Date PHN Problem Outcomes Actions Additional Information (specific for family) Initials Covered PHN will provide information on Nutrition information pamphlet provided to family. the food recommendations to the family. PHN will encourage families not to give children supplements unless under the direct supervision of a physician. Check one: Potential for will be Family receiving WIC services poor PHN will determine WIC enrolled in WIC if nutrition. Eligibility. Family referred to WIC eligible. (continued) Not eligible for WIC services Caregiver will get assistance in PHN will provide families with providing good additional nutritional referrals as nutritional referrals recommended for the family: nutrition for the needed. child. Need for Family will PHN will discuss with the family Date of ASQ screening if done: long-term verbalize an the need to look for behaviors development understanding of that may interfere with learning al follow-up. the need for long- (e.g., inattention, distractibility, term development impulsivity). follow-up. PHN will discuss with the family Specific recommendations for the family based on and primary care provider development screen (check all that apply): periods when development Recommend HeadStart/ Early HeadStart. st th delays may be apparent (1 , 4 , Refer to Early On. th th 6 or 7 grade). Consider YMCA program/other enrichment programs. PHN will encourage parental Encourage play groups. sharing of child’s diagnosis w/ Recommended games for parents to play on-one-one classroom teacher(s) with child. Provide contact information for the appropriate MSU Extension program if applicable in your area.
Problem Outcomes Actions Additional Information (specific for family) Date Covered PHN Initials PHN will provide information on the food recommendations to the family. Nutrition information pamphlet provided to family. PHN will encourage families not to give children supplements unless under the direct supervision of a physician. Potential for poor nutrition. (continued) will be enrolled in WIC if eligible. PHN will determine WIC Eligibility. Check one: Family receiving WIC services Family referred to WIC Not eligible for WIC services Caregiver will get assistance in providing good nutrition for the child. PHN will provide families with additional nutritional referrals as needed. nutritional referrals recommended for the family: Need for long-term development al follow-up. Family will verbalize an understanding of the need for long- term development follow-up. PHN will discuss with the family the need to look for behaviors that may interfere with learning (e.g., inattention, distractibility, impulsivity). Date of ASQ screening if done: PHN will discuss with the family and primary care provider periods when development st th delays may be apparent (1 , 4 , th th 6 or 7 grade). PHN will encourage parental sharing of child’s diagnosis w/ classroom teacher(s) Specific recommendations for the family based on development screen (check all that apply): Recommend HeadStart/ Early HeadStart. Refer to Early On. Consider YMCA program/other enrichment programs. Encourage play groups. Recommended games for parents to play on-one-one with child. Provide contact information for the appropriate MSU Extension program if applicable in your area.
EBL%20Case%20Management%20Guide%20Updated%201_24_2017.docx