maternal plan of Care – part 2 – Food/Nutrition
Michigan Department of Health and Human Services
Beneficiary
INTERVENTION LEVEL	INTERVENTIONS Using Motivational Interviewing, complete the following brief interventions.
LOW	Refused all interventions
Date of Intervention Level Change:	Discuss beneficiary/family diet and typical method of accessing food. Discuss food intake changes since becoming pregnant and/or baby was born. Discuss importance of appropriate weight gain and prenatal vitamins (i.e. Folic Acid, Iron) and address any barriers to consistent prenatal vitamin intake during pregnancy. Discuss family and household attitudes, beliefs and practices and how they may impact current diet. Discuss importance of nutritious food intake and maintenance of appropriate weight. Identify local WIC provider and assist beneficiary with access. Discuss foods to avoid during pregnancy and how to adapt current diet. Discuss food availability in community and identify barriers and solutions. Discuss food assistance programs and assist with application, appointments and follow-up, as needed. Discuss safe storage of foods. Develop a plan for ensuring food access and availability. Discuss medical care provider concerns with beneficiary’s nutrition, if applicable. Refer to Registered Dietician. Encourage beneficiary to discuss PICA (eating non-food items) with medical care provider.
/ /
Poor nutritional intake or consumption of unsafe foods
MODERATE
Date of Intervention Level Change:
/ /
Concerns about nutrition No or limited access to affordable nutritious food Not currently enrolled in food assistance program (i.e. WIC) Not taking prenatal vitamins
high
Date of Intervention Level Change:
/ /
Current PICA (eating non-food items)
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.

ADDITIONAL CONSIDERATIONS – Multiple Domain POC 2 Multiple Domain POC 2 There are two POC 2s that combine multiple domains from the Risk Identifier Score Sheet. For the multiple domain POC 2s, MIHP providers must pull the POC 2 if one or more domains score on the Risk Identifier Score Sheet. •• Food/Nutrition POC 2 - Basic Needs Food and Basic Needs Nutrition domains. If Basic Needs Food or Nutrition (or both) have a score on the Risk Identifier, the Food/Nutrition POC 2 must be pulled for the beneficiary’s plan of care. •• Medical Considerations POC 2 - Health History Asthma, Health History Diabetes and Health History Hypertension domains. If Health History Asthma, Health History Diabetes and Health History Hypertension (or multiple) have a score on the Risk Identifier, the Medical Considerations POC 2 must be pulled for the beneficiary’s plan of care. The multiple domain POC 2s may be added to the beneficiary’s plan of care based on professional judgement. Documentation must support the addition of the multiple domain POC 2 following the ‘New risk domain is added to the beneficiary’s care’ instructions.