REACH included case management provided by a hospital-based registered nurse case manager who coordinated mothers’ contacts with participating REACH agencies, made referrals to social service organizations, and provided counseling.
The first home visit occurred two weeks after hospital discharge and was conducted by a two-person team that included a community health advocate (CHA) and the registered nurse case manager. Each mother received a physical and psychological assessment and each infant received a physical and developmental assessment. The team also completed an environmental assessment of the home and observed mother-child interaction. Families with no identified acute issues during the first home visit received three subsequent visits at the infant’s age of six to eight weeks, 4 months, and 8 months. A public health nurse or aide from the CDPH collected information on the infant’s health and development. A final visit occurred at 12 months, during which the two-person registered nurse case manager and CHA team returned and conducted a physical and developmental examination of the infant, reviewed family program records, and verified immunizations.
If problems were identified during the first home visit, the family was referred to VNA. VNA conducted a home visit within seven days to address the identified issues; these families did not receive a visit at six to eight weeks. After the issues had been addressed, the family was referred back to the nurse case manager for reassignment to the standard program schedule.
Telephone or mail contact was used to check the outcome of referrals, address concerns voiced by mothers, confirm appointments and follow up regarding missed appointments, verify immunization status, and verify the most recent address. Monthly newsletters mailed to mothers provided age-appropriate information and reminded them to contact staff if they planned to move.