An infant’s journey from the NICU to an HRIF clinic. 

Referral from the NICU

The discharging NICU or the last CCS-approved NICU providing care is responsible for identifying eligible high-risk infants and referring them to an HRIF clinic. To complete the referral and tracking process, either the NICU or the HRIF clinic must submit a Service Authorization Request (SAR) form to the appropriate County CCS Program or State Systems of Care Division (SCD) Office.  The referring NICU must then log into the HRIF Reporting System and submit a Referral/Registration (RR) Form for the infant. 

Registration by the HRIF Program 

Once the eligible infant has been accepted for HRIF services, the receiving HRIF clinic will be able to view the approved SAR form online via the Provider Electronic Data Interchange (PEDI). If the clinic does not have access to PEDI, a hard copy of the approval will be mailed or faxed to them by the local county CCS Program or SCD Office. If an HRIF clinic is concerned about a denial of authorization for a particular infant, they should contact Dr. Maria Jocson at California Children’s Services.

Infants who are not authorized for HRIF services should still be entered into the HRIF Reporting System and the denial of authorization should be documented. HRIF clinics can do this by using the Client Not Seen/Discharge (CNSD) Form. 

The HRIF Team 

All HRIF clinics are required to have a multidisciplinary team of medical specialists including pediatricians or neonatologists, pediatric nurse practitioners (PNPs), nurse specialists, ophthalmologists, audiologists, social workers, psychologists, physical therapists, and occupational therapists. An individual provider may simultaneously serve in more than one of these roles. Every member of the HRIF team must be CCS approved with the exception of the PNP, who only requires CCS-approval if serving as the HRIF Coordinator.

Be sure that all HRIF team members are listed in the CCS Program HRIF SCC Directory. If a NICU does not have its own HRIF clinic, the Directory should list the program to which that NICU refers infants.

Role of the HRIF Coordinator  

The HRIF Coordinator is a critical member of every HRIF clinic, serving as the nexus for both information and care. The coordinator may be a clinician providing direct care to high risk infants, though this is not required. The coordinator’s three most important responsibilities are:

  • Coordinating care and referral for eligible infants, children, and families
  • Collecting and reporting critical data through the HRIF Reporting System to California’s Systems of Care Division, California Children’s Services, and CPQCC
  • Facilitating case management 

Coordinating Care, Referral, and Education

The HRIF Coordinator plays a key role in:

Coordination

  • Serve as the primary person coordinating all needed services from various providers and agencies 
  • Participate in NICU discharge planning process or multidisciplinary rounds
  • Ensure identification of HRIF eligible infants/children
  • Ensure the NICU discharge planning process includes referral and SAR submission to the Country CCS Program or State SCAD Office
  • Ensure copies of the authorization are distributed to HRIF team members and consultants
  • Gather medical reports and assessments for review by team members and prepare a summary report 
  • Ensure that a copy of the summary report is sent to the County CCS Program
  • Ensure that a copy of the summary report is sent to the County CCS Program or State SCD Office 
  • Confer with parents regarding services provided and assessment of their infant or child
  • Assist families in establishing a medical home for the infant or child
  • Assist families in making linkages to necessary medical and social services
  • Ensure there is a system in place to follow-up with families, especially those who have missed appointments. Document the reasons for the missed appointments and develop a plan of action to help families adhere to visit schedule. 
  • Coordinate care between the HRIF Program and the child's primary care physician, specialists, and County CCS Program or State SCD Office, when appropriate
  • Coordinate HRIF services with the Country CCS Program and State SCD Office and other local programs
  • Coordinate follow-up service needs among CCS-approved Regional, Community, and Intermediate within the community catchment area and with NICUs that provide HRIF referrals to their agency

Client Referral & Follow-up

  • Ensure and document referrals made to the Early Start (ES) Program
  • Ensure referrals are made to the regional center when those services are appropriate 
  • Ensure referrals to HRIF diagnostic assessment are made with CCS-approved providers
  • Ensure referrals to CCS Medical Therapy Program (MTP) are made as needed. Please note, eligibility and referral criteria for MTP are different than the HRIF data collection definitions for MTP. 
  • Provide referral and information on resources for other social and developmental programs within the community, as required

Education

  • Provide education and conduct outreach about the HRIF clinic, services, clinical care, required documents for transfer, and referral options. Outreach should be made to NICUs that have a Regional Cooperation Agreement to refer to CCS-approved Community and Intermediate NICUs as well as to other community referral agencies, as appropriate 
  • Develop and provide education to parents and family members about the high-risk infant or child's medical conditions, care and treatment, special needs and expected outcomes of care
  • Provide education to parents and family members about the system 

Collecting and Reporting Data

The HRIF Coordinator is responsible for:

  • Coordinating the collection and collation of all required data for entry into the HRIF Reporting System
  • Entering data through the HRIF Reporting System accurately and in a timely fashion using the:
    • Referral/Registration (RR) Form
    • Standard Visit (SV) Form
    • Additional Visit (AV) Form
    • Client Not Seen/Discharge (CNSD) Form
  • Reviewing and sharing results of the HRIF Summary Report and the HRIF CCS Annual Report with members of the HRIF clinic team, the referring NICU Medical Director, and the NICU team
  • In collaboration with the NICU Medical Director, ensuring that the HRIF clinic fully participates in the CCS Program Evaluation including obtaining the required information and data from the HRIF Reporting System, as needed

Case Management

After each visit, the HRIF team is required to submit a “Team Visit” summary report. Note, the report is NOT submitted through the HRIF Reporting System but is submitted directly to the County CCS Program or State Regional Office. If desired, the HRIF team can submit the report in their own format as long as it summarizes key findings and recommendations.

The team report should also be distributed to the NICU Medical Director, the Medical Home or primary care provider, and any other providers involved in the infant or child’s care.