWH/RFTS/R036a – Initial Client Assessment Prenatal/Revised 9-19-2011 Page 1

Right From The Start Program Initial Client Assessment – Prenatal

Name: Last First MI Date of Birth: Age: Social Security #:

Address: Street City State Zip Code

County of Residence: Telephone #: Alternate #: Current Address: (if not staying at home) Street City Zip Code

Directions to home:

Race: White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Ethnicity: Hispanic/Latino Not Hispanic/Latino (Check all that apply)

U.S. Citizen: Yes No

Marital Status: Single Married Separated Widow Divorced

Employed: Yes No Medicaid/RFTS Maternity Services/HMO Name & Number:

OB Provider Name & Number:

Emergency Contact: Telephone #: Relationship to Client:

Address: Street City Zip Code

PREGNANCY HISTORY Gravida Para #Abortions (insert # in box) # Living Children Past Deliveries (insert # in box) Spontaneous: Vaginal: VBAC: C-Section:

Induced: Reason for C-Section:

Complications with Past Deliveries:

CURRENT PREGNANCY

Estimated Date of Delivery (EDD): Trimester for initial prenatal visit: 1st 2nd 3rd Present illness (non-pregnancy related):

Current Medications (prescription or OTC):

MEDICAL HISTORY

Illness/Disease Yes No Assistance Needed Referred To Diabetes

Gestational Diabetes

History of Gestational Diabetes

Heart Disease/Defect

Birth Defect

Physical Impairment/Disability

Mental Impairment/Disability

High/Low Blood Pressure

Seizures

Stressful Life Event

STDs

History or Risk of Depression

History of Postpartum Depression

History Psychiatric Illness

Past Date: Diagnosis:

Present Date: Diagnosis:

Therapist:


MATERNAL LEGAL HISTORY Issue Yes No Assistance Needed Referred To

Is client a minor? If yes, who is your legal guardian?

CPS Involvement? Past Current Self Child(ren)

Describe:

Involvement with criminal justice system? If yes, Past Current

Self Partner Other

Describe (charges, dates, findings, incarceration, probation):

EDUCATION

Issue Yes No Assistance Needed Referred To Currently in school?

Name of School: Purpose:

Years of school completed (list number in box): 1-12 12+

Degree obtained: GED High School Diploma Certification College Degree

Learning Style: Visual Auditory Tactile Unknown

Special Education History:

Future Education Plans:

Employment Goals:

SUPPORT SYSTEM Father of Baby: Last First MI

Age: Supportive: Yes No Living with Client: Yes No

Other household members:

Name Age Relationship to client

Other Support:

Children living outside home:

Name Age In custody of

LIVING ARRANGEMENTS Where client lives √ Monthly Expenses √ Amount Total monthly family income √ Amount

Own Home House Payment Employment

Mobile Home Rent Payment Disability

Apartment Utilities Child Support

Public Housing Loans Spousal Support

Foster Home Car Payment Food Stamps

Parent’s Home Other Loans

Friend’s Home Settlement

Shelter None

Homeless Other

Other


ENHANCED SERVICES - NUTRITION

Issue Yes No Assistance Needed Referred To Med. condition requiring dietary modification

Nausea/Vomiting

Non-food cravings (if yes, list below)

(Type):

Frequently skips meals/fasts/binges

Bulimia/Anorexia or History

Food allergy or intolerance

Prior nutritional counseling

Dental impairment affecting diet

ENHANCED SERVICES – PREVENTIVE SELF CARE/CHILDBIRTH EDUCATION

Issue Yes No Assistance Needed Referred To Poor previous pregnancy experience

Significant apprehension/anxiety

Poor pregnancy information

Lack of knowledge of risk factors

Lack of knowledge of prescribed Tx

Non-compliant with prescribed Tx

Unrealistic expectations for infant

Desires parenting/infant care education

Desires information on infant development

Non-stimulating environment for infant

Desires childbirth education

HOME/FAMILY NEEDS ASSESSMENT

Issue Yes No Assistance Needed Referred To Adequate housing

Safe neighborhood

Adequate space

Heating/cooling adequate

Environmental Tobacco Smoke

CPR Training

Transportation

Bathtub/Shower

Hot water

Concern about unsafe water (if yes, list below)

(Concerns):

Toilet Facilities

Enrolled in WIC

Safe Crib/Bedding

Baby care items needed

Working fire extinguisher

Working smoke detector

Working Carbon Monoxide Detector

Fire escape plan

Refrigerator

Cooking facilities

Telephone access

Washer/Dryer

Pets (explain dangers of cat litter)

Child care plan (if no, refer)

Adequate support system

Service providers in home (if yes, list below)

(Service providers in home):


HOME/FAMILY NEEDS ASSESSMENT – Con’t Issue Yes No Assistance Needed Referred To

Bed sharing

Risks explained

Co-sleeping (room sharing)

Concern about mother’s feelings regarding pregnancy/parenting/infant

Unplanned Unwanted Ambivalent Happy Nervous

Concern about biological father/partner’s feelings regarding pregnancy/parenting/infant

Accepting Denying Rejecting Unable to assess Happy

Recent loss of partner

Abandonment Separation/divorce Death Other

Current conflict in home

Parent(s) Partner Other

Dysfunctional family relations

Abuse in past year

Physical Verbal Sexual Other

Religious/ethnic/cultural factors affecting pregnancy outcome

Two (2) or more preschool children in home

Poor/ineffective parenting

Difficulty budgeting money/food stamps

Handicapped/disabled family member

Illiteracy (self)

Illiteracy (partner)

Smoker

CPD: SCRIPT presented: Yes No SCRIPT Refused:

CO level obtained

Refused CO Breathalyzer:

2nd hand smoke exposure

Current medications

Alcohol/Drug use (If yes, describe)

(Describe):

Special needs for child(ren)

Adequate food

Past surgery(ies)

OTHER REFERRALS/NOTES

DCC Signature: Title: Agency: Region: Date:

Please remember to forward a signed copy to RCC.

