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Provider and Facility Reference Manual

Section 17 - Right Start Program

Beneficial for Physicians, Mothers and their Babies

Pregnant women need care, support and education from the first signs of pregnancy, through birth and after the baby is born. To ensure all our pregnant members receive the services they need, we recommend our Right Start Program. This program covers moms and their babies from the time the pregnancy is identified to six months after birth.

The Right Start Program begins with our prenatal assessment form. Registered moms will receive prenatal education and interventions when identified as high-risk. Of particular interest to physicians are the following elements of the program: $100 reimbursement for physicians to enroll each high-risk patient prior to their 15th week gestational period.

Please click on the Right Start clinical practice guidelines and prenatal referral form.

Newborn Education Component

New mothers may not recognize the basic signs of illnesses in their babies, simply because they lack the necessary education, experience and materials. As a result, these moms frequently take their newborns to the emergency room when possibly home care was all that was needed.

To help educate new moms about basic care of their newborns, we are working with hospital nurseries to identify mothers who want or need newborn education. Nursery department staff will initiate basic wellness education, along with instruction about recognizing signs and symptoms of newborn illnesses. Through home nursing visits, education will continue over a six-month period as needed, or through telephone intervention.

By providing newborn care information to new moms, we hope to:

  • Teach moms how to recognize signs of illness in their babies.
  • Help them to better communicate with their baby's pediatrician.
  • Avoid unnecessary trips to the emergency room.
  • Reinforce proper preventive care and immunization schedules with moms.

Fact Sheet

The Right Start Program is designed to follow mother and child from the time the pregnancy is identified to six months after birth. All pregnant women should be registered during their first trimester. They will receive educational support and materials. Patients who are identified as high-risk will also receive case management services that reinforce the physician's care instructions and offer additional patient education. In-home nursing visits or telephonic options are available to those that qualify. After the birth of their babies, new moms will receive newborn education to help them care for their babies.

All pregnant patients should be enrolled in the Right Start Program.

The Right Start Program's four major components are:

  • Enrollment of pregnant patients in the program
  • Prenatal education for all patients
  • Interventions for high-risk patients
  • Health education for newborn care

Enrollment by Physician

Physicians need to complete a prenatal assessment form for each pregnant patient at the time of her first prenatal visit. It's important that we receive a form for every member, not just those who may be high-risk. Please fax or mail the completed forms to us at the number or address on the form. Forms can also be electronically submitted online on our website.

Once received, we will enroll the patient in our Right Start program and send you $100.00. This $100.00 is an incentive payment for referring our high-risk members to the program prior to the member's 15th week gestational period and does not apply to any medical services you provide.

Prenatal Education

The program emphasizes the importance of early and ongoing prenatal care. Women will also be encouraged to attend one of our many prenatal education classes. Additionally, education regarding importance of postpartum care and follow-up are reviewed.

Interventions for High-Risk Patients

Patients who are identified as high-risk on the prenatal assessment form will be evaluated to possibly receive an at home risk assessment by a nurse specializing in maternal or obstetrical care. The nurse will act as a liaison between you and your patient by reinforcing your care instructions and offering patient education. If needed, with the consent of the mother, additional monthly home visits may be scheduled. One example is a home visit from a registered dietician to assist the mother with meal planning for gestational diabetes, hypertension, obesity, hyperemesis or other nutritional concerns identified by the physician. There is no member copayment for any nursing visits coordinated through the Right Start Program.

HIV Services

DOHM (AI 99-01) is the standard of care for HIV services.

a.    Provide all pregnant women with HIV counseling and education;
b.    Offer the pregnant woman confidential HIV testing; and
c.    Provide the HIV positive woman and her newborn infant the following services or make the necessary referrals for these services:

1.    Management of the HIV disease
2.    Case management to assist in coordination of necessary medical, social and addictive services

HIV pretest counseling should be provided to all prenatal clients. If a woman is found to be HIV positive, the clinician ordering the HIV test is responsible for arranging for a follow up appointment to an HIV specialist or designated AIDS Center.

