Care Coordination Services Offered


                                           Care Coordination Service Offered

Care Management for At-Risk Children (CMARC)
is an at-risk population management program that serves children from birth to 5 years of age who meet certain risk criteria. The main goals of the program are to improve health outcomes and reduce costs for enrolled children.

Program Services: Services provided by (CMARC) care managers are tailored to patient needs and risk stratification guidelines. A comprehensive health assessment, including the Life Skills Progression, assists the care manager in identifying a child’s needs, plan of care and frequency of contacts required. Contacts occur in medical homes, hospitals, in the community and in children’s homes.
Referral Criteria:
  • Children with Special Health Care Needs (chronic physical, developmental, behavioral, or emotional conditions) who require health and related services of a type and amount beyond that required by children generally.
  • Children exposed to severe stress in early childhood, including:--
  • Extreme poverty in conjunction with continuous family chaos
    Recurrent physical or emotional abuse
    Chronic neglect
    Severe and enduring maternal depression
    Persistent parental substance abuse
    Repeated exposure to violence in the community or within the family
  • Children in foster care who need to be linked to a Medical Home
  • Children in neonatal intensive care needing help transitioning to community/Medical Home care.
  • Children with “potentially preventable” hospital costs identified under methodology developed by Treo Solutions, Inc.

Care Management for High-Risk Pregnancies (CMHRP) CMHRP is a collaborative set of interventions and activities, including assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services that address the health care and preventive services needs of pregnancy and postpartum women through communication and available resources to promote quality, cost effective outcomes. CMHRP is outcome-focused, with an emphasis on improving birth outcomes through reducing the rate of preterm birth, and monitors the Medicaid population and prenatal service delivery system using data collected during the pregnancy and postpartum periods. 

Program Services:

Care Management for High-Risk Pregnancies applies system and information to improve care and assist patients in becoming engaged in a collaborative process designed to manage medical, social, and behavioral health conditions more effectively. CMHRP serves as a means for achieving prenatal and postpartum wellness through advocacy, communication, education, identification of service resources, and service facilitation. CMHRP services are best offered in a climate that allows direct communication between the pregnancy care manager, the patient, and all service providers, in order to optimize the outcome for all concerned.
Referral Criteria:
• Multi-fetal gestation
• Fetal complications
• Chronic conditions that may complicate pregnancy
• Current use of drugs and alcohol; recent drug use or heavy alcohol use (month prior to learning of pregnancy)
• History of preterm birth (<37 weeks)
• History of low birth weight (<2500 grams)
• Unsafe living environment (physical/sexual abuse, domestic violence, homelessness)
• Tobacco use (current smoker, or quit after learning of pregnancy)
• Late entry to care (>14 weeks/missed 2+ prenatal appointments)
• Hospital utilization during pregnancy (emergency department, antepartum admission, labor and delivery triage and/or observation)
• Provider request for care management for any reason

Healthy Start Baby Love Plus - The Baby Love Plus program promotes strong and healthy communities designed to give babies the best possible start by improving families access to essential health and social services. The program is staffed by a family outreach worker who actively reach into the community to recruit pregnant women into early prenatal care and promote the importance and availability of health and social services to women of childbearing age and their families. A Family Care Coordinator (Social Worker) provides counseling and support services to women identified as high-risk during the inter-conceptional period which is 60 days postpartum through two years.

The goals of this program are to empower the clients to effectively manage their health and psycho-social needs; better navigate the health and social service system; and increase use of contraception. Transportation is available to families for emergency medical appointments, department of social services visits and appointments to receive counseling for women experiencing postpartum depression.

For public comments or questions, please call 252-641-7511