WVDHHR/BPH/OMCFH/DPWH/RFTS/R036b – Initial Client Assessment Infant/Revised 9-19-2011 Page 1

Right From The Start Program Initial Client Assessment – Infant

Name: Last First MI Date of Birth: Male Female Social Security #:


County of Residence: Telephone #: Alternate #:

Current Address: (if not staying at home) Street City State Zip Code

Directions to home:

Medicaid/HMO Name: Medicaid/HMO #:

Birth Score (high or low):

U.S. Citizen: Yes No

Race: White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Ethnicity: Hispanic/Latino Not Hispanic/Latino (Check all that apply)

Birth Weight:

Birth Score ID:

Apgar: 1 min. 5 min. Gestational Age (#wks)

Birth Facility:

Parent/Guardian Last First MI If not parent, relationship to infant:

Pediatrician Phone#:

Name of Emergency Contact: Telephone #: Relationship to Client:


Father of infant: Last First MI Age: Living with client

MEDICAL HISTORY

Issue Yes No Assistance Needed Referred To

Illnesses/Conditions:

Respiratory Distress

Hyperbilirubinemia

Seizures

IVH

Visual Impairment

Hearing Impairment

Herpes

Chlamydia

Hepatitis

HIV

Sickle Cell

Down’s Syndrome

Cystic Fibrosis

Genetic Disorder


MEDICAL HISTORY – Con’t Issue Yes No Assistance Needed Referred To

Drug Addicted

Past Surgery(ies)

Other

NICU stay Days Weeks Months (Check one)

High Risk Clinic

Need for Specialty Physician(s)

History Psychiatric Illness (mother/father)

Breast Feeding

Bottle Feeding

Formula changes

Fluoride Supplement

Feeding Problems

Diarrhea/Constipation

Started Solid Foods Type: Started:

Other Beverages Type: Started:

Current Medicines Type: How Often:

Techonology Dependent Type:

Newborn Hearing Screening Done

Date L Passed Failed R Passed Failed

Rescreen Date L Passed Failed R Passed Failed

If failed rescreen, date referred: Audiologist Sky Hi* BTT CSHCN

Other health issues (list):

LIVING ARRANGEMENTS

Where client lives √ Family monthly expenses √ Amount Total monthly family income √ Amount Parents Own Home House Payment Employment

Mobile Home Rent Payment Disability

Apartment Utilities Child Support

Public Housing Loans Spousal Support

Foster Home Car Payment Food Stamps

Friend’s Home Other Loans

Shelter Settlement

Homeless None

Other Other


HOME/FAMILY NEEDS ASSESSMENT

Issue Yes No Assistance Needed Referred To

Adequate housing

Safe neighborhood

Adequate space

Heating/cooling adequate

Environmental Tobacco Smoke

Parent(s) CPR Training

Transportation

Bathtub/Shower

Hot water

Concern about unsafe water (if yes, list below)

(Concerns):

Toilet Facilities

Enrolled in WIC

Safe Crib/Bedding

Baby care items needed

Working fire extinguisher

Working smoke detector

Working Carbon Monoxide Detector

Fire escape plan

Refrigerator

Cooking facilities

Telephone access

Washer/Dryer

Pets

Child care plan (if no, refer)

Adequate support system

Service providers in home (if yes, list below)

(Service providers in home):

CPS Involvement (Parent/Guardian) Past Present If yes, describe

Bed sharing

Risks explained

Co-sleeping (room sharing)

Concern about mother/guardian’s feelings regarding parenting/infant

Unplanned Unwanted Nervous Ambivalent Happy


HOME/FAMILY NEEDS ASSESSMENT – Con’t

Issue Yes No Assistance Needed Referred To Concern about biological father/guardian’s feelings regarding parenting/infant

Accepting Denying Rejecting Unable to assess Happy

Parent’s recent loss of partner

Abandonment Separation/divorce Death Other

Current conflict in home

Parent(s)/guardian Partner of parent Grandparents Other

Dysfunctional family relations

Abuse in past year (mother of infant)

Physical Verbal Sexual Other

Religious/ethnic/cultural factors affecting access to healthcare

Two (2) or more preschool children in home

Poor/ineffective parenting

Family difficulty budgeting money/food stamps (inappropriate spending)

Handicapped/disabled family member

Illiteracy (parent/guardian)

2nd hand smoke exposure

Provide education on smoke free environment Refused

Parent/guardian alcohol/drug use

(If yes, describe):

Special healthcare needs

Adequate food for family

Parent/guardian significant apprehension/anxiety

Lack of knowledge for prescribed Tx

Non-compliant with prescribed Tx

Unrealistic expectations for infant

Desires parenting/infant care education

Desires information on infant development

Non-stimulating environment for infant

OTHER REFERRALS/NOTES

DCC Signature: Title: Agency: Region: Date:

Please remember to forward a signed copy to RCC.

