Council of the Southern Mountains

A. Coordinate the health, education, and nutritional care for the RFTS eligible pregnant woman and infant.

1.Receives referrals from the Regional Care Coordinator.

2. Provides follow-up and coordination on all newborn Hearing Screening referrals, offers RFTS care cooordination to all eligible infants.

3. Completes assessment and PRSI/Alternate Entry, if necessary, to

identify barriers to a healthy care outcome.

4.Develops service care plan with client using the RFTS Service Care Plan.

5.Arranges intervention which meet identified needs.

6. Makes home visits and client contacts according to policy.

7. Follows a standardized recording system for documenting client care.

8. Reassess and revise service care plan as needed.

9. Updates medical provider of client's progress/change in service care plan as needed.

10. Sends required information to Regional Care Coordinator serving the client.

11. Arranges for/participates in interdisciplinary/interagency problem/service care plan meeting for problem clients to determine the appropriate agency to serve as primary case manager and to assign service care plan responsibilities.

12.Coordinators/Monitors with other program providing care management to infants such as Birth to Three Projects, and or child with Special Health Needs.

13. Referral of client into appropriate case management system at time of closure/ or at risk are determined.

14. At or near care closure, complete Outcome Measures form and forward to RCC.

B. Increase the pregnant woman/infant's and the family's knowledge regarding the importance of quality health care.

1. Communicate with the client/infant and the family concerning the values of self care.

2. Plan with the client for perinatal care/pediatric care.

3. Plan with the client for participation in WIC for nutritional needs, counseling and food supplements.

4. Models and teaches problem solving skills.

5. Plans with the client for receiving a postpardum exam and family planning services.

6. Plans with the client for support system.

7. Plans with the child for receiving well child visits and immunization services.

C. Advocates for primary needs of the family, including, but not limited to, food, shelter, safety, crisis intervention, transportation assistance and child care.

1. Advocates for the child is in the community.

2. Intervenes immediately when mother or child is in unsafe environment.

3. Intervenes in times of crisis.(Exception: for incidents of child abuse/neglect. These must be reported by telephone to Child Protective Services, the Child Abuse Hotline, or local DHHR office.

D. Use appropriate referral and follow-up procedures to acquire necessary resources for the client.

1. Establishes cooperative agreements and contracts for referral on the local level.

2.Coordinates services for all disciplines.

3. Communicates with medical care providers.

4. Refers very low birth weight, preterm infants' parent to SSI. (if not referred by hospital at birth.)

5. Monitors receipt of services.