Universal Recommendation for Testing of Pregnant Women

New York’s regulatory framework for preventing mother-to-child transmission (MTCT) of HIV has proven highly effective and remains unchanged. The only exception is that the 2017 updates to HIV testing do remove the requirement to obtain consent for HIV testing in writing or orally. All pregnant women must be offered HIV testing as a clinical recommendation as early as possible during pregnancy. Third trimester testing is recommended for all pregnant women in NYS who tested negative for HIV earlier in their pregnancy. When being offered HIV testing, the woman should be provided the key points of information and informed of her right to decline the test .Pregnant women who are diagnosed as living with HIV should be linked to treatment as soon as possible to protect their health and prevent transmission of HIV to the newborn.

Women who present to the labor/delivery setting with no history of HIV testing during their current pregnancy should be counseled with the recommendation for HIV testing. If the mother declines testing in labor/delivery, the mother should be informed that her newborn will be tested immediately at birth without her consent. All newborns, including those tested at birth, are routinely tested for HIV through the New York State Newborn Screening Program. Documentation of the woman’s prenatal HIV testing should be forwarded to the delivering hospital and a copy of the mother’s HIV test history results should be placed in the newborn’s medical record to ensure administration of medications during labor/delivery and initiation of medication to the infant for the first four-six weeks of life or until the infant is definitively excluded from HIV infection.

To access the latest regulations visit:

Acute HIV Infection During Pregnancy                         

The acute HIV infection in pregnancy guidelines recommend the following:

  • Confirmation of preliminary positive expedited HIV test results
  • Vigilance for acute HIV infection in pregnant women who present with a compatible clinical syndrome, even if a previous HIV antibody test during current pregnancy was negative
  • Evaluation for acute HIV infection in pregnant or breastfeeding women who present with a febrile “flu” or “mono” like illness, or rash that is not otherwise explained
  • Immediate screening for suspected acute HIV infection by obtaining an HIV serologic screening test in conjunction with a plasma HIV RNA assay (a fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test, if available)
  • Repeat HIV RNA testing from a new specimen to confirm the presence of HIV RNA if HIV RNA or antigen was detected in the absence of HIV antibody
  • Baseline genotypic testing and initiation of ART while waiting for the results of resistance testing

For HIV positive women, documentation should reflect receipt of appropriate care.

Labor and Delivery

  • Offering of testing during labor and delivery for those who do not have documented third trimester HIV test results
  • Availability of expedited testing of pregnant women who present for delivery without documentation of a negative HIV test

Partner Services and the Role of Partner Services Programs

Medical providers or their designee must explain to all newly diagnosed patients the importance of notifying any sexual or needle-sharing partners that they may have been exposed to HIV. Partner services is a cornerstone of HIV prevention efforts that provides an opportunity for sexual or needle sharing contacts of a person living with HIV to be offered testing in a timely manner, and if diagnosed with HIV infection, be linked into care. Every physician or other person authorized to order diagnostic testing is required to report HIV and AIDS diagnoses to the health department. This report must include identifying information about any contacts known to the clinical provider or provided to the clinical provider by the patient.

The HIV/AIDS Provider Portal may be used to report cases, including partners and to request assistance from the health department with partner notification. As part of post-test counseling, the following must be provided to the patient:

  1. An explanation of the importance of notifying sexual or needle sharing partners to prevent further transmission, and to promote early access of exposed persons to HIV testing, health care, and prevention services;
  2. A description of notification options and assistance available to the protected individual;
  3. A discussion about the risk of domestic violence and screening for domestic violence prior to partner notification in accordance with NYSDOH domestic violence screening protocol;
  4. The fact that known contacts, including a known spouse, will be reported to the health department. That protected persons will also be requested to cooperate in contact notification efforts of known contacts and that protected persons may name additional contacts they wish to have notified with the assistance of the provider or authorized public health officials; and
  5. An explanation that the name and other information about the person living with HIV will be protected during the contact notification process.

The NYSDOH Partner Services Program and the NYC Health Department Contact Notification Assistance Program (C-NAP) provide a wide range of services, including: performing notifications; assisting patients with decision making; and consulting with health care providers. In some situations, Partner Services Specialists can meet with the patient at the same time that the laboratory results are given to assist with post-test counseling and development of a partner notification plan. Additional NYSDOH/NYC Department of Health and Mental Hygiene (NYCHMH) services may be available such as assistance in locating persons who test positive but who do not return for their results.

