Common Data Exchange Partners for Local Public Health Maternal and Child Health Targeted/Family Home Visiting Services

Transcription

1 Common Data Partners for Local Public Health Maternal and Child Health Targeted/Family Home Visiting Services The State Community Health Advisory Committee (SCHSAC) Building Health Information Capacity Workgroup Kathy Grantham, Business Analyst Wendy Nelson, Project Manager

2 We visited several local public health agencies, both rural and urban (green): Anoka Carlton Cottonwood-Jackson Dakota Lake Mower Renville St. Paul-Ramsey We also met with (yellow): The Minnesota Visiting Nurses Association to discuss their work for Hennepin County and Minneapolis Olmsted County to discuss their involvement with the SE Minnesota BEACON Program.

3 18. Create CIF entry (from info provided by nurse) MMIS Records Room (office support or volunteers get chart) Anoka CIF System AS/400 1c. Lookup 2b. data found/ not found 2c. data found/ not found 19. CIF Printout Information Packet materials Follow-up with referral source (usually letter) Time tracking and billing 1b. Lookup Intake System Specialist 2a. data found/ 1a. Lookupnot found : Open/closed? Intake System AS/ Request existing chart 10. Receive Existing chart Return chart 1a. 3. Enter new client Nurse 4. Paper 5. Intake consultation 6. Answers Office Support 20. Printed CIF for chart 8. Paper 7a. Nurse assignment data 17. New CIF information Supervisor Mail any required materials for physician or other Requests to mail information 13b. - declined service File Box (shredded by Office Support afted 1 year) 7b. Log entry (phone call) Coordinate If needed Interpreter (contract) Xx. to Provide 11. Offer 12. accepts/declines Service. Schedule visit Statistics for staff productivity Monthly Distribution Log (paper) Physicians/ Other 14. Initial visit Assessment questions 15. Assessment answers, observations 22. Post-visit followup 23. Completed forms (CIF + others) 13a. Record visit date 16. Assessment/ Observations, forms 21. Printed CIF Form for transferring/referring client to another County health agency Xx. to Does this happen at initial visit follow-up, or both? calls Supervisor To complain or compliment Anoka County General Intake/Supervisor Intake Chart Who makes chart if one does not exist? At what point? Chart may include: CIF form Information Print out FHV Infant and Children Form FHV Primary Caregivers and Prenatal Form Other County Service Providers Service providers clients may be referred to include but are not limited to: Child-Teen Checkup (phone call to nurse) ECFE (form) Epiphany Church (crib form) (also have client contact them) Early Head Start Child protection Follow-Along Insurance company incentive Attempts to contact the client are recorded on the paper referral form. Three phone calls are attempted, then a letter is sent. If are declined, it is noted on the paper form and referral goes to the File Box (same for referrals where you can t contact the client?) Triggers: Transaction Input Out of Scope Of Process

4 21. Create CIF entry (from info provided by nurse) 22. CIF Printout Office Support 25c. Mail any required materials for physician or other Physicians/ Other 15a. Record visit date Anoka County Antepartum Initial Home Visit Triggers: Transaction MMIS Records Room (office support or volunteers get chart) Anoka CIF System AS/400 1c. Lookup Intake process for Antepartum is depicted as the same as for general, through Supervisor hand-off the referral to the nurse. Is this accurate? 2b. data found/ not found 2c. data found/ not found Information Packet materials 25a. Follow-up with referral source (usually letter) 25b. Time tracking and billing 1b. Lookup Intake System Specialist 2a. data found/ 1a. Lookupnot found : Open/closed? Intake System AS/ Request existing chart 12. Receive Existing chart Return chart 3. Enter new client 23. Printed CIF for chart Antepartum Home Visit Nurse 15b Paper declined service Into mailbox 4. Paper 5. Intake consultation 6. Answers 7. Nurse assignment data 20. New CIF information Requests to mail information Supervisor Log entry Coordinate If needed File Box (shredded by Office Support afted 1 year) 14. accepts/declines Service. Schedule visit calls Supervisor To complain or compliment Statistics for staff productivity Monthly Distribution Log (paper) 16. Initial visit Assessment questions 19. Assessment, forms Antepartum Flow Sheet 24. Printed CIF 17. Assessment answers, Completed forms & authorizations Antepartum Flow Sheet Interpreter (contract) Form for transferring/referring client to health agency In another county 9. Lookup data 10. data If found 18a. to Chart Who makes chart if one does not exist? At what point? 18b. to Provide 13. Offer Other County Service Providers Chart may include: CIF form Information Print out Antepartum flow sheet FHV Primary Caregivers and Prenatal Form HIPAA form, other authorizations Service providers clients may be referred to include but are not limited to: Same service providers as for general (below)? Child-Teen Checkup (phone call to nurse) ECFE (form) Epiphany Church (crib form) (also have client contact them) Early Head Start Child protection Follow-Along Insurance company incentive Attempts to contact the client are recorded on the paper referral form. Three phone calls are attempted, then a letter is sent. If are declined, it is noted on the paper form and referral goes to the File Box (same for referrals where you can t contact the client?) Input Out of Scope Of Process

