2 Rev CHT Guidebook 102411

Community Health Team
Guidebook
For CHT Partners
This Community Health Team (CHT) Guidebook contains the information, approaches and instructions that will help CHT Partners effectively help families recognize their health risks and needs, develop customized health plans to address those needs, use their PhilHealth benefits, and find appropriate and accessible health providers.
Included Modules: Newborn Health Infant Health Child Health Pregnancy / Prenatal Care Postpartum Care Family Planning Chronic Cough Management Department of Health October 2011
TABLE OF CONTENTS
LETTER TO THE CHT PARTNER COMMUNITY HEALTH TEAM GUIDEBOOK I. The CHT Partner: On the Frontlines of Community Health A. Introduction: You and Your Communitys Health B. Your Role as a CHT Partner: An Overview of the CHT Process C. The Family Health Guide: A Tool for Sharing Information With Families D. Preparing for Your Role as a CHT Partner The CHT Process: Guiding Families in Accessing Health Care A. Steps and Tasks in the CHT Process B. Pre-session: Setting the Family Health Hour C. On-session: The Family Health Hour 1. PROFILE: Completing the Household Profile 2. ORIENT: Orientation on the Family Health Guide 3. ASSESS: Assessing Members Health Risks 4. INFORM: Delivering Key Health Messages 5. PLAN: Assisting Families with Health Plan Implementation 6. MONITOR: Following-up and Monitoring Health Plan Adherence D. Post-session: Reporting Summaries of Health Information 7. REPORT: Providing Summary Report to Rural Health Midwife Health Plan Implementation Modules A. Form 2A: Newborn Health (Ages 0-28 days) B. Form 2B: Infant Health (Ages 29 days less than 12 months) C. Form 2C: Child Health (Ages 12 months 5 years) D. Form 2D: Maternal Health: Pregnancy/Prenatal Care E. Form 2E: Maternal Health: Postpartum Care F. Form 2F: Family Planning G. Form 2G: Chronic Cough Management 3 4 5 8 10 12 13 14 16 17 26 27 29 30 34 37 40 41 48 56 62 70 76 84
II.
III.
BOOKLET NI NANAY AT NI BABY FAMILY GUIDE TO PHILHEALTH: BENEFITS, CILMENTS AND RESPONSIBILITIES LIST OF HEALTH PROVIDERS AND HEALTH EMERGENCY CONTACTS
Community Health Team Guidebook
I. The CHT Partner

On the Frontlines of Community Health
A. INTRODUCTION: YOU AND YOUR COMMUNITYS HEALTH
Many Filipino families in our communities suffer from health conditions that could have been prevented if they had only been treated early enough or had received the proper attention and care. One of the largest hurdles is the limited capacity of these families to access health services, because they often (1) do not know their health risks and needs, (2) have no financial means to get the health services they need, (3) have little knowledge of available and appropriate health providers in their area, and/or (4) do not have ready access to transportation that can bring them to these providers. To help break these barriers to health care use, Community Health Teams (CHTs) give direct assistance to underserved Filipino families all over the country by helping them navigate or find their way through the health system. CHTs are tasked to help especially the poorest families as identified by the Department of Social Welfare and Development (DSWD) in the NHTS1, including those covered by Pantawid Pamilya2. As a CHT Partner, you will be assigned to some of these families within your community or purok who are most in need of health assistance. You will be at the frontlines of giving them the information and guidance they need to improve their ability to access health services.
Stands for the National Household Targeting System - a project of the DSWD that builds the database of households from which the beneficiaries of national social protection programs will be identified.
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Pantawid Pamilya is a program where families are given cash to encourage them to use health services and keep their children (aged 0-14 years old) in school.
B. YOUR ROLE AS A CHT PARTNER: AN OVERVIEW OF THE CHT PROCESS

As a CHT partner, your major role will be to guide families in accessing health care, and thus manage their health. The CHT Process is a cycle of major steps (each one broken down into smaller steps, called tasks) to follow in your interactions with families. By understanding the CHT process, you will be able to effectively perform your role as a CHT Partner. Figure 1 below shows the major steps in the CHT process. In a later section of this Guidebook (II. The CHT Process: Guiding Families in Accessing Healthcare, p. 12), each of these steps (and its component tasks) is described in more detail.
Figure 1. OVERVIEW OF MAJOR STEPS IN THE CHT PROCESS.
RE-ASSESS
UPDATE HOUSEHOLD PROFILE
Brief Description of Major Steps in the CHT Process 1. PROFILE

For discussion on protocol for conducting household profiles, see p. 17 CHT Tool: FORM 1 - Household Profile
In this step, you will make a household profile by getting basic information on each family member, to identify which persons in the household are most in need of health care.
2. ORIENT
For discussion on protocol for orienting families, see p. 26 CHT Tool: Family Health Guide
In your role as a navigator, you should orient the the household to the different sources of health information Available to them. The Family Health Guide is a set of booklets that you will be sharing with the household. As a talking book, you will show how the family how they can directly benefit from the information the Family Health Guide contains. For a discussion of the component sections of the Family Health Guide, see page 8.
3. ASSESS
For discussion on protocol for assessing health risks, see p. 27 See also individual Health Plan Implementation modules starting on p. 40 Material: Forms 2A-2G (Part 1) Health Plan Implementation Forms
In this step, you will be making health risk assessments of individual members. Risk assessments will focus primarily on the modules included in the CHT Guidebook; namely, pregnancy/pre-natal care; post-partum care; newborn, infant and child health; family planning; and chronic cough management. Other modules may be added to your materials later on depending on the needs of your region or locality.
4. INFORM
For discussion on protocol for delivering health messages, see p. 29 Ssee also individual Health Plan Implementation modules starting on p. 40 Material: Forms 2A-2G (Part 1) Health Plan Implementation Forms
Depending on the members health risks, you will share key messages that will help them make decisions about their health. You will also use other reference materials in your CHT Guidebook to share related messages with the family member at risk.
5. PLAN
For discussion on protocol for assisting members in health planning, see p. 30 See also individual Health Plan Implementation modules starting on p. 40 Material: Forms 2A-2G (Parts 2 and 3) Health Plan Implementation Forms
You will assist members in planning their health goals and use of health services. Using the reference materials in the Family Health Guide, you will help members choose health service
providers and transport options, schedule visits for availment of services, and make emergency plans if needed.
6. MONITOR
Detailed discussion on p. 34 Material: CHT Monitoring Forms; Forms 2A-2G (Parts 4, 5) Health Plan Implementation Forms
Monitoring families means reminding members about their planned visits to health providers, and checking on adherence to their health plans. If they are having difficulties with compliance to their plans, you will also try to help them find ways to overcome these difficulties. It is also important to remember that you will be periodically re-assessing the family to identify new or emerging health needs as their circumstances change. The two dashed arrows in Figure 1 pertain to this cyclical process: a. Update the Household Profile as the household members health and other circumstances change (for example, a previously pregnant woman already gave birth; a newborn baby grows up and becomes an infant then a child; etc.). You will need to monitor these changes and update the profile accordingly. b. Reassess
every time the health status of a household member changes, you will need
to go through the CHT process again with that member, starting with assessing his/her new health risk/s.
7. REPORT
Detailed discussion on p. Error! Bookmark not defined.37 Material: CHT Monitoring Forms
Periodically accomplish and submit summary forms to your supervising Midwife. The information you give to the RHU/MHO will be indispensable in monitoring the overall health status of your community and will also be valuable in helping the RHU make decisions about your communitys health programs.
C. THE FAMILY HEALTH GUIDE: A TOOL FOR SHARING INFORMATION WITH FAMILIES
Helping families navigate the health system means giving them useful information necessary to maximize their opportunities for getting health care. This includes information on their health risks and needs, the health services available to them, and the means to obtain such services to safeguard their health. The Family Health Guide is an important tool which you will use throughout the CHT Process to guide the family in accessing health care. It is a set of booklets containing integrated information that the family needs to develop and implement sound health plans, that will lead them to the health services they need. The Family Health Guide is composed of: 1. Family Health Guide: A. Health Messages a booklet for the family that contains helpful information on how to have safe pregnancies and deliveries, prevent common childhood illnesses, plan desired family size, and manage chronic cough. The Family Health Guide also contains a space (Our Family page) for the family to write their names (using the last name of the NHTS household head) and basic information such as their NHTS household ID number, the name of the CHT partner and contact number, and the Family Health Hour (day and hour of home visit). 2. Household Profile Form identical to the Form 1 in your CHT Guidebook, this contains basic information about household members, their health profile and other relevant information. This form is included in the Family Health Guide so that you can show the family how they can, on their own if needed, identify important health risks among themselves.
3. Health Plan Implementation Modules These materials help families recognize their health
risks, know and understand the core messages appropriate to their specific health goals, develop appropriate health plan/s, and schedule visits to health providers. The different Health Plan Implementation modules for specific health concerns are shown in Table 1. NOTE! Your PHO/MHO/CHO may expand the Health Plan Implementation Modules
depending on the priority health concerns of your province/municipality/city.
Community Health Team Guidebook Table 1. HEALTH PLAN IMPLEMENTATION MODULES FOR SPECIFIC HEALTH GOALS.
Module Health Plan Form Health Goals
Newborn Health
2A (p. 41)
To ensure proper care for babies (0-28 days old) by helping the mother/parents recognize the importance of newborn screening, BCG and Hepatitis B immunizations, and exclusive breastfeeding.
Infant Health
2B (p. 48)
To encourage full immunization of babies (29 days to less than 12 months old) to protect them from common illnesses
Child Health
2C (p. 56)
To ensure that children (12 months to 5 years old) are completely immunized, given deworming tablets and micronutrient supplements to boost their immune system, and common serious childhood illnesses are prevented and/or treated early.
Maternal Health: Pregnancy / Prenatal Care Maternal Health: Postpartum Care Family Planning Chronic Cough Management
2D (p. 62)
To help pregnant women have healthy pregnancies and safe deliveries, through prenatal care and delivery in health facility
2E (p. 70) 2F (p. 76) 2G (p. 84)
To ensure that mothers are given prompt care after delivery to avoid post-partum complications. To help couples have the number of children they want To facilitate diagnosis and management of family members with cough lasting more than 2 weeks
4. List of Health Providers and Health Emergency Contacts a booklet that contains a list of health providers that the family can turn to for health care, plus useful information on each provider, such as clinic hours, PhilHealth accreditation status, and the services being offered. It also contains a list of health emergency contacts or service providers which has the names and contact information of available transport and service providers that the family can call on during health emergencies. 5. Booklet ni Nanay at ni Baby contains detailed information on the proper care for the mother before, during and after giving birth, as well as for her newborn baby. 6. Family Guide to PhilHealth: Benefits, Availment and Responsibilities contains basic information on PhilHealth coverage, benefits of members and their dependents, and the steps required to avail of these benefits.
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D. Preparing for Your Role as a CHT Partner
Before you begin going through the CHT Process with a family, there are some things you will need to prepare so that you can maximize your guidance time with them. The preparation steps described below may seem tedious at first glance, but remember that each of these steps is key to ensuring that the process of guiding the families will go smoothly and have maximum benefits for them. Prep Step 1: Make sure your materials are complete. Get the following materials from your Rural Health Midwife (RHM) or CHT supervisor: List of NHTS families assigned to you This contains the names of the household head and members, their contact information and household ID number. You may use this to locate and contact families for your first home visits with them. Family Health Guide Make sure that the component booklets and references are complete (see p. 8) and familiarize yourself thoroughly with their content. Health Plan Implementation forms on: Newborn Health (2A) Infant Health (2B) Child Health (2C) Maternal Health: Pregnancy / Prenatal Care (2D) Maternal Health: Post-partum Care (2E) Family Planning (2F) Chronic Cough Management (2G) Prep Step 2: Pre-fill Form 1 and plan your visits. Using the NHTS list of families, fill in the NHTS Household ID Number in the Household Profile Form beforehand, for each family. Then, identify whom among the NHTS households assigned to you are members of Pantawid Pamilya. Prioritize these families for home visits. Prep Step 3: Schedule a Pre-Session. Get the contact information of your assigned NHTS households, and set an appointment with the household head and/or spouse or partner for the first meeting (or Pre-Session, see p. 14). Be familiar with the background of the households under your care (for example, household setup, religious/cultural beliefs and practice).
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Prep Step 4: Practice. Practice introducing the Family Health Guide, explaining what it is all about, and how the family can benefit from it. Especially if you are unfamiliar with the area or with the families assigned to you, you should also practice introducing yourself and what you do as a CHT Partner. Be aware of your body gestures, mannerisms, facial reactions, tone and volume of voice. Remember that to most effectively guide a family, you will need to know and understand very well your CHT materials and the different parts of the Family Health Guide. You may ask your RHM or CHT supervisor for help on topics with which you are unfamiliar or having trouble. Finally, once you have scheduled a Pre-Session with a family, make sure that you meet them on time! This will show families that you value their time and that you are serious about your intent to assist them in managing their health.
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Guiding Families in Accessing Health Care
II. The CHT Process
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A. STEPS AND TASKS IN THE CHT PROCESS

The major Steps in the CHT Process were explained in section I.B. Your Role as a CHT Partner: An Overview of the CHT Process (p. 5). Figure 2 below shows how each Step can be thought of as representing a more specific Task or set of component Tasks, detailing the actual activities involved in accomplishing each Step. The six Tasks are distributed over three phases of interaction with your assigned households: the Pre-Session, the On-Session, and the Post-Session.
Figure 2. STEPS AND TASKS IN THE CHT PROCESS
STEPS
TASKS
PHASE I: PRE-SESSION
Task 1: Set the Family Health Hour.
PHASE II: ON-SESSION: FAMILY HEALTH HOUR HELPING FAMILIES FULFILL THEIR HEALTH GOALS
PROFILE Task 2. Complete
Household Profile to identify members with health conditions.
ORIENT Task 3. Orient

household on the Family Health Guide.
ASSESS Task 4. Help

family members make their Health Plans.
4.a Assess the

members health risks.
INFORM MONITOR Task 5.R Followup and monitor health plan adherence.
4.b Deliver key

health action messages.
PLAN 4.c Help

members develop Health Plans; Refer to health provider and transport.
PHASE III: POST-SESSION: RECORDS & REPORTING

