N.M. Code R. § 8.10.5.9

Current through Register Vol. 35, No. 11, June 11, 2024

Section 8.10.5.9 - PLAN OF CARE (POC)

A. A plan of care with services is to be offered prior to a newborn's discharge from the hospital when substance exposure has been identified.

B. The purpose of POC is to ensure continuity and engagement of support services for the newborn and caregivers. A POC is the document completed by a healthcare professional with the family or designated caregiver(s) of the newborn when substance exposure has been identified. POCs are jointly created by the healthcare professional and the family to support them to obtain resources and services that sustain family relationships and support the health and well-being of the infant and family members. The implementation of services in the POC shall be modified and updated as often as required to address changes in the needs and circumstances of the family. All services in the plan are voluntary and at the option of the family. All POC's must include the following information:

(1) The newborn's birth information: This shall include date of hospital admission, birth date, discharge date, and name of infant.

(2) The identified key household members: All key household members over 18 years of age shall be documented in the POC and offered supportive services listed in the plan of care.

(3) The discharge address for the family: The discharge address shall be the physical address of the caregiver who will be taking the newborn home. This may include, but is not limited to:

(a) parents;

(b) relatives or fictive kin; or

(c) resource family.

(4) In-utero exposures: If a newborn is exposed to any substances during pregnancy, all exposures shall be documented in the POC and on the notification of CARA newborn status form when applicable. Documentation of exposures include exposures occurring during the timeframe in which the mother may not have known she was pregnant, and all substance exposures, including, but not limited to illicit and prescription drugs, alcohol, marijuana (medical or recreational), and medication assisted therapy such as methadone and buprenorphine.

(5) Substance use assessment: The parents, domestic partners and key household members shall also be assessed for substance use disorders. If it is determined they have a substance use disorder, it shall be documented in the POC. If there is substance use present, the parents, domestic partners and key household members shall be offered services to address treatment and recovery goals of each individual. A copy of the POC will be provided to individuals for whom such referrals are made.

(6) Services and referrals: The POC shall also include the services for which the family agrees to be referred as well as services the family is already participating in. If the family declines services in their community, the healthcare professional clearly documents this within the POC. Families shall be informed that they may request a referral for services at a later time, even if they have declined these services during the initial development of the POC, by communicating with their health insurance care coordinator or the CARA navigator(s) whose contact information shall be included on the POC.

(7) Health insurance and care coordinator information: The POC shall identify the managed care organization (MCO) or private insurer that the mother is enrolled with and include contact information for the assigned care coordinator (CC) when known at the initial creation of the POC. The initial POC shall specify if a CC has not yet been assigned or if the family has declined care coordination with their MCO or private insurer. children's medical services (CMS) shall serve as the care coordinator for the newborn if the newborn is uninsured, fee for service exempt (Medicaid), or military if care coordination is unavailable.

(8) Release of information: The POC shall include a release of information that includes an explanation of the entities with whom the information in the plan may be shared. The parent or designated caregiver completing the initial POC shall sign the document to indicate informed consent for the release of information and referrals included in the plan. A POC shall be considered inactive until it has been signed by the parent or designated caregiver. The individual completing the POC shall document that they reviewed the release of information with the caregivers. Any person or agency receiving information from the POC shall be directed to treat it as a confidential document and only to be used for the purpose of collaboration on this POC. The release of information is valid for two years.

(9) Caregiver acknowledgment of notification to CARA program: The POC shall be submitted to the CARA program at New Mexico children youth and families department and New Mexico department of health per the requirement of the CARA Statute, this includes a POC that is unsigned by the caregiver. The health care provider who completes the form with the caregiver shall inform the caregiver of this requirement.

C. When a POC should be completed by and sent to the CARA Navigators: A POC shall be completed by the hospital staff with the parent or designated caregiver prior to the newborn's discharge from the hospital. In the case of births that occur without hospital admission, or when substance exposure has been identified after the newborn's discharge from the hospital, a POC may be created with the parent or designated caregiver by the infant's healthcare provider, or by the assigned insurance care coordinator or the CARA navigator. The POC shall be considered active upon the date of signature of the parent/designated caregiver. The individual who creates the plan with the family shall also sign and date the POC. Once the POC has been signed it shall be sent to the CARA navigators at CYFD and NMDOH by secure transmission or submitted through the CARA portal at New Mexico healthy families by the provider who has initiated the POC.

D. Unknown information: If the individual completing the POC does not have specific information necessary to complete the POC, they shall fill it out to the best of their ability and write unknown where the information is not known. The assigned care coordinator (CC) is responsible for completing the missing information once they receive the POC. If a caregiver declines care coordination, then a provider working with the family will complete the missing information.

E. Who receives copies of the POC: The caregiver, relative, guardian, fictive kin or resource family of the newborn, the parents, designated CARA navigators at department of health (DOH) and children, youth and families department (CYFD), the care coordinator (CC), the newborn's primary care provider (PCP), and the referred supportive service providers will each receive a copy of the completed POC.