5 21. Create CIF entry (from info provided by nurse) Records Room (office support or volunteers get chart) Anoka CIF System AS/400 MMIS 22. CIF Printout Information Packet materials 25a. Follow-up with referral source (usually letter) 25b. Time tracking and billing 2b. data found/not found 1c. Lookup 1b. Lookup 2c. data found/ not found 1a. Lookup : Open/closed? 11. Request existing chart 12. Receive Existing chart Return chart 2a. data found/ not found Intake System AS/400 Nor sure if this is correct, or if intake goes through Intake specialist as for other processes I *thought* referrals came straight to Postpartum nurse, Or is there a supervisor assignment in this process as well? Office Support 23. Printed CIF for chart Postpartum Home Visit Nurse 3. Enter new client 20. New CIF information 7. Nurse assignment data 25c. Mail Postpartum report to pediatrician and mother s physician. Hep-B data If necessary. Requests to mail information 15b. - declined service 14. accepts/declines Service. Schedule visit 16. Initial visit;assessment questions Coordinate If needed File Box (shredded by Office Support afted 1 year) 17. Assessment answers, PMAP form, completed forms & authorizations Postpartum Flow Sheet? 15a. Record visit date 19. Assessment, forms, PMAP form, Postpartum Flow Sheet? Track referrals to agencies? 24. Printed CIF Form for transferring/referring client to health agency In another county 9. Lookup data 10. data If found Interpreter (contract) Look up immunization And HEP-B info Info, if available Physicians 18a. to MIIC Chart Who makes chart if one does not exist? At what point? 18b. to Provide 13. Offer Anoka County Postpartum Initial Home Visit Chart may include: CIF form Information Print out PMAP form HIPAA form, other authorizations Postpartum flow sheet? Other County Service Providers Service providers clients may be referred to include but are not limited to: ECFE (form) Same service providers as for general (below)? Child-Teen Checkup (phone call to nurse) Epiphany Church (crib form) (also have client contact them) Early Head Start Child protection Follow-Along Insurance company incentive Attempts to contact the client are recorded on the paper referral form. Three phone calls are attempted, then a letter is sent. If are declined, it is noted on the paper form and referral goes to the File Box (same for referrals where you can t contact the client?) Triggers: Transaction Input Out of Scope Of Process

6 exchange Bin 7. Paper copy of to Assigned Nurse 5. Assign Nurse to 1 4. Review Carlton County Family/Targeted Home Visiting 18a. Follow-Along Enrollment Form (paper) 18b. Prenatal-Healthy Promises Report (paper) 18d.PDSS form (paper) 21. Certified Doctor s Orders (paper)?? Customer Satisfaction Survey (paper) 10. Notify of Healthy Promises eligibility Certified Doctor s Orders (WordPerfect Template) 20. Printed Certified Doctor s Orders (paper) 19. Doctor s Order info 29. AAPI Assessment Data (client completed form) AAPI score AAPI website (scoring tool) 11. Contact, offer, Schedule visit Accept/Decline 14. Assessment questions 15.Assessment Answers, Observations, consent 3b. Paper 3a. Printout of Elec. Electronic s (Multiple) Paper s (Single) Doctor/ Clinic Certified Doctor s Order Tracking Sheet Excel 60 day tickler/ reminder* ECFE Coord. 22. Doctor s Orders (paper or PDF) 24. Signed Doctor s Orders 5 23/25. Record doctor s orders Sent and received?? Request Demographic data Receive Demographic data 28. PDSS Info (from paper form) Post-Partum Depression Screening (PDSS) Intake Specialist 27. Enrollment Info (from paper) PPMRS MDH 8. Check for Births and eligibility 9. Eligibility and birth info Healthy Promises 1a. Check for Family info, phone # 1a. Family info 1b. Check for Family info 1b. Family info 2. Enter info 6. Enter Assigned Nurse 1c. Check for Phone number 1c. Phone info 26. Follow-Along Enrollment (paper form) Excel Spreadsheet And PPMRS Data* Eventually PPMRS data* FHV database Access (provided by MDH) CareFacts Database 6 (Access) Follow-Along Database (what kind?) 17. Enter client Assessment, consent 4? PCH intake/discharge 13. Track accept/decline?? Customer Satisfaction Survey data Go through client list and enter quarterly* File Cabinet Yearly report done on Parent & Child Health (PCH) Programs Customer Satisfaction Survey tally (Quarterly tally & review)*?? PCH intake and discharge forms Nurse?? Check for Billing info Billing info *Out of scope of initial visit 1 If a Nurse has worked with the previously, an effort is made to assign that same Nurse 3 Phone, texting, , postcard if no phone number, letter and packet if no phone contact can be made 4 Nurses may upload/download & enter client data to CareFacts on laptop or directly to system (similar to Dakota Co.) 5 Signed Doctor s Orders go into Nurse s chart for the client 6 database reports: Quarterly statistics, Semiannual Teen Parents Class 16b. Coordinate service delivery 16c. for 16d. High-risk referrals, phone or 16e.Report and FHV databases are duplicative in terms of the data that needs to be entered into them. Carlton does Universal Contact for Family Home Visiting. Contact rate for pre and postnatal is near 100% Nurses have phone conversations with approx. 70% of clients contacted, home visit with approx. 63%?? Completed Customer Satisfaction survey (paper) 16a. for?? Customer satisfaction Survey (paper) Family Resource Team Service Provider(s) Doctor, Medical, or Mental Health Services Child Protection Information shared with the Family Resource Team can be detailed, with client consent. Family Resource Team is a crossdiscipline/cross-agency group. May be out of scope of initial visit. Service Providers may include but are not limited to: HeadStart (for sibling) Car seat Income Maintenance Dental varnish Child & Teen Checkup Financial Aid Worker Domestic abuse counseling Chemical abuse counseling Legal advice/counseling