West Virginia Birth Score Program High Birth Score Referral and Tracking Form

Date of Birth Mother's SSN: Address:

Pay Type:

Case ID: Birth Score:

Mother's Name:

Phone:

Birth Hospital:

Primary Care Physician: PCP Phone:

GA Type

BWt. Grams Mom's Age Sex Feeding Prev. Preg Mom Ed. Nicotine

Factors

DCC/Health Check Worker Signature: Date:

Abnormality Left Ear:

Dev. Risk: VLBW APGAR <3 Hearing Screen Results: Test Type: Right Ear:

Transfer Hosp:

First Birth Score Surveillance Visit: Kept: Not Kept Unknown: (Within 3 weeks after discharge) Second Birth Score Surveillance Visit: Kept: Not Kept Unknown: (4-6 weeks after discharge) Enrolled in WIC: Enrolled in Health Check: Yes: No: Yes: No:

If infants PCP is not the same as above make corrections here and notify Birth Score Office: Infant's PCP/Clinic: PCP Phone PCP/Clinic Address:

Tracking Outcome: (Check all that apply for High Birth Tracking only) High Score Tracking Complete Moved Out of State Infant Death

Lost to Follow-up Refused High Score Follow-up Other: (Explain)

Agency: RCC County: Date Received From BSO: RCC Region:

Infant's Name:

Unable to Locate

R038A - High Birth Score Referral and Tracking Form WVDHHR/BPH/OMCHF/DPWH/RFTS/1-09

Birth Score Office

West Virginia University Birth Score Developmental Risk & Newborn Hearing Screen Program

Department of Pediatrics Post Office Box 9214

Morgantown, WV 26506-9214

DO NOT COPY BLANK FORM

Client Record RCC

Copy to:

Complete and submit to:



Phone: (304) 558-5388 Toll-Free (in WV): 1-800-642-8522 or 1-800-642-9704 FAX: (304) 558-7164 OMCFH/RFTS-R039 White: Provider Revised: 6-2011 Yellow: DCC Pink: RCC





_________________________________ (Date)

Re: ________________________________________ S. S. Number: _______________________________ Dear Provider, This is to inform you that this client's case record is being closed for Right From The Start services as of

_______________________________________. The reason for closure is indicated below:

REASON

Completed Program

Program Incomplete (If incomplete, please indicate reason below) Spontaneous Aborted Pregnancy Induced Aborted Pregnancy Moved Out-of-State Transferred Out of Region Death Lost to Follow-up Did not Meet Program Protocols Preterm Delivery Closed at RCC Level

Enhanced Services Only Sincerely, _____________________________________________ Designated Care Coordinator

_____________________________________________ Agency Name _____________________________________________ Agency Address _____________________________________________ Agency Telephone Number

OMCFH/RFTS-R040 White: DCC Revised 12-2011 Pink: RCC

Right From The Start Program QUALITY ASSURANCE REPORT (10 Infants and 10 Prenatals Quarterly)

PROVIDER AGENCY

PERSON COMPLETING THE FORM

Title: RN GN LSW TLSW Please indicate Y (Yes), N (No), or N/A (Not Applicable)

Client Name (Active File)

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9)

10)

11)

12)

13)

14)

15)

16)

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20)

REGIONAL CARE COORDINATORS TIME SHEET

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R041A/10-06 Copy to OMCFH

ACTIVITY CODE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31MONTHLY TOTALS

Project Eligibility 1

Referral for Services/Tracking 2

Project Development/Training/ Technical Assistance

3

Client Tracking 4

Community Activities 5

Reports/Surveys/Billing /Budget Preparation 6

Outreach/Certification of Service Providers/Provider Recruitment

7

Time Off 8

Newborn Hearing Screening 9

Miscellaneous(Must include explanation of activities)

10

Daily Totals

REGIONDATES

STAFF PERSON AGENCY MONTH

REGIONAL CARE COORDINATORS TIME SHEET

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R041A/10-06 Copy to OMCFH

DATE Miscellaneous Activity Explanations

REGIONAL CLERK TIME SHEET

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R041B/10-06 Copy to OMCFH

ACTIVITY CODE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31MONTHLY TOTALS

Computer Input100

Technical Assistance 101

Typing102

Copying103

Records104

Reports 105

Appointments106

Billing107

Training108

Tracking109

Time Off 115

Miscellaneous (Must include explanation of activities)

116

Daily Totals

REGIONDATES

STAFF PERSON AGENCY MONTH

REGIONAL CLERK TIME SHEET

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R041B/10-06 Copy to OMCFH

Miscellaneous Activity ExplanationsDATE






_____________________________ (Date) Dear : We have not heard from you about Right From The Start. Right From The Start offers pregnant women and their babies free services to help keep them healthy. We can help you find things in your area that you may need, like WIC, a place to live, a way to get to the doctor, baby care items and other things you may need during this happy, but sometimes hard time. We can help you learn about things like:

• baby care • how to tell if your baby has a fever • how/why you may feel different when you’re pregnant • what you should eat • baby blues • and much more

If we do not hear from you by ______________________, we will know you are not interested in RFTS. I hope you will call about these free services. I look forward to hearing from you.

Sincerely,

Designated Care Coordinator

______________________________________ DCC Name (Please Print)

______________________________________ Agency

______________________________________ Agency Address

______________________________________

______________________________________ Telephone/Email




OMCFH/RFTS-R042-DCC Contact Letter #3 White: Client Revised: 6-2011 Yellow: DCC





________________________________

(Fecha/Date) Estimada : No hemos oído de usted sobre el programa Desde el Principio. Desde el Principio puede asistirle a usted y su bebé encontrar cosas gratis que usted puede necesitar como WIC, un lugar para vivir, maneras para conseguir al doctor, cosas para su bebé y otros servicios que a lo mejor le falta durante este tiempo feliz aunque a veces difícil. Pueden ayudarle a aprender:

• maneras fáciles de tomar cuidado de su bebé • cómo saber si su bebé tiene una fiebre • porque se siente diferente cuando usted está embarazada • Lo que debe de comer • depresión postparto • y mucho mas

Si no comunicamos por el día ______________________, sabremos que no le interesa el programa Desde el Principio. Tengo esperanza que usted llamara sobre estos servicios gratuitos. Sinceramente, ________________________________ Designated Care Coordinator


________________________________ Agency

________________________________ Agency Address

________________________________ Telephone/Email

OFICINA DE LA SALUD MATERNAL, DEL NIÑO Y DE LA FAMILIA Oficina para la salud pública 350 Capitol Street, Room 427 Charleston, WV 25301-3714


RIGHT FROM THE START PROGRAMENHANCED SERVICES EDUCATION REPORT

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/R060 - SavableRevised 1-2010

Original: Enhanced Service ProviderCopy: OB (At case closure)

RCC (At case closure)RCC(Initial Assessment)

(S9442 HD)

Enhanced Services DCC Signature:

Verbal Approval Received from RCC on This

Date: No Refused

DCC’s Initials

Date:

Service Provider:

Referred for Right From the Start Care Coordination:

DCCs should complete a Tracking Sheet (RFTS-R001A) for each client encounter and submit it to the RCC within 5 working days.

