Survey of Health Plans, Community Health Centers/Clinics, Public Health Nursing Agencies


I. Mission, philosophy, and scope of practice:
What is your organization’s mission and overall strategic approach to maternal and child health interventions during the perinatal period as defined above? (This can be an important starting point for understanding system structure and function.) Existing organizational documents may be attached to address the topics below relevant to services for perinatal health.Use general internal sources if more specific documentation is not available, but if there doesn’t seem to be any documentation for a particular subject, please indicate as unspecified rather than creating a response.

A. Formalized “mission statement” for perinatal care:
B. Statement of program goals and objectives related to perinatal care as stated in your organization’s internal and external documents, ie: grants, contracts, etc.:
C. What is the scope of perinatal services your organization provides (provide examples or attach documents as appropriate):
D. Intended population served (per mission statement, grant agreements, etc.):
E. Describe or list your external organizational partners in perinatal services and indicate the nature of the partnership:

1. contracts
2. memos of understanding
3. informal

F. What type of qualitative or quantitative evaluation summaries or outcome measures do you use in terms of goals and objectives (may identify and attach as addendum)

II. Community and System-level:
A number of activities of local public health might be directed at defining and improving the inter-connectedness of the perinatal care system. To achieve integration of systems for clients, you may have been working with other organizations such as hospitals, clinics and providers, public health nurses, managed care organizations, community clinics, school health, and other community-based organizations. In terms of improving pregnancy outcomes and infant outcomes through the first year of life, describe your organization’s activities related to the following areas:

A. Coalition building: (Creating alliances among different organizations for a common purpose.)
B. Collaboration, both internal and external: (Exchanging information, altering activities, sharing resources, enhancing the capacity of another for mutual benefit and to achieve a common purpose.)
C. Community organizing: (A planned process to activate a community to use its own social structure to accomplish community goals consistent with local values.)
D. Provider education: (Continuing education for providers on assessment and intervention on social and environmental risk factors affecting families.)
E. System direction: In the last five years, has the system become better or worse? In what ways? Use examples or data. What have been and are some of the forces that are changing the system?
F. Other

III. Client-level:
A. Perinatal Population Numbers

How many pregnant women do you provide services to per year?
How many post partum women do you provide services to per year?
How many newborns and infants up to the age of one year do you provide services to per year?

B. Perinatal Population Demographics

Estimated % of perinatal population per year

Race of Mother

White, African American, Hispanic, Asian, American Indian,Other

Age of Mother

Under 18, 18-35, 36 and over

Health Insurance or Source of Payment

PMAP, MA (fee for service), MN Care, Other HMO, Commercial
Indemnity, Self-pay: full fee, reduced sliding fee

(A number of services might be directed at individual clients, either pregnant women or families with infants. For each of the activities listed below, indicated whether there is a written protocol or standard of care for the provision of this type of service, and whether there are any data on service volume.)

C. Resource Advocacy

1. Determine eligibility for Medical Assistance (MA),Minnesota Care (MN Care)
Protocol? (Y/N ) Volume(Y/N) ( If yes, report #s per year)

2. Assist in application process for MA, MN Care
Protocol? (Y/N ) Volume(Y/N) ( If yes, report #s per year)
3. Assist in access to benefits i.e., transportation, child care
Protocol? (Y/N ) Volume(Y/N) ( If yes, report #s per year)
4. Determine eligibility for WIC
Protocol? (Y/N ) Volume(Y/N) ( If yes, report #s per year)
5. Assist in application for WIC
Protocol? (Y/N ) Volume(Y/N) ( If yes, report #s per year)

D. Health Teaching (promote a family’s understanding of good health practices through appropriate teaching)

Protocol? (Y/N ); Classes? (Y/N); # class participants/yr; one to one? (Y/N); #/yr

1. healthy pregnancy
2. preterm birth
3. childbirth education
4. parenting
5. child spacing (“rest” intervals between pregnancies to optimize health for mothers and children)

E. Brief Counseling within your organization (A therapeutic intervention to assist individuals and/or families to become more effective at self care and problem solving.Not a class or support group, just brief counseling by a professional.)

Protocol? (Y/N) if Y, attach protocols; Data on volume?; If Y, report #s of perinatal patients served per year.

1. Healthy lifestyle (balance of rest, exercise, nutrition, personal safety)
2. Coping/ psychological support (stress, depression, alcohol/drug use, violence, support)
3. Smoking cessation

F. Case Management/Care coordination: At the client level, case management/care coordination may be defined as a client- centered, goal-oriented process for assessing the needs of an individual for particular services, assisting them in obtaining those services, and coordinating those services to avoid gaps and duplication. It is ongoing until goals are met. (You may submit flow sheets or other forms you are using to describe and document these activities.)

