In addition to the participation requirements established
in Chapter 1101 (relating to general provisions), HBP providers are required,
as a condition of participation, to have a current MA provider agreement. HBP
providers shall formally enroll in the HBP Program. To participate, HBP
providers shall have an approved qualified provider application and shall
satisfy the requirements contained in this section, consistent with the
implementation plan delineated in each provider's approved qualified provider
application.
(1) The qualified
provider, whether enrolled in the MA Program as a hospital obstetrical clinic,
community health center, migrant health center, rural health center, birthing
center, family planning clinic, home health agency or private obstetrical or
family practice, even if providing other types of medical care, have a
concentration of specialization in prenatal services.
(2) The qualified provider shall employ one
or more care coordinators who:
(i) Have had
clinical experience in maternity care.
(ii) Can determine nutrition risks of
applicants for the Pennsylvania Women, Infants and Children (WIC)
Program.
(iii) Are onsite during
the client's prenatal care visits to perform initial and periodic risk
assessments and timely health promotions.
(iv) Are available at the clinic to
coordinate all aspects of the client's care, including reinforcement of
postpartum health promotion that was initiated post delivery in the hospital;
that is, postpartum physical and psychological changes, lactation,
parent-infant care and interim family planning method information.
(3) A care coordinator shall be
assigned to each client to serve ongoing as the client's primary contact and
facilitator of multidisciplinary communication. The care coordinator shall be a
registered nurse with clinical maternity care experience or a physician
assistant. Other types of health care practitioners may serve as care
coordinators if they have the HBP required maternity care experiences and
training as stated in the Department's Healthy Beginnings Plus
Maternity Services Manual, Section II: "Program Requirements, Staff
Qualifications" (Manual). The qualified provider would be required to give
assurances of the individuals' qualifications to function as care
coordinators.
(4) If one or more of
the care coordinator functions are to be delegated to others, the care
coordinator shall retain overall responsibility for these functions. Names and
titles of individuals to whom care coordinator functions will be delegated, and
the specific functions they will be delegated, shall be identified.
(5) The ratio of clients to care coordinator
will be based on the mix of clients requiring basic versus high-risk and
special services and coordination of these services. A coordinator may serve
not more than 75 clients, unless the qualified provider can provide assurances
that a higher number of clients can be serviced without jeopardizing the
quality of service provided.
(6)
The qualified provider shall provide services for a client within 14 days of
the client's request for an appointment.
(7) The qualified provider shall render by
its staff or through a subcontractor the following obstetrical services by an
authorized obstetrician, nurse midwife, family practice physician, ob/gyn nurse
practitioner, physician assistant or ob/gyn clinical nurse specialist within
their legal authority and scope of professional competence. If an MA provider
subcontracts for services, the qualified provider shall ensure that the
subcontractor, when applicable, meets enrollment and participation requirements
as found in Chapter 1101.
(i) Routine
antepartum care.
(ii) Intrapartum
care, including vaginal and cesarean deliveries, and postdelivery
care.
(iii) Ambulatory postpartum
examination (4-to-8-week visits that include family planning services
appropriate to the client's needs).
(8) Obstetrical care shall be organized to
assure continuity. If hospital inpatient obstetrical care is not provided by
the same HBP outpatient obstetrical care professionals, explicit contract terms
shall be executed to ensure continuity of care for the client.
(9) Contract terms between the HBP provider
and the HBP hospital inpatient obstetrical care professional shall include the
following:
(i) Identification of the
responsible obstetrical care practitioner in charge, overall, of HBP
obstetrical care as well as the individual obstetrical care providers and
assurance of the qualifications of each to perform the inpatient hospital
services they are being contracted to perform.
(ii) Arrangements for HBP client visits to
the inpatient hospital obstetrical suite where delivery is expected.
(iii) Arrangements for timely transmission of
copies of the clients' prenatal records to the expected hospital of
delivery.
(iv) Language regarding
the content of client discharge summaries and the time frame within which they
will be sent to the outpatient provider.
(v) Language regarding communication to be
conducted between inpatient hospital staff and the outpatient care coordinator
about the status of the HBP clients.
(vi) Procedures for scheduling the
4-to-8-week postpartum obstetrical visit with the outpatient provider following
hospital discharge.
(10)
The qualified provider shall arrange for basic in-hospital infant care services
and outpatient infant care (first visit) provided or directly supervised by a
pediatrician, a family practice physician or provided by a pediatric nurse
practitioner, who is acting within legal authority. These services may be
provided by the qualified provider's own staff or through a formal referral
process. The qualified provider shall explain the benefits of the Early and
Periodic Screening, Diagnosis and Treatment (EPSDT) Program to the HBP mother
and when the mother is interested in the program make arrangements for
enrollment of her infant in EPSDT. It is encouraged that the qualified provider
be affiliated with an EPSDT provider when possible.