F. Duration and Monitoring of Plans of Care: Once the CC has been assigned and has met with the family, the CC shall contact the newborn's primary care provider (PCP) and other referred providers to ensure that referrals have been received; to provide support for family engagement with the services on the POC; and to ensure that providers have received a copy of the POC as permitted by the release of information (ROI) and informed consent signed by the caregiver. The POC shall remain in place for at least the first year of the child's life and shall remain active if continued services are needed for the child or caregivers after the first year. The implementation of services on the POC shall by monitored by the CC assigned under the newborn's MCO or private insurer; CMS when an infant lacks health insurance or is not eligible for CC; or by a designated CARA navigator or by a designated provider. The delivery of services and family engagement shall be monitored at the frequency and intensity needed to ensure the safety and well-being of the infant, and to support progress toward achieving the parents' or designated caregivers' expressed objectives for their POC. At one year from the child's birth, a re-assessment of the POC with the family by the assigned CC shall occur and, if necessary, the POC may be extended for a period of time to be determined jointly by the family and assigned CC, by a designated provider, or CARA navigator.

G. Plan of care modifications: A POC may be modified in the following situations, including but not limited to when:

(1) there is a change in caregivers during the active POC, the plan shall be adjusted, as needed, based on the new caregivers' location, and identified needs;

(2) a caregiver moves to a different city or town in the state of New Mexico;

(3) reunification of the child with their parents occurs during the first year, the POC shall remain active and can be modified if needed;

(4) the needs of the child have changed;

(5) a child comes into CYFD custody, and the caregiver needs to continue following the POC; or

(6) the needs of the caregiver change.

H. Notice of transfer of newborn between medical facilities:

(1) If a newborn is born outside of New Mexico and is a New Mexico resident, and an agreement has been made with that birthing hospital, then the out-of-state hospital shall complete a notification of CARA newborn status to alert the CARA navigators at DOH and CYFD.

(2) If a New Mexico hospital is transferring a newborn to another facility either in-state or out of state, the notification of CARA newborn status shall be sent to the receiving hospital/facility and the CARA Navigators.

(3) For in-state hospital transfers of a newborn, the receiving hospital shall create the POC and should be notified by the transferring hospital.

I. Late identification of substance use/exposure: Late identification is when substance use or newborn exposure to substances is not known or identified until the newborn has already been discharged. If late identification occurs:

(1) The notification of CARA newborn status shall be utilized to notify the CARA CYFD and DOH navigators. If the hospital notifies the caregiver of the positive result on the newborn, the hospital shall explain that the CARA navigators shall be notified, and that a CARA navigator shall contact the caregiver to offer a POC for their newborn.

(2) If the CC or another healthcare provider is informed of an exposure following the newborn's discharge from the hospital or birthing facility, they shall inquire if the caregiver has a POC. If not, they shall inform the caregiver of the newborn that the CARA navigators may be notified using the notification of CARA newborn status and may be contacting the caregiver to offer a POC for the child.

J. Open CYFD case or case needs to be opened:

(1) When hospital staff or other providers who are involved in creating a POC with the family have concerns about the safety of the newborn upon discharge, the individual shall make a report to CYFD statewide central intake (SCI). The referral to SCI shall be indicated on the POC when known by the professional completing the POC. Upon receipt of a POC, the CYFD CARA navigator shall review if there is current involvement of CYFD protective services with the parent or designated caregiver of the newborn. The CARA navigator shall provide a copy of the POC to assigned CYFD worker when CYFD involvement has been identified. The CARA navigator shall also notify the designated CC of the newborn when there is an investigation involving the caregiver(s) of the newborn. If the CC has concerns around the safety of the newborn, they shall contact the CYFD worker and the CARA navigators. If the CC or other providers have immediate concerns they shall immediately make a report to the CYFD SCI and notify this is a family that has an active POC.

(2) If a newborn enters CYFD custody after a POC has been created, the POC shall be modified by the CC or the CARA navigator to address the needs of the infant in the new setting. The new POC shall contain the resource family's information and shall be re-sent to all entities required to receive copies of the POC.

K. Implementation of the plan of care: Once the CC has been assigned and has met with the family, the CC shall contact the newborn's primary care provider (PCP) and other referred providers to ensure that referrals have been received and that the provider has a copy of the POC as permitted by the release of information (ROI) and informed consent signed by the caregiver. The CC shall periodically communicate with the family and review the family's engagement with the services on the POC. If the CC is unable to connect with the family and is not able to confirm the newborn is established with a PCP, along with other services, they will inform the CARA navigator, and follow an internal process (within their MCO/agency) for potentially calling in a report to CYFD SCI.

N.M. Code R. § 8.10.5.9

Adopted by New Mexico Register, Volume XXXIII, Issue 04, February 22, 2022, eff. 2/22/2022