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 West Virginia

Right From The Start Program

Program Overview

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350 Capitol Street, Room 427, Charleston, West Virginia 25301-3714
(304) 558-5388 or Toll Free in WV 1-800-642-8522
Fax (304) 558-7164


The RFTS Program was implemented in 1988 for infants. In recognition of the importance of developing systematic approaches to dealing with the problems of access to prenatal care, House Bill 4242 was implemented. Under the provisions of the bill, the Department of Health and Human Resources, Bureau for Public Health, has the responsibility to administer the provision of prenatal care for low-income women and their infants. Through the RFTS Program, the Office of Maternal, Child and Family Health fulfills this responsibility by:

  1. Instituting standards for care

  2. Contracting with providers for obstetrical care, care coordination and patient education for low-income women with a high risk of adverse pregnancy outcome or for those low-income families with infants at risk of poor health or death

  3. Offering technical assistance to those providers

  4. Facilitating cooperation among programs and providers with the potential to serve the target population

  5. Monitoring service providers for quality assurance

The state is divided into eight (8) regions for management of the RFTS Program. Each region has a Regional Care Coordinator (RCC) who administers the activities of the Registered Nurse and Licensed Social Worker (Designated Care Coordinators-DCC). The primary objective of the DCC is to ensure women and children receive all of the services they need. Pregnant women enter the RFTS Program based on Medicaid eligibility. The Prenatal Risk Screening Instrument (PRSI) is completed on each prenatal client and identifies risk factors. The risk factors for the project include, but are not limited to, medical complications, nutritional needs, and psychosocial factors. Infants are assessed for risk though the Birth Score System at the time of delivery in all West Virginia hospitals offering obstetrical services.

The RCC refers the patient (pregnant woman or infant) to a DCC who develops a Service Care Plan with the patient to ensure continuity of care and receipt of all the support services required. The other crucial component of RFTS is health education which includes preventive self care such as the signs of pregnancy complication, smoking cessation, childbirth education, parenting education and nutrition counseling.

Ensuring access to health care for low‑income women and children has been an ongoing concern for state and federal officials.  The Bureau for Medical services (Medicaid) and Office of Maternal, Child and Family Health (OMCFH) have worked collaboratively to develop special initiatives that extend support services to women and infants at risk of adverse health outcomes.  This partnership has not only expanded the stateís capacity to finance health care for women and children, but has also strengthened the delivery of care by establishing care protocols, recruiting medical providers and developing supportive services such as case management and nutrition counseling which contribute to improved patient well‑being.

Medicaid and the OMCFH share a common commitment to the goal of ensuring healthy births, reducing the incidence of low birth weight, and improving the health status of West Virginiaís children.  We recognize the importance of maximizing scarce fiscal resources, and the benefit of collaborative efforts in the development of programs that support our shared goals.

This Project is a comprehensive statewide initiative for government sponsored pregnant women (Title XIX/Medicaid/ TitleV/MCFH) whose incomes are at or below 185% of the federal poverty level. The Project provides in-home case management services for at risk infants up to age one year.   A major component of RFTS is to provide in‑home care coordination services whereby nurses and social workers visit eligible prenatal clients in their homes throughout their pregnancy and until their infants reach one year of age to assess  educational, social, nutritional and medical needs and to facilitate their access to appropriate service providers.  Coordination components include a personalized in‑home assessment to identify barriers to health care, an individually designed care plan to meet the patientís needs, community referrals as necessary, follow‑up and monitoring.  All pregnant Medicaid and Title V cardholders are eligible for educational activities designed to improve their health (i.e., childbirth education, smoking cessation counseling, parenting and nutrition.)  These women and infants have access to transportation to their medical appointments through the Access to Rural Transportation (ART) Project under RFTS.

Eight registered nurses, referred to as Regional Care Coordinators (RCC), who are located in the eight Public Health regions, coordinate, monitor, and facilitate program components and services.  They provide education and support to obstetricians, facilitate educational seminars for the Designated Care Coordinators (DCC), and promote the purpose of RFTS to the community.      

RFTS services are provided in collaboration with the primary medical provider.  A  Prenatal Risk Screening Instrument (PRSI) is completed on pregnant women to assess the client's risk status.  A Registered Nurse or Social Worker  (DCC), is assigned to the client, who interviews the woman in her home for a detailed assessment of her needs. Based on this assessment, the individualized Service Care Plan is developed.   The DCC locates resources, makes referrals, and arranges for treatment and support services relative to the clientís service plan.  The DCC ensures appropriate quality, quantity and effectiveness of services and confers with the client to review the service plan periodically to determine continuity of needs and services received. 

A critical role of the community-based workforce of RFTS DCCs is that of linkage to the medical community.  The DCCs work closely with the patient's medical provider in order to exchange important information regarding case developments that impact pregnancy outcomes. The DCCs also provide enhancements to the physicians plan of care for each patient through various types of individualized educational components.


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