(11) The qualified provider shall provide by
its own staff or through a subcontractor, or be able to provide the following
services at the same time and in proximity to the obstetrical services:
(i) Nutrition counseling by a nutritionist or
a registered dietitian to clients with obstetrical high-risk conditions. See
the Manual for provider qualifications.
(ii) Genetic risk assessment, information and
referral by the obstetrical services provider as described in the
Manual.
(iii) Outpatient and
inpatient obstetrical services to clients with medical or obstetrical high-risk
conditions.
(iv) Psychosocial
counseling services by a social worker, a professional who performs these
services under supervision of the social worker or by an individual who has the
experience and competence to perform these services as assured, whose
qualifications shall be submitted, by the qualified provider and approved by
the Department for clients with psychosocial high-risk conditions, including
substance abuse assessment and referral as described in the Manual.
(v) Tobacco smoking cessation counseling by
the obstetrical provider or care coordinator.
(12) For each non-English-speaking and
hearing-impaired person requesting entrance into the HBP, the qualified
provider shall be able to provide interpreter or sign language
services.
(13) The qualified
provider shall describe provisions that have been made to support play
activities for children accompanying clients on prenatal/support service
visits.
(14) The qualified provider
shall identify problems in the area of transportation, including a
pre-assessment of emergency transportation needs of the client, for each client
enrolled and describe plans to resolve these problems. This includes a
designation and availability of transportation services within the geographic
area of the population they serve. In developing solutions to these problems,
providers shall consult their county office responsible for administering the
MA Transportation Program. A listing of these offices may be found in the
Manual.
(15) The qualified provider
shall provide, when necessary, the following services either onsite or in the
local community provided by the qualified provider's own staff or through a
subcontractor that is a provider of these programs as described in the Manual:
(i) Prepared childbirth classes.
(ii) Parenting education program.
(16) The qualified provider shall
provide, when necessary, the following community/home-based services and
support services provided by the qualified provider's staff or through a
subcontractor:
(i) Outreach services for
enrollment of eligible women, including casefinding/recruitment from other
agencies, and follow-up for missed appointments, home assessment and patient
education.
(ii) Home health
services by nurses and home health aides for pregnant women and newborn
infants.
(iii) Personal care
services as previously approved by the Department.
(17) The qualified provider shall provide WIC
services, preferably at the same time as maternity services, and obtain a
letter from the local WIC Program which states concurrence with the applicant's
proposed strategy for providing WIC services. The qualified provider may be a
WIC provider or may offer WIC services through a formal arrangement with the
local WIC contractor. The WIC services shall be located onsite or in proximity
to the obstetrical services.
(18)
If the qualified provider is not a provider of one or more of the following,
the provider shall provide, when requested or required, the client with
alternative referral sources for the following, preferably in geographic
proximity to the qualified provider:
(i)
Laboratory services.
(ii) X-ray
services.
(iii) Ongoing family
planning services.
(19)
If the qualified provider is not a provider of one or more of the following,
the qualified provider shall have a formal, documented coordination system in
place, preferably in geographic proximity to the qualified provider for
nonobstetrical services in support of high-risk obstetrical care, such as
cardiac, hematology, diabetes, renal, specialized clinical genetics services
and psychiatric.
(20) Because there
will be clients who need drug and alcohol treatment services, qualified
providers shall either develop a formal documented coordination system or a
formal agreement between the local single county authority or licensed
providers in the provider's service area responsible for drug and alcohol
services, including drug and alcohol inpatient detoxification, drug and alcohol
outpatient counseling and, if services exist, for drug and alcohol residential
rehabilitation and drug and alcohol partial hospitalization services.
(21) The qualified provider shall provide a
smoke free environment in areas onsite where clients receive HBP
services.
(22) The qualified
provider shall be able to utilize a medical/obstetrical record format
acceptable to the Office of MA Programs for HBP clients.
(23) The qualified provider shall agree to
incorporate the HBP care coordination record and its supporting documents into
its medical/obstetrical record, and shall assure that the medical/obstetrical
record with the care coordination record is accessible, on a timely basis, to
providers involved in the client's care.
(24) The qualified provider and
subcontractors shall agree to send designated staff persons working in the HBP
to attend HBP orientation and other training sessions, as deemed necessary by
the Department.
(25) The qualified
provider shall agree to make statistical data available to the Department as
required for evaluation purposes.