The Care Coordination Program (CCP) is an outreach and short-term care coordination program.
The M-CES will use creative, trauma-informed strategies to connect vulnerable, pregnant and postpartum women and infants to needed services/ resources and to educate them about their health benefits. Depending on the needs, special populations of women served may include those with congenital syphilis or other special health circumstances.
- Work collaboratively with multiple agencies such as; emergency departments, clinics, detention facilities, social service organizations, etc. to assure that women are connected to prenatal, postpartum, sexual health or infant services.
- Complete face-to-face outreach to clients in the settings listed above or in client homes as needed
- Use all resources to attempt client location, such as client's emergency contacts, identified PCP site, MCO Special Needs Coordinators or other agencies to determine possible contact information for clients.
- Provide additional outreach attempts based on newly identified demographic information following provider and agency investigative efforts. These outreach attempts include additional home addresses and places identified where client may stay, outreach at OB or Pediatric Provider appointments, shelters, etc.
- Provide linkage and coordination to OB, MCO, pediatric or primary care, dental care, specialty care, as well as linkage to the Maryland Medical Care Programs as needed.
- Assessment, triage and referral of pregnant women and infants to Baltimore City Home Visiting Programs for long term case management services.
- Aid with the removal of barriers to accessing healthcare through referral to Medical Assistance Transportation and other support services.
- Documentation of all outreach activities according to CCP standard operating procedures in E-Clinical Works database
- Completion of Monthly outreach activities in e-Medicaid.
- Collaborate with Congenital Syphilis Surveillance Coordinator (CSSC) to contact pregnant women who have been identified as having syphilis and reconnect them with their medical providers to ensure that they receive the prescribed treatment regimen