7 Carlton County Family/Targeted Home Visiting High-level view exchange AAPI website (scoring tool) 29. AAPI Assessment Data (client completed form) AAPI score 11. Contact, offer, Schedule visit Accept/Decline 14. Assessment questions 15.Assessment Answers, Observations, consent Electronic s (Multiple) Paper s (Single) 22. Doctor s Orders (paper or PDF) Carlton County Public Health?? Completed Customer Satisfaction survey (paper) 16a. for?? Customer satisfaction Survey (paper) Doctor/ Clinic 24. Signed Doctor s Orders 5?? Request Demographic data?? Check for Billing info Billing info Eventually PPMRS data* 16b. Coordinate service delivery 16c. for 16d. High-risk referrals, phone or Family Resource Team Service Provider(s) Information shared with the Family Resource Team can be detailed, with client consent. Family Resource Team is a crossdiscipline/cross-agency group. May be out of scope of initial visit. ECFE Coord. Receive Demographic data PPMRS MDH 16e.Report Doctor, Medical, or Mental Health Services Service Providers may include but are not limited to: HeadStart (for sibling) Car seat Income Maintenance Dental varnish Child & Teen Checkup Financial Aid Worker Domestic abuse counseling Chemical abuse counseling Legal advice/counseling Child Protection *Out of scope of initial visit 3 Phone, texting, , postcard if no phone number, letter and packet if no phone contact can be made 5 Signed Doctor s Orders go into Nurse s chart for the client Carlton does Universal Contact for Family Home Visiting. Contact rate for pre and postnatal is near 100% Nurses have phone conversations with approx. 70% of clients contacted, home visit with approx. 63%

8 No Services File (keep forever) Chart File (keep forever) 15. Chart, signed 4b. if: Doctor s Orders No response to contact Declined 1b. Check for client info Triggers: Input Out of Scope Of Process 2b. info 12d. to Provide Follow-Along UCare TRIGGER s 5a.Verify client has Medical Assistance 6a. Verification of MA 16. Request authorization for carseat visit. Car Seats 12e. to program (form) Interpreter3 1d. or 7. Schedule prior to call or visit Family Home Visiting Nurse 6b. Authorization For payment 5b. Get authorization For payment of (phone call) Private Insurer or Payor 2c. Phone number 13. Doctor s Orders 485 Document 14. Signed Doctor s Orders 12c. to Provide 1a. Check for info 17. records When needed (fax) 1c. Call for client phone number Billing Physician/ Clinic1 11. Create new record or Enter data into existing record Dailies 2a. info Admin. Professional Cottonwood-Jackson Family Home Visiting: referral/intake, registration, initial visit Process is similar for both counties 3. Contact, offer (phone or letter) 2 4a. Accept/decline, Schedule visit 8. Assess, question, observe 9. Answers, observations, signed forms If client moves after initial visit, contact new agency to find out what they need 12b. to provide 10a. to If client moves after initial visit, give number for new agency Dailies & Stats for billing Reporting CHAMP System (shared by Cottonwood & Jackson) MDH County Services 12a. to provide Data & Stats PPMRS Reporting Director of Public Health Agency Different County or State School Nurses The CHAMP software system and client base is shared between Cottonwood and Jackson. s frequently move back and forth between the two counties. Family has ID number with letters to differentiate individuals. CHAMP data likely to be shared with other counties would be OMAHA and vitals. Cottonwood-Jackson has universal family home visiting. Nurse attempts to contact family for all births. Both counties deal with out-of-state hospitals, clinics, and health systems (Avera, Sanford). May get referrals from: Physicians, clinics and service providers, in-state or out-of-state. Not consistent for out-of-state, usually for births with needs & firsttime mothers. Hospitals, in-state or out-of-state. There is no maternal hospital in Jackson County. Not consistent for out-of-state, usually for births with needs & first-time mothers. Minnesota Vital Statistics Service Providers (Iowa) Elizabeth House Family Services School nurses Births out-of-state are recorded in the vital statistics for that state, even if the family resides in Minnesota. Those vital statistics records are not sent to Minnesota counties. County Services/Resources: Early Intervention-Healthy Grow Elizabeth House (positive outcomes) Family Services Child Protection Financial Assistance Day Care Western Community Action (finance and housing assistance) Food Shelf Workforce1 s to other counties: s who move to other counties/ states will be given information to contact those agencies. Watonwan and Nobles-Rock have targeted rather than universal family home visiting. 1. Physician/Clinic may be in-state or out-of-state. 2. For high-risk referral, contact may involve going to home. 3. Interpreter is through an agency and can bill to public/private insurer.