REPORT Task 6. Provide summary report
to Rural Health Midwife
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B. PRE-SESSION: SETTING THE FAMILY HEALTH HOUR

PHASE I: PRE-SESSION
Task 1: Set the Family Health Hour.
Your first meeting with the household is called the Pre-Session. During this brief visit, your main objective is to simply come to an agreement with the household on when you can come back or might have more time with them in a Family Health Hour. The Family Health Hour is a specific day and time agreed upon by you and your assigned household. During this time, the household can discuss with you their health concerns, while you can also help them identify health risks and make plans to access health services to address their concerns. The Family Health Hour is also known in this Guidebook as the On-Session. The first household visit is critical. It determines whether the family will accept the health assistance you offer or reject it altogether. This is the make or break point in providing health navigational support to families. You can either lose families at this point, or get them hooked to your assistance in planning for their health and using Available quality health services. However, remember that some families might want to continue straight into the On-Session on your very first visit with them. If you also have time to do so, then it would be best to agree. Be sensitive; as the familys CHT Partner, you should adapt the Process to each familys particular needs and circumstances. Here are some steps you can take to accomplish Task 1: Setting the Family Health Hour. 1. Greet the family and introduce yourself. Upon arrival, look initially for the household head (as designated in your NHTS list of families) and their spouse/partner if available. If not present, you may ask for the medical decision-maker or any responsible member of the household.
HELPFUL TIP! The Buddy System If you feel uncomfortable about meeting new families, another member of your CHT could accompany you to the Pre-Session, while you are still getting to know them.
If you are not yet known to the family, dont forget to give them your name and your designation (for example,I am Rosa dela Cruz, a barangay health worker/barangay nutrition scholar and your Community Health Team Partner.) 2. Inform the household of the purpose of your visit. If you have an endorsement letter from your supervisor or RHU, share it with the household. Be sure to let them know that your assistance and the process you will be guiding them through is
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part of the local governments effort to improve the health of families in your municipality, especially of mothers and children. Let them know that the process will include helping them assess their health risks, and helping them access the health services they need. 3. Agree on the best time when you can regularly visit the household. Finding the best time means that you need to decide on a specific time and day when the family can sit down with you to discuss their health concerns, preferably with both the father and mother (or the primary Medical DecisionMaker/s). Ideally, this should be after work and household chores are finished, usually around afternoon siesta. Ask the family for the maximum time they are willing to give you to avoid disrupting their regular schedules.
This best time is the Family Health Hour. During the HELPFUL TIP! The Medical Decision-Maker. Remember that the person in charge of making medical decisions for the family may not necessarily be the household head. Be sensitive to family dynamics, or, if possible, you can also ask the family directly. It will be important to include the medical decision-maker in future discussions on the familys health.
Family Health Hour, you will be visiting the family again to discuss their health concerns, give them appropriate health messages, explain their PhilHealth benefits, and point them to the health providers they can go to for quality care. activities. 4. Once the Family Health Hour is set, encourage the family to schedule it in their activities for the week/month. Make an appointment with the family if possible, emphasizing that the fathers/partners presence is equally important in ensuring the health of the family. Again, try as much as possible to ensure that the familys medical decision maker will always be present. If the family is willing to give you more time, go to the steps in II.C. On-Session: The Family Health Hour - Helping Families Fulfill their Health Goals on page 16.
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C. ON-SESSION: THE FAMILY HEALTH HOUR: HELPING FAMILIIES FULFILL THEIR HEALTH GOALS
The Family Health Hour forms the largest part of your interactions with your assigned families. During each Family Health Hour, you will have the following objectives: a. To identify household members with health conditions (members at risk). To do this, you will be using the Household Profile Form (Form 1). b. To help at-risk household members recognize their health risks and give them important messages about their health. To do this, you will be using Part 1 of the Health Plan Implementation Forms (Forms 2A to 2G) and corresponding sections of the Family Health Guide and/or Booklet ni Nanay at ni Baby. c. To help at-risk household members make their own health plans, based on the health goals that each member desires. To do this, you will be using Parts 2 and 3 of the Health Plan Implementation Forms (Forms 2A to 2G). Figure 2 (p. 13) shows how each of these objectives will be accomplished through On-Session Tasks 2 to 5. If you are not familiar with the figure yet, now would be a good time for you to go back and review it before moving on. The next few sections will discuss each of the tasks in more detail.
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1. PROFILE
(Task 2: Completing the Household Profile)
PROFILE
PHASE II: ON-SESSION
Task 2. Complete
As the first part of assessment, the Family Roster and Health Profile is an important step to identify those members of the family with health conditions and concerns. Form 1: Household Profile Form will be your tool to collect basic information about the members of the NHTS households. It directs you to the rest of the forms you need to assist the family in accessing health care. You, as the CHT partner, will keep the accomplished Household Profiles. This form has 3 main parts (see p.18): Basic Information - basic data about the household including the date of visit, name of respondent, and NHTS household ID number. Family Roster and Health Profiles a focused listing of all the members of the household, including their names, relations, sex, ages, birthdays and answers to specific questions for women of reproductive age (15-49 years old), children, and (for all members) chronic cough, PhilHealth enrolment, and schedules for interview. Notes includes special instructions on how to accomplish the form.
IMPORTANT! Form 1 First. Complete Form 1: Household Profile before moving on to any of the other forms. This way, you can be sure that you have not missed out on any member who might have health risks.
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Figure 3. OVERVIEW OF FORM 1: HOUSEHOLD PROFILE
Basic Information
Family Roster and Health Profiles
Notes
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STEPS TO FILLING UP FORM 1: HOUSEHOLD PROFILE
1. Introduce the Household Profile to the family. Show the form to the household head, spouse/partner, or the health decision-maker who can provide you with the necessary information. Then, explain that you will be asking them for some health and related information so that, together, you can assess the health risks of individual household members and later track their progress in using the health services they need based on their health risks. 2. Fill up the Basic Information, following the instructions below (Table 2).
Table 2. INSTRUCTIONS FOR FILLING UP BASIC INFORMATION IN FORM 1.
Number 1. 2.
Item DATE OF VISIT
Instruction
Write the current date using the format mm/dd/yy.
Example
August 10, 2011 08 / 10 / 11 A S. Cruz CRUZ, A SANTOS
Write the complete name of the NAME OF RESPONDENT respondent using the format Last Name, First Name, Mothers Maiden Name.
3.
NHTS HOUSEHOLD ID NUMBER
This is a unique, pre-assigned 18digit number found in the NHTS Household list. Copy the correct and complete number into the boxes on the form.
023452000-5413-00018
0 2 34 5 20 00 5 4 13 0 0 018
3. Fill up the Family Roster (Columns Number 4-8). 4. NAME Ask for the complete names of ALL the members of the household starting from the household head, followed by the spouse/partner, their son(s)/daughter(s) from eldest to youngest, and lastly, other members of the household. Write the names in PRINT and in CAPITAL LETTERS following the format Last Name, First Name, Mothers Maiden Name.
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Be careful to SPELL NAMES CORRECTLY. Incorrect spelling will create inconsistencies between the list of NHTS households and the name on the PhilHealth ID. Example: ASK : ANSWER: WRITE: What is the name of the household head? Joel C. Natividad NATIVIDAD, JOEL CRUZ
5. RELATIONSHIP to HOUSEHOLD HEAD After the name of each member, immediately ask for the relationship of the member to the household head. Write down the relationship as: HEAD (for the household head) SPOUSE / PARTNER SON / DAUGHTER OTHERS (Specify the relation, i.e. GRANDSON, FIRST COUSIN, etc.)
6. SEX After completing the names and relationship to household head, ask for the sex of each household member and write only F for females or M for males. Example: ASK : ANSWER: WRITE: 7. AGE Ask the age of each household member. How you write the answer will depend on the age of the member. For adults more than 19 years old Write the age in completed number of years. Example: 29 YEARS Is _________ (name of member) male or female? Female / Male F/M
For young persons age 10-19 years old Write the age in years and encircle. This will serve as your cue that messages for adolescents should be delivered to this member (see Family Health Guide A. Health Messages: Caring for Adolescents, p.10). Example: 17 YEARS
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For newborns (babies 28 days or younger) Write the age in days and encircle the age. This will serve as your cue that Form 2A: Health Plan Implementation Form on Newborn Health should be administered to the newborn through the mother/father or any responsible member of the household. Example: 8 DAYS
For children age 29 days to less than 12 months Write the age in completed months and encircle the age. This will serve as your cue that Form 2B: Health Plan Implementation Form on Infant Health should be administered to the child through the mother/father or any responsible member of the household. Example: 10 months 10 MONTHS
For children age 12 months to less than 5 years Write the age in completed years and encircle the age. This will serve as your cue that Form 2C: Health Plan Implementation Form on Child Health should be administered to the child through the mother/father or any responsible member of the household. Example: 8. BIRTHDAY Indicate the date of birth of the family member using the format mm/dd/yy. For unknown or non-standard birthdates (i.e. for Indigenous Peoples), please refer to NHTS-PR listing or the DSWD system for assigning birthdates. Example: ASK : ANSWER: WRITE: What is _________s (name of member) birthday? October 30, 1980 10 / 30 / 80 2 years 3 months 2 YEARS
9. FOR WOMEN 15-49 YEARS OLD Questions 9a and 9b are for all women members of the household who are 15-49 years old. For the family members who do not belong to this group, put a long dash (--). 9a. Currently pregnant Ask the respondent if the woman member of the household who is 15-49 is currently pregnant. For all those currently pregnant, write YES and encircle. This
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will serve as your cue that Form 2D: Health Plan Implementation for Maternal Health: Pregnancy/Prenatal Care should be administered to this woman. She may also be assisted in developing Form 2F: Health Plan Implementation for Family Planning to help ensure the health of the family after she has given birth. If there are pregnant women in the household who are less than 15 or more than 49 years old, include them in the profiling of pregnant women as well. Write YES in the row corresponding to their names in this column (9a). Example: ASK : ANSWER: WRITE: ANSWER: WRITE: THEN: Is _________s (name of member) currently pregnant? Yes YES No NO Go to Question 9b.
9b and 9c Currently not pregnant Ask if the woman had just given birth less than 6 weeks or 42 days ago (Column 9b); or given birth more than 6 weeks ago, or has never been pregnant (Column 9c). Encircle any YES answer. If the YES is in Column 9b, this will be your cue that Form 2E: Health Plan Implementation Form for Maternal Health: Post-Partum Care AND Form 2F: Health Plan Implementation Form for Family Planning should be administered to this woman. If the YES is in Column 9c, this will be your cue that Form 2F: Health Plan Implementation Form for Family Planning should be administered to this woman. Example: ASK : When was the last time ____ (womans name) was pregnant? Less than 6 weeks (or less than 42 days) ago YES in column 9b (--) in column 9c More than 6 weeks (or more than 42 days ago) OR Never been pregnant NO in column 9b YES in column 9c
ANSWER WRITE:
ANSWER: WRITE: .
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HELPFUL TIP! Being sensitive. Keep in mind that not all families or women (especially young or unmarried women) will be open to questions on pregnancy or reproductive health. Be aware of the cultural background and sensibilities of your community. If you are unsure of how to ask certain questions, ask the other members of your CHT or your CHT supervisor on the best possible approach.
10. FOR ALL MEMBERS 10 YEARS OLD AND ABOVE For each member of the household older than 10 years, ask if he/she has been coughing for two weeks or more. If the answer is YES, encircle the answer. This will serve as your cue that Form 2G: Health Plan Implementation for Chronic Cough Management should be administered to this member. Example: ASK : ANSWER: WRITE: ANSWER: WRITE: Is _________ coughing for more than two weeks? Yes YES No NO
11. FOR ALL MEMBERS 21 YEARS OLD AND ABOVE Questions 11a and 11b are for household members who are 21 years old and older. 11a . Enrolment in PhilHealth For each household member 21 years old and above, ask if the household member is enrolled in PhilHealth. If the answer is YES, write the answer and go to Question 11b. If the answer is NO, write NO and encircle it. This will serve as your cue that this member needs information on how to enroll in PhilHealth. You can then refer the respondent to the Family Guide to PhilHealth: Benefits, Availment and Responsibilities, in particular Section II. The Family is Not Enrolled in PhilHealth, on p. 17. Example: ASK : Is _________s (name of member) enrolled in PhilHealth? ANSWER: Yes WRITE: YES THEN: Go to Question 11b.
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ANSWER: WRITE: 11b . PhilHealth ID Number
No NO
For those who answered YES to Question 11a, ask for their complete and correct PhilHealth ID Number. You should ask the members to show you their PhilHealth ID cards if possible. If there is a PhilHealth ID shown, copy the exact PhilHealth ID Number. If the respondent does not know the PhilHealth ID Number, please indicate DONT KNOW. You may discuss the members and his/her dependents entitlements in PhilHealth. Refer to the Family Guide to PhilHealth: Benefits, Availments and Responsibilities, in particular Section I: "The Family is PhilHealth- Enrolled" (p. 4). 12. SCHEDULE OF INTERVIEW If a health condition has been identified for a particular household member, ask that person when s/he is available for a discussion with you on his/her health risks and plans. If the person is available on the same day of your visit to the household, write the current date in the format mm/dd/yy and go to the administering the appropriate Health Plan Implementation Form. If the person is not available on the day of your visit to the household, ask the member when s/he might be available for a discussion. Write the agreed date under Column 12 in the format mm/dd/yy.
As you may realize by now, after completing the Household Profile, members with specific health conditions can be easily identified from Form 1. Using age as filter, you can identify newborns (0-28 days), infants (29 days to less than 12 months), children (12 months to less than 5 years old), adolescents (10-19 years old) and women who are 15-49 years old. For members older than 10 years old, a screening question on cough is asked, and for members 21 years old and above, a question on PhilHealth enrollment is asked. Figure 4 summarizes how the family members identified in Task 2 can be routed to specific Health Plan Implementation modules and messages depending on their health risks.
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Figure 4. LINKS BETWEEN FORM I PROFILES OF HOUSEHOLD MEMBERS (TASK 2) AND HEALTH PLAN IMPLEMENTATION FORMS AND/OR HEALTH MESSAGES (TASK 4). ASSESS 4.a Assess the
INFORM 4.b Deliver key

