Each HRIF Program must designate one of its team members as the HRIF Coordinator. The PNP is only required to be CCS-approved when functioning as an HRIF Coordinator.
- As the HRIF Program is a CCS Program Special Care Center (SCC), the required team members include a CCS Program-approved: HRIF Program medical director (pediatrician or neonatologist), HRIF coordinator, ophthalmologist, audiologist, social worker, and an individual to perform the developmental assessment. Each of these professionals may be reimbursed for the diagnostic services they provide. See CCS HRIF Program, for description of the health care professionals who perform developmental assessments. NOTE: An individual provider may simultaneously serve in more than one role on the HRIF team.
- All HRIF Programs shall develop policies and procedures, including job descriptions assigning function responsibilities, to ensure consistent implementation of the above policy regardless of staff changes. These documents shall be available for review during CCS Program site reviews.
- Team members of CCS Program-approved HRIF Programs are to be listed on the CCS Program HRIF SCC Directory. Names of providers must be approved by the HRIF Program Medical Director to provide services to HRIF eligible infants and children. If your NICU does not have a HRIF Program, you are required to complete the CCS Program HRIF SCC Directory form to identify your NICU and the facility that you have made arrangements with to provide HRIF services. If there are subsequent changes to the HRIF Program SCC directory, you must submit an update.
NOTE: HRIF Directory Forms are on the CCS Program website http://www.dhcs.ca.gov/services/ccs/Pages/HRIF.aspx#hrifdirectory.
The HRIF Coordinator shall be a CCS-approved: pediatrician or neonatologist, PNP, nurse specialist, psychologist, social worker, physical therapist, or occupational therapist. The PNP only requires CCS-approval when functioning in the CCS HRIF Program as a HRIF Coordinator.
The Coordinator has the key role in follow-up and coordination of services for eligible infants and children and their families. The specific responsibilities of the coordinator are:
- Serve as the primary person coordinating HRIF services among the local county CCS Programs, other HRIF Programs located in CCS Program-approved Regional, Community, and Intermediate NICUs, State Regional Offices, clients/families, and others in matters related to the client’s HRIF services.
- Participate in NICU discharge planning process or multidisciplinary rounds.
- Ensure identification of HRIF eligible clients according to HRIF eligibility criteria.
- Ensure the NICU discharge planning process includes referral and SAR submission to the County CCS Program or State SCD Office. (See page NICU Program Responsibilities)
- Ensure copies of the authorizations are distributed to HRIF team members and consultants.
- Gather medical reports and assessments for review by team members, and prepare a summary report.
- Ensure that a copy of the summary report is sent to the local county CCS Program or State SCD Office.
- Confer with parents regarding services provided and results of clinical evaluations and assessments of their infant or child.
- Assist families in establishing a Medical Home for the infant or child.
- Assist clients/families in making linkages to necessary medical and social services.
- Ensure there is a system in place to follow-up with families including those who have missed appointments. Collect documentation of the reason for missed appointments and develop a plan of action for improving HRIF Program adherence for evaluations and assessments.
- Provide coordination between the HRIF Program and the infant’s or child’s (pediatric) primary care physician, specialists, and local county CCS Program or State SCD Office when appropriate.
- Coordinate HRIF services with the local county CCS Program and SCD Offices and other local programs.
- Coordinate follow-up service needs among the CCS Porgram-approved Regional, Community and Intermediate NICUs within the community catchment area and with those NICUs that provide HRIF referrals to their agency.
- Client Referral Services and Follow-Up
- Ensure and document referrals are made to the Early Start (ES) Program for children who meet ES eligibility criteria. Refer to the Department of Developmental Services website for ES information: https://dds.ca.gov/General/Eligibility.cfm
- Ensure referrals are made to the Regional Center when those services are appropriate.
- Ensure referrals to HRIF diagnostic consultations and assessments are made with CCS Program-approved providers.
- Ensure referrals to CCS Medical Therapy Program (MTP) are made as needed. Reminder: CCS Program eligibility and referral criteria for MTP are different from CCS/CPQCC HRIF data collection definitions for MTP eligibility.
- Provide referral and resource information for other social and developmental programs within the community, as required.
- Education Services Program
- Provide education and outreach about the HRIF Program and services, clinical care, required documentation on transfer, and referral options, including outreach to NICUs that have a Regional Cooperation Agreement to CCS Program-approved Community and Intermediate NICU’s and other community referral agencies, as appropriate.
- Develop and provide education to parents and family members about the high-risk infant’s medical condition(s), care and treatment, special needs and expected outcomes of care.
- Provide education to parents and family members about the system of care and services (including social services) available to help them nurture, support, and care for the high risk infant.
HRIF Program Reporting Requirements
The HRIF Coordinator is responsible for ensuring that data is collected and
reported to the Systems of Care Division, CCS Program and the California Perinatal Quality Care Collaborative (CPQCC). Reporting forms referenced in CCS Numbered Letter 09-0606, HRIF P.L. 01-0606, and HRIF P.L. 03-0606 are all superseded and updated. The HRIF Coordinator will:
- Coordinate the collection, collation, and reporting of required data.
- Provide data to CCS/CPQCC Quality Care Initiative (QCI) HRIF Web-Based Reporting System. The reporting forms include:
- Referral/Registration (RR) Form
- Standards Visit (SV) Form
- Additional Visit (AV) Form
- Client Not Seen/Discharge (CNSD) Form
- Ensure required data is submitted accurately and in a timely fashion to the CCS/CPQCC HRIF QCI and meets all required deadlines.
- Review and share results of the HRIF Summary Report and the HRIF CCS Annual Report with members of the HRIF program team, with referring NICU Medical Directors, and NICU team.
- In collaboration with the NICU Medical Director, ensure that the HRIF Program fully participates in the CCS Program evaluation, including submission of required information and data.
- Provide data and information that is required for the evaluation.
Required Reports for Case Management
A summary report of the HRIF Team Visit is required to be submitted to the County CCS Program or State Regional Office. This information is necessary for the County CCS Program or Regional Office staff case management activities.
A HRIF Program can download a template HRIF Team Visit Report form at http://www.dhcs.ca.gov/services/ccs/Documents/hrifteamvisit.pdf or
submit its own team report which shall include the required summary reporting elements.
A copy of the HRIF Team Visit Report and copy of the comprehensive physician report (either the template form or in lieu of this form, a dictated team report and physician report) should also be distributed to the:
- County CCS Program or State Regional Office, NICU medical director (if the director is not directly involved with HRIF Program)
- Medical Home (or primary care provider)
- Other providers involved in the infant’s or child’s care