9 1b. Check for client info Triggers: Input Out of Scope Of Process 2b. info 12d. to Provide Follow-Along UCare TRIGGER s 5a.Verify client has Medical Assistance 6a. Verification of MA 16. Request authorization for carseat visit. Car Seats 12e. to program (form) Interpreter3 1d. or 7. Schedule prior to call or visit Cottonwood-Jackson Public Health Agencies 6b. Authorization For payment 5b. Get authorization For payment of (phone call) Private Insurer or Payor 2c. Phone number 13. Doctor s Orders 485 Document 14. Signed Doctor s Orders 12c. to Provide 17. records When needed (fax) 1c. Call for client phone number Billing PPMRS Reporting Reporting Physician/ Clinic1 MDH 3. Contact, offer (phone or letter) 2 4a. Accept/decline, Schedule visit 8. Assess, question, observe 9. Answers, observations, signed forms Cottonwood-Jackson Family Home Visiting: High-Level If client moves after initial visit, contact new agency to find out what they need 12b. to provide 10a. to If client moves after initial visit, give number for new agency County Services 12a. to provide 1. Physician/Clinic may be in-state or out-of-state. 2. For high-risk referral, contact may involve going to home. 3. Interpreter is through an agency and can bill to public/private insurer. Different County or State School Nurses Cottonwood-Jackson has universal family home visiting. Nurse attempts to contact family for all births. Both counties deal with out-of-state hospitals, clinics, and health systems (Avera, Sanford). May get referrals from: Physicians, clinics and service providers, in-state or out-of-state. Not consistent for out-of-state, usually for births with needs & firsttime mothers. Hospitals, in-state or out-of-state. There is no maternal hospital in Jackson County. Not consistent for out-of-state, usually for births with needs & first-time mothers. Minnesota Vital Statistics Service Providers (Iowa) Elizabeth House Family Services School nurses Births out-of-state are recorded in the vital statistics for that state, even if the family resides in Minnesota. Those vital statistics records are not sent to Minnesota counties. County Services/Resources: Early Intervention-Healthy Grow Elizabeth House (positive outcomes) Family Services Child Protection Financial Assistance Day Care Western Community Action (finance and housing assistance) Food Shelf Workforce1 s to other counties: s who move to other counties/ states will be given information to contact those agencies. Watonwan and Nobles-Rock have targeted rather than universal family home visiting.

10 MMIS = Medicaid SSIS=Social Services MAXIS=Economic Assistance Minnesota Dept. of Human Services MMIS, SSIS, MAXIS systems MCH Home Visiting * 1a. Check for /Family info 4b. Letter to referral source: not accepted This is not tracked in system s come in by phone, fax, or . Any data-based submissions? s can come from are referrals ever made directly to after initial visit, if client not already in system? 1 status remains Pending after step 10 until: declines, after which status changes to Not Admitted, case closed cannot be contacted after 3 attempts including letter, after which status changes to Not Admitted, case closed After Initial visit, after which status changes to Admitted 2a. /Family info if available Are all referrals logged or just accepted referrals? If all, are accepted logged anywhere before going to data entry? Intake Log (Access database) 3. Log referral, Information call Intake Nurse 4a. Paper Form Intake System Data Entry Information call to whom?? 1b. Check for /Family info Does Intake Nurse have any contact with prior to HV Nurse? 2b. /Family info if available PHIS (old Dakota Co.system) 1c. Check for /Family info? 2c. /Family info if available? 5. Check for client ID, open case 6. /Family info 7. Check for /Family info 8. /Family info if available 9. Enter new as Pending Print out Case Packet 11. Case Packet and Entry In Sign-out Notebook Case Packet consists of Face Sheet and referral info Notes not clear about PROD s role with Intake Nurse. Intake Nurses do login to it. PROD (Dakota Co. Mainframe) CareFacts Pool Drawer & Sign-Out Notebook Or Case Packet goes interoffice mail to Western-Apple Valley 2 Breastfeeding referral: HV Nurse is contacted ASAP by phone call Case number = Family number = Individual index number = Countywide identifier (at family or individual level?) Does anything from CareFacts ever get transferred or entered into PROD or the reverse? It appears data is manually transferred. 15. Download case data 24. Upload case data 14. Assign self to referral as Case Manager 12. Case Packet 13. Sign out referral in Sign-Out notebook Dakota County Targeted Home Visiting Intake & Initial Visit Draft Context Diagram Nurse Laptop CareFacts HV Nurse Outlook Calendar 23. Record next Appointment date Child Protection 16b. No contact, Change from Pending to Not Admitted 1 Home Visiting Nurse 2 Western has its own notebook for nurses to sign out cases. 21. Enter data Assign Pathway(s) Enter as Admitted Enter billing info 18. Record contacts/ Record Accept/Decline 1 Billing info must be an output from CareFacts somewhere in this process 24. Reporting 20. Assessment answers, Observations, next appointment date 19. Initial Visit Assessment questions 17. Accept/Decline 16a. Offer Home Visiting Services Identified problems become Pathways Pathways define interventions to address those problems Child Pathway medically fragile children would go under this Growth and development Abuse & neglect Adult every admission includes this Assess all problems: parenting, income, residence, mental health, abuse, substance abuse, etc. Pregnant Postpartum Parenting Health Care Supervision 22. Provide Interventions Per assigned Pathway(s) Triggers: Input Out of Scope Of Process HV Nurses provide the or connect families to the resources Other intervention outputs? Any direct reports or other outputs to MDH,, etc.