1. Prescreening: Are clients “triaged” for risk potential? If yes, what are client triage criteria? Describe your system of setting the first appointment or home visit based on risk potential.

2. Assessment: Is activity standardized? If yes, provide protocols and assessment tools for prenatal and post partum/newborns and data on volume.

a. medical risk assessment, including preterm risk
b. nutrition
c. smoking
d. alcohol use
e. drug abuse
f. psychosocial stress
g. depression
h. heavy physical work
i. violence/abuse
j. social support system
k. housing/living condition
l. food resources
m. transportation resources
n. child care resources
o. employment concerns
p. education concerns
q. attitudes re: this pregnancy
r. family planning
s. needs counseling/support group
t. other

How many prenatal patient assessments do you do each year?
How many infant/mother assessments do you do each year?

3. Care plan development: Required? Standard forms? If yes, provide protocol, forms.

How many care plans do you do per year?
How many perinatal care plans end with goals met?
Are care plans monitored over time and reassessed? If yes, describe system for doing this.

4. Process for tracking prenatal and pediatric patients

Indicate the process and who is responsible for the following activities regarding logging, review and follow-up of prenatal patients.
Do you maintain a prenatal tracking log?
Prenatal log is: (circle one) Hand written log Electronic log

Log is maintained by:_________________________________(name/position)
List information that is tracked on this log
(You may attach a copy of your tracking log).
Do your prenatal patients sign consent for record release from the hospital prior to delivery? Yes ( ) No ( )
How often do you receive information from the hospital? (circle one)


Is someone responsible for contacting patients regarding post partum visits? Yes ( ) No ( )
Do you have a system for tracking newborn information of babies born to your prenatal patients? Yes ( ) No ( )
Briefly describe your newborn tracking system. Use back of page if necessary.

5. Referrals for other services: For each of these activities, indicate volume of referrals made, whether service is provided on site or off site, and whether there is a system for follow-up to determine success of referral.

List: approx.#s per yr; off site organization(s) used or indicate if your organization has this service on site; system to determine success of referral (Y/N)

a. Nutrition counseling
b. Smoking cessation programs
c. Alcohol abuse counseling
d. Substance abuse counseling
e. Psychosocial counseling
f. Support groups (list types)
g. Domestic violence/abuse support
h. Housing support
i. Food resources assistance
j. Transportation assistance
k. Child care services
l. Employment counseling
m. Insurance application assistance
n. Pregnancy related classes (list types)
o. Family planning services Service approx. #s per yr
p. Parenting classes
q. Public health nurse
r. Other home visitor
s. Home care nurse
t. Other referral(s)

How many total referrals do you make per year to prenatal clients?
To post partum newborn clients?
To pediatric clients up to one year?

6. Referrals in to your organization: For each of the following potential referral sources for prenatal or post-partum clients, indicate data on volume and how the referral gets to you (i.e., phone, letter, client told to call)
Volume ( # per yr) Referral method

a. site where pregnancy test is given
b. community clinic
c. public health clinic
d. other prenatal care provider
e. hospital post partum/newborn
f. local public health
g. managed care case manager
h. WIC clinic
i. public health nurse
j. birth certificate from MDH
k. other (describe)
l. outreach

To locate more clients, especially those at high risk, describe what you do and your budget for this activity.
How many prenatal clients do you get from your own outreach per year?
How many post partum/newborn clients do you get from your own outreach per year?
How many pediatric clients up to one year of age do you get from your own outreach per year?

IV. Financial Structure:
Please describe your sources of income and the approximate percentage of your budget that comes from each. Please indicate which funds are available for perinatal services including prenatal, post partum, and maternal and child health through the first year of life.

Funding source;% of budget; % for perinatal related services

a. Federal funding
b. State funding
c. City/county funding
d. Charitable donations, fund raising
e. Private/grant/foundation funding
f. Insurance reimbursement (which plans? commercial or PMAP? MA?, MN Care?)

Do you anticipate any change in your capacity to provide services in the near future? If so, please describe anticipated changes, either increased or decreased capacity.

Please describe any problems your agency has with reimbursement for perinatal services, especially case management/care coordination, and service integration. (You may include failed appointments or “not home not found” visits if they represent a significant loss of income.)

Does your organization have any financial concerns, past, current, or future that you would like to share with us?

V. Closing
Is there anything else that sets your organization’s model of perinatal service delivery apart from other providers of perinatal care and services in the community?

What are three recommendations you would make to improve the coordination of perinatal services?

Acknowledgement and Reference:

Population-Based Public Health Nursing Interventions: A Model from Practice by Keller, L.O., Strohschein, S., Lia-Hoagberg, B., and Schaffer,M.was used as a model to design this survey.

From Public Health Nursing, (June,1998) Vol.15 No. 3, pp. 207-215



Previous Page
Page 16 of 21