mdhhs-5713, mihp case manager chart review (Optional)

Michigan Department of Health and Human Services (MDHHS)

Maternal Infant Health Program (MIHP)

(Revised 5-22)

section 1

Beneficiary Name	Date

Quarter October - December January - March April - June July - September

1. Has beneficiary been seen monthly (at least once in a given month) this quarter? Yes No If No, is the reason documented?

2. Does the POC need to be modified? Yes No If Yes, which domains should be added?

3. Are all of the appropriate interventions being implemented in each domain? Yes No If No, indicate the domain and which interventions should be implemented. Domain: Intervention Numbers:

4. Were all high-risk domains addressed within the first three visits? Yes No If No, indicate the high-risk domains that need to be addressed. Domain:

5. If beneficiary scored out as high risk in the Stress/Depression, Abuse/Violence, or Substance-Exposed Infant domain, was a safety plan addressed? Yes No If No, indicate the high-risk domains requiring that safety plan be addressed. Domain:

6. Have the appropriate referrals been made this quarter? Yes No If No, what referrals need to be made?

7. Have all referrals been followed up on within three visits in this quarter? Yes No If No, which referrals need to be followed up on?

8. When is the next ASQ-3 screening due?	9. When is the next ASQ: SE-2 screening due? NA

10. What has beneficiary said about the extent to which MIHP services are meeting her needs this quarter? (check one) MIHP is meeting her needs/she is satisfied with services. MIHP is meeting some of her needs/she is somewhat satisfied with services. MIHP is not meeting some of her needs/she is somewhat dissatisfied with services. MIHP is not meeting her needs/she is dissatisfied.

11. What did beneficiary say she needed from MIHP this quarter?

12. Comments

Section 2 - signatures

Signature	Date

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.