11 Dakota County Targeted Home Visiting Intake & Initial Visit Draft Context Diagram High-level view Billing info must be an output from CareFacts somewhere in this process MMIS = Medicaid SSIS=Social Services MAXIS=Economic Assistance Minnesota Dept. of Human Services MMIS, SSIS, MAXIS systems 1a. Check for / Family info MCH Home Visiting * 2a. /Family info if available 4b. Letter to referral source: not accepted This is not tracked in system Child Protection Report Dakota County Public Health 22. Provide Interventions Per assigned Pathway(s) 20. Assessment answers, observations, Next appointment date 19. Initial Visit assessment questions Identified problems become Pathways Pathways define interventions to address those problems Child Pathway medically fragile children would go under this Growth and development Abuse & neglect Adult every admission includes this Assess all problems: parenting, income, residence, mental health, abuse, substance abuse, etc. Pregnant Postpartum Parenting Health Care Supervision HV Nurses provide the or connect families to the resources s come in by phone, fax, or . Any data-based submissions? 17. Accept/Decline 16a. Offer Home Visiting Services s can come from are referrals ever made directly to after initial visit, if client not already in system? Does anything from CareFacts ever get transferred or entered into PROD or the reverse? It appears data is manually transferred. Does Intake Nurse have any contact with prior to HV Nurse? Triggers: Other intervention outputs? Any direct reports or other outputs to MDH,, etc. Input Out of Scope Of Process

12 Contact Resources 2 Request client info info Tracking form (paper) Record contact attempts 1, unable to contact, and declined Track visit date chart Forms, observations notes Info off charts compiled for annual PPMRS report PPMRS Lake County Public Health Targeted/Family Home Visiting Funded by grant, no billing done Contact, offer, Schedule visit Accept/Decline Pre-Assessment Survey Pre-Assessment responses Visit - Assessment questions Assessment Answers, observations, consent for sources include but are not limited to:: State birth list Hospitals, doctor s offices, clinics Lead, EDHI, or other MDH Child Protection or other county / Approx. 110 births per year, approx. 90 clients per year. Priority are firsttime births, approx. 60 per year. 1 After three attempts at contact by phone with no answer, a letter is sent to the client. 2 contact resources include checking with: Financial Worker to find out about MMIS Social Worker to find out if familiar with client Referring Hospital for more information Internet for phone information 3 County include but are not limited to: Child Protection Family Support Financial Assistance (MA) Personal Care Assistance Car seat program Licensed Child Care Providers Request for client info from MMIS Info if available Packet of information for client Office Support Staff MCH Nurse (also Nurse) Check for client info info if available exchange to provide MMIS (DHS) Refer client for, if needed County Services 3 Follow-up on referral Follow-up to referring to provide service Arrowhead Health Alliance to client Doctor/Dental/ Clinic/Hospital Follow-up to referring to provide Data similar to PPMRS to (face sheet) provide Case by case & annual Look up client data data Add client if appropriate MDH (Lead, EHDI) Service Providers School District (School Nurse, ECFE, Solo Program) Breast Feeding Support Group including Peer Breast Feeding Service providers include, but are not limited to: Arrowhead Economic Opportunity Agency (AEOA) Head Start Food stamps Child & Teen Checkup, MMIS (DHS) Mother and Child Food Program (MAC) Personal Care Assistance (PCA) Postpartum depression screening Mental health Smoking cessation Landlord and Tenants Union Family planning (number of agencies)

13 PPMRS Lake County Public Health Targeted/Family Home Visiting High-Level Contact Resources 2 Request client info info Info off charts compiled for annual PPMRS report Contact, offer, Schedule visit Accept/Decline Pre-Assessment Survey Pre-Assessment responses Visit - Assessment questions Assessment Answers, observations, consent for Lake County Public Health Agency Look up client data data Add client if appropriate sources include but are not limited to:: State birth list Hospitals, doctor s offices, clinics Lead, EDHI, or other MDH Child Protection or other county / Approx. 110 births per year, approx. 90 clients per year. Priority are firsttime births, approx. 60 per year. Check for client info MMIS (DHS) info if available Refer client for, if needed to provide County Services 3 Follow-up on referral Follow-up to referring to provide service Arrowhead Health Alliance to client Doctor/Dental/ Clinic/Hospital Follow-up to referring to provide Data similar to PPMRS to (face sheet) provide Case by case & annual MDH (Lead, EHDI) Service Providers School District (School Nurse, ECFE, Solo Program) Breast Feeding Support Group including Peer Breast Feeding exchange Service providers include, but are not limited to: Arrowhead Economic Opportunity Agency (AEOA) Head Start Food stamps Child & Teen Checkup, MMIS (DHS) Mother and Child Food Program (MAC) Personal Care Assistance (PCA) Postpartum depression screening Mental health Smoking cessation Landlord and Tenants Union Family planning (number of agencies)

