049-2 Wyo. Code R. §§ 2-2 - Developing the Plan of Safe Care

(a) Patient care teams shall engage the family, family support network, and medical professionals in a discussion regarding the needs of the infant and household members.

(i) The discussion shall include how each identified need will be addressed and by whom, including:

(A) Whether services are already being provided or are needed; and

(B) Circumstances where the pregnant or birthing individual has been prescribed medication due to a physical illness or mental illness, including medications to treat substance use disorder(s). Patient care teams shall verify the pregnant or birthing individual is:

(I) Adhering to the requirements of the treatment plan;

(II) Taking the prescribed dose of medication at the prescribed schedule for the prescribed duration of therapy; and

(III) Refraining from using other substances.

(b) The patient care team shall complete a written Plan of Safe Care document, using a template developed and provided by the Department.

(i) The written Plan of Safe Care document shall include:

(A) Contact information for the family, family support network, and current service providers;

(B) A list of the referrals that need to be made for the family;

(C) Patient care team members responsible for making the referrals; and

(D) A termination date not to exceed one (1) year following the date the plan is initiated after the infant's birth.

(ii) The written Plan of Safe Care documents:

(A) Identified needs of the infant, such as:

(I) Healthcare:

(1.) Identification of a primary care provider.

(2.) Referral to specialty care.

(3.) High-risk follow-up care.

(II) Safety of the infant with the caregivers.

(III) Developmental screening and assessment.

(IV) Linkage to early intervention services.

(V) Early care and education program.

(VI) A consistent and stable primary caregiver.

(B) Identified needs of the pregnant or birthing individual, such as:

(I) Health care:

(1.) Primary care provider.

(2.) Obstetrics and gynecological provider.

(3.) Specialty care provider.

(4.) Medication management.

(5.) Pain management.

(II) Feeding support for the infant.

(III) Substance use treatment connection, which should include the following:

(1.) Timely access;

(2.) Engagement, retention, and recovery supports;

(3.) Appropriate treatment, to include but not limited to, gender-specific, family focused, accessible, medication assisted treatment, trauma responsive treatment; and

(4.) Identifying and assisting the pregnant or birthing individual in accessing the appropriate assessments and treatment services.

(IV) Parenting/Family support:

(1.) Coordinated case management/home visits to assess/address infant care, parent/infant bonding, nurturing, pregnant or birthing individual's understanding of the special care needs of the infant(s) and ability to provide that care, parenting guidance and skill development, safe sleep practices, and maternal support.

(2.) Child Care.

(V) Benefits/Eligibility determination, including but not limited to:

(1.) Employment support,

(2.) Housing,

(3.) Transportation,

(4.) Child Care assistance, or

(5.) Social Security benefits.

(VI) Family Support Network.

(C) Needs of father, other parent, or other family members, as indicated:

(I) Substance use disorder assessment and treatment.

(II) Healthcare:

(1.) Mental health assessment and treatment.

(2.) Medication management.

(III) Parenting skills (i.e. bonding, nurturing, understanding of the special care needs of the infant and the ability to provide it, safe sleep practice, etc.).

(IV) Protective factors, meaning the ability to meet the care and protection needs of the infant and any other children living in the home.

(D) Needs of other children in the home, as indicated:

(I) Identification of a consistent pediatrician/healthcare provider.

(II) Safety with the caregivers.

(III) Developmental screening and assessment.

(IV) Linkage to early intervention services.

(V) Early care and education program.

(E) Other services as identified by the patient care team, family, or service providers.

(iii) Prior to discharge, the Plan of Safe Care shall be reviewed, discussed, and finalized through signatures obtained from the pregnant or birthing individual, father or other parent, other caregiver(s), and a member of the patient care team. All members of the patient care team shall receive a copy of the plan.

(c) The patient care team shall obtain consent(s) or authorization(s) to share the Plan of Safe Care with identified service providers and family support network members and collect needed information for the implementation of the Plan of Safe Care and associated services.

(i) Consent(s) or authorization(s) shall be filled out and signed by each individual the Plan of Safe Care applies to.

(ii) Consent(s) or authorization(s) shall be obtained to allow for communication among service providers aiding in the family care and well-being, including to allow for referrals identified in the Plan of Safe Care to be made.

(d) Patient care teams shall ensure that the family is connected to appropriate support services through a warm referral prior to discharge.

(i) A warm referral shall be conducted as follows:

(A) The patient care team provides detailed information to the family about the location of the service, hours of operation, eligibility requirements, cost or insurance acceptance, services offered, etc.; and

(B) The patient care team and family call the provider together to schedule an appointment.

(ii) The patient care team shall refer the family to the local Early Intervention and Education Programs pursuant to W.S. § 35-2-1401(b)(iii) and 42 U.S.C 5106(a)(7)(C)(iii). The patient care team shall provide a copy of the written Plan of Safe Care along with the referral to the Early Intervention and Education program.

(A) The Early Intervention and Education Program shall:

(I) Perform the necessary screening to determine eligibility for developmental services through the Early Intervention and Education Program.

(1.) If eligibility for Early Intervention and Education Program services is determined, share the developmental service plan with the patient care team and Plan of Safe Care Collaborative, if applicable.

(2.) If eligibility for Early Intervention and Education Program services is not substantiated, the Early Intervention Program shall refer the family back to the Plan of Safe Care Collaborative or patient care team for identification of other resources.

(iii) As applicable, and when consent or authorization allows, patient care teams may make referrals to:

(A) Public Health Nursing Infant Home Visitation subprogram pursuant to W.S. § 35-27-102;

(B) Primary care provider(s);

(C) Mental health or substance use disorder treatment provider for:

(I) Substance use disorder treatment;

(II) Medication assisted treatment; or

(III) Mental health treatment;

(D) Wyoming Medicaid or Enroll Wyoming;

(E) Women, Infants, and Children Program (WIC); and

(F) Other services as identified.

(iv) Plan of Safe Care Collaborative Referrals

(A) Patient care teams that have initiated a Plan of Safe Care may discuss with the family, participation in the local Plan of Safe Care Collaborative.

(I) If the family provides voluntary written consent or authorization to participate in the Plan of Safe Care Collaborative, the patient care team may provide a referral to the collaborative, which shall include:

(1.) Family name;

(2.) Signed consent or authorization form(s); and

(3.) Plan of Safe Care document.

Notes

049-2 Wyo. Code R. §§ 2-2

Adopted, Eff. 3/6/2024.