Based on the needs assessment, the status of case management services varies by county. There is much opportunity to improve adequacy of prenatal care, patient education, and monitoring and management of high-risk patients who are usually a considerable distance from their primary provider.
Much groundwork has been completed for a collaborative case management model in which Healthy Start and local Enterprise Community county health departments will partner to provide comprehensive case management to patients served locally in the counties, and, if referred to MCGHI for prenatal high-risk medical management or delivery, HS will act as liaison, assuring linkage back to the community and transitional care.
The case management model is conceptualized on three tracking tiers: education, monitoring, and disease management and on two levels of intensity. Along with case management, PRS, which in Georgia is a separate but complementary program, will also be provided. The core elements of complete case management span from preconceptual counseling, early and late pregnancy care, early postpartum and neonatal care, postpartum care in the home, and interconceptional counseling, as well as parenting education and anticipatory guidance through the second year of an infant’s life. Special care will be afforded teens and women at high risk for poor outcomes.
Case management objectives center on supporting optimal health for mother and infant. Thorough and systematic risk appraisal, nutritional assessment and counseling, psychosocial assessment, and assessment for knowledge deficits and health promotion reinforcement undergird case management services and culminate in a plan of care tailored to a patient’s needs.