14 Paper s After due date Closed Files (box) Paper Chart in Open Files 5b. Scheduled Date of visit 5c. s forms Where Services declined 5d. forms Where 5a. Record accepted Contacts/ Declined serv. 9b. Family Admission form MCH Intake/ Visiting Nurse 1b. Contact info 1a. Check for Contact Info 3c. Place alert in if unable to contact 10a. Pre-Assessment if needed 12b. to if needed 3a. Contact/offer 3b. Pre-assessment via phone 4a. Accept/Decline (MDH) 4b. Pre-assessment responses 11a. Assessment/Questions/Observe 11b. Assessment/Responses/observations 12a. to 3c. Mailer if Can t contact & f. update for referring doctor Doctor (paper) 12e. for client if needed 12c. for client if needed 12d. for client If needed 10b. Pre-Assessment if needed 2. Coordinate Contacts and Visits if necessary Medical Assistance (MA) County Interpreter 12. Pre-Assessment if needed 14e. for client if needed (paper or phone) Family Facilitators (county social workers) 5f. Check for Contact Info 5d. Letter offering 8a/10a. Check pay source (DHS) 5a. Contact/offer 5b. Pre-assessment via phone 6a. Accept/Decline 6b. Pre-assessment responses 13a. Assessment/Questions/Observe 13b. Assessment responses/observations 14a. to Secretary 14c. for client if needed (release form from client) 5g. Contact info 14b. to Services if needed (make appt or mail appt) 5c. form if mail contact is needed 5e. form with date letter was sent Info packets for visit 4. Coordinate Contacts and Visits if necessary 5h. Place alert In if unable to contact Healthy Beginnings Visiting Nurse 7c. forms Where Services declined Filing Cabinet Paper 7d. forms 7a. Record Where Contacts/ accepted Declined serv. Chart in Open Files Family Admission form 7b. Scheduled Date of visit Calendar Chart (Paper s, Worksheets, HIPAA form, Etc) when case closed Calendar Mower County Home Visiting: referral/intake, registration, initial visit exchange after due date (IEIC form) MCH Follow-up form after due date Daily information (including billing data from Initial visit) Interagency Early Intervention (IEIC) 6. Family admission form 9. Family admission form with Number and pay source Enter HB data HB Follow-up 13b. Charting from Paper (How is this Different from 13a?) 13a.After visit, enter off form if in (what if not In?) Follow-Along Nurse?? FHV Form 7a/9a. Look up Family # Clerical 7b/9b. Family # if PH-DOC FHV File (Compiled at end of year for PPMRS report) 15b. Mark HB referral open or closed 8b/10b. Pay source Info Enter HB data Enter MCH data?? FHV Form Follow-Along System (MDH) 8. Family admission Form 11. Family admission form with Number and pay source 15a. After Visit info to keep open or to close Daily information (including billing data from initial visit) 14d. Follow-Along or IEIC referral forms Child Protection 14f. Report if needed (paper or phone) Child and Teen Checkups (DHS) 14g. Document contact And referral 1b. HB referral goes to MCH if already client 1a. Check if HB referral Is already an MCH client Healthy Beginnnings Intake Nurse 1c. Non-resident referrals County of residence Clipboard (paper database ) 3. Paper referral To assigned nurse 2. Notes, Assigned Nurse, Info Off referral

15 Check for Contact Info Contact info Letter offering Contact/offer Pre-assessment via phone Accept/Decline Pre-assessment responses (MDH) Assessment/Questions/ Observe Mower County Home Visiting: referral/intake, registration, initial visit High-level view Interactions/exchanges with entities outside Mower County LPHA Place alert in if unable to contact Pre-assessment if needed To Services If needed Mower County Local Public Health Agency Assessment Responses/ observations to 3c. Mailer if Can t contact & 18+ HB document contact And referral Report if needed (paper or phone) Child and Teen Checkups (DHS) Child Protection exchange (DHS) Check Pay Source Pay Source Info County of residence Non-resident referrals MCH Pre- Assessment if needed Medical Assistance (MA) MCH For client If needed for client if needed Family Facilitators (county social workers) update for referring Doctor (paper) Coordinate Contacts and Visits if necessary for client if needed County Interpreter Doctor Not sure whether this is a public health position or a county-wide position

