maternal plan of Care – part 2 – TOBACCO
Michigan Department of Health and Human Services
Beneficiary
INTERVENTION LEVEL	INTERVENTIONS Using Motivational Interviewing, complete the following brief interventions.
MODERATE	Refused all interventions
Date of Intervention Level Change:	Discuss consequences of tobacco use on mother/caregiver health. Discuss consequences of tobacco exposure on fetus/infant. Discuss individual and family history of tobacco use. Discuss infant safe sleep in relation to tobacco use. Discuss stress and depression in relation to tobacco use. Discuss breastfeeding in relation to tobacco use. Discuss postpartum tobacco use and relapse reduction strategies. Discuss 2nd and 3rd hand tobacco exposure and promote smoke-free home. Discuss electronic cigarettes use. Discuss spouse/partner, family, friend and household member tobacco use and promote harm reduction. Discuss safe storage of tobacco products and equipment (e.g. electronic cigarettes, lighters). Utilize the 5 R’s to encourage quit attempt. Relevance, Risks, Rewards, Roadblocks, Repetition Utilize the Tobacco Clinical Guidelines (5 A’s) to encourage tobacco cessation. Ask, Advise, Assess, Assist, Arrange Encourage beneficiary to set a quit date and follow a quit plan. Refer beneficiary to appropriate medical care provider or community resources to discuss treatment options.
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Currently using tobacco Currently using smokeless tobacco or electronic cigarettes Exposure to 2nd hand smoke
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.

MATERNAL PLAN OF CARE – PART 2 INSTRUCTIONS
These instructions are intended to clarify data fields on the Plan of Care, Part Two (POC 2). If you have additional questions, please contact the MDHHS MIHP Team.
Beneficiary: At the top of the page, write the first and last name of the maternal or infant beneficiary. If the beneficiary is an infant, use the infant’s full name even if the POC 2 domain falls under the ‘Maternal Considerations’.
COLUMN 1 Intervention Level Check the box that matches the risk level on the Risk Identifier Score Sheet or professional judgement determination of the risk criteria. Beneath each Intervention Level are brief descriptions of the risk criteria that correspond to each Intervention Level within a domain.
Date of Intervention Level Change A date is entered in this space for one of two reasons: The Intervention Level was changed based on professional judgement. The Intervention Level is changed only when observation and professional judgement determine the beneficiary/caregiver meets the criteria for a higher or lower Intervention Level. •• If an increase or decrease of Intervention Level occurs, check the appropriate Intervention Level box and document the reason for the change on the Professional Visit Progress Note or Contact Log. The POC 3 does not need to be updated when changing an Intervention Level.
New risk domain is added to the beneficiary’s care. •• A new risk domain may be added when observation or new information demonstrates a beneficiary/caregiver meets the criteria for a domain that did not score on the Risk Identifier or can only be added based on professional judgement (e.g. Breastfeeding). •• Documentation must support the addition of the new risk domain. - If adding a POC 2 prior to signing the POC 3 for the first time, write the addition in the comments section of the Risk Identifier. The additional POC 2(s) may also be documented on the Contact Log. - If adding a POC 2 after the POC 3 has been signed documentation on the POC3 must identify which POC2 (s) was added, with the date, signature and credentials of the nurse or social worker who added it.
COLUMN 2 Interventions Interventions reflect evidence-based best practices to be utilized by home visitors with beneficiaries and caregivers to address the identified risk domain. Using Motivational Interviewing skills and professional judgement MIHP providers are expected to implement interventions most appropriate for the beneficiary/caregiver. It is not required to implement all interventions. It is not required to implement interventions in number order.