PLAN 4.c Help

members develop Health Plans
0 to 28 days
Form 2A: Newborn Health
29 days to less than 12 months
Form 2B: Infant Health
1 to less than 5 years
Form 2C: Child Health
10 to 19 years old
PROFILE Task 2. Complete
Health Messages: Family Health Guide: Caring for Adolescents
10 years old & above
Form 2G: Chronic Cough Management
Form 2D: Maternal Health: Pregnancy / Pre-natal Care
15 to 49 years old, females only
Form 2E: Maternal Health: Post-Partum Care
Form 2F: Family Planning
21 years old & above
Health Messages: Family Guide to PhilHealth:
Benefits, Availment and Responsibilities
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2. ORIENT
(Task 3: Orientation on the Family Health Guide)

ORIENT
Task 3.
Orient family on Family Health Guide.
Now that you have completed the Household Profile, during this part of the session, you will be giving the family an overview of the Family Health Guide. Your major task will be to share the purpose of the Family Health Guide and to briefly go over its various components and how the family can benefit from it and the information it contains.
STEPS TO ORIENTING THE HOUSEHOLD ON THE FAMILY HEALTH GUIDE
1. Show the Family Health Guide to the members of the household. Give the Family Health Guide to the couple/medical decision-maker of the household and give them a few minutes to browse through it. Allow them to discover what the Family Health Guide is for instead of telling them. Affirm if their idea is correct and explain if incorrect. Never say Wrong. The first step in the convincing the family is to help them learn on their own with your guidance.
2. Give a brief overview of the Family Health Guide. Discuss briefly the contents of the Family Health Guide (see p. 8 for a description of the Family Health Guide). Explain how they could benefit from each component. Once the family has seen all the parts of the Family Health Guide, go to making individual health risk assessments for those at-risk members you identified from the Household Profile.
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3. ASSESS
(Task 4a: Assessing Members Health Risks)

ASSESS Task 4. Help 4.a Assess the
Task 4a is the first part of helping family members make their Health Plans. Your main tools for this task are the Health Plan Implementation Forms 2A to 2G. Each Health Plan Implementation Form is divided into 4 parts (see Figure 5 below). To accomplish Task 4a, you will be using Part 1 (Health Risk Assessment and Key Health Messages) of the Health Plan Implementation Forms. For more detailed discussions of the different Health Plan Implementation modules, see pages 40 onwards.
Figure 5. PARTS OF A SAMPLE HEALTH PLAN IMPLEMENTATION FORM (FRONT ONLY). PART 1: HEALTH RISK ASSESSMENT & KEY HEALTH MESSAGES
FORM 2A: Health Plan Implementation for NEWBORN HEALTH
Part 1: HEALTH RISK ASSESSMENT & KEY HEALTH MESSAGES (Indicate Y, if yes; N if no) A1 Was the baby delivered in a health facility? ________
Message for A1 Bring your baby to a health provider for appropriate newborn care services. Message for A2 Newborn screening is important because it can save babies from mental retardation and death and it can help in the early detection of illnesses. Newborn screening is available for free for sponsored members in Philhealth accredited government facilities (Refer to section on Inpatient Coverage of the Philhealth Module in your Family Health Guide). Have your baby immunized with BCG and Hepatitis B to protect him/her from preventable diseases. You may also refer to your Mother and Child Book on What I Need During the First Few Weeks after Birth. Message for A3 Giving your baby breast milk only for the first 6 months (with no other liquid like milk formula or water and other semi-solid foods) will protect him/her from ear infections, diarrhea and respiratory illnesses. You may also refer to your Mother and Child Book on Feeding Recommendations from birth to 6 months.
PART 2: GENERAL INFORMATION
Part 2: GENERAL INFORMATION (to be filled out with the help of the CHT partner)
Name of Mother (Last name, first name, middle name) Name of Newborn (Last name, first name, middle name) Name of CHT partner (Last name, first name, middle name)
NHTS HH ID:
Date of Birth:
Date of Visit:
A2. Was the baby provided with any of the following? (please check if Yes) Newborn assessment/screening BCG Hepatitis B **If without check in any of the above, provide Message B2
Date of initial visit (mo/day/year)
Part 3: HEALTH PLAN (to be filled out with the help of the CHT partner) 3.1 Plan for REGULAR Cases Health Goal bring my baby to the health provider To for newborn care services bring my baby to health provider for To newborn screening, BCG and Hepa B immunization exclusively breastfeed my baby To
Referral Provider/s (name and address) (use the list of health providers in the Family Health Guide)
PART 3:
HEALTH PLAN
3.2 Plan for EMERGENCY Cases (If check in any item in A4) A3. Do you only give breast milk (exclusive breastfeeding) to your baby?
Reasons for Emergency Referral Emergency transport providers (name and contact no.) Heal th Servi ce Providers (name and address)
Consultation for immediate assessment and management of danger signs Part 4: ACTIONS TAKEN (to be filled out by the midwife, nurse or doctor) (Please accomplish/update the Immunization Schedule in the Mother and Child Book ) Name and address of health provider: Services provided: (specify antigens and schedule, example: BCG, HepaB1 within the 1st 24 hrs or HepaB1 after 24hrs) Date of consultation:
A4. Does your baby have any of the following danger signs? (please check ,if Yes) Convulsions Stopped breastfeeding/poor sucking Feels hot or cold Foul smelling discharge or blood form cord Yellowish soles/eyes/skin or less movement No Fast or difficult breathing **If with check in any of the above, provide Message for A4
Message for A4 Bring your baby to a health provider if you observe any of these signs. Bring with you this form (2A), your PhilHealth card, Member Data Record (MDR), and the babys Birth Certificate. On your way to the health facility Keep your baby warm Breastfeed your baby every after two hours (if the baby is able to breastfeed)
PART 4:
Instruction of the provider:
ACTIONS TAKEN
Schedule of next check-up:
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During the Family Health Hour, Task 4a (or ASSESSMENT) is done simultaneously with Task 4b (or INFORMING). Together, Tasks 4a and 4b make up PART 1 of the HEALTH PLAN IMPLEMENTATION FORMS.
STEPS TO ASSESSING MEMBERS HEALTH RISKS
1. Ask the questions on the left side of Part 1. Questions should be directed to the particular family member with the health condition that may be risky. For newborns, infants, and children, ask the parents or any responsible member of the household. For adolescents, you may ask him/her directly, with or without his/her parents or guardians. Write the responses on the spaces provided. Depending on the response, you should then follow the instructions on the form to either go to another question or to deliver the corresponding key health message. 2. Deliver the corresponding key health message where you are directed to go. Part 1 of the Health Plan Implementation Forms also contains directions on which key health messages should be given to the respondent. Health messages are discussed in more detail in the next section. Some messages are to be given REGARDLESS of the respondents answer; others are only given in response to SPECIFIC answers. Be aware of the flow of questions and messages, and follow these carefully.
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4. INFORM
(Task 4b: Delivering Key Health Messages)

ASSESS Task 4. Help 4.a Assess the
INFORM 4.b Deliver key

Task 4b is the second part of helping family members make their Health Plans. As mentioned in the previous section, in reality, assessing is done simultaneously with informing. Again, as for Task 4a, your main tool for this task is Part 1 (Health Risk Assessment and Key Health Messages) of the Health Plan Implementation Forms. For more detailed discussions of the different Health Plan Implementation module, see pages 40 onwards. To accomplish this task, you should deliver the Key Health Message indicated in Part 1 which corresponds to the instructions on the Form. Key health messages are designed to be short and concise. These represent your main and initial message for the member at risk. Most often, you will notice that Key Health Messages end with a prodding to the member (or the members parent/primary care giver if the member is a newborn, infant or child) to seek care from a health provider for specific health needs. Delivering these messages is a major part of your roles as a CHT Partner and health navigator for the family. BEYOND THE KEY HEALTH MESSAGES If you feel that a particular message needs more explaining, or if the family member would like to know more, you may refer to the Family Health Guide for more information and messages that you could point out to that particular member whom you are assessing and informing. Flash cards may also be used in subsequent home visits to reinforce messages you have given before, or to emphasize certain aspects of the members health condition. Flash cards can also be a valuable resource during small group discussions, such as during mothers classes, health classes, Tumpukan sa Barangay, purok meetings, and more. HELPFUL TIP! Adolescents (age 10 to 19 years old) are a special group with unique health needs and varying sensibilities. They should be directed to the messages in the Family Health Guide. Dont forget to remind them that they can always approach their health provider if they have any questions or concerns about their health.
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The Booklet ni Nanay at ni Baby will also be a valuable reference to you, as it contains a wide array of health messages that are relevant to mothers, newborns, infants, and children. Finally, the Family Guide to PhilHealth: Benefits, Cilments, and Responsibilities will also be important as you share with the family how enrollment in PhilHealth can benefit them in their particular situations.
5. PLAN
(Task 4c: Helping Members Develop Health Plans)

PLAN Task 4. Help 4.c Help members
develop Health Plans; refer to health provider and transport.
Task 4c is the third and last part of helping family members make their Health Plans. You will be using Part 2 (General Information) and Part 3 (Health Plan) of the Health Plan Implementation Forms. For more detailed discussions of the different Health Plan Implementation module, see pages 40 onwards. Health plans are made by members and belong to the members. You may write the information yourself, or the member may do so. What is important is that the family member recognizes that the plans written on the form are his/her plans, not your (the CHT partners) plans. It is important to impart to the family member a sense of ownership and responsibility to adhere to the plan. If you are the one writing the information, you will need to accomplish this part of the Health Plan Implementation Form working closely with the member concerned, or with the parent or primary care-giver if the member is a newborn, infant, or child. Once a member or respondent has completed Part 2 and 3, you should leave the Health Plan Implementation Form with him/her. You can copy the information into your logbook for recordkeeping purposes, but the form belongs to the family member. Remind them that they should: a. Keep the form safe, in a place where it will not get damaged or lost; b. Bring the form with them when they visit the health provider as planned; c. Remind the health provider to fill up the appropriate part of the form (Part 4 if it is the initial visit to the provider, or Part 5 on the back of the form for follow-up or succeeding visits); and d. Bring the form back home with them after visiting the health provider.
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STEPS TO HELPING MEMBERS DEVELOP HEALTH PLANS
1. Fill up Part 2 (General Information). In the spaces provided, write down the information asked. Depending on the type of form (see Health Plan Implementation Modules, p. 40), these will include the complete name of the respondent, the complete and correct NHTS household ID number, the name of the CHT partner (your name), and the date of visit (the date the health plan was accomplished). For newborns, infants, and children, there are separate spaces for the childs name and birth date, as well as space for the name of the childs parent or primary care-giver. 2. Fill up Part 3 (Health Plan). For the first 5 Health Plan Implementation forms (Forms 2A to 2E - Newborn Health, Infant Health, Child Health, Pregnancy/Pre-Natal Care, and Post-Partum Care), the Health Plan is divided into two parts (Regular Cases, and Emergency Cases). a. Regular cases In this section, regular cases refers to those situations in which the health goal is not an emergency. Regular cases would include, for example, referrals for immunization, counseling, or follow-up checkups. i. Health Goal Health goals are outcomes that the member desires based on his/her realization of his/her health risks. For example, for newborns, a health goal might be To bring my baby to a health provider for newborn screening. Place a check next to the health goal of the member, or, if the members goal is not included in the choices given, place a check next to OTHERS, then write the goal on the space provided. If the member has more than one health goal, check all those that are applicable. ii. Referral Provider/s Once a member has indicated his/her health goals, show the member the List of Health Providers and Health Emergency Contacts, one of the component booklets in the Family Health Guide. Help the member look for those health
32
providers or facilities in the vicinity that offer the services they need, are easily accessible, and are affordable. Many of the providers in the List are PhilHealth-accredited. If the member is covered by a PhilHealth enrolment, show him/her the benefits and availments applicable to his/her health needs. If the member is not covered by PhilHealth, you can likewise encourage them to seek enrolment so that they can avail of the appropriate benefits. You should refer to the Family Guide on PhilHealth: Benefits, Availments and Responsibilities in guiding the family on these matters. If the family has questions regarding PhilHealth of which you are uncertain, you can refer them to your local PhilHealth Coordinator for further guidance. iii. Planned Date of Visit This is the date, decided by the member, when he/she will visit the health provider indicated in the previous column. b. Emergency cases In this section, emergency cases refers to those situations in which the respondent or member needs urgent treatment or care. Part 1 of Forms 2A to 2E contains a list of DANGER SIGNS to watch out for in particular age groups or conditions. As the CHT Partner, you should look for these danger signs in the member during your visit with the family. It is also part of your task to teach the respondent or member to watch out for these signs at all times, and to let them know that these signs could indicate a serious health condition in him/her or his/her child.
If any of these signs are present at the time of your visit, you should make an urgent referral to the nearest health provider for emergency care.
If none of these signs are present at the time of your visit, but had occurred some time in the past before your visit, you should make an urgent referral to a health provider for assessment.
If none of these signs are present at the time of your visit, and had never occurred in the past, you should still fill out the section for emergency cases so that, in the event of an emergency, the family already has a plan for who to go to for help, and how to get there.
33
i.
Health Goal For emergency cases, the health goal is always Consultation for immediate assessment and management of danger signs. Place a check next to this health goal if the member is in need of emergency care.
ii.
Emergency Transport Provider/s Show the member or respondent the List of Health Emergency Contacts, and help them choose the Emergency Transport Providers that they would approach in case of an emergency. Note the Transport Providers name and contact number/s on the form. If possible, choose more than 1 so that the family has alternatives.
iii.
Health Service Providers Again, show the member or respondent the List of Health Emergency Contacts and help them choose the emergency health service providers to whom they would go in case of an emergency. Note the providers name and contact number/s in the form. If possible, choose more than 1.
3. Ask for the member or respondents consent. Finally, after the health plan has been made, jointly review it with the respondent. If the respondent agrees to the plan, have him/her name and signature affixed in the space provided at the bottom of Part 3: HEALTH PLAN. Once the form has been signed, give the form to the respondent. For newborns, infants and children, it is the parent or primary care-giver who will sign here. For adolescents who have been administered Health Plan Implementation Forms (i.e., a pregnant adolescent), they will affix their own signatures to the bottom of Part 3. 4. Copy the information in the Health Plan Implementation form in your CHT Monitoring Form. The Health Plan Implementation form stays with the family but you need to know the information it contains for you to be able to remind the respondent/concerned household member on the scheduled provider visits. This is why it is important for you to copy the information in Parts 2 and 3 of the Health Plan Implementation form in the corresponding CHT monitoring form (see Tables 4-8 for examples). Make sure that you also get the accomplished Form 1: Household Profile to easily track household members that you need to assist with health plan development and implementation.
34
6. MONITOR
(Task 5: Following-up and Monitoring Health Plan Adherence)
MONITOR Task 5.R Follow-
up and monitor health plan adherence.
Monitoring a members adherence to his/her plans begins with the members visits to a service provider. This is recorded in Part 4 (Actions Taken) and Part 5 (Service Utilization and Monitoring Form) of the Health Plan Implementation Forms. Both Parts 4 and 5 are to be filled up by the Health Service Provider. Remind the member to bring the form to every visit to the Service Provider, and to be responsible for checking that the Service Provider fills out these sections completely. As the CHT Partner, you will be using Parts 4 and 5 as a basis for monitoring adherence to health plans. Part 4: Actions Taken This will be filled-up by the Health Provider as soon as the respondent or newborn, infant or child is brought to the facility. This will serve as your starting point for monitoring compliance to the instructions of the provider. Part 4 includes the following: Name and address of health provider Services provided Date of consultation Instructions of the provider Schedule of next visit to provider for check-up.
Part 5: Service Utilization Monitoring Form This is located at the back of the Health Plan Implementation Form (see Table 3, below). This should be filled out by the service provider if there are follow-up visits to the initial visit recorded in Part 4, using one row of the form per visit. If only one visit was necessary, then only Part 4 need be filled out and Part 5 can be left blank.
35
Part 5 contains the following information: Date of consultation recorded by the health provider as the date of the clients visit, in the format of mm/dd/yy. Name and address of provider the health provider should indicate his/her name and address of the facility where the family member was served Service/s provided or commodities prescribed brief description of the services provided/commodities prescribed during the clients visit to the health facility Instruction of the provider based on the findings of the health provider, he/she will make the necessary referral to higher level facilities and suggest schedule of visit Schedule of next visit to provider for checkup - this should be recorded in the corresponding column following the format: month/day/year.
Table 3. SAMPLE SERVICE UTILIZATION AND MONITORING FORM.