16 Renville Targeted Home Visiting Intake & Initial Visit Draft Context Diagram MCH Home Visiting * Confirm that system should be considered external to local agency are referrals ever made directly to by staff after initial visit, if client not already in system? 9. Send Prime West form 3. Check for /Family info System 4. /Family info Intake System Specialist 16. Check Flag chart for Next appointment *s are placed in one of the following categories: -- NFP. First-time, low-income pregnant women before 28 weeks of pregnancy. If service declined, they receive regular prenatal referral. -- Prenatal. Pregnant mothers on Medical Assistance are automatically referred. Prenatal may continue after birth as New Baby. If service declined, they receive regular New Baby or Positive Parenting referral. -- New Baby. Universal new baby program. Hospitals send form if mother agrees. MDH or recorders office send records of births. -- Positive Parenting. Child can be enrolled anytime after birth. s may come from diverse sources such as a doctor, Well Child clinics, pre-school or school screenings, child protection,, etc. Any of these will be assigned to a nurse who has worked with the client before, or available for that territory (in rotation). 1. Check for /Family info 2. /Family info if available 5. Update info with data if more current 6. Enter new referral And assign nurse 7. Print Face Sheet 8. Print Prime West form if applicable 10. Face Sheet 14b. Can t contact client If client cannot be contacted, Intake Specialist checks system. If client is in system, chart is flagged so can be offered at next appointment MDH: Lead Early Hearing SIDS, etc Reporting Is billing info an output somewhere in this process? 11. Check for / Family info Assigned Home Visiting Nurse 22. Doctor s Orders 23. Signed Doctor s Orders (Referring) Doctor 12. / Family history 15. Record Accept/ Decline* Reporting Intake System (CHAMP) 19. Enter Assessment results, Next appointment 24. Record Doctor s Orders returned 13. Offer Home Visiting 14a. Accept/Decline 17. Initial Visit Assessment questions 18. Assessment answers, observations 20. Refer client to OUTCOME 21. for service(s) OUTCOME Child Protection Step 15 options: Nurse requests and receives report on whether report to Child Protection is substantiated or not. If client accepts, the first home visit is scheduled during the initial contact. Contact and date of first appointment recorded in CHAMP. If client declines, contact is recorded in CHAMP and Discharge form is completed to close case. may be contacted for other later (e.g., refused prenatal will be offered New Baby or Positive Parenting after birth). Service Provider* During 17-18:: Further appointment(s) scheduled at first visit. Otherwise nurse will call later to schedule. Recorded in CHAMP either way. Service Providers include but are not limited to: phone contact Schools Help Me Grow referral (paper form) Mental Health Services Nurse follows up on service referral one way or another. Follow-up is recorded in CHAMP. exchange

17 Renville Targeted Home Visiting Intake & Initial Visit Draft Context Diagram High-level view Confirm that system should be considered external to local agency are referrals ever made directly to by staff after initial visit, if client not already in system? MCH Home Visiting * 3. Check for /Family info 9. Send Prime West form Renville County Public Health Billing info must be an output somewhere in this process 13. Offer Home Visiting 14a. Accept/Decline exchange System 16. If client cannot be contacted, Intake Specialist checks system. If client is in system, chart is flagged so can be offered at next appointment 4. /Family info 16. Check - Flag chart for Next appointment MDH: Lead Early Hearing SIDS, etc Reporting 22. Doctor s Orders 23. Signed Doctor s Orders (Referring) Doctor Reporting 17. Assessment questions 18. Assessment answers, observations 20. Refer client to OUTCOME 21. for service(s) OUTCOME Child Protection Service Provider*

18 St. Paul Ramsey MCH Targeted Family Home Visiting: referral/intake, registration, initial visit Binder (retained for 1 year) NFP System Efforts to s (ETO) MAXIS MMIS TRIGGER Workforce1 9d2. Not taken up 16b. Enter client NFP data if applicable 1d. Check if Info 2d. Info if 1c. Check if Info 2c. Info if * not taken up means client either refused or was unable to be located MFIP4. Enrollment Info 2e. status 1e. Check Status if appropriate Support Staff 1a. Check if Info Intake Specialist 2a. Info if Old FoxPro Database Social Worker MFIP2. Group Meeting Info 4. Paper Form 8d. Not taken up* Basket for Appropriate Team per decision tree 20c. Followup Form (note if can t Locate) 3. Enter New client MFIP5. Notify client Fulfilled requirements 1b. Check if Info Nursing Supervisor MFIP6. Transfer paperwork Source family members 9d1. Enter Not taken up 5. Paper Form 2b. Info if Financial Worker 7c. Declined Intensive Services, referral goes to other team basket 7d. Not taken up* 8a. Request - add client family members to CareFacts 17. Printouts for chart 18. Chart 9a. Add client MFIP1. Letter with Group meeting information 7b. Can t locate client 15b. Visit information For ETO CareFacts Nurse s File Cabinet MFIP7. Notify That nurse is MFIP Case manager 20d. Contact If needed Nurse 10. Download 8a. Record client data scheduled visit date (opt.) Interpreter 11. Schedule Interpreter (opt.) 19. Chart 20a. to Provide service (Forms) 15d. Record of Visit form 12. Assessment, questions 13. Answers, Signed forms 15a. Upload/Enter 14. s visit data, to Care plan 16a. Print visit, Care plan, Intake info MFIP3. Confirmed attendance At group meeting Service Provider(s) Billing 8b.Coordinate contact when can t locate 20b. Notify Of PH Services Bill 6. Offer 7a. Accept/Refuse Payer s Primary Care Provider exchange MFIP

19 St. Paul Ramsey MCH Targeted Family Home Visiting: referral/intake, registration, initial visit High Level View 6b. Enrollment Info Workforce1 MAXIS Social Worker 2f. status 1f. Check Status if appropriate 1d. Check if Info 2d. Info if TRIGGER MMIS Source 1c. Check if Info 18b. Followup 8b1. Notify Can t contact client 5b. WF1 Paper Form 2c. Info if s Primary Care Provider 18c. Notify Of PH Services 8b2. Coordinate contact When can t locate St. Paul Ramsey Local Public Health Bill Payer 15c. Contact if needed Service Provider(s) 18c. to Provide service (Forms) 15b. Enter client NFP data if applicable Financial Worker NFP System Efforts to s (ETO) 10b. Schedule Interpreter (opt.) 6. Offer 7a. Accept 12. Assessment, questions 13. Answers, Signed forms 14. s to Interpreter exchange