For more information about partner services and how to contact partner services programs throughout NYS, visit: https://health.ny.gov/diseases/communicable/std/partner_services/index.htm.

IMPORTANT POINT:
In recognition of the need for ongoing partner services beyond the time of initial diagnosis of HIV, the 2016 updates to the NYSDOH Regulations formally prioritized partner services for people who were previously diagnosed with HIV who are at elevated risk of transmitting the virus to others. Several factors are considered as evidence of elevated risk of transmitting the virus to others.  Those factors include that the individual: 1) is not engaged in health care services 2) is not virally suppressed 3) has had a recent STD or 4) has recently moved back to NYS from another jurisdiction.

In addition, the updated NYSDOH Regulations remove the requirement that data on the partners of HIV cases be destroyed after three years. The NYSDOH or local health department will establish a new policy for record retention and disposition.

Health Care Provider HIV Reporting Requirements

New York State Public Health Law Article 21 requires the reporting of persons with HIV infection and AIDS to the NYSDOH. The law also requires that reports contain the names of sexual or needle-sharing partners known to the medical provider or whom the patient wishes to have notified. Under the federal HIPAA Privacy Rule, public health authorities have the right to collect or receive information “for the purpose of preventing or controlling disease” and in the “conduct of public health surveillance…” without further authorization. This provision of HIPAA regulations authorizes medical providers to report HIV/AIDS cases to the NYSDOH or NYC Health Department without obtaining patient permission.

The Medical Provider HIV/AIDS and Partner/Contact Report Form (PRF) (DOH-4189) must be completed within 14 days of diagnosis for persons with the following diagnoses or with known sex or needle-sharing partners:

  • Initial/New HIV diagnosis - First report of testing documenting HIV diagnosis
  • Previously diagnosed HIV (non-AIDS) - Applies to a medical provider who is seeing the patient for the first time
  • Initial/New diagnosis of AIDS - Including <200 CD4 cells/μL or an opportunistic infection (AIDS-defining illness)
  • Previously diagnosed AIDS - Applies to a medical provider who is seeing the patient for the first time
  • Known sex or needle-sharing partners of persons with diagnosed HIV infection

Clinicians seeing for the first time a patient previously diagnosed with HIV or AIDS should report to the NYSDOH using the PRF. The rationale is that this is often the only indication the NYSDOH receives of a patient new to New York, but not newly diagnosed, and perhaps not in need of extensive Health Department Partner Services. Additionally, particularly for the well suppressed patient who moves into NYS, the report by the clinician can be the only indication that the person is in fact HIV positive.

Information regarding electronic reporting via the HIV/AIDS Provider Portal (see below) or paper forms are available from the NYSDOH at 518-474-4284; clinicians located in NYC, call 212-442-3388. In order to protect patient confidentiality, faxing of reports is not permitted.

HIV/AIDS Provider Portal

The HIV/AIDS Provider Portal is an electronic system that enables clinicians to: 1) meet their reporting requirements electronically 2) provide a mechanism for clinicians statewide to notify the NYSDOH that a patient needs linkage to Health Department Partner Services and 3) submit inquiries for patients with diagnosed HIV infection who are thought to be in need of assistance with linkage to or retention in HIV medical care. A NYSDOH Health Commerce System (HCS) Medical Professionals account is required. After logging into the Health Commerce Systems, select “Refresh My Applications List” on the left side and then under “My Applications” select HIV/AIDS Provider Portal. Follow the prompts to set up an account.

Laboratory Reporting Requirements

Laboratory reporting of suspected or confirmed positive findings or markers of HIV infection is mandated under New York State Public Health Law. Guidance has been prepared in an effort to assist permitted clinical laboratories and blood banks in meeting their obligations to report HIV-related laboratory test results, as well as other communicable disease markers. The guidance is available on the Wadsworth Laboratory website.