Part 5. Service Utilization and Monitoring Form for Newborn Health Date of Name and address Services Instructions of Schedule of next Consultation of provider Provided the provider visit to provider (month/day/year) for check-up
36
STEPS TO FOLLOWING-UP AND MONITORING HEALTH PLAN ADHERENCE
1. Visit the family again to check on the members adherence to their health plans. In the succeeding household visits, you should review the following: (For Forms 2A to 2E): Booklet ni Nanay at ni Baby check if the appropriate sections were completely filled out by the Health Provider. Make sure also that Part 4 of the Health Plan Implementation Form has been completely filled out, and that the Form has been attached to the Booklet ni Nanay at ni Baby. This will enable you to determine whether they sought and obtained health care services as discussed during your earlier visit where you and the family completed the Health Plan Implementation Forms. This portion will also tell you if the member was referred by the health provider to a higher level of care. Copy the pertinent details into the CHT Monitoring Forms or your logbook (for templates, see the examples on pages Error! Bookmark not defined. toError! Bookmark not defined.). (For all Forms): Part 4 (Actions Taken) and Part 5 (Service Utilization Monitoring), if applicable check to see if these sections were duly accomplished by the health provider. Especially for those members whose health plans require repeated visits to a health provider (such as, for example, multiple pre-natal care visits for pregnant women), routinely check the Service Utilization Monitoring Form to know the providers instructions and the schedule of next visit to the facility. You should also constantly remind concerned household members to comply with the providers instructions and follow their scheduled provider visits. Copy the pertinent details into your CHT Monitoring Forms/Logbook.
D. POST-SESSION: REPORTING SUMMARIES OF HEALTH INFORMATION
37
7. REPORT
(Task 6: Provide Summary Report to Rural Health Midwife)
Using your CHT Monitoring Form/logbook, record and update the health profile of the NHTS household members assigned to you. You can add NHTS under the Remarks column or in the portion where you write notes for each client or family member. a. Record family members according to their health condition, using separate logbook tables for: (1) Newborn and Infant Health; (2) Child Health; (3) Maternal Care; (4) Family Planning; and (5) Chronic Cough Management. From these five, select the appropriate logbook table to record basic information for each NHTS-PR family member you assist, include the following information: name, age or birthdate, address, health services needed, health services provided, and date of initial or followup visit to health provider (see the Sample CHT Monitoring Forms/Logbook templates in Tables 4 to 8). b. For the recording of health services provided, ensure that you record antenatal care (ANC) visits (specify in the Remarks section if the respondent has already reached 4 or more), facility-based deliveries (FBD), Vitamin A, fully-immunized child (FIC), exclusive breastfeeding up to 6 months (EBF), and modern family planning use. c. You should also note in your logbook, for each health service recorded, whether this was provided by a private or public health provider. d. If the NHTS family member was able to use his/her PhilHealth to pay (partially or fully) for the health service, test, medicines or drugs, note this in the Remarks column, as used PhilHealth.
Table 4. SAMPLE CHT MONITORING FORM/lOGBOOK FOR NEWBORN AND INFANT HEALTH.
NEWBORN & INFANT HEALTH MONITORING

NAME (Last, First, Middle) HEALTH SERVICE NEEDED DATE OF VISIT TO PROVIDER HEALTH SERVICE PROVIDED DATE OF NEXT VISIT HEALTH SERVICE PROVIDER AND TYPE (Public/ Private) Laging Handa Health Center (public)
AGE
ADDRESS
REMARKS
REYES, ANA CRUZ
10 months
Lot 3, Blk 8, Purok 2, Brgy Laging Handa
Immunization
9/30/2011
Hep B3 immunization
11/5/2011 for measles vaccine
NHTS
38 Table 5. SAMPLE CHT MONITORING FORM/lOGBOOK FOR CHILD HEALTH.
CHILD HEALTH MONITORING

NAME (Last, First, Middle) DATE OF VISIT TO PROVIDER HEALTH SERVICE PROVIDED DATE OF NEXT VISIT HEALTH SERVICE PROVIDER AND TYPE (Public/ Private) Delgado NHTS Hospital (private)
AGE
ADDRESS
HEALTH SERVICE NEEDED
REMARKS
Lot 4, Blk CRUZ, B SANTOS 1, Purok 3, 4 years Brgy Laging Handa, QC Vitamin A supplementation 10/12/2011 Vitamin A supplementation 10/19/201 1
Table 6. SAMPLE CHT MONITORING FORM/lOGBOOK FOR MATERNAL HEALTH.
MATERNAL HEALTH MONITORING

HEALTH SERVICE PROVIDER AND TYPE (Public/ Private)
NAME (Last, First, Middle)
AGE
ADDRESS
DATE OF VISIT TO PROVIDER
HEALTH SERVICE PROVIDED
DATE OF NEXT VISIT
REMARKS
REYES, ANA CRUZ
35
Pre-natal checkup
9/30/2011
NHTS
Laging Handa Health Center (public)
Table 7. SAMPLE CHT MONITORING FORM/lOGBOOK FOR FAMILY PLANNING.
FAMILY PLANNING MONITORING

NAME (Last, First, Middle) FIRST TIME USER OF ADDRESS FP METHOD? (Y/N) HEALTH SERVICE/ COMMODITIES NEEDED HEALTH SERVICE / DATE OF COMMODITIES DATE OF VISIT TO PROVIDED NEXT REMARKS PROVIDER (Specify VISIT Quantity of Commodity) HEALTH SERVICE PROVIDER AND TYPE (Public/ Private)
AGE
FLORES, CORA HEBRON
25
No
Lot 1, Blk 6, Purok 4, Pills (1 cycle) Brgy Laging Handa
10/5/2011 Pills (1 cycle)
10/27/201 1
NHTS
LM Midwife Clinic (private)
Community Health Team Guidebook Table 8. SAMPLE CHT MONITORING FORM/lOGBOOK FOR CHRONIC COUGH MANAGEMENT.
39
CHRONIC COUGH MANAGEMENT MONITORING

HEALTH NAME (Last, First, Middle AGE ADDRESS HEALTH SERVICE/ DUGS NEEDED Lot 1, Blk FLORES, JOCELYN 6, Purok 4, 36 years Brgy Laging Handa Checkup 10/5/2011 Sputum exam 10/27/2011 NHTS Maco Rural Health Unit (public) DATE OF VISIT TO PROVIDER SERVICE/DRUGS PROVIDED (Specify name and quantity of drugs) DATE OF NEXT VISIT REMARKS HEALTH SERVICE PROVIDER AND TYPE (Public/ Private)
2. The CHT monitoring forms/logbook shall be submitted to the RHM during the monthly meeting for reconciliation with the TCL. These forms/logbook shall be returned to you for safekeeping. 3. During your monthly meeting with the RHM, also show her/him the accomplished family profiles (Form 1) of NHTS households assigned to you. Update the RHM on the following: a. Number of assigned NHTS households you visited vis--vis the number of NHTS households assigned to you b. Number of assigned NHTS-PR households with at least one health use plan c. Number of assigned NHTS households with PhilHealth ID
40
Included Modules: Newborn Health Infant Health Child Health Pregnancy / Prenatal Care Postpartum Care Family Planning Chronic Cough Management
III. Health Plan Implementation _____Modules____
41
HEALTH PLAN IMPLEMENTATION FORM 2A:
NEWBORN HEALTH (0-28 DAYS)

This form will be used for newborns (0 to 28 days old). Step 1: Route from Form 1 (Household Profile). In the example shown in Figure 6, B Cruz Santos is 20 days old. As directed, you will go to accomplishing FORM 2A: Health Plan Implementation for NEWBORN HEALTH (0-28 days) with the parent or primary care-giver who can provide information as the respondent.
Figure 6. EXAMPLE OF ROUTING A NEWBORN HOUSEHOLD MEMBER FROM FORM 1 TO FORM 2A.
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Step 2: Assess members health risks and deliver key health messages. Ask the questions under Part 1 (see Figure 7). Ask each question in order, then deliver the corresponding key health message to the parent or primary care-giver, where you are directed to go. Remember that the Key Health Messages found in Form 2A are your initial and most important messages for the parent or primary care-giver of the newborn. You may refer to the appropriate sections in the Booklet ni Nanay at ni Baby or the Family Health Guide, A. Messages: Caring for Newborn (p. 6) for more information. Flash cards (Card 4) may also be used in subsequent home visits to reinforce or emphasize certain aspects of the newborn condition.
Figure 7. SAMPLE FORM 2A: HEALTH PLAN IMPLEMENTATION FOR NEWBORN HEALTH.
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QUESTIONS and KEY HEALTH MESSAGES (refer the respondent to the Family Health Guide, A. Health Messages, Caring for Newborn on p. 6 while conducting this health risk assessment) A1. Was the baby provided with any of the following? (Please check, if yes) Appropriate newborn care is provided during the first few weeks after birth to ensure his/her survival. These newborn services include: a) Advice on exclusive breastfeeding until the baby is 6 months of age; b) Newborn screening to detect some congenital conditions that could cause mental retardation and even death if not managed early in life; and, c) Immunization with BCG and Hepatitis B to protect him/her from preventable diseases
Place a check next to the services that the newborn has already received. Newborn assessment/screening BCG Hepatitis B Regardless of the answer to Question A1, deliver the Message for A1, then go to Question A2. o If none or only 1 or 2 of the services were checked, then emphasize that the baby must be brought to a skilled health provider to receive appropriate newborn care. Babies less than 1 week old should be referred immediately to a health facility for newborn screening and immunization.
o
For the items that were checked, commend the parent/care-giver and reinforce their action by sharing the Message for A1.
Message for A1 Newborn screening (NBS) is important because it can help in the early detection of diseases like mental retardation Bring your baby to a doctor, nurse, midwife or any skilled health provider for newborn screening 24-72 hours after delivery Newborn Screening (NBS) is free for dependents of PhilHealth-sponsored members in accredited government facilities. (Refer to Section A on INPATIENT COVERAGE, p. 7 and Table 2, p. 8 of the Family Guide on PhilHealth) Have your baby immunized with BCG and Hepatitis B vaccines to protect
44 him/her from TB and Hepatitis B Refer to your Booklet ni Nanay at ni Baby - "Ang Aking Mga Pangangailangan sa Unang Linggo ng Aking Pagsilang", p. 24
A2. Do you only give breast milk (exclusive breastfeeding) to your baby? Newborns should start breastfeeding within the first 1 hours of life. Exclusive breastfeeding means giving the baby only breastmilk (without milk formula, water, or other foods) and should be done for the first 6 months of life. Aside from being completely adequate for the nutritional needs of babies, exclusive breastfeeding has also been proven to protect babies from ear infections, diarrhea, and respiratory illnesses. Ask the question, then write the response on the form: Y if Yes, and N if No. Regardless of the answer to Question A2, deliver the Message for A2, then go to Question A3. o If the answer is No, then emphasize the importance of exclusive breastfeeding for the health of the newborn. o If the answer is Yes, then commend the parent/care-giver and reinforce their action by sharing the Message for A2.
Message for A2 Breast milk is adequate for your baby's needs for the first 6 months. (Exclusive Breastfeeding) Breastfeed starting at birth up to 2 years and beyond Breastfeeding for the first 6 months (without milk formula, water or other foods) will protect your baby from ear infections, diarrhea and respiratory illnesses respiratory illnesses. Refer to your Booklet ni Nanay at ni Baby, p. 26 - Tagubilin sa Pagpapakain.
A3. Does your baby have any of the following danger signs? Danger signs are conditions that could point to a more serious illness or complication of a disease. If a baby shows danger signs, it is important to bring him/her immediately to the nearest health facility for urgent attention and treatment.
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Place a check next to the danger sign that the newborn is showing or has shown in the past. Convulsions Stopped breastfeeding / poorly sucking Feels hot or cold to touch Foul-smelling discharge or blood from cord stump Yellowish soles / eyes / skin No or less movement Fast / difficulty breathing Regardless of the answer to A3, deliver the Message for A3 and accomplish Part 3.2 of the Health Plan Implementation Form. o If the baby is showing danger signs at the time of your visit, immediately refer the child to the nearest health provider for emergency care. o If the baby is not showing danger signs at the time of your visit, but has shown danger signs some time in the past, refer the child to a health provider for assessment. o If the baby is not showing and has never shown danger signs, instruct the parents / primary care-giver to watch out for these signs, and to refer to their Health Plan for Emergency Cases (the completed Part 3.2 of the Health Plan Implementation Form for Newborn Care) so that they can bring their child immediately to their planned Emergency Providers in case they observe any of these signs in their child.
Message for A3 Bring your baby to a health provider if you observe any of these signs. Bring with you Form 2A, your PhilHealth card, Member Data Record (MDR) and the babys birth certificate. On your way to the health facility: Keep your baby warm Breastfeed your baby every two hours (if baby is able to feed)
Step 3: Help members develop health plans. Parts 2 (General Information) and 3 (Health Plans) are accomplished with the parents or primary caregiver who can provide the necessary information.
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Part 2 (General information) includes information such as complete name of the respondent, complete and correct NHTS household ID number, complete name, date of birth of the newborn, and your name as the CHT partner.
Part 3 (Health Plan) is divided into two parts: a. Part 3.1: Referral for regular cases (Newborn screening, BCG and Hepatitis B immunization). Place a check next to the Health Goal that the parent or primary care-giver has identified based on his/her childs health risks. Then, continue to fill out the health plan as described previously (p. 30). Possible Health Goals for newborns (regular cases) include: To bring my baby to health provider for newborn care services To exclusively breastfeed my baby Others b. Part 3.2: Referral for emergency cases (Newborn with signs of danger in HRA Question A4) Fill out the Health Plan for Emergency Cases as described above (p. 30) Dont forget to ask the newborns parent or primary care-giver to affix his/her signature in the space allotted at the bottom of Part 3 as a sign of his/her consent to the Health Plan. Before giving the Health Plan Implementation form to the respondent, fill out the CHT Monitoring Form/Logbook for Newborn and Infant Health based on the information contained in Parts 2 and 3. Use this referral information to remind the respondent of his/her scheduled visit to the provider.
Step 4: Follow-up and monitor health plan adherence. On your subsequent visits to the household, you may use Flash card 4 to reinforce newborn care messages. Check if the Health Plan has been adhered to by reviewing the following: Booklet ni Nanay at ni Baby (particularly Tala ng Aking mga Bakuna on p. 25) completely filled out by the Health Service Provider Parts 4 (Actions Taken) and 5 (Service Utilization Monitoring Form) of Form 2A (see Table 9) to be filled out by the provider in the absence of the Booklet ni Nanay at ni Baby
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Table 9. SAMPLE SERVICE UTILIZATION AND MONITORING FORM FOR NEWBORN HEALTH. Part 5. Service Utilization and Monitoring Form for Newborn Health Date of Name and address Services Instructions of Schedule of next Consultation of provider Provided the provider visit to provider (month/day/year) for check-up
Copy the details in Form 2A Parts 4 and 5 or in Tala ng Aking Bakuna in the Booklet ni Nanay at ni Baby in your CHT Monitoring form/Logbook for NEWBORN AND INFANT HEALTH MONITORING (see Table 10). In case the latter is used, ask if the baby was examined for newborn screening.
Table 10. SAMPLE CHT/BHW LOGBOOK MONITORING ENTRY FOR NEWBORN AND INFANT HEALTH.
NEWBORN AND INFANT HEALTH MONITORING

