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(1) These requirements are in addition to those requirements contained in rule and statutory provisions generally applicable to Medicaid providers.

(2) To be qualified as a provider of case management services for high risk pregnant women, an entity must:

(a) be approved by the department;

(b) meet the requirements in (3) through (7);

(c) have experience in the delivery of home and community services to high risk pregnant women;

(d) demonstrate an understanding of the concept of prenatal care coordination services; and

(e) have developed relationships with health care and other agencies in the area to be served.

(3) A case management provider must use an interdisciplinary team that includes members from the professions of nursing, social work, and nutrition.

(a) The professional requirements for these professionals are the following:

(i) nursing must be provided by a licensed registered professional nurse who is either:

(A) a registered nurse with a bachelor of science degree in nursing, including course work in public health; or

(B) a certified nurse practitioner with two years experience in the care of families;

(ii) social work must be provided by a social worker with a masters or bachelors degree in behavioral sciences or related field with one year experience in community social services or public health. A social worker with a masters in social work (MSW), masters in counseling, or a bachelors in social work (BSW) with two years experience in community social services or public health is preferred; and

(iii) nutrition services must be provided by a registered dietitian who is licensed as a nutritionist in Montana and has one year experience in public health and/or maternal-child health.

(b) To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements may be allowed if approved by the department.

(4) The case management provider must be able to provide the services of at least one of the professional disciplines listed in (3) directly. The other disciplines may be provided through subcontracts.

(5) Where services are provided through a subcontractor, the subcontract must be submitted to the department or designee for review and approval.

(6) A case management provider must:

(a) conduct activities to inform the target population and health care and social service providers in the geographic area to be served of its prenatal care coordination services;

(b) deliver prenatal care coordination services appropriate to the individual client's level of need;

(c) respond promptly to requests and referrals for targeted case management clients;

(d) perform assessments and develop care plans for the appropriate level of care and document services provided;

(e) schedule services to accommodate the client's situation;

(f) inform clients regarding whom and when to call for pregnancy emergencies;

(g) establish working relationships with medical providers, community agencies, and other appropriate organizations;

(h) assure that ongoing communication and coordination of client care occurs within the case management team and with the client's medical prenatal care provider;

(i) provide services in a home setting in addition to office or clinic settings. Home visiting, particularly by the community health nurse, is an integral part of targeted case management;

(j) have a system for handling client grievances; and

(k) maintain an adequate and confidential client records system. All services provided directly or through a subcontractor must be documented in this system.

(7) A case manager providing services for a case management provider must have:

(a) knowledge of:

(i) federal, state, and local programs for children and pregnant women such as Title V programs, WIC, immunizations, perinatal health care, handicapped children's services, family planning, genetic services, hepatitis B screening, kids count (EPSDT), etc.;

(ii) individual health care plan development and evaluation;

(iii) community health care systems and resources; and

(iv) nationally recognized perinatal and child health care standards;

(b) the ability to:

(i) interpret medical findings;

(ii) develop an individual case management plan based on an assessment of a client's health, nutritional and psychosocial status, and personal and community resources;

(iii) inform a client regarding health conditions and implications of risk factors;

(iv) encourage a client's responsibility for health care;

(v) establish linkages with service providers;

(vi) coordinate multiple agency services to the benefit of the client; and

(vii) evaluate a client's progress in obtaining appropriate medical care and other needed services.

History: Sec. 53-6-113, MCA; IMP, Sec. 53-6-101, MCA; NEW, 1991 MAR p. 1295, Eff. 7/26/91; AMD, 1997 MAR p. 496, Eff. 3/11/97; TRANS, from SRS, 2000 MAR p. 481.

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