Services

The Wilson County Health Department offers a variety of different services in the Social Work Program. These services are designed to help improve the lives of families and to assist them with coping with issues in their everyday lives.

Our social workers offer free case management services to pregnant women and children from ages birth to five years.

Programs

  • Care Management for High Risk Pregnancies (CMHRP) 

    is outcome-focused, with an emphasis on achieving prenatal and postpartum wellness through advocacy, communication, education, resources, and service facilitation.  CMHRP strives to improve birth outcomes by reducing the rate of preterm and low birthweight births and monitors the pregnant Medicaid population and prenatal service delivery system using data.   CMHRP meets the diverse and complex needs of members through a holistic, person-centered approach that addresses both physical and behavioral health.                                                                                                                                                                                             

     Referral Criteria:          

  • Multi-fetal gestation
  • Fetal complications
  • Chronic conditions that may complicate pregnancy
  • Current use of drugs and alcohol; recent drug use or heavy alcohol use (month prior to learning of pregnancy)
  • History of preterm birth (<37 weeks)
  • History of low weight birth (<2500 grams)
  • Unsafe living environment (physical/sexual abuse, domestic violence, homelessness)
  • Late entry to care (>14 weeks/missed 2+ prenatal appointments)I
  • Hospital utilization during pregnancy (emergency department, antepartum admission, labor and delivery triage and/or observation)
  • Provider request for care management for any reason  

  •  Care Management for At Risk Children (CMARC) 

 Services provided include:

  • Assessment or screening to identify needs and concerns
  • Assistance setting and meeting goals addressing prioritized needs and concerns
  • Parent/caregiver education related to needs or concerns
  • Support in identifying and addressing obstacles that prevent the family to reach goals
  •  Education and strategies to reduce the impact of adverse childhood events
  • Linkage to a medical home
  • Linkage and referral of children and families to needed community programs and supports
  • Coordination of the child’s care to ensure appropriate medical care, social services and other supports are obtained to increase the quality of care and decrease the cost

 The CMARC target group includes children:

  • With special health care needs
  • Discharged from the neonatal intensive care unit (NICU)
  • Other - specifics requested to be provided
  • Exposed to adverse childhood experiences that could result in unmanageable stress, including, but not limited to:
    • Child in foster care
    • History of abuse and neglect
    • Caregiver unable to meet infant's heath and safety needs/neglect
    • Parent(s) has history of parental rights termination
    • Parental /caregiver/household substance abuse, neonatal exposure to substances
    • CPS Plan of Safe Care referral for "Substance Affected Infant" (Complete section "Infant Plan of Safe Care")
    • Child exposed to family/domestic violence
    • Unsafe where child lives/environmental hazards or violence
    • Incarcerated family or household member
    • Parent/guardian suffers from depression or other mental health condition, maternal postpartum depression
    • Homeless or living in a shelter/Unstable housing
    • Other - specifics requested to be provided

 

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