Fy 2014 Public Health Master Agreement Annex s2

FY 2014 PUBLIC HEALTH MASTER AGREEMENT ANNEX Program Description and Reporting Requirements

PROGRAM NAME: Perinatal Health Partners

PROGRAM CODE: 449, 152

FUNDING SOURCE: State

PURPOSE: To improve birth outcomes by providing case management to high risk pregnant/postpartum/inter-conceptional women and their babies in 11 of 16 counties of the (Southeast Health District) 9-2 (Coffee, Atkinson, Clinch, Jeff Davis, Appling, Ware, Pierce, Brantley, Charlton, Clinch and Wayne).

FUNDING REQUIREMENTS:  Equipment purchases shall not be charged to this program.  Funds shall not be used to supplant local funds.  Program funds not utilized by the end of the fiscal year shall be returned to the state office.  Indirect costs shall not be charged to this program unless a cost allocation plan has been approved by the Office of Financial Services.  Funds shall solely be used to support the Perinatal Health Partners program.  Allowable costs shall include travel, personnel, personnel background checks, community outreach, supplies and educational materials/pamphlets.

Deliverables: Primary

 Public Health Nurse Specialist/Registered Nurse (PHNS/RN) as case managers to provide and document case management, nursing assessment, follow-up and community outreach to pregnant women and their babies who are referred to the PHP Program by medical providers. RNs are responsible for the following: o Attempt to contact client within 24 hours (1 business day) of receipt of referral to schedule a home visit for nursing and needs assessment, o Develop an individual service plan within 5 working days of client contact. o The Home Visitation Program model after The New Mexico Department of Health Families FIRST will be utilized to provide on-going face to face visits, and nursing assessments every week for four weeks, or as needed until delivery. Case management services will follow-up until 10 weeks postpartum with patients. o Refer and track referral of clients to appropriate public health and community agencies per the client’s individual needs assessment. o Collect data quarterly on performance measures. o Provide nursing assessment and progress notes to referring physician within one week of visit. o Evaluate postpartum clients for depression twice utilizing the Edinburgh Postnatal Depression Screening tool at the six week visit and the ten week visit. Refer clients with abnormal scores for appropriate follow-up.

1 o Refer clients to the Family Planning Program and ensure client transitions to PHP Outreach Worker (LPN) at ten weeks postpartum for follow-up.

 LPN is responsible for the following : o Enroll and maintain a caseload of approximately 35 clients annually. o Provide and document ongoing case management for mom and baby from 10 weeks for up to two years post partum to ensure adequate pregnancy spacing, assess and maintain chronic illness management, keeping well-visit appointments and other public health program and social service needs, as appropriate. o Conduct a quarterly home visits for two years. o Tracks and documents all data and information into the PHP Access database.  PHP Program Coordinator is responsible for the following: o Oversee day to day operations, budget, communication with district and state staff; collect/analyze data, and supervision of PHP Program staff. o Provide at least one yearly staff program updates to regional tertiary center. o Consults with Georgia Southern University as an external evaluator to conduct fiscal year program evaluation that includes outcome data and interpretation. Data shall include a previous year’s data comparison to evaluate birth outcomes.

All Staff are responsible for the following:  Provide individualized, culturally and linguistically appropriate health education related to perinatal and child health issues to clients at every contact.  Promote the program in the communities served, utilizing the following: telephone, flyers, and meeting presentations.  Advocacy forms are received from any of the following organizations or individuals but are not limited to: Health Departments, Family Connections, local hospitals, former clients, and individuals in the community.  Target outreach to a minimum of 1500 high-risk women including African American, Hispanic, and other clients living in isolated rural areas.  Provide, document and track client referrals, follow-up and linkages to the Family Planning Program, WIC, Immunizations, public health services and other community agencies quarterly through data entry and clients record review, during pregnancy and postpartum.  Provide quarterly health education presentations to community groups.  Participates in four community activities and programs annually to promote the PHP program. (At least one community outreach project shall be targeted to the non-English speaking population and one targeted at the African American population annually.)  Refer, document and follow-up at-risk children 0-5 years of age to Children 1st as the single point of entry to all public health services. PHP services infants up to age two.  Conduct client, staff and physician satisfaction surveys semi-annually to assess program efforts. The survey’s results will be evaluated and reported annually to the Program Coordinator by an outside evaluator.  Participate in quarterly teleconferences and an annual site visits with programmatic manager.

Secondary

2  Participate as needed and as appropriate in the Title V 5-year needs assessment and other planning processes.

PERFORMANCE MEASURES: Objective:  Ensures 70 % of clients receive ongoing home visitation and case management through year 2.

Objective:  Ensures 80% of clients will complete a minimum of two Edinburgh depression screenings. Objective:  Ensures 80% of eligible clients receive Family Planning services for at least two years from delivery date. Objective:  Follows-up on 90% of advocacy forms received from area agencies and sent to local providers. Outreach workers will follow-up with local provider for potential enrollment of these clients.

ALLOCATION METHOD: As one of the districts that demonstrate a high rate of infant mortality, a key priority area for DPH, Southeast Health District 9-2 will receive this continuation of grant funding.

REFERENCES: Family Planning (Title X Guidelines) Perinatal Health Guidelines,http://www.hhs.gov/opa/title-x-family-planning/title-x-policies/program-guidelines/ PHP Policy and Procedure Manual, SEHD protocols; From Conception to Birth to Infant Protection: A Regional Look at Periods of Risk for Georgia’s Newborns (GA Department of Public Health, Maternal and Child Health Section, 2012); Title V Needs Assessment www.health.state.ga

REPORTING REQUIREMENTS:  Submit quarterly perinatal planning reports to the state programmatic contact. The report shall include dates and numbers of meetings of perinatal collaboration, description of outreach and educational activities, and demonstration of cooperation between district public health planner and the regional perinatal center planner.  Submit annual district budget form, 5410 to the state office program manager by July 15th.  Submit data for performance measures using mutually agreed upon data tracking tool quarterly.  An annual program evaluation will be conducted and reports will be submitted within 30 days of the end of the fiscal year.  Provide names/credentials of staff employed by this program. Any change in staff shall be submitted to the state office program manager within 15 days of the change.

PROGRAMMATIC/STATISTICAL REPORTS ARE TO BE TRANSMITTED ELECTRONICALLY DIRECTLY TO:

PROGRAMMATIC CONTACTS:

Rhonda Simpson, MS Relda Robertson-Beckley, DrPH, Director Perinatal Health Director Office of Family and Community Health Department of Public Health Department of Public Health 2 Peachtree St. N.W. Suite 11-482 2 Peachtree St. N.W. Suite 11-482 Atlanta, GA 30303-3142 Atlanta, GA 30303-3142 404-657-2465 (Phone) 404-651-7442 (Phone) 404-463-6729 (Fax) 404-657-6729 (Fax) [email protected] [email protected]