Beneficiary: INTERVENTIONS INTERVENTION Using Motivational Interviewing, complete the following brief interventions RESOURCE - REFERRAL - COMMUNICATION LEVEL (Format dates: MM / DD / YY) Refused all interventions RESOURCES MODERATE Discuss perinatal anxiety and depression. Perinatal Depression Workbook (MIHP Website) Date of Intervention Beneficiary’s perception Postpartum Support International Level Change: Educate on symptom presentation and treatment options / / Moms’ Mental Health Matters Hormonal changes, Baby Blues vs. Postpartum Depression Identified mental Discuss partner, family, friend, household member awareness of beneficiary health concern Michigan Statewide Perinatal Mood Disorder symptoms and support. Coalition Currently being treated Discuss stress reduction and self-care strategies. for mental health Introduce and/or discuss Perinatal Depression Workbook. Other Resource: _____________________________ concern Discuss and/or prepare action plan about self-care and/or postpartum support (i.e. REFERRALS Moderate score (6-10) infant care, meals, going back to work). on Perceived Stress Medical Care Provider (PCP, OB/GYN, etc.) Discuss childbirth expectations and/or experience. Date: / / Scale Encourage beneficiary to join a community-based support group. Did the beneficiary access referral? Yes No Moderate score (9-12) Encourage beneficiary/caregiver to communicate with primary care provider to discuss CMH for Infant Mental Health/Home-based Services on Edinburgh appropriate diagnostic assessment and treatment provider. Date: / / Postnatal Depression Did the beneficiary access referral? Yes No Re-administer Edinburgh Postnatal Depression Scale and discuss results with Scale beneficiary. Behavioral Health Provider: Date: / / Pregnancy: once per trimester (recommendation) Did the beneficiary access referral? Yes No Postpartum: every 3 months (recommendation) Support Group: Re-administer Perceived Stress Scale and discuss results with beneficiary. Date: / / Pregnancy: once per trimester (recommendation) Did the beneficiary access referral? Yes No Postpartum: every 3 months (recommendation) Medicaid Health Plan (Case Manager, benefits, etc.)
Beneficiary: INTERVENTION LEVEL INTERVENTIONS Using Motivational Interviewing, complete the following brief interventions RESOURCE - REFERRAL - COMMUNICATION (Format dates: MM / DD / YY) MODERATE Date of Intervention Level Change: / / Identified mental health concern Currently being treated for mental health concern Moderate score (6-10) on Perceived Stress Scale Moderate score (9-12) on Edinburgh Postnatal Depression Scale Refused all interventions Discuss perinatal anxiety and depression. Beneficiary’s perception Educate on symptom presentation and treatment options Hormonal changes, Baby Blues vs. Postpartum Depression Discuss partner, family, friend, household member awareness of beneficiary symptoms and support. Discuss stress reduction and self-care strategies. Introduce and/or discuss Perinatal Depression Workbook. Discuss and/or prepare action plan about self-care and/or postpartum support (i.e. infant care, meals, going back to work). Discuss childbirth expectations and/or experience. Encourage beneficiary to join a community-based support group. Encourage beneficiary/caregiver to communicate with primary care provider to discuss appropriate diagnostic assessment and treatment provider. Re-administer Edinburgh Postnatal Depression Scale and discuss results with beneficiary. Pregnancy: once per trimester (recommendation) Postpartum: every 3 months (recommendation) Re-administer Perceived Stress Scale and discuss results with beneficiary. Pregnancy: once per trimester (recommendation) Postpartum: every 3 months (recommendation) RESOURCES Perinatal Depression Workbook (MIHP Website) Postpartum Support International Moms’ Mental Health Matters Michigan Statewide Perinatal Mood Disorder Coalition Other Resource: _____________________________ REFERRALS Medical Care Provider (PCP, OB/GYN, etc.) Date: / / Did the beneficiary access referral? Yes No CMH for Infant Mental Health/Home-based Services Date: / / Did the beneficiary access referral? Yes No Behavioral Health Provider: Date: / / Did the beneficiary access referral? Yes No Support Group: Date: / / Did the beneficiary access referral? Yes No Medicaid Health Plan (Case Manager, benefits, etc.)