AGE
ADDRESS
REMARKS
REYES, ANA CRUZ
1 day
Newborn screening
Nov. 28, 2011
Newborn screening
Dec. 3, 2011
NHTS; used PhilHealth
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HEALTH PLAN IMPLEMENTATION FORM 2B: INFANT HEALTH (29 DAYS-LESS THAN 12 MONTHS)
This form will be used for infants who are 29 days to less than 12 months old. Step 1: Route from Form 1 (Household Profile). In the example shown belows (Figure 8), Reggie is 4 months old. As directed, you will go to accomplishing Form 2B: Health Plan Implementation for Infant Health (29 days-Less Than 12 Months) with the parent or primary care-giver who can provide information as the respondent.
Figure 8. EXAMPLE OF ROUTING AN INFANT HOUSEHOLD MEMBER FROM FORM 1 TO FORM 2B.
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Step 2: Assess members health risks and deliver key health messages. Ask the questions under Part 1 (see Figure 9 below). Ask each question in order, then deliver the corresponding key health message to the parent or primary care-giver. Remember that the Key Health Messages found in Form 2B are your initial and most important messages for the parent or primary care-giver of the infant. You may refer to the appropriate sections in the Booklet ni Nanay at ni Baby or the Family Health Guide A. Messages: Caring for Infants and Children (p. 8) for more information and messages relevant to infants.
Figure 9. SAMPLE FORM 2B: HEALTH PLAN IMPLEMENTATION FOR INFANT HEALTH.
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QUESTIONS and KEY HEALTH MESSAGES (refer the respondent to the Family Health Guide, A. Health Messages, Caring for Infant and Child on p. 8 while conducting this health risk assessment) Check the immunization card of the baby when asking the respondent the following questions: B1. Did your baby receive his/her first OPV, DPT & 2nd Hepa-B scheduled on the 6th week after birth? o If the answer is No (or the immunization card shows that the baby has not yet received the vaccines), deliver Message for B1 and emphasize that the infant must be brought to a skilled health provider to receive the right immunizations.
Message for B1 You can get free OPV and DPT from the health center. This helps prevent your baby from having infectious diseases that may lead to permanent disability and even death.
If the answer is Yes (or the immunization card shows that the baby was already immunized) and the baby is 10 weeks or above, ask Question B2. Go directly to Question B4 if the baby is below 10 weeks.
B2. Did your baby receive his/her second OPV & DPT scheduled on the 10th week after birth? o If this is not yet received by the baby, deliver Message for B2 to B3, then ask Question B4.
Message for B2 to B3 Follow the schedule of immunization to ensure that your baby is fully immunized by age 12 months Bring your baby to the health center before he/she is 1 year old to complete his/her immunization: BCG, DPT 1,2,3, OPV 1,2,3; Hepa 1,2,3 and measles Bring your baby's immunization card or Booklet ni Nanay at ni Baby every time you bring him/her to your health provider
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If this is already received by the baby and he/she is 14 weeks or above, ask Question B3. Go directly to Question B4 if the baby is below 14 weeks.
B3. Did your baby receive his/her third OPV, DPT & Hepa B scheduled on the 14th week after birth?
o o
If the answer is No, deliver Message for B2 to B3, then ask Question B4. If Yes and the baby is 6 months or below , ask Question B4. Go directly to Question B5 if the baby is above 6 months.
You may refer to your Booklet ni Nanay at ni Baby, p. 25 - Tala ng Aking mga Bakuna for more information on the right immunization schedule. B4. (For babies 0-6 months old) Is your baby exclusively breastfeeding?
Regardless of the answer to Question B4, deliver the Message for B4, then go to Question B5. o If the answer is No, emphasize the importance of exclusive breastfeeding for the health of the infant.
o
If the answer is Yes, commend the parent/care-giver and reinforce their action by sharing the Message for B4.
Message for B4 Breastfeeding for the first 6 months (without milk formula, water or other foods) will protect your baby from ear infections, diarrhea and respiratory illnesses Breast milk is adequate for your baby's needs for the first 6 months
B5. (For babies 6-11 months old) Was your baby given Vitamin A? . Regardless of the answer to Question B5, deliver the Message for B5, then go to Question B6. o If the answer is No, emphasize the importance of Vitamin A supplementation for the health of the infant.
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If the answer is Yes, then commend the parent/care-giver and reinforce their action by sharing the Message for B6.
Message for B5 Your baby must receive Vitamin A at 6-months old. Do this every 6 months until 5 years old. Vitamin A increases your babys resistance to infectious diseases and helps prevent blindness.
B6. (For babies older than 6 months) Is your baby eating solid food?
Regardless of the answer to Question B6, deliver the Message for B6, then go to Question B7. o If the answer is No, emphasize the importance of complementary feeding for the health of the infant, and of growth monitoring for checking nutritional status of the infant. o If the answer is Yes, then commend the parent/care-giver and reinforce their action by sharing the Message for B6.
Message for B6 Refer to Booklet ni Nanay at ni Baby on page 26 for Tagubilin sa Pagpapakain mula anim na buwan hanggang 12 buwan Refer to Booklet ni Nanay at ni Baby on page 29 for Pagsubaybay sa aking paglaki at Pagbabago
B7. Does your baby have any of the following signs? Place a check next to the sign that the infant is showing. Cough Diarrhea (soft stools at least 3 times a day) Fever Swelling of hands and feet Convulsions eat or drink Vomits everything Chest indrawing Fast or difficulty in breathing Very sleepy/unconscious
Poorly or unable to breastfeed,
Regardless of the answer to B7, deliver the Message for B7 and accomplish Part 3.2 of the Health Plan Implementation Form. o If the infant is showing danger signs at the time of your visit, immediately refer the child to
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the nearest health provider for emergency care. o If the infant is not showing danger signs at the time of your visit, but has shown danger signs some time in the past, refer the child to a health provider for assessment. o If the infant is not showing and has never shown danger signs, instruct the parents / primary care-giver to watch out for these signs, and to refer to their Health Plan for Emergency Cases (the completed Part 3.2 of the Health Plan Implementation Form for Infant Health) so that they can bring their child immediately to their planned Emergency Providers in case they observe any of these signs in their child.
Message for B7 Immediately bring your child to a health provider if you notice any of these signs Bring with you Form 2B, your PhilHealth card, Member Data Record (MDR) and the babys birth certificate.
Step 3: Help members develop health plans. Parts 2 (General Information) and 3 (Health Plans) are accomplished with the parents or primary caregiver who can provide the necessary information. Part 2 (General information) includes information such as complete name of mother, complete and correct NHTS household ID number, complete name, date of birth of the infant and your name as the CHT partner. Part 3 (Health Plan) is divided into two parts: Part 3.1: Referral for regular cases (Immunization and common childhood illnesses, Exclusive Breastfeeding, Complementary Feeding and Vitamin A Supplementation). Place a check next to the Health Goal that the parent or primary care-giver has identified based on his/her childs health risks. Then, continue to fill out the health plan as described previously (p. 30). Possible Health Goals for infants (regular cases) include: To bring my baby to health provider on the scheduled immunization date/s
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To exclusively breastfeed my baby for 6 months To ensure that my baby receives vitamin A supplementation every 6 months To ensure that after 6 months, my baby receives proper solid food (Complementary Feeding) To bring my baby to a health facility for consultation, growth monitoring and treatment Others Part 3.2: Referral for emergency cases (Infants with signs of danger in HPI Question B9) Fill out the Health Plan for Emergency Cases as described above. Finally, dont forget to ask the infants parent or primary care-giver to affix his/her signature in the space allotted at the bottom of Part 3, as a sign of his/her consent to the Health Plan. Before giving the Health Plan Implementation form to the respondent, fill out the CHT Monitoring Form/Logbook for Newborn and Infant Health based on the information contained in Parts 2 and 3. Use the referral information to remind the respondent of his/her scheduled visit to the provider.
Step 4: Follow-up and monitor health plan adherence.
On your subsequent visits to the household, you may use Flash cards 4 and 5 to reinforce messages for the newborn and infant. Check if the Health Plan has been adhered to by reviewing the following: Booklet ni Nanay at ni Baby (particularly Tala ng Aking mga Bakuna on p. 25) completely filled out by the Health Service Provider Parts 4 (Actions Taken) and 5 (Service Utilization Monitoring Form) of Form 2B see Table 11 below) to be filled out by the provider in the absence of the Booklet ni Nanay at ni Baby
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Table 11. SAMPLE SERVICE UTILIZATION AND MONITORING FORM FOR INFANT HEALTH. Part 5. Service Utilization and Monitoring Form for Infant Health Name and address Services Instructions of Schedule of next of provider Provided the provider visit to provider for check-up
Date of Consultation (month/day/year)
Copy the details in Form 2B Parts 4 and 5 or in Tala ng Aking Bakuna in the Booklet ni Nanay at ni Baby in your CHT Monitoring form/Logbook for NEWBORN AND INFANT HEALTH MONITORING (see Table 12).
Table 12. SAMPLE CHT MONITORING FORM/LOGBOOK ENTRY FOR INFANT HEALTH
INFANT HEALTH MONITORING