HIV laboratory reporting is an essential source of information for New York’s HIV surveillance efforts and maintaining high quality, complete data is critical to tracking progress toward National HIV/AIDS Strategy retention and care measures and New York’s effort to end the epidemic.  To keep pace with advances in HIV care, testing technologies and disease monitoring, there have been some important changes to HIV laboratory reporting requirements. Laboratories and blood/tissue banks performing tests for screening, diagnosis or monitoring of HIV infection for NYS residents and/or NYS health care providers (regardless of patient residence) shall report the following laboratory tests or series of tests used in the diagnosis of HIV infection:

  • All reactive/repeatedly reactive initial HIV immunoassay results AND all positive, negative or indeterminate results from all supplemental HIV immunoassays performed under the second or third step in the diagnostic testing algorithm, including HIV-1/2 antibody differentiation assay, HIV-1 Western blot, HIV-2 Western blot or HIV-1 Immunofluorescent assay
  • All HIV nucleic acid (RNA or DNA) detection tests (qualitative and quantitative), including tests on individual specimens for confirmation of nucleic acid-based testing (NAT) screening results
  • All CD4 lymphocyte counts and percentages, unless known to be ordered for a condition other than HIV
  • HIV genotypic resistance testing via the electronic submission of the protease, reverse transcriptase and integrase nucleotide sequence
  • Positive HIV detection tests (culture, P24 antigen)

All HIV-related laboratory reporting, including by NYC providers and for NYC residents, should be made directly to the NYSDOH, submitted electronically via the NYSDOH Electronic Clinical Laboratory Reporting System (ECLRS).

To improve the quality of data, and in keeping with changes that allow for enhanced use of surveillance data to improve linkage and retention in care, laboratories are required to report results using patient identifying, demographic and locating information, as well as the requesting provider and facility ordering the lab test. The 2016 update requires that when labs report HIV-related test results, the following information should be included:

  • Patient name, date of birth, and other identifying information;
  • Patient demographic information, e.g., sex at birth, race/ethnicity, etc.
  • Patient address and telephone number
  • Provider ordering the test and facility name
  • Complete provider and facility address and telephone number
  • Provider and facility National Provider Identification

For a complete list of this information and instructions on how to report required data elements, please call 518-474-4284 or contact BHAELab@health.state.ny.us.

In Labor and Delivery Settings, recommendations are:

  • Adoption of point of care rapid HIV testing in labor and delivery settings
  • Availability of expedited HIV test results prior to delivery to allow maximum benefits of intrapartum ARV prophylaxis for the fetus
  • Steps to follow when expedited HIV testing yields a preliminary positive result
  • Steps to follow when definitive test results indicate HIV infection is present
  • Steps to follow when HIV infection has been definitely excluded in the mother

Pregnant women and exposed infants lost-to-care require immediate action for re-engagement. HIV-positive pregnant women and their exposed infants are a priority when identified as lost-to-care and require immediate action for reengagement. Reengagement in care is especially important for HIV-positive pregnant women who are in their third trimester due to possible increasing viral loads from being non-adherent to ART, leading to increased risk of transmitting HIV to their infants. Ensuring exposed infants are engaged in care is critical during the first 4-6 months to ensure appropriate antiretroviral and opportunistic infection prophylaxis, as well as definitive documentation of the infant’s HIV infection status.

If routine attempts for re-engagement of the HIV-positive pregnant woman or her exposed or infected infant(s) are not successful, please contact the NYSDOH Perinatal HIV Prevention Program at (518) 486-6048 or submit a request via the NYSDOH HIV/AIDS Provider Portal (see below) for assistance. New York City providers should call the NYC DOHMH Field Services Unit at (347) 396-7601 for assistance with re-engagement of pregnant women.

