Maternal, child & family information and technology company that combines innovation and collaboration to securely integrate health care and public health.
Well Family System - CIR
Coordinated Intake & Referral
WFS-CIR provides a central process for identifying clients in intake types (Preconception, Prenatal, Interconception, Postpartum, Male) which are eligible for services in a one or more of a variety of programs based on Home Visiting Referral Decision Tree and program availability. WFS-CIR utilizes a central standard process of assessment that will determine program options for clients on a case by case basis per the Home Visiting Coordinated Intake and Referral Form. WFS-CIR tracks and reports the assessment process, the subsequent referral actions, and referral outcomes for clients.
BASIC CIR COMPONENTS
Intake process includes preconception, prenatal, interconception, postpartum, male intake types
Outreach/Engagement tracking (Attempts and Encounters)
Intake Type specific assessment (Home Visiting Coordinated Intake and Referral Form)
Triage/Program options algorithm based on the Home Visiting Referral Decision Tree
Program referral algorithm connected to Provider Portal “program availability” tool
PROGRAMS INCLUDE (Referral to multiple programs per Decision Tree)
Maternal and Infant Community Health Collaboratives Initiative (MICHC)
Healthy Start
Nurse Family Partnership
Early Head Start
Healthy Families
Fatherhood Matters
PROVIDER REFERRAL PORTAL COMPONENTS
Provider Programs manage program availability/capacity that connect to CIR Intake algorithm logic
SAMPLE PROVIDER PROGRAM CAPACITY TOOL
Populates Assessment Logic on the CIR side. Each Program manages this information so that during the CIR Intake/Triage process up-to-date program options are available for the client.
SAMPLE CAPACITY MONITOR
CIR program sees real-time stats on each program capacity/availability. Intake logic adjusts accordingly.
When a referral is made the Provider receives the referral -
Referral Provider receives the referral on a tickler system on their Provider Portal. Each tickler item tracks the status of the referral on each stage of the referral tracking process. Clicking on the status item number will provide access to the list of all referrals at that various stage of the process.
Referrals made connect to Provider Portal follow up tracking tool – basic outcome options track status of referral. Both CIR and Referral Provider(s) see client/referral status in real time.
Pending
Connected
Enrolled
Enrolled 90-day retention
Unable to Locate
Wants referral to another HV program
Other reason not engaged
Return to CIR
No further services wanted
Declined Services
Provider receives a read-only copy of the client record (demographics, CIR Intake form, Outreach, other notes) redacted, where applicable, per data share agreements. The referral status tracking options are linked and managed from each client referral record.
Referral status is tracked during the life of the client referral.
REFERRAL REPORT
Referral Report includes all referral types, referral organizations and referral outcomes. Both CIR and Referred Provider have access to the WFS-CIR Referral Status Report in real time.