20 Different County or out-of-state LPHA Public Health Software System 1e. Send referral to correct local public health agency 11. Record contacts, Accept/Decline 8. /Family history 7. Get /Family info 15a. Enter Assessment results, referrals, next appointment 15b. Track hours/ for billing 1a. Check for /Family info 2a. /Family info if available 3. Enter/update info 4. Enter new referral 5. Assign Nurse to referral MCH Home Visiting * MMIS SSIS MAXIS Much overlap In these roles DHS System(s) *This role is one of the most variable in the agencies interviewed. Subsets of activities within the Intake role may be handled by any of the following staff roles or all may be handled directly by the Home Visiting Nurse: Clerical Intake Specialist/Nurse Nursing Supervisor Current Generic MCH Targeted Home Visiting Intake & Initial Visit Draft Context Diagram Assigned Home Visiting Nurse 6. Intake* 1c. Check for /Family info 2c. /Family Info and eligibility 2b. Check for /Family info System (MDH) 16f. for service 16i. follow-up 1d. Request contact info 1b. / Family Info If available 2d. Contact info 9a. Offer Home Visiting 10. Accept/Decline 12. Initial Visit Assessment questions 13. Assessment answers, observations, consent forms 14. Refer client to OUTCOME 16a. for service(s) OUTCOME 16d. Reporting, 9b. Flag chart to for next appointment 16c. Reporting 16b. For Child Protection Doctor/ Clinic/ Hospital/ Other Medical/ Dental MDH 3 Out-of-state Hospitals Primary care Service Provider 2 16e. Reporting, to Data collected from this process may be used in reporting to grantors DHS Program(s) 4 Hours recorded for this process may be billed to payors 16h. to other county 16g. to School-based 1 Other County/LPH Services County-delivered/coordinated may include but are not limited to: Other food/nutrition Lactation/breast feeding program Child Protection Coordinated family Family Facilitators Family Resource Team Car seat Dental varnish Counseling Domestic abuse Chemical abuse Legal advice Income Maintenance/Financial Aid Housing Family Planning Mentoring Foster Care 2 Other Service Provider Services provided may include but not be limited to: Interagency Early Intervention Committee (IEIC) (changing to regional) HeadStart (for sibling) Mental Health /Depression screening Transportation Services for handicapped Support groups Home care/medical supply company Schools ECFE Coordinator School Nurse Other Grantors Billing/ Payors Other County Services 1 3 MDH Programs Programs clients may be referred to may include but not be limited to: Lead EHDI BDIS MIIC MN Children with Special Health Needs/Follow-Along HuBERT PPMRS Vital Statistics 4 DHS Programs Programs clients may be referred to may include but not be limited to: Medical Assistance (MA) Child & Teen Checkup Cash Assistance Food Support MMIS SSIS MAXIS 5 Legal Legal communications may include but not be limited to: Law Enforcement Courts Lawyers Community Corrections exchange

21 Out-of-state Health departments Hospitals Primary care Doctor/Clinic/Hospital/ Other Medical/Dental May be a referrer as well as referral Schools ECFE Coordinator School Nurse Other Follow-up On referrals s for High-risk and First-time births Grantors s to program(s) Follow-up, signed doctor s orders, referral for service s to program(s) for Legal 5 Request contact info Other Service Providers 2 Report on grant-funded activities Orders to continue Services, requests for information Demographic info, medical info, related legal issues s to program(s) DHS Programs 4 for Local Public Health Agency Requests for client data family, demographic, eligibility data Billing/Payors Billing for reimbursement for hours/ for s to program(s) Data on client moved from county Data on client moved to county Requests for client data, reporting data Immun. Data, etc. LPHA in Another County contact efforts, Offer visit information and nurse observations Consent forms s to program(s) for Birth notices, data, Reporting data, etc. to s to program(s) to, report to MCH Targeted/Family Home Visiting Most common partners with whom Local Public Health Agencies may exchange information for this service Other County/LPHA Services 1 MDH Programs 3 1 Other County/LPH Services County-delivered/coordinated may include but are not limited to: Other food/nutrition Lactation/breast feeding program Child Protection Coordinated family Family Facilitators Family Resource Team Car seat Dental varnish Counseling Domestic abuse Chemical abuse Legal advice Income Maintenance/ Financial Aid Housing Family Planning Mentoring Foster Care 2 Other Service Provider Services provided may include but not be limited to: Interagency Early Intervention Committee (IEIC) (changing to regional) HeadStart (for sibling) Mental Health / Depression screening Transportation Services for handicapped Support groups Home care/medical supply company 3 MDH Programs Programs clients may be referred to may include but not be limited to: Lead EHDI BDIS MIIC MN Children with Special Health Needs/Follow-Along HuBERT PPMRS Vital Statistics 4 DHS Programs Programs clients may be referred to may include but not be limited to: Medical Assistance (MA) Child & Teen Checkup Cash Assistance Food Support MMIS SSIS MAXIS 5 Legal Legal communications may include but not be limited to: Law Enforcement Courts Lawyers Community Corrections