Records and Reports
 

  • Create and maintain records and reports that are complete, legible, retrievable and available for review; such records and reports shall include: a comprehensive prenatal care record for each pregnant woman that documents the provision of care and services required by this section and is maintained in a manner consistent with medical record confidentiality requirements
  • A comprehensive prenatal care record should be maintained on each client. Entries should be complete, legible and accurately reflect any of laboratory testing and special procedures
  • Records should be maintained in a manner that safeguards confidentiality requirements
  • Develop/implement system to track trimester of entry, low birth weight (LBW) infants, number of prenatal visits, postpartum rate of return, number of c/sections, vaginal births after cesarean sections (VBACs), number of women choosing to breastfeed, and number of teen pregnancies
  • An annual report should be accurately completed and submitted within the expected time frame
     

Internal Quality Assurance
 

  • Develop and implement written policies and procedures establishing an internal quality assurance (IQA) program to identify, evaluate, resolve and monitor actual and potential problems in patient care
  • Implement IQA activities focusing on prenatal care within system-wide QA program
  • Develop policies/procedures establishing internal quality assurance plan for prenatal care program
  • Recommend IQA should be multidisciplinary and review issues such as nutrition, psychosocial, educational methods, care coordination, risk assessment, and HIV services

Have periodic IQA meetings to discuss prenatal issues:

  • A documented and filed prenatal chart audit performed periodically on a statistically significant number of current prenatal client records
  • An annual written summary evaluation of all components of such audits
  • A system for determining patient satisfaction and for resolving patient complaints
  • A system for developing and recommending corrective actions to solve identified problems
  • A follow-up process to assure that recommendations and plans of correction are followed

Prenatal chart audits should be performed using 85-40 indicators.

A tool to conduct chart audit should be developed.

Prepare written summary evaluation of audit findings on an annual basis. Maintain audit summary on file.

Develop system for determining patient satisfaction with prenatal program and resolving patient complaints. Recommend administering patient satisfaction survey during client's third trimester or at the postpartum visit.

Documentation should include: summary reports of chart audit findings; analysis of outcome statistics; analysis of patient satisfaction survey results with recommendations to correct identified problems. All follow up is done in a timely manner.

Postpartum Services

Coordinate with the neonatal care provider to arrange for the provision of pediatric care services and patient services.

Stress importance of postpartum/pediatric visit to the mother during third-trimester visits. Develop strategies to encourage client to return for postpartum visit (i.e., incentives). Implement missed visit policy for ‘no-shows.’

A postpartum visit with a qualified health professional shall be scheduled and conducted in accordance with medical needs, ideally between 7-84 days after delivery. For the interim, furnish each woman with a means of contacting the provider in case postpartum questions or concerns arise.

Provide home visits to assess needs (e.g., adjustment to parenting, feeding, etc.) as indicated. Refer to Care Coordination section for additional guidance. Contents of home visit should be documented in the record.

Develop arrangements for client to contact provider between delivery and scheduled postpartum visit.

Postpartum Visit Components
 

  • Identify any medical, psychosocial, nutritional, alcohol treatment and drug treatment needs of the mother or infant that are not being met;
  • Refer the mother, or other infant caregiver to resources available for meeting such needs and provide assistance in meeting such needs where appropriate;
  • Assess family planning needs and provide advice and services or referrals where indicated;
  • Provide preconception counseling as appropriate and encourage a preconception visit prior to subsequent pregnancies for women who might benefit from such visit;
  • Refer infants for preventive and special care.

Establish a protocol to provide all postpartum components of care (i.e., identify the needs of woman/infant, necessary referrals, family planning, etc.)

Postpartum documentation should include: delivery outcome, maternal physical exam, health status of mother/infant including medical, nutritional, psychosocial needs with referrals.

Use a standardized medical record with postpartum section or separate postpartum visit tool outlining indicated components of care. If you have questions about the Right Start Program please call 1-800-871-5531. Supporting Documentation is found on our provider website.

  • Assessment Form
  • NYSDOH Best Practices for Breast Feeding
  • Early Risk Identification for Consultation
  • Ongoing Pregnant Risk Identification for Consultation
  • Interpretive Guidance for Prenatal Care:Guidance For Prenatal Standards 

Medicaid Prenatal Guidelines

The New York State Department of Health worked with internal and external stakeholders to develop updated prenatal standards of care for all pregnant women enrolled in Medicaid. Additionally, Blue Cross Blue Shield has adopted these guidelines for all other lines of business for the maternity program.

These comprehensive changes will improve the quality of prenatal/postpartum care provided to pregnant women.