AGE
ADDRESS
REMARKS
REYES, ANA CRUZ
10 months
Immunization
9/30/2011
Hep B3 immunization
11/5/2011 for measles vaccine
NHTS
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HEALTH PLAN IMPLEMENTATION FORM 2C: CHILD HEALTH (12 MONTHS-LESS THAN 5 YEARS)
This form will be used for children who are 12 months to less than 5 years old. Step 1: Route from Form 1 (Household Profile). In the example shown below (Figure 10), Kristoffer Santos Cruz is 4 years old. As directed, you will accomplish Form 2C: Health Plan Implementation for Child Health (12 Months-Less Than 5 Years) with the parent or primary care-giver who can provide information as the respondent.
Figure 10. EXAMPLE OF ROUTING A CHILD HOUSEHOLD MEMBER FROM FORM 1 TO FORM 2C.
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Step 2: Assess members health risks and deliver key health messages. Ask the questions under Part 1 (see Figure 11 below). Ask each question in order, then deliver the corresponding key health message to the parent or primary care-giver. Remember that the Key Health Messages found in Form 2C are your initial and most important messages for the parent or primary care-giver of the child. You may refer to the appropriate sections in the Booklet ni Nanay at ni Baby or the Family Health Guide A. Messages: Caring for Infant and Child (p. 8) for more information and message relevant to children.
Figure 11. SAMPLE FORM 2C: HEALTH PLAN IMPLEMENTATION FOR CHILD HEALTH.
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QUESTIONS and KEY HEALTH MESSAGES (refer the respondent to the Family Health Guide, A. Health Messages, Caring for Infant and Child on p. 8 while conducting this health risk assessment) C1. Has your child been fully immunized against common childhood diseases, which are preventable, before his/her 1st birthday? Fully immunized means the child received the ff: BCG, HepaB1,2,3; OPV1,2,3; DPT1,2,3; measles before his/her 1st birthday) Ask the question , then write the response on the form: Y if Yes, and N if No. o If the answer is Yes, request to see the immunization or ECCD card/Booklet ni Nanay at ni Baby and review if all immunizations have been given as scheduled and the child is fully immunized, then go to Question C2. o If the answer is No, deliver the Message for C1, then go to Question C2.
Message for C1 Complete your childs immunization [tuberculosis (BCG), diphtheria, tetanus and whooping cough (DPT); polio (OPV), Hepatitis B and measles] to protect him/her from infectious diseases that may lead to permanent disability or death Free vaccines are available in your health center Bring with you ECCD card or Booklet ni Nanay at ni Baby during immunization
C2. Has your child received the following in the last 6 months?
Place a check next to the services that the child received within the last 6 months. Vitamin A supplementation Deworming tablets
Regardless of the answer to Question C2, deliver the Message for C2, then go to Question C3. o If only one or none of the items are checked, emphasize the importance of Vitamin A and deworming to the health of children. o If both items are checked, then commend the parent/care-giver and reinforce their action by sharing the Message for C2.
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Message for C2 Your baby must receive Vitamin A at 6 months old. Do this every 6 months until 5 years old. Vitamin A increases your babys resistance to infectious diseases and helps prevent blindness. Deworming tablets help prevent intestinal worms. It impairs healthy nutrition, reduces appetite and leads to mal-absorption of nutrients that cause stunting, under-nutrition and anemia. Give your child deworming tablets at 1 year old. Do this every 6 months.
C3. Does your child have any of the following signs? Place a check next to the sign that the child is showing. Cough Diarrhea (soft stools at least 3 times a day) Fever Swelling of hands and feet Convulsions Poorly or unable to eat or drink Vomits everything Fast or difficulty in breathing Very sleepy/unconscious Regardless of the answer to C3, deliver the Message for C3 and accomplish Part 3.2 of the Health Plan Implementation Form. o If the child is showing danger signs at the time of your visit, immediately refer the child to the nearest health provider for emergency care. o If the child is not showing danger signs at the time of your visit, but has shown danger signs some time in the past, refer the child to a health provider for assessment. o If the child is not showing and has never shown danger signs, instruct the parents / primary care-giver to watch out for these signs, and to refer to their Health Plan for Emergency Cases (the completed Part 3.2 of the Health Plan Implementation Form for Infant Health) so that they can bring their child immediately to their planned Emergency Providers in case they observe any of these signs in their child.
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Message for C3 Bring your child to a health provider immediately. Bring with you Form 2C, your PhilHealth card, Member Data Record (MDR) and the childs birth certificate.
Step 3: Help members develop health plans. Parts 2 (General Information) and 3 (Health Plans) are accomplished with the parents or primary caregiver who can provide the necessary information. Part 2 (General information) includes information such as complete name of mother, complete and correct NHTS household ID number, complete name, date of birth of the child, and your name as the CHT partner. Part 3 (Health Plan) is divided into two parts: a. Part 3.1: Referral for regular cases (Children completing immunization, Vitamin A Supplementation, deworming and treatment for common childhood illnesses). Place a check next to the Health Goal that the parent or primary care-giver has identified based on his/her childs health risks. Then, continue to fill out the health plan as described previously (p. 30) Possible Health Goals for newborns (regular cases) include: To have my child completely immunized To bring my child to the health facility for vitamin A and deworming To bring my child to a health facility for consultation and treatment Others b. Part 3.2: Referral for emergency cases (Children with signs of danger in HRA Question C4) Fill out the Health Plan for Emergency Cases as described above (p. 30). Finally, dont forget to ask the newborns parent or primary care-giver to affix his/her signature in the space allotted at the bottom of Part 3, as a sign of his/her consent to the Health Plan.
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Before giving the Health Plan Implementation form to the respondent, fill out the CHT Monitoring Form/Logbook for Child Health based on the information contained in Parts 2 and 3. Use the referral information to remind the respondent of his/her scheduled visit to the provider.
On your subsequent visits to the household, you may use Flash card 5 to reinforce messages on child health. Check if the Health Plan has been adhered to by reviewing the following: Booklet ni Nanay at ni Baby (particularly Tala ng Aking mga Bakuna on p. 25) completely filled out by the Health Service Provider Parts 4 (Actions Taken) and 5 (Service Utilization Monitoring Form) of Form 2C (see sample on Table 13) to be filled out by the provider in the absence of the Booklet ni Nanay at ni Baby
Table 13. SAMPLE SERVICE UTILIZATION AND MONITORING FORM FOR CHILD HEALTH. Part 5. Service Utilization and Monitoring Form for Child Health Name and address Services Instructions of Schedule of next of provider Provided the provider visit to provider for check-up
Date of Consultation (month/day/year)
In your succeeding household visits, copy the details in the Form 2C Part 4 and 5 on your CHT Monitoring Form/Logbook under CHILD HEALTH MONITORING (see Table 14 below).
Table 14. SAMPLE CHT/BHW LOGBOOK MONITORING ENTRY FOR CHILD HEALTH.
CHILD HEALTH MONITORING

HEALTH NAME (Last, First, Middle) AGE ADDRESS HEALTH SERVICE NEEDED DATE OF VISIT TO PROVIDER HEALTH SERVICE PROVIDED DATE OF NEXT VISIT REMARKS SERVICE PROVIDER AND TYPE (Public/ Private) CRUZ, B SANTOS 4 years Lot 4, Blk 1, Purok 3, Brgy Laging Handa, QC Vitamin A supplementation 10/12/2011 Vitamin A supplementation 10/19/201 1 Delgado NHTS Hospital (private)
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HEALTH PLAN IMPLEMENTATION FORM 2D:
MATERNAL HEALTH: PREGNANCY / PRENATAL CARE

Once a pregnant woman member of the household is identified from the Family Profile List (Form 1) under the column for women 15-49 years of age, go to accomplishing Form 2D, which is the Health Plan Implementation (HPI) for pregnancy/ Prenatal Care. There may be more than one pregnant woman in the household, or there may be a pregnant woman outside the age range (<15, >49), and in this case, a Form 2D should be prepared for each of them. If during the first visit, a pregnant woman in the household is identified to be in need of immediate attention, go to accomplishing the Part 3.2 of Form 2D (Emergency Case Referral) for her and immediately refer to the nearest health provider. Otherwise this task can be done during the second visit.
Step 1: Route from Form 1 (Household Profile). In the example shown below (Figure 12), A Santos, 42 years old, is found pregnant. The CHT partner will go to interview her as the respondent, and record her answers in Form 2D.
Figure 12. EXAMPLE OF ROUTING A PREGNANT HOUSEHOLD MEMBER FROM FORM 1 TO FORM 2D.
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Step 2: Assess members health risks and deliver key health messages. Ask the questions under Part 1 (see Figure 13 below) . Ask each question in order, then deliver the corresponding key health message to the pregnant woman, where you are directed to go. Remember that the Key Health Messages found on Form 2D are your initial and most important messages for the pregnant woman. You may refer to the appropriate sections in the Booklet ni Nanay at ni Baby or the Family Health Guide A. Messages: Caring for Pregnant Women (p. 11) for more information and message relevant to this period.
Figure 13. SAMPLE FORM 2D: HEALTH PLAN IMPLEMENTATION FOR PREGNANT / PRENATAL CARE.
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QUESTIONS and KEY HEALTH MESSAGES (refer the respondent to the Family Health Guide, A. Health Messages, Caring for Infant and Child on p. 11 while conducting this health risk assessment)
D1. How many months are you pregnant? D2. How many pre-natal visits did you have? If the mother has had prenatal visits during her current pregnancy, check her Booklet ni Nanay at ni Baby (if available) and review the service providers instructions together with the pregnant mother. Ask the question, then write the responses on the form. Write the number of months the mother is pregnant Write the number of pre-natal visits made
Regardless of the answers to Questions D1 and D2, deliver the Message for D1 and D2, then go to Question D3.
Message for D1 and D2 Healthy pregnancy means a healthy baby Have at least 4 prenatal check-ups (at least 1 visit during the first 3 months; at least 1 visit during the 4th to 6th months; and at least 2 visits during the 7th to 9th months). Receive Tetanus Toxoid. Ask your health provider to help you accomplish "Plano sa Paghahanda sa Oras ng Panganganak at Emergency" in your Booklet ni Nanay at ni Baby, p.14
D3. Are you experiencing any of the following danger signs? Place a check next to the sign that the respondent is experiencing or has experienced. Severe headache Vaginal bleeding Convulsions Fever Severe abdominal pain Paleness Regardless of the answer to D3, deliver the Message for D3 and accomplish Part 3.2 of the Health Plan Implementation Form. o If the respondent is experiencing danger signs at the time of your visit, immediately refer
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her to the nearest health provider for emergency care. The pregnant mothers Health Plan Form may be filled up along the way or at the health facility. o If the respondent is not showing danger signs at the time of your visit, but has shown danger signs some time in the past, refer her to a health provider for assessment. o If the respondent is not experiencing and has never experienced danger signs, instruct her to watch out for these signs, and to refer to her Health Plan for Emergency Cases (the completed Part 3.2 of the Health Plan Implementation Form) so that she can go immediately to her planned Emergency Providers in case she experiences any of these signs.
Message for D3 Go to the nearest health provider immediately if you are experiencing any of these danger signs Bring Form 2D-1, your PhilHealth card and Member Data Record (MDR)
D4. Are you going to deliver in a health facility? Ask the question, then write the response on the form: Y if Yes, and N if No. Regardless of the answer to Question D4, deliver the Message for D4, then go to Question D5. o If the answer is No, emphasize the importance of facility-based delivery for the health of the mother and her child. o If the answer is Yes, then commend the mother and reinforce her decision by sharing the Message for D4.
Message for D4 Give birth at a health facility to promptly manage possible complications during childbirth Use your PhilHealth benefits. See the Family Guide on PhilHealth if you are a member or dependent, p.7
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D5. Are you going to have check-up visits after your delivery? Ask the question, then write the response on the form: Y if Yes, and N if No. Regardless of the answer to Question D5, deliver the Message for D5, then go to Question D6. o o If the answer is No, emphasize the importance of post-partum checkups for her health. If the answer is Yes, then commend the mother and reinforce her decision by sharing the Message for D5.
Message for D5 Visit your health provider on the 3rd and 7th day after delivery for check-up, early detection and management of complications.
D6. Are you aware of the essential care for your baby within the first 24 hours of his/her life? Ask the question, then write the response on the form: Y if Yes, and N if No. Regardless of the answer to Question D6, deliver the Message for D6, then go to Question D7. o If the answer is No, emphasize the importance of essential newborn care for her babys health . o If the answer is Yes, then commend the mother and reinforce her knowledge by sharing the Message for D6.
Message for D6 The first 30 minutes of your newborn babys life is critical. Breastfeed your newborn and keep him/her dry and warm through skin-to-skin contact Within 24 hours from chilbirth, your baby must undergo Newborn Screening (NBS) and should be immunized for BCG and Hepatitis B
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D7. Do you intend to practice family planning after giving birth? Ask the question, then write the response on the form: Y if Yes, and N if No. Regardless of the answer to Question D7, deliver the Message for D7. o If the answer is No, emphasize the importance of family planning to the mothers health and the health of her family. o If the answer is Yes, then commend the mother and reinforce her decision by sharing the Message for D7.
Message for D7 Space your children 3-5 years apart to allow your body to fully recover Go to your health provider to know the right Family Planning (FP) method for you and your partnerFamily Planning methods which are effective and suit your needs
Step 3: Help members develop health plans. Parts 2 (General Information) and 3 (Health Plans) are accomplished with the pregnant woman. In case the pregnant woman has already sought prenatal consultation/s, then you can jointly refer to the Birth and Emergency Plan that is found in the Booklet ni Nanay at ni Baby that has been prepared by the pregnant woman with assistance from the service provider. Part 2 (General information) includes information such as complete name of mother, complete and correct NHTS household ID number, and your name as the CHT partner. Part 3 (Health Plan) is divided into two parts: a. Part 3.1: Referral for regular cases Place a check next to the Health Goal that the pregnant woman has identified based on her health risks. Then, continue to fill out the health plan as described previously (p. 30).
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Possible Health Goals for pregnant women (regular cases) include: To have 4 or more prenatal checkups (preferably in a PhilHealth-accredited facility) To develop a Birth and Emergency Plan with the health provider To deliver in a health facility (preferably PhilHealth-accredited) To receive care within 12 hours, 3 days and 7 days after delivery for myself and my baby To receive family planning counseling Others b. Part 3.2: Referral for emergency cases (Pregnant women with danger signs in D3) Fill out the Health Plan for Emergency Cases as described above (p. 30). Refer back to the list of danger signs in Part 1 Health Risk Assessment question D3 when identifying the reason for emergency referral, which can be stated as Consultation for immediate assessment and management of danger signs. These danger signs can also be found in the Booklet ni Nanay at ni Baby. Identify and list down the name/s and contact number/s of the emergency transport providers and the name and address of the health service provider selected by the respondent. Finally, dont forget to ask the pregnant woman to affix her signature in the space allotted at the bottom of Part 3, as a sign of her consent to the Health Plan. Before giving the Health Plan Implementation form to the respondent, fill out the CHT Monitoring Form/Logbook for Maternal Care based on the information contained in Parts 2 and 3. Use the referral information to remind the respondent of his/her scheduled visit to the provider.
In your subsequent visits to the household, you may use Flash cards 2 and 3 to reinforce messages on pregnancy and prenatal care. Follow-up on the pregnant mother whether she sought and obtained health care services as discussed during the first visit and followed the referral message (if they were referred further) and the instructions of the provider. If you find out that the pregnant mother has not gone to any service provider or health facility as advised during your first visit, ask for the reason/s why
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so that you can find a way to assist the pregnant mother in seeking consultation. If the problem concerns lack of money for transportation, for instance, you may refer the mother to the list of emergency transport network or seek transport assistance from barangay officials. To check whether the health plan has been adhered to, review the following: Booklet ni Nanay at ni Baby check the services provided by the Health Service Provider with the to the pregnant woman. Parts 4 (Actions Taken) and 5 (Service Utilization Monitoring Form) of Form 2D (see Table 15 below) to be filled out by the provider in the absence of the Booklet ni Nanay at ni Baby
Table 15. SAMPLE SERVICE UTILIZATION AND MONITORING FORM FOR MATERNAL HEALTH (PREGNANCY). Part 5. Service Utilization and Monitoring Form for MATERNAL HEALTH (PREGNANCY) Date of Name and address Services Instructions of Schedule of next Consultation of provider Provided the provider visit to provider (month/day/year) for check-up
Note that once Form 2D has been accomplished, also accomplish Form 2F: Health Plan Implementation for Family Planning. Copy the details in Form 2D Parts 4 and 5 (or in the Booklet ni Nanay at ni Baby) in your CHT Monitoring Form/Logbook for MATERNAL HEALTH MONITORING (see Table 15 below).
Table 16. SAMPLE CHT MONITORING FORM FOR MATERNAL HEALTH: PREGNANCY.
MATERNAL HEALTH MONITORING (PREGNANCY)