(FOR USE BY AGENCIES THAT ONLY PROVIDE ENHANCED SERVICES EDUCATION)

Region #:RLA Name:

Medicaid: HMO #:

RFTS Maternity Services

Nutritional Evaluation/Counseling

Health Education

(S9452 HD)

(S9445 HD)

Childbirth Education

Parenting Education (S9444 HD)

Service Provided Date(s) CompletedEnhanced Service

RCC Name:

Yes

SS#:

Birth Date: Telephone #:

EDC:

Patient’s Name:

Address:

City State Zip

Last First MI

White: DCC Yellow: RCC WVDHHR/BPH/OMCFH/PWH/PP/RFTS/R065 Pink: OB Provider 4/2012 Goldenrod: Client

RIGHT FROM THE START PROGRAM EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)

*Name: _____________________________________________________________ Last First MI

*Social Security #: ___________________________ *DOB: ___________________

*Prenatal *Pregnancy Due Date: __________________ *Postpartum *Baby’s DOB: __________________________

Because you are pregnant or you have recently had a baby, which can often result in mood changes, we would like to know how you are feeling. Please underline the answer which comes closest to how you have felt IN THE PAST SEVEN (7) DAYS, not just how you feel today. Please complete all ten items.

1. I have been able to laugh and see the funny side of things.

As much as I always could Not quite so much now Definitely not so much now Not at all

_________

Score

2. I have looked forward with enjoyment to things.

As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all

_________

Score

3. I have blamed myself unnecessarily when things went wrong.(*)

Yes, most of the time Yes, some of the time Not very often No, never

_________

Score

4. I have been anxious or worried for no good reason.

No, not at all Hardly ever Yes, sometimes Yes, very often

_________

Score

5. I have felt scared or panicky for no very good reason. (*)

Yes, quite a lot Yes, sometimes No, not much No, not at all

_________

Score

6. Things have been getting the best of me. (*)

Yes, most of the time I haven’t been able to cope at all Yes, sometimes I haven’t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever

_________

Score

7. I have been so unhappy that I have had difficulty sleeping. (*)

Yes, most of the time Yes, sometimes Not very often No, not at all

_________

Score

8. I have felt sad or miserable. (*) Yes, most of the time Yes, quite often Not very often No, not at all

_________

Score

9. I have been so unhappy that I have been crying. (*)

Yes, most of the time Yes, quite often Only occasionally No, never

_________ Score

10. The thought of harming myself has occurred to me. (*)

Yes, quite often Sometimes Hardly ever Never

_________

Score

Client’s Signature: ______________________________________________________________ Date: ________________________

DCC Signature: ________________________________________________________________ Date: ________________________

DCC Agency: _________________________________________________________________________________________________

*EPDS Score: *Referred to : Medical Provider *Date: ____________________________ Emergency Room

*Required Fields

White: DCC Yellow: RCC WVDHHR/BPH/OMCFH/PWH/PS/RFTS/R065

Pink: OB Provider

1-03 Goldenrod: Client

Edinburgh Post-Partum Depression Screen Information (EPDS)

Instructions for Users: 1. The mother is asked to underline the response which comes closest to how she has been feeling in the

previous seven (7) days. 2. All ten (10) items must be completed. 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. 4. The mother should complete the scale herself, unless she has limited English or has difficulty with

reading. Scoring Response categories are scored 0, 1, 2, 3 according to increased severity of the symptoms. Items marked with an asterisk (*) are reverse scored (i.e. 3, 2, 1 & 0). The total score is calculated by adding together the scores for each of the ten items. Use Users may reproduce the scale without further permission providing they respect copyright by quotinga the names of the authors, the title and the source of the paper in all reproduced copies. Interpretation ⊄ Women who score above the threshold of 12 to 13 are likely experiencing an episode of depression and

must be referred to a physician or mental health care provider. If evidence of suicidal tendencies/hopelessness exists, establish a safety plan with the client/family and arrange urgent (24 - 48 hrs.) or emergency evaluation at a Mental Health Center or Emergency Room based on your assessment.

⊄ A score of 9-11 might indicate depression. A careful assessment should be carried out to confirm the

diagnosis, and in uncertain cases it may be useful to repeat the EPDS after two (2) weeks. ⊄ A score of 0 - 8 may indicate minimal/mild depression. The client should be carefully assessed and the

RFTS individualized service care plan followed. If questions or concerns arise, the screen should be repeated.

a Reprint with permission from: Cox, J. L., Holder, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782 - 786.

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS TS001 Page 1 of 1 June 11, 2008

RIGHT FROM THE START PROJECT (RFTS) TS001 TOBACCO SCREENING FORM

Prenatal CO VALUE PPM Postpartum Refused

# of weeks: Equipment Problem Date: / / Explanation in Progress Notes MM DD YYYY

Date of Birth: / / SSN: - -

Name: Last Name MI First Name

County: Region: DCC ID#: DCC Name: Agency Name:

1. Which statements best describes your tobacco use now? (choose all that apply) I have never smoked cigarettes. (Mark here if you have only tried smoking) I stopped smoking BEFORE I found out I was pregnant - I am not smoking. I stopped smoking AFTER I found out I was pregnant - I am not smoking. I dip, chew, or use smokeless tobacco. I smoke regularly now-about the same number BEFORE I became pregnant.

