PHP Advocacy and Referral Form (Word doc)

2013 PHP Final Evaluation (PDF)


Perinatal Case Management
Perinatal Case Management (PCM) is a service offered to pregnant females that supports, enhances, and coordinates the health and other services recommended for mothers and babies.

Perinatal Case Management services are personalized and highlights are as follows:

  • Individualized assessments, plans, linkage to services and follow-up
  • PCM begins early in pregnancy to build support systems for needed resources
  • PCM is comprehensive it provides assessment and planning in the areas of: Economic, Nutritional, Psychosocial, Educational, Medical and health areas of care throughout the pregnancy and into the postpartum period.
  • Major goal of PCM is to reduce infant illness and death by improving pregnancy outcomes.
  • PCM ensures the provision of comprehensive preventative services to pregnant women and their infants.
  • PCM provides:
    • Referrals for medical costs
    • Referrals for prenatal care
    • Referrals for prenatal education
    • Referrals for WIC services
    • Referrals to other needed services
    • Regular contact with pregnant women and their infants

Contact your local county health department for additional information.

Perinatal Health Partners
Perinatal Health Partners (PHP) is an in-home nursing case management programs for medically diagnosed high-risk pregnant women. Goal of the program is to maximize pregnancy outcomes for mothers and their newborns and decrease the infant mortality rate in 11 rural Southeast Georgia counties by:

  • Earlier identification of high-risk prenatal and interconceptual patients
  • Partnering with the local OB/GYN, Savannah Perinatology Associates, Local Birthing Hospitals, Local County Health Departments to provide a regionally coordinated system of perinatal care including: referrals, perinatology consult, and Level II ultrasounds.

Perinatal Health Partner services include: clinical assessment of mother and baby, care coordination, case management, education for high-risk pregnant woman and her family and linkages to needed resources at each home visit.

Primary care physicians (PCP) refer clients for enrollment, and are active participants in customizing each client’s plan of care according to their medical/psychosocial needs.

Criteria may include:                                                                                   

  • History of Miscarriage (2 or more) or Second or Third Trimester Pregnancy Loss
  • Previous Fetal/Neonatal Death (If baby dies due to prenatal complications)
  • Prior Premature Labor/Delivery or PROM
  • Incompetent Cervix
  • Diabetes – Gestational Type I or Type II
  • PIH – Pre-eclampsia
  • Pre-term Labor
  • Multiple Gestation with Complications (Current pregnancy)
  • Pre-existing Medical Conditions (i.e. HTN, Lupus, Auto-Immune Disease, Cardiac Disease, Epilepsy, HIV, STC.)
All other diagnosis will be considered on a case-by-case basis:                                               Examples:
  • Fetal Abnormality (Current pregnancy)
  • Physician ordered Bed Rest
PHP area includes the following counties:
  • Appling
  • Atkinson
  • Bacon
  • Brantley
  • Charlton
  • Clinch
  • Coffee
  • Jeff Davis
  • Pierce
  • Ware
  • Wayne

A Perinatal Health Partners newsletter is published semi-annually (click here).

(The newsletter is in a PDF format. In order to view them, you must have the Adobe Acrobat Reader plug-in installed on your computer. Almost all computers now have this plug-in installed, however, if yours does not, you may download it for free by clicking here.)

First Care
These services are provided by local county health departments.

First Care is designed to assure that families with high risk infants: 

  • Receive appropriate health and/or medical screenings, nursing assessments, interventions, follow-up and referrals;
  • are linked to a medical home; have the knowledge, skills, and abilities to provide and access the services required for the infants’ health;
  • and receive appropriate, timely, family centered and culturally sensitive services.

Who is eligible?

The target populations are infants who are discharged from a Neonatal Intensive Care Unit (NICU), and may be at increased risk for morbidity and mortality. Eligible conditions may include: conditions identified in the newborn period, congenital or acquired infections, genetic conditions, birth defects, serious problems or abnormalities of body systems and other significant conditions.

Referrals for First Care can be made through our Children 1st Coordinator or through Parent-to-Parent of Georgia, toll-free at 800-229-2038. 

Contact your local county health department for additional information.

Check out these links...


Southeast Health District
1101 Church Street
Waycross, GA 31501
P: 912-285-6002
F: 912-284-2980


Website design, hosting and maintenance by InterWeb Designs, Inc.
Copyright © 2007-2012 by InterWeb Designs, Inc. All rights reserved.
This website may not be copied or reproduced in any form, in whole or in part,
by anyone without the express written permission of InterWeb Designs, Inc.