NAME (Last, First, Middle) REYES, ANA CRUZ
AGE
ADDRESS
DATE OF NEXT VISIT
REMARKS
35
Pre-natal checkup
9/30/2011
NHTS
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HEALTH PLAN IMPLEMENTATION FORM 2E:
MATERNAL HEALTH: POSTPARTUM CARE

Once a female member of the household is identified to be in the postpartum period (she is within 42 days of giving birth) in the column 9b For women 15-49 years old of the Household Profile (Form 1), accomplish Form 2E, or the Health Plan Implementation for Maternal Health: Postpartum Care during your planned visit. In case there is more than one postpartum woman in the household, this Form 2D should be prepared for each of them. If during the first visit you find a postpartum mother in the household who needs immediate medical attention, your priority is to assist her and facilitate her referral. Fill-out the Part 3.2 Emergency Case Referral of Form 2E and immediately refer. Otherwise this task can be done during the second visit. Step 1: Route from Form 1 (Household Profile). In the example shown below (Figure 14), C Santos, 28 years old, is found to be in her postpartum period. Go to interviewing C as the respondent and record her answers in Form 2E.
Figure 14. EXAMPLE OF ROUTING A POSTPARTUM HOUSEHOLD MEMBER FROM FORM 1 TO FORM 2E.
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Step 2: Assess members health risks and deliver key health messages. Ask the questions under Part 1 (see Figure 15 below) . Ask each question in order, then deliver the corresponding key health message to the postpartum mother as directed. Remember that the Key Health Messages found on Form 2E are your initial and most important messages for the postpartum woman. You may refer to the appropriate sections in the Booklet ni Nanay at ni Baby or the Family Health Guide A. Messages: Caring for Mothers After Giving Birth (p. 13) for more information and message relevant to postpartum mothers.
Figure 15. SAMPLE FORM 2E: HEALTH PLAN IMPLEMENTATION FOR POSTPARTUM CARE
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QUESTIONS and KEY HEALTH MESSAGES (refer the respondent to the Family Health Guide, A. Health Messages, Caring for Mothers After Giving Birth on p. 13 while conducting this health risk assessment) E1. Were you checked by a doctor, nurse or midwife immediately after giving birth? Ask the question, then write the response on the form: Y if Yes, and N if No. Regardless of the answer to Question E1, deliver the Message for E1, then go to Question E2. o If the answer is No, emphasize the importance of having postpartum checkups from a professional health service provider. o If the answer is Yes, then commend the mother and reinforce her action by sharing the Message for E1.
Message for E1 Complications may arise within 42 days after delivery. You are at risk. Visit your health provider to detect and treat possible complications following these schedules: - Within 12 hours after delivery - On the 3rd day - On the 7 day If you have not visited a health provider 7 days after delivery, go for postpartum check-up immediately
th
Additionally, inform the mother that: She needs to receive one Vitamin A capsule within one month after delivery to increase her body resistance against infections. It is important to exclusively breastfeed her newborn baby until six months of age. It is important that she bring with herthe newborn baby when she goes for postpartum checkup. E2. Are you experiencing any of the following danger signs? Place a check next to the sign that the respondent is experiencing or has experienced. Difficulty breathing Paleness Severe headache Difficulty in urinating Severe vaginal pain Engorged and painful breast Heavy vaginal bleeding
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Fever Foul-smelling vaginal discharge
Regardless of the answer to E2, deliver the Message for E2 and accomplish Part 3.2 of the Health Plan Implementation Form. o If the respondent is experiencing danger signs at the time of your visit, immediately refer her to the nearest health provider for emergency care. The postpartum mothers Health Plan Form may be filled up along the way or at the health facility. o If the respondent is not showing danger signs at the time of your visit, but has shown danger signs some time in the past, refer her to a health provider for assessment. o If the respondent is not experiencing and has never experienced danger signs, instruct her to watch out for these signs, and to refer to her Health Plan for Emergency Cases (the completed Part 3.2 of the Health Plan Implementation Form) so that she can go immediately to her planned Emergency Providers in case she experiences any of these signs.
Message for E2 Go to the nearest health provider immediately if you are experiencing any of these danger signs Bring Form 2E, your PhilHealth card and Member Data Record (MDR)
Step 3: Help members develop health plans. Parts 2 (General Information) and 3 (Health Plans) are accomplished with postpartum mother. In case the postpartum mother has already sought postnatal consultation/s, then you can jointly refer to the Birth and Emergency Plan that is found in the Booklet ni Nanay at ni Baby that has been prepared by the pregnant woman with assistance from the service provider. Part 2 (General information) includes information such as complete name of the postpartum mother, complete and correct NHTS household ID number, and your name as the CHT partner. Part 3 (Health Plan) is divided into two parts: a. Part 3.1: Referral for regular cases
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Place a check next to the Health Goal that the postpartum woman has identified based on her health risks. Then, continue to fill out the health plan as described previously (p. 30). Possible Health Goals for postpartum mothers (regular cases) include: To receive care within 12 hours, 3 days and 7 days after delivery Others b. Part 3.2: Referral for emergency cases (Postpartum mother with danger signs in E2) Fill out the Health Plan for Emergency Cases as described above (p. 30). Refer back to the list of danger signs in Part 1 Health Risk Assessment question E2 when identifying the reason for emergency referral, which can be stated as Consultation for immediate assessment and management of danger signs. These danger signs can also be found in the Booklet ni Nanay at ni Baby. Identify and list down the name/s and contact number/s of the emergency transport providers and the name and address of the health service provider selected by the respondent. Finally, dont forget to ask the postpartum mother to affix her signature in the space allotted at the bottom of Part 3, as a sign of her consent to the Health Plan. Before giving the Health Plan Implementation form to the respondent, fill out the CHT Monitoring Form/Logbook for Maternal Health based on the information contained in Parts 2 and 3. Use the referral information to remind the respondent of his/her scheduled visit to the provider. Step 4: Follow-up and monitor health plan adherence. In your subsequent visits to the household, you may use Flash card 3 to reinforce messages on postpartum care. Ask the postpartum mother on whether she sought and obtained health care services as discussed during the first visit.
If the postpartum mother has not gone to any service provider or health facility as advised during your first visit, inquire about the reason/s and find a way to assist her in seeking care.
If the mother is worried that no one will take care of the children when she goes to the facility, make the necessary arrangements to have someone from the community to watch over the children while she is away.
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Check health plan adherence by reviewing the instructions of the health provider in Parts 4 (Actions Taken) and 5 (Service Utilization Monitoring Form) of Form 2E (see Table 16).
Table 16. SAMPLE SERVICE UTILIZATION AND MONITORING FORM FOR MATERNAL HEALTH (POSTPARTUM). Part 5. Service Utilization and Monitoring Form for MATERNAL HEALTH (POSTPARTUM) Date of Name and address Services Instructions of Schedule of next Consultation of provider Provided the provider visit to provider (month/day/year) for check-up
Note that once Form 2E has been accomplished, also accomplish Form 2F: Health Plan Implementation for Family Planning. Copy the details in Form 2E Parts 4 and 5 in your CHT Monitoring Form/Logbook for MATERNAL CARE (see Table 17).
Table 17. SAMPLE CHT MONITORING FORM FOR MATERNAL HEALTH: POSTPARTUM.
MATERNAL HEALTH MONITORING (POSTPARTUM)

NAME (Last, First, Middle)
AGE
ADDRESS
DATE OF NEXT VISIT
REMARKS
REYES, ANA CRUZ
35
Post-natal checkup
9/30/2011
10/6/11
NHTS
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HEALTH PLAN IMPLEMENTATION FORM 2F:
FAMILY PLANNING
Form 2F is intended for pregnant women and non-pregnant women aged 15 to 49 yrs old identified in the Form 1 Household Profile. This definition is important, because if the pregnant woman is not within the age group, but pregnant e.g. adolescent, then she should still be referred for Family Planning.
Step 1: Route from Form 1 (Household Profile). The example below shows 4 types of women with different cases: A married, pregnant four years ago but not currently pregnant B recently gave birth, single mother C single, never been pregnant D pregnant adolescent
You need to help these women recognize possible health risks. Each should have her own Form 2F.
Figure 16. EXAMPLE OF ROUTING HOUSEHOLD MEMBERS FROM FORM 1 TO FORM 2F.
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Step 2: Assess members health risks and deliver key health messages. The Family Planning Module is slightly more complex than the others, because of the different scenarios that are possible for the respondents who will be administered Form 2F. As an aid to understand the flow of questions, study Figure 17 below to visualize how the four types of cases in the example would answer Part 1 of their Health Plan Implementation forms.
Figure 17. FLOWCHART FOR FORM 2F, PART 1.
LEGEND
A married, pregnant four years ago but not pregnant now B recently gave birth, single mother C single, never been pregnant D pregnant adolescent
YES (A, D)
F1. Do you have a spouse/ partner now?
NO (B, C)
F3. How many living children do you have? ____ (Fill in the blank)
YES (B)
F2. Did you have a partner before?
NO (C)
Accomplish PARTS 2 and 3
F4. Do you want to have a
child/ another child?
YES (D)
When or how soon from now?
SOON (Within 1 year) (D)
NO (A, B) LATER (More than 1 year)
F5, F6. Are you currently using any FP Method?
NO (B)
YES (A)
GO TO F7 and F8
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QUESTIONS and KEY HEALTH MESSAGES (see Figure 17 above; refer the respondent to the Family Health Guide, A. Health Messages, Planning for a Healthy Family on p. 14 while conducting this health risk assessment)
F1. Do you have a spouse / partner now? A partner is defined as any one with whom the respondent has a sexual relationship. This question is meant to identify those respondents who are currently sexually active. If the answer is Yes, write Y then skip Question F2 and go to Question F3. If the answer is No, write N then go to Question F2. Example: Both A and D have current partners, and so will both proceed directly to Question F3. Neither B nor C have current partners, so they will go to question F2.
F2. Did you have a partner before? A partner is anyone with whom the respondent has had a previous sexual relationship. If the answer is Yes, write Y then go to Question F3. If the answer is No, write N then proceed to filling out Parts 2 and 3 of Form 2F. Example: B had a previous partner with whom she has a son. She would then go to F3. C has no history of any sexual relations. Therefore, if F1 and F2 are succeedingly answered with NO, the respondent is directed to Part 2, and does not need to answer questions from F3 to F7. From Part 2, you, the CHT partner would guide her to Part 3 and develop the Health Plan, specifically the 1st Health Goal. To go to a health provider for Family Planning counselling should still be among Cs health goals. In Cs case, since she is an adolescent, the health provider is expected to raise awareness on pertinent to the Adolescent Module.
HELPFUL TIP! Adolescents 15-19 years old and Form 2F. For adolescent girls who have been routed to Form 2F through the family profile, and have answered NO to both Questions F1 and F2, share the messages in the Family Health Guide: Caring For Adolescents (p. 10) instead of proceeding to referral for FP counselling. You may also refer the teenager to providers of adolescent reproductive health services if they are available in your locality. Ask your CHT supervisor or RHM for help if you are unsure of what to do in such situations.
Family Planning methods, prevention of Sexually Transmitted Illnesses (STIs) and other topics
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F3. How many living children do you have?
Regardless of the answer to F3, write the answer then go to Question F4. If the woman has no living children, write 0. If the woman has living children, write the number of children (i.e, 1, 2, etc.). Example: Both A and B will answer Question F3 and proceed to Question F4. F4. Do you (or your spouse/partner) want to have a/another child?
Regardless of the answer to F4, write the answer then deliver Message for F3 and F4. If the answer is Yes, write Y then ask the follow-up question: If yes, when? o If Yes but soon (within 1 year), skip Questions F5-F7 and proceed to Parts 2 and 3 of Form 2F, and refer for fertility counselling. o If Yes but later (more than 1 year from now), go to Question F5.
If the answer is No, write N then go to Question F5.
Message for F3 and F4 Go to your health provider for counselling on family planning if: You do not want to have a child or another child You want to have a child later If you want to have a child soon, consult your provider to help you on fertility concerns For more information you may refer to the Family Health Guide.
F5. Have you or your spouse/partner ever used any modern Family Planning method? You will need this information to tag whether the woman is a new acceptor of FP method or not during the monitoring activities. For example D has no history of any FP method, and may be referred to become a new acceptor. If the respondent asks what are the FP methods, use the list of modern FP methods listed in F6.
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F6. Are you or spouse/partner currently using any Family Planning Method? If the woman specifies that she is currently not using any method, the CHT partner should no longer ask the remaining questions. You go to Part 2 and 3 to develop the Health Goals. If a woman said YES to a Traditional method, you will no longer ask the remaining questions. Deliver message F5 and F6. After delivering the message, guide the woman in filling the Part 2 and 3 of the HPI
Message for F5 and F6 Space your children 3-5 years apart Go to your health provider for counseling on FP. Your health provider can advise you on effective Family Planning methods that suit your needs
F7. What method are you/your partner currently using? If the answer is YES to a Modern FP method, you need to ask the specific modern FP method currently being used by the woman (or spouse/partner). Check the modern FP methods currently being used by the woman/partner. For example, suppose A uses pills, her partner uses condoms. Given this, A has to be reminded that they need to go to a health provider since commodities like pills and condoms follow a schedule. Inform her that she and her partner need to have an adequate supply of pills and condoms. Also, A might need to consult a health provider regarding her use of pills. Deliver message for F7.
Message for F7 Visit your health provider for check-up and re-supply of Family Planning commodities (e.g. pills, condoms)
8. Are you (/your) partner satisfied with the current FP method you are using? If the respondent is not satisfied with their current FP method, deliver Message for F8.
Message for F8 Your health provider can help you choose an appropriate method for you (or spouse/partner).
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Step 3: Help members develop health plans. The Health Plan and Referral form is divided into three main parts, (i) General information, (ii) Referral to provider, and (iii) Actions taken during the first visit for FP counselling. The general information simply asks for the name of the woman and the NHTS ID. Copy the information from the HRA or the family profile. In the example, C is referred to a provider for FP counselling, check the appropriate box and fill in the name of the provider and the scheduled visit. You would use this to check on the woman whether she actually visited a provider or not.
Suppose the woman is a current user of a method (pills), check the appropriate box and fill in the name of the provider and the scheduled visit. You would use this to check on the woman whether she actually visited a provider or not.
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Dont forget to ask the patient/caregiver to affix his/her signature in the space allotted at the bottom of Part 3, as a sign of his/her accountability and ownership of the Health Plan. Before giving the Health Plan Implementation form to the respondent, fill out the CHT Monitoring Form/Logbook for Family Planning based on the information contained in Parts 2 and 3. Use the referral information to remind the respondent of his/her scheduled visit to the provider. Tell the respondent to
request the provider to give detailed instructions, especially the schedule dates of re-supply for commodities like condoms and pills. Remind her to bring the Health Plan Implementation Form when she visits the provider so the latter can fill out the Service Utilization Form section.
Step 4: Follow-up and monitor health plan adherence. You should remind the woman that during the visit to a health provider, she should request the provider to be specific in terms of writing the services provided. For example, if pills and counselling were given during the visit, the woman should request the provider to specifically write that they gave the family pills and counselling. In the box where a provider should fill in the instructions, inform the woman to request the providers to be specific in terms of filling this up. For example, if FP method is advised, the woman should request the provider to specify the method and instruction. For example, if BTL or NSV is instructed, the family should prompt the provider to specify the schedule and referral facility. Inform the woman that you would need these details when checking up on them during your regular visits.
\ a. FP service/commodity given or bought-provider should fill this out with the appropriate FP services given or bought. If the commodity (e.g. pills, condoms) is bought, the pharmacist, nurse, or attendant should assist the family in filling this out b. Date the service/commodity is given or bought- the provider should fill this in following the mm/dd/yy form
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c. Name of facility - If the FP method is a service, say IUD insertion. The provider should fill in the name of the facility. If the FP method is a commodity (say pill or condom), the attendant/pharmacist should write the name of the store. d. Next service/purchase date - For FP commodities like pills, condoms, DMPA, the health provider should fill in these dates. Suppose during 1st visit conducted by the woman/family for FP counseling, the provider could actually fill in advance these scheduled dates in order to remind the woman/family that she needs to get those commodities on the specified date. Case: Woman was provided with pills during the FP counselling, was asked to return back or purchase pills on specific dates.
In the succeeding household visits, follow-up on the woman whether she sought and obtained the FP services/commodities from the health provider. Copy in the CHT Monitoring Form/Logbook details of the health services availed by the woman (contained in Parts 4 and 5 of Form 2F). You will use this to remind the respondent to get pills or purchase the pills on or before the dates.
Table 18. SAMPLE CHT MONITORING FORM/LOGBOOK ENTRY FOR FAMILY PLANNING.
FAMILY PLANNING MONITORING