Number of cigarettes I smoke each day: I smoke, but I cut down on the number of cigarettes I smoke AFTER I became pregnant.

Number of cigarettes I smoke each day: I have increased smoking since I found out I was pregnant. I have started smoking since I found out I was pregnant.

2. How many cigarette smokers live in the same house with you? (choose only one) 0 1 2 or more

3. How is cigarette smoking handled where you live? (choose only one) No one smokes where I live - they smoke outside. People may only smoke in certain rooms where I live. People may smoke anywhere I live.

4. How many of your family and friends are cigarette smokers? (choose only one). None A few Some Most

If Never Smoked or Recently Quit - STOP HERE / Continue ONLY if Currently Smoking

5. How soon after you wake up do you usually use tobacco? (choose only one). 5 minutes or less 6 to 30 minutes 31 to 59 minutes 1 to 2 hours Greater than 2 hours

6. How sure are you that you could/can stop smoking for 24 hours? (choose only one). Low 1 2 3 4 5 6 7 8 9 10 High

7. How harmful do you feel cigarette smoking or smokeless tobacco is to you? (choose only one). Low 1 2 3 4 5 6 7 8 9 10 High

8. How harmful do you feel cigarette smoking or smokeless tobacco is to your baby? (choose only one). Low 1 2 3 4 5 6 7 8 9 10 High

9. Do you want to quit? Yes No

10. The SCRIPT Program provided me with: (choose all that apply). Guide Counseling Time Spent (in minutes)

11. My doctor advised me to quit. Yes No

12. I have used the WV Quitline. Yes No

RCC DCC OB Provider Client

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS TS002 Page 1 of 1 June 11, 2008

RIGHT FROM THE START PROJECT (RFTS) TS002 TOBACCO FOLLOW-UP FORM

Prenatal CO VALUE PPM Postpartum Refused

Follow-Up #: Equipment Problem Date: / / Explanation in Progress Notes MM DD YYYY

Date of Birth: / / SSN: - -



1. Have you smoked a cigarette, even one puff, within the last 7 days? (choose only one) Yes No Never Smoked

2. Since you started maternity care with the Right From The Start Project (RFTS) has the smoking pattern changed where you live? (choose all that apply)

No change. I have started/increased smoking since pregnant. No one smokes where I live – they People may smoke anywhere I live. smoke outside. People may smoke in certain rooms.

If Never Smoked - STOP HERE

3. Since your first RFTS home visit, which statements best describes your cigarette smoking? I smoke about the same number. Number of cigarettes smoked each day: I smoke, but I have cut down on the number of cigarettes. Number of cigarettes smoked each day: I have started/increased smoking. Number of cigarettes smoked each day: I dip, chew, or use smokeless tobacco. I have quit!

4. If you are a smoker, how many times since your first RFTS visit have you made a serious attempt to stop smoking (went without a cigarette for at least 24 hours). (choose only one)

0 1 2 3 I have quit!

5. How soon after you wake up do you usually smoke your first cigarette or use other tobacco? (choose only one) 5 minutes or less 6 to 30 minutes 31-59 minutes 1 to 2 hours Greater than 2 hours I am not smoking!

6. Since you started RFTS, has your DCC provided the following: (choose only those methods provided) I received no information. I watched the "Commit To Quit" video. My Right From The Start worker counseled me to quit. I was advised to call the WV Quitline. I was given A Pregnant Woman's Guide To Quit Smoking. My DCC called me on my quit date.

7. a. My doctor advised me to quit. Yes No b. My doctor advised me to call the WV Quitline. Yes No c. I called the WV Quitline. Yes No d. The WV Quitline called me. Yes No

8. I found the SCRIPT Program helpful? (choose only one). Low 1 2 3 4 5 6 7 8 9 10 High

9. During this pregnancy, has anyone who is living with you: a. Tried to quit smoking. Yes No b. Successfully quit smoking. Yes No


WVDHHR/BPH/OMCFH/DPWH/PP/RFTS TS006 Page 1 of 1 April 2012

RIGHT FROM THE START PROGRAM (RFTS) TS006 SCRIPT INTERVENTION FORM

Prenatal CO VALUE PPM Postpartum Record CO value if not measured

Date: at Screening Visit MM DD YYYY

Date of Birth: SSN:



1. ASK < 1 Minute

Document smoking status and number of cigarettes per day (CPD): (# cigarettes per day) A. Quit since screening visit B. Smoker

Response A. Congratulate her on success - stop home and social ETS exposure Response B. ASSESS, ADVISE, ASSIST AND ARRANGE

2. ASSESS < 1 Minute

Readiness to quit Yes No (If No, stop here)

3. ADVISE < 1 Minute

Provide clear, strong messages about risks of smoking to mother/fetus Yes No • Provide clear, strong and personal advice to quit and stay quit • Advise client to stop ETS exposure • Review "Commit to Quit" Video

4. ASSIST > 15-20 Minutes Provide SCRIPT Overview • Provide A Pregnant Woman's Guide to Quit Smoking Briefly review cessation skills in the "Commit To Quit" Video and the Guide: • STEP 1: Review Agreement to Quit, sign the contract and set Quit Date (Page 3) • STEP 2: Review Smoking Diary - #cpd (Page 4) • STEP 3: Review Scheduled Smoking (Page 5) • STEP 4: Review Yuck Jar (Page 6) • STEP 5: Promote Deep Breathing (Page 6) • STEP 6 & 7: Review Stop Smoking Buddy (Pages 8 to 11) • STEP 8: Learn Smoke - Tasting (Page 13) • STEP 9: Review Smoking Alternatives (Page 14) • STEP 10: Review Smoking Habits (Page 16) Express confidence that use of the Guide and methods will help them quit • Build Self-Efficacy (Page 19)

5. ARRANGE < 1 Minute

• Remind client of next visit and label as "smoker" in notes • Explain/schedule DCC follow-up telephone call(s) • Recommend call WV Quitline • Recommend talk with doctor about quitting

Summarize counseling session:


WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/9-2010 1

Regional Care Coordinator:

Counties Served:

Add, Delete or Continue

County Codes Served by DCC

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No NoTLSW

Date Date

PART ARIGHT FROM THE START PROGRAM

DESIGNATED CARE COORDINATORS AND ENHANCED SERVICES PROVIDERS

*Provider/Agency must complete a "Part A" for each region they serve or each site within the same region.

