Section 640.100  High-Risk Follow-up Program

a)         Local Health Nursing Follow-up for the High-Risk Mother

1)         Purpose

            Home visits to families of high-risk/pregnant and postpartum women have a two-fold purpose: assessment of the woman and the family/environment and facilitation of early intervention for identified problems.

2)         Agencies to Provide Services

A)        All Local Health Departments should provide follow-up services to residents of their counties.

B)        The Department may contract with a local health agency or county nurse to provide follow-up services to residents of areas without a Local Health Department.

3)         Eligibility for Services

            Any pregnant or postpartum patient identified as high-risk by a Level III hospital and referred to a Local Health Department or other designated local health agency should be offered follow-up services. The patient may decline such services.

4)         Services to be Provided

A)        Home visits to high-risk pregnant women should be scheduled as often as the client's condition warrants or as requested by the attending physician. A post-discharge visit should be made as soon as possible after discharge. Additional visits may be made during the postpartum period (i.e., 6 weeks following the date of delivery) for pregnancy-related conditions as indicated or as requested by the attending physician. If additional visits are for chronic health conditions (e.g., chronic hypertension, CVA, advanced cardiac disease), the patient should be referred to the licensed home health agency in the area for long-term follow-up.

B)        Local health agencies which provide services must adhere to the provisions of the Maternal and Child Health Services Code (77 Ill. Adm. Code 630).

b)         Local Health Nursing Follow-up for High-risk Infants

1)         Purpose

            The purpose of the infant follow-up program is to minimize disability in high-risk infants by identifying as early as possible conditions requiring further evaluation, diagnosis, and treatment and by assuring an environment that will promote optimal growth and development.

2)         Agencies to Provide Services

A)        All Local Health Departments should provide follow-up services to residents of their counties.

B)        The Department may contract with a local health agency to provide follow-up services to residents of areas without a Local Health Department.

3)         Eligibility for Services

            Any infant eligible for the Adverse Pregnancy Outcomes Reporting System (APORS) and referred to a Local Health Department or other designated local health agency should be offered follow-up services. The family may decline such services.

4)         Services to be Provided

A)        A minimum of 6 visits should be made by the follow-up nurse: as soon as possible after newborn hospital discharge, and at infant chronological ages 2, 6, 12, 18, and 24 months. Infants and their families having actual or potential health problems identified by the nurse should be visited more frequently for health monitoring, teaching, counseling and/or referral for appropriate services. Occasionally, when an infant is receiving services at the health department, a follow-up visit may be conducted by the nurse at that time.

B)        Follow-up services should include:

i)          Health History including: prenatal and natal history; parental concerns; family history of genetic disease or unexplained mental retardation; compliance with medical regimen, if any, including medications, treatments, and visits to the physician; infant care, including nutrition, elimination, and sleep activity; and family/infant interaction, family coping and parental knowledge of injury prevention.

ii)         Physical assessment, developmental assessment, and age specific anticipatory guidance based on the American College of Obstetricians and Gynecologists guidelines or current recommendations of the State that are found in subsection (b)(5) of this Section.

iii)         Based on the results of the health history and physical assessment, the nurse will identify problems and nursing diagnoses and arrange for intervention. Intervention may include: counseling the family as to the importance of regular primary health care by the family physician, pediatrician, or clinic; encouraging scheduled return visits to Perinatal Center; family teaching/counseling by the follow-up nurse; referral to the physician or other screening, diagnostic or support services depending on the nature of the problem; and follow-up on referrals.

5)         Local health agencies must adhere to the provisions of the Maternal and Child Health Services Code (77 Ill. Adm. Code 630) and the Department's High Risk Infant Tracking Supplement for Local Health Departments, which may be obtained from the Department's Office of Family Health.

(Source:  Amended at 24 Ill. Reg. 12574, effective August 4, 2000)