NAME (Last, First, Middle) FIRST TIME USER OF ADDRESS FP METHOD? (Y/N) HEALTH SERVICE/ COMMODITIES NEEDED HEALTH SERVICE / DATE OF COMMODITIES DATE OF VISIT TO PROVIDED NEXT REMARKS PROVIDER (Specify VISIT Quantity of Commodity) HEALTH SERVICE PROVIDER AND TYPE (Public/ Private)
AGE
CRUZ, AILEEN
25
No
Lot 1, Blk 6, Purok 4, Pills (1 cycle) Brgy Laging Handa
10/5/2011 Pills (1 cycle)
10/27/201 1
NHTS
LM Midwife Clinic (private)
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HEALTH PLAN IMPLEMENTATION FORM 2G:
CHRONIC COUGH MANAGEMENT

Once a member of the household (ages 10 years old and above), has cough of more than 2 weeks is identified,, accomplish Form 2G, or the Health Plan Implementation for Chronic Cough Management during your planned visit. In case there is more than one chronic cough patient in the household, this Form 2G should be prepared for each of them.
Step 1: Route from Form 1 (Household Profile). Take for example the case of Ken Santos below (Figure 18). He has been identified to have cough of more than 2 weeks duration. You need to help his mother fill up Form 2G: Health Implementation Plan for Chronic Cough Management.
Figure 18. EXAMPLE OF ROUTING A HOUSEHOLD MEMBER WITH CHRONIC COUGH FROM FORM 1 TO FORM 2G.
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Step 2: Assess members health risks and deliver key health messages. Ask the questions under Part 1 (see Figure 19 below) . Ask each question in order, then deliver the corresponding key health message to the patient/caregiver, where you are directed to go. Remember that the Key Health Messages found on Form 2G are your initial and most important messages. Refer to the Family Health Guide: A. Health Messages - Caring for Family Members With Chronic Cough (p. 19) for more information.
Figure 19. SAMPLE FORM 2G: HEALTH PLAN IMPLEMENTATION FOR CHRONIC COUGH MANAGAMENT
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QUESTIONS and KEY HEALTH MESSAGES (see Figure 17 above; refer the respondent to the Family Health Guide, A. Health Messages, Caring for Family Members with Chronic Cough on p. 19 while conducting this health risk assessment)
G1. Have you consulted a health provider regarding your cough for more than two weeks? If family member has not yet consulted a health provider for the cough of 2 weeks or more, explain that he or she may have TB. Ask the question, then write the response on the form: Y if Yes, and N if No.
If the answer to Question G1 is No, deliver the Message for G1, then go to Question G2.
If the answer is Yes, then go to Question G2.
Message for G1 Go to the health center for checkup and testing.
G2 . If consulted a health provider, what was the diagnosis? If chronic cough is due to TB, place a check next to the sign indicating TB and deliver the Message for G2a (TB).
Message for G2a (TB) Go to a TB-DOTS provider immediately for treatment TB can be treated. Free Anti-TB Drugs are available at the health center or any DOTS facility Patient needs to take anti-TB drugs for at least 6 months AND must be supervised by a treatment partner Improper treatment of TB may lead to more serious complications. Because TB is an infection transmitted thru air, it may spread to other members of the family, especially children. TB may cause death if left untreated or not properly treated. Return to the health center/DOTS facility for your follow-up tests/ check-ups
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If the answer to the diagnosis is NOT TB, and a condition or disease that also presents as chronic cough, deliver Message for G2b (Other non-TB diseases).
Message for G2b (Other cough-like diseases)
Take your medicines as prescribed by your health provider Improper use of medicines may worsen your condition and could lead to a more serious illness Go back to your health provider for follow-up
Step 3: Help members develop health plans.
Parts 2 (General Information) and 3 (Health Plans) are accomplished with chronic cough patient. Part 2 (General information) includes information such as complete name of the postpartummother, complete and correct NHTS household ID number, and your name as the CHT partner. Part 3 (Health Plan) is the section for Referral.
Place a check next to the Health Goal that the patient has identified based on his/her health risks. Then, continue to fill out the health plan as described previously (p. 30). Possible Health Goals for chronic cough patients include: To go to the health facility for check-up, testing and treatment To go to the health facility for scheduled follow-up To continue treatment/resupply of medication (for TB patients) Others Dont forget to ask the respondent/care-giver to affix his/her signature in the space allotted at the bottom of Part 3, as a sign of his/her accountability and ownership of the Health Plan. Before giving the Health Plan Implementation form to the respondent, fill out the CHT Monitoring Form/Logbook for Chronic Cough Management based on the information contained in Parts 2 and 3. Use the referral information to remind the respondent of his/her scheduled visit to the provider.
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Remind the respondent to bring the Health Plan Implementation Form when he/she visits the health provider so the latter can fill out the Service Utilization Form section in the Health Plan Implementation Form.
The duly accomplished 2G Health Plan Implementation Form with the action taken written should be stapled to the NTP ID Card if the patient is diagnosed with TB.
In your subsequent visits to the household, you may use Flash card 12 to reinforce messages on cough of two weeks or more. This visit is also a good opportunity to discuss/review the health messages on chronic cough management in the Family Health Guide. Ask the patient/caregiver on whether he/she sought and obtained health care services as discussed during the first visit.
If the respondent fails to go to a health service provider as agreed in the Helath Plan, ask about the reason/s for not going to the provider and find a way to assist her in seeking care.
If the respondent is worried that no one will take care of the children or the household, make the necessary arrangements to have someone from the community to watch over the children while the patient or caregiver is away.
Review with the patient Parts 4 (Actions Taken) and 5 (Service Utilization Monitoring Form) of Form 2G (see Table 19). This form, when duly accomplished, serves as a tracking tool for patient compliance to instructions on medications if any, and when to return for her follow-up visit; or if and when the patient complied in making an actual visit to a higher level - service provider when further referred. Copy the details in the Form 2G Parts 4 and 5 or NTP ID card in the CHT Monitoring Form/Logbook for Chronic Cough Management (Table 20).
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Table 19. SAMPLE SERVICE UTILIZATION AND MONITORING FORM FOR CHRONIC COUGH MANAGEMENT.
Table 20. SAMPLE CHT MONITORING FORM/LOGBOOK FOR CHRONIC COUGH MANAGEMENT.
CHRONIC COUGH MANAGEMENT MONITORING

HEALTH NAME (Last, First, Middle AGE ADDRESS HEALTH SERVICE/ DUGS NEEDED Lot 1, Blk FLORES, JOCELYN 6, Purok 4, 36 years Brgy Laging Handa Checkup 10/5/2011 Sputum exam 10/27/2011 NHTS Maco Rural Health Unit (public) DATE OF VISIT TO PROVIDER SERVICE/DRUGS PROVIDED (Specify name and qnty of drugs) DATE OF NEXT VISIT REMARKS HEALTH SERVICE PROVIDER AND TYPE (Public/ Private)
Figure 19 below shows a sample NTP ID card. It contains information on the following: (a) name of the DOTS facility; (b) name of the patient; (c) address of the patient; (d) name of treatment partner; (e)
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disease classification and category; (f) type of patient; (g) date of start of treatment; (h) sputum examination results; and (i) calendar to monitor intake of anti-TB medications.
Figure 19. NTP ID Card
Note to CHT: Copy the details from the NTP ID card to your own records.

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Community Health Team

Community Health Team Guidebook

I. The CHT Partner

A. INTRODUCTION: YOU AND YOUR COMMUNITYS HEALTH

Community Health Team Guidebook

B. YOUR ROLE AS A CHT PARTNER: AN OVERVIEW OF THE CHT PROCESS

UPDATE HOUSEHOLD PROFILE

Brief Description of Major Steps in the CHT Process 1. PROFILE

Community Health Team Guidebook

2E (p. 70) 2F (p. 76) 2G (p. 84)

D. Preparing for Your Role as a CHT Partner

Community Health Team Guidebook

Guiding Families in Accessing Health Care

II. The CHT Process

Community Health Team Guidebook

A. STEPS AND TASKS IN THE CHT PROCESS

ORIENT Task 3. Orient

ASSESS Task 4. Help

4.a Assess the

4.b Deliver key

PLAN 4.c Help

PHASE III: POST-SESSION: RECORDS & REPORTING

B. PRE-SESSION: SETTING THE FAMILY HEALTH HOUR

Community Health Team Guidebook

Community Health Team Guidebook

(Task 2: Completing the Household Profile)

PHASE II: ON-SESSION

Figure 3. OVERVIEW OF FORM 1: HOUSEHOLD PROFILE

Family Roster and Health Profiles

Community Health Team Guidebook

STEPS TO FILLING UP FORM 1: HOUSEHOLD PROFILE

Item DATE OF VISIT

NHTS HOUSEHOLD ID NUMBER

Community Health Team Guidebook

Community Health Team Guidebook

ANSWER: WRITE: 11b . PhilHealth ID Number

Community Health Team Guidebook

INFORM 4.b Deliver key

PLAN 4.c Help

Form 2A: Newborn Health

29 days to less than 12 months

Form 2B: Infant Health

1 to less than 5 years

Form 2C: Child Health

Health Messages: Family Health Guide: Caring for Adolescents

10 years old & above

Form 2G: Chronic Cough Management

Form 2D: Maternal Health: Pregnancy / Pre-natal Care

15 to 49 years old, females only

Form 2E: Maternal Health: Post-Partum Care

Form 2F: Family Planning

21 years old & above

Health Messages: Family Guide to PhilHealth:

Benefits, Availment and Responsibilities

(Task 3: Orientation on the Family Health Guide)

PHASE II: ON-SESSION

STEPS TO ORIENTING THE HOUSEHOLD ON THE FAMILY HEALTH GUIDE

Community Health Team Guidebook

(Task 4a: Assessing Members Health Risks)

PHASE II: ON-SESSION

family members make their Health Plans.

PART 2: GENERAL INFORMATION

Date of initial visit (mo/day/year)

III. Health Plan Implementation _Modules