Region : Please indicate: FT = Full Time or 2080 Hours a Year (100% RFTS) PT = Part Time (< 100% RFTS)

Provider Agency:

Street Address:

City/State/Zip:

City/State/Zip:

Regional Lead Agency:

Address:

As you have additions or deletions to this listing, please send an updated copy to the Regional Lead Agency. RCC must send a copy of each Part A including additions/deletions to the OMCFH/RFTS office. NEW DCCs MAY NOT PROVIDE SERVICES UNTIL APPROVED AND TRAINED BY THE RCC. New Agencies may not provide services until approved by OMCFH, WV Medicaid and Health Maintenance Organizations (HMOs).

DCC Email Address

"I certify that the individual(s) listed above meet the qualifications outlined in the OMCFH RFTS Program Policy and Procedures Manual and will provide services to RFTS eligible clients according to protocol outlined in the Manual."

License or Certificate Expiration

Date

Administrative Person Viewing Licensure (DCC Agency) Regional Care Coordinator

Enhanced Services

Care Coord. Prenatals

Care Coord. Infants

Full or Part TimeName of DCC Title

Telephone/Fax#:

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/9-2010 2

Add, Delete or Continue Title County Codes

Served by DCC

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

RN FT Yes Yes Yes

LSW PT No No No

TLSW

DCC Email Address Care Coord. Prenatals

Care Coord. Infants

Enhanced ServicesName of DCC Full or Part

Time

License or Certificate Expiration

Date

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/8-2010

Health Education:

Health Education:

Date Date

You must notify the Regional Care Coordinator of changes in your caseload or Designated Care Coordinators.

Preventive Self Care


Nutrition:

ANNUAL CASELOAD PROJECTION(estimate total of all levels of care for contract year)

ENHANCED SERVICES ONLY

Parenting

Preventive Self Care


Nutrition:

(received in last contract year) (received in last contract year) (in last contract year) (in last contract year)

PRENATALS ANNUAL CASELOAD PROJECTION(estimate total of all levels of care for contract year)

PART BRIGHT FROM THE START

DCC AGENCY CASELOAD PROJECTIONNumber of Prental Referrals: Number of Infant Referrals: Number of Prenatals Served: Number of Infants Served:

Assessment/Service Care Plan:

Administrative Person Viewing Licensure (DCC Agency) Regional Care Coordinator

Care Coordination:

INFANTS ANNUAL CASELOAD PROJECTION(estimate total of all levels of care for contract year)

Parenting

Assessment/Service Care Plan:

Care Coordination:

Enhanced Services:

RIGHT FROM THE STARTINFANT ANTICIPATORY GUIDELINES

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS 10/04/2011 Partners for a Healthy Baby Curriculum-FSU

Client Name: SS #: Service Date:

DCC

Purpose Sheet # Handout #(s) Initials

53, 77, 87 1, 2, 57, 75, 82

1, 7, 17, 31, 53, 65 9, 24, 35, 38, 39, 58, 61, 67

1, 53 1, 2, 39, 58, 59, 60, 75

23, 31 30, 31, 40

7, 17, 41, 65 10, 47, 48

7, 17, 23 11, 67

17, 41, 53, 65 25, 49

23 NONE

41 NONE

41 47

41 NONE

NONE NONE

1, 7, 17, 41, 53, 65, 77 4, 5, 12, 13, 14, 15, 26, 50, 62, 63

1, 7, 17, 41, 65 6, 15, 16, 26, 44, 63

53, 87 63, 76, 83, 84, 86

7, 17, 41, 65, 77, 87 17, 69

1, 7, 17, 31, 41 3, 19, 20, 21, 27, 41, 52, 58

7, 17, 23, 31, 41, 65, 87 18, 28, 32, 33, 70

1, 7, 23, 53, 65, 77, 877, 8, 18, 22, 34, 35, 36, 51, 56, 64, 70, 76, 85, 86, 90

7, 17, 31, 53 23, 43, 71

17, 23, 31, 41, 77, 87 29, 35, 37, 46, 51, 56, 77, 78 100, 121, 135, 136, 137, 156, 185, 186

31, 41, 53, 65, 77, 87 42, 44, 45, 46, 53, 54, 55, 65, 66, 71, 72, 73, 74, 79, 80, 81, 87, 88, 89

DCC Signature: Agency:

FAMILY DEVELOPMENT

Empowerment

Purpose Sheet #

30, 60, 92, 120, 144

Months 0-6 Months 7-12 Prenatal

Family Planning

Sex & STDs

Depression

Diet & Exercise

Health Care

Alcohol, Drugs & Tobacco

Relationships & Support

Planning & Problem Solving

Career Development & Finances

MOTHER'S NEEDS

Physical Changes & Discomforts

Emotional Changes

Health Care

Common Concerns

BABY'S DEVELOPMENT

Bonding & Attachment

Responding to Baby's Cues

Infant Development

CARING FOR BABY

Breastfeeding

Bottle Feeding

Nutrition

Sleeping

Daily Care Routines

31, 61, 93, 121, 145

3, 31, 61, 93, 121, 145

3, 31, 61, 93, 121, 145

93

NONE

3, 31, 61, 93, 121

61, 93, 121

3, 31, 121

Handout #(s)

