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Screen shot of a flowchart showing the steps for providing a pregnant woman with healthcare in Richland County.
Identify/enroll at risk and Care Coordination Steps:
Initiation Step: Any woman in Richland County confirmed to be pregnant through a pregnancy test
Provide pregnancy education -PAT or newborn home visit nurse
Determine and document woman's:
- Insurance Status
- Source(s) of Prenatal Care
- Barriers to getting prenatal care
Evidence based Intervention Steps:
Schedule appointment with prenatal care provider
Confirm that woman kept 1st prenatal appointment. Document:
- Date of 1st appointment and next scheduled appointment.
- Due date
- Concerns identified during prenatal visit.
Final Outcome Steps:
Check on woman's prenatal appointments at least monthly.
Healthy baby > 5 lbs 8 ounces (2500 grams)
Document baby's birth weight, estimated age in weeks and any complications
Newborn Home Visit by RN completed and confirmed through Early Track
In this example a child must be identified in the community and confirmed to be behind on their immunizations. The child may have been thrown out of three practices, the family has no transportation, no phone and no real interest in medical care. All of these are considered risk factors but the case worker is not done until a registered nurse confirms that the immunizations are now up to date.
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