1, 2, 3, 4, 31, 49, 81

57, 58

29, 30, 81

37, 55

3, 31, 61, 121, 145

3, 31, 61, 93, 145

2, 60, 144

30, 60

2

2, 30, 60, 92

30, 120

92

2, 30, 60, 92, 120, 144

2, 30, 60, 92

2, 30, 60, 92, 120, 144

NONE

60, 92, 144

NONE

NONE

10, 63, 62

152

NONE

116, 165

153

96, 117

97, 131, 132, 166, 167, 168, 169, 181

114, 129

95

113, 128

115, 164

NONE

106, 107, 125, 141, 142, 143, 159, 174

90, 91, 92, 108, 109, 110, 144, 145, 155, 160, 161, 162, 175

93, 111, 126, 146, 147

93, 94, 112, 127, 130, 148, 163, 176

NONE

130, 150, 151 ,177

NONE

NONE

NONE

NONE

Handout #(s)

98, 99, 118, 133, 154, 182, 183

119, 120, 134, 155, 170, 184

101, 102, 103, 104, 105, 122, 123, 124, 138, 139, 140, 157, 158, 171, 172, 173, 187, 188

10, 62, 63

62

NONE

NONE

NONE

NONE

NONE

10, 62, 63

NONE

49

NONE

40

RIGHT FROM THE START PROGRAMPRENATAL ANTICIPATORY GUIDELINES

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS 09/02/2011 Partners for a Healthy Baby Curriculum-FSU

DCC

PS# HO# PS# HO# PS# HO# PS# HO# PS# HO# PS# HO# PS# HO# Initial

2 1, 2, 3, 4, 5 48 29, 30, 31, 32 84 54, 55, 56 114 72, 73 142 31,32,80 176 94, 95 206 104

2 6 48 33, 34, 35 84 57, 58, 59, 60 114 74 142 26, 27, 49, 59, 81 176 35, 96 206 35, 96, 97

2 8, 9 48 33, 36 84 61 114 75 142 82 176 59, 97 206 90, 108

2 N/A 48 37 N/A N/A 114 N/A 142 N/A 176 N/A N/A N/A

3 10, 11 48 N/A 84 62, 63 114 63 142 N/A 176 N/A N/A N/A

N/A N/A 48 38 N/A N/A 114 N/A 142 83 176 98 N/A N/A

3 12, 13, 14, 15 48 13, 14 84 12, 64 114 12, 64 142 13, 14 176 N/A 206 12, 13, 14

3 16, 17 49 39, 40, 41, 42, 43 84 41, 42 114 41 142 41, 84 176 41 206 40

3 18, 19, 20, 21 49 20, 44, 45 84 44 114 N/A 142 21 176, 177 N/A 206 106

3 22 49 46 84, 85 46 114 76 143 85 177 66, 67, 85 206 83, 85

N/A N/A 49 47 85 65 115 64 143 65, 86, 87, 88 177 86, 87, 97, 99, 100, 101 206 107

N/A N/A N/A N/A 85 66, 67 115 65, 66 143 66, 67 N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 206 40, 108, 109

3 24, 25, 26, 27 49 27, 48, 49 85 68, 69, 70 115 77, 78 143 87, 89, 90 177 27, 49, 69, 87, 102, 103 207 110, 111

N/A N/A 49 50, 51 N/A N/A 115 N/A 143 51, 91 177 51 207 50, 51, 91, 112

N/A N/A N/A N/A 85 71 115 N/A 143 92 177 92 N/A N/A

N/A N/A 49 52 N/A N/A 115 52 N/A N/A N/A N/A 207 N/A

3 28 49 53 85 53 115 79 143 93 177 N/A N/A N/A

3 N/A 49 N/A 85 N/A N/A N/A N/A N/A N/A N/A 207 113

Fetal Development

Infant Mental Health

Nutrition & Feeding

Diet & Nutrition

Month 7

Empowerment

1st Trimester

Relationships & Support

Fatherhood

FAMILY DEVELOPMENT

Career Development & Finances

Topic

Client Name: SS #: Service Date:

Month 4 Month 5 Month 6 Month 8 Month 9

DCC Signature:

Agency:

MATERNAL & FAMILY HEALTH

PREPARING FOR BABY/CARING FOR BABY

BABY'S DEVELOPMENT

Daily Care Routines

Exercise & Physical Activity

Alcohol, Drugs & Tobacco

Sex, STDs & Family Planning

Family Health Care & Safety

Physical Changes & Discomforts

Childbirth Preparation

Preterm Labor

Postpartum Care

Emotional Health

Health & Safety

Prenatal Month 4 Prenatal Month 6 Prenatal Month 8FAMILY DEVELOPMENT FAMILY DEVELOPMENT FAMILY DEVELOPMENT

Empowerment Empowerment EmpowermentRelationships & Support Relationships & Support Relationships & SupportFatherhood Fatherhood FatherhoodCareer Development & Finances Career Development & Finances Career Development & Finances

MATERNAL & FAMILY HEALTH MATERNAL & FAMILY HEALTH MATERNAL & FAMILY HEALTHDiet & Nutrition Diet & Nutrition Diet & NutritionExercise & Physical Activity Exercise & Physical Activity Exercise & Physical ActivityAlcohol, Drugs & Tobacco Alcohol, Drugs & Tobacco Alcohol, Drugs & TobaccoSex, STDs & Family Planning Sex, STDs & Family Planning Sex, STDs & Family PlanningFamily Health Care & Safety Family Health Care & Safety Family Health Care & SafetyPhysical Changes & Discomforts Physical Changes & Discomforts Physical Changes & DiscomfortsChildbirth Preparation Childbirth Preparation Childbirth PreparationPreterm Labor Preterm Labor Preterm LaborPostpartum Care Postpartum Care Postpartum CareEmotional Health Emotional Health Emotional Health




Nutrition & Feeding Nutrition & Feeding Nutrition & FeedingDaily Care Routines Daily Care Routines Daily Care RoutinesHealth & Safety Health & Safety Health & Safety

BABY'S DEVELOPMENT BABY'S DEVELOPMENT BABY'S DEVELOPMENTFetal Development Fetal Development Fetal DevelopmentInfant Mental Health Infant Mental Health Infant Mental Health

No (0)Yes (12)

Mother's Last Name

Mother's First Name

Insurance WV Medicaid Self-Pay Other

Payment Method

Mother's Maiden Name

Infant's Last Name

Infant's First Name

WV Birth Score-DevelopmentalRisk Screen And Newborn

Hearing Screen

Street Address City

/ /Infant's Birth Date

Gestational Age

Mother's Race

WhiteBlackAsian

HispanicMixed RaceOther

<1501 (90)1501-2000 (77)2001-2500 (55)2501-3000 (10)>3000 (0)

Birth Weight (grams)

<17 (75)17-19 (60)>19 (0)

Maternal Age

Infant's Sex Male (40)Female (0)

Breast Only (0)Bottle or Both (36)

FeedingIntention

None (0)1-3 (3)4-6 (12)7-8 (18)9 or more (21)

PreviousPregnancies

10th grade or lower (12)

11th grade or above (0)MaternalEducation

Nicotine useduring pregnancy

Zip Code

ITEM ANSWER CODE SCORE

- -Parent Phone

- -

PRIMARY CARE PHYSICIAN/CLINIC

WVKYMD

OHPAVA

Other

City

Was infant transferred to NICU?NO YES

Cabell Huntington WVU Hospital Women & Childrens Other

NEWBORN HEARING

1. Type of Test:

2. Test Results:

3. Reason if not screened:

ABR OAELeft EarRight Ear

Pass Fail Not ScreenedPass Fail Not Screened

Infant Death Parent Refusal Equipment Failure Other

My baby's Birth Score, Developmental Risk Screen and Newborn Hearing Screenhave been explained to me. I understand my baby may be eligible for a specialservice such as case management or early intervention.

Parent/guardian signature Date

Witness' signature Date

For Office Use____RFTS Region _____ ______Outreach county _____________Birth to Three Site ___________OMCFH Hearing Referral_______

Packet Sent _______Yes ______ NoDate _______________ Initials _________

Distribution Copies: BirthScore Office, Chart,Parent/Guardian

Birth Score Total

DEVELOPMENTAL RISK Automatic High Score Answer each. Definition of abnormalities on back.

YES NO

Birth Weight 1500 gms or less

5 Minute APGAR 3 or less

YES NO Congenital Abnormalities

Which of the following substances / drugs have you used during pregnancy?

alcoholcocaineheroinother opioids

marijuanamethadonemethamphatamine

Mother's SS #

WVKYMD

OHPAVA

Other

Zip CodeOffice Phone

High Birth Score is above 99.

QUESTIONS FOR MOTHER:

SmokingOral tobaccoPatch

Delivery Hospital

Please indicate if you experienced prolongedperiods of stress during your pregnancy:

Not at allYes, moderate stressYes, very stressed

All in all, would you say your health is:ExcellentGoodFairPoor

Have you ever been diagnosed by aphysician with the following conditions?

No, I have never been diagnosed with diabetesType I diabetes (juvenile type)Type II diabetes (adult onset)

Gestational diabetes (pregnancy related)

Pre-DeliveryAdmission WeightHeight - self reported by mom

ft inches lbs

33892

E018672

Typewritten Text

SAMPLE

E018672

Typewritten Text

E018672

Typewritten Text

WVDHHR/BPH/OMCFH/DPWH/PP/RFTS/12-2011DCC Training Certificate

DCC received the following training:

Health EducationParenting EducationChildbirth EducationNutritional Evaluation/Counseling (RD Only)

cc: OMCFH/Perinatal Programs Director

TelephoneFace to Face

This certifies that (DCC Name and Title)

Address:

Right From The Start ProgramOffice of Maternal, Child and Family Health

350 Capitol Street, Room 427Charleston, West Virginia 25301-3714

304-558-5388 or 1-800-642-8522Fax: 304-558-7164

Designated Care Coordinator Training CertificationAgency Name: Region (1-8)

Registered Nurse Social Worker CBE RDDCC License Number: (Observed by RCC No

Service Care PlanAppropriate Documentation/Record Keeping

Newborn Hearing Screening

Client Eligibility (Medicaid & Maternity Services)

Depression Screening

Counties to be served by this DCC are:

Other:(Specify)

"I agree to return assigned equipment to Regional Lead Agency upon termniation."

(To be placed on file at RLA)

Spent

Information and Referral

Serial #:Date:

Learning Community ResourcesQuarterly DCC Training Attendance

Equipment Assigned: Teaching Dolls

NICU

Client Referral TypesPRSIAlternate EntryBirth Score

How to Conduct a Home VisitHow to Open a Case

Required Visits

Other

Access to RFTS Forms/Literature (Materials Management)

Billable/Nonbillable Services & Instructions

Interviewing Techniques

Reporting RequirementsSCRIPT (Tobacco Cessation & CO Monitor)

Quality AssuranceCase Closure

Enhanced Services

received initial Right From The Start Program training on(Date)

RFTS Forms

HIPAA RegulationsRFTS Program Overview DCC Job Description/ResponsibilitiesRFTS Policy and Procedure Manual

DVD Player and AccessoriesCO Monitor

Yes

RCC Signature: Training Completion Date:

Care Coordination

days of field training with a qualified DCC

InfantPrenatalTwo Day PHB Curriculum Training

DCC Signature: Training Completion Date:

Newborn Hearing ScreeningBirth ScoreTransportation Assistance

Standards of Care

Appendix D FORMS - WV DHHR · • To choose the agency which will provide services agreed upon. •...

Documents

Transcript of Appendix D FORMS - WV DHHR · • To choose the agency which will provide services agreed upon. •...