Home Visiting Services

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Community Services of the Guilford County Department of Public Health encompasses programs that are community based, meaning services are rendered to residents at places other than the health department. Some of these services are referred to as Home Visiting Services. Please read on for more information on some of the different types of Home Visiting Services we provide.

Guilford Family Connects

Guilford Family Connects offers nurse home visits to all deliveries throughout Guilford County. Nurse home visits provide support, education, and early identification and referral of health & safety concerns. Nurses with advanced knowledge and experience in public heath, perinatal nursing and lactation support will conduct post-delivery visits with follow-up as needed. Interpreter assistance is provided to Spanish-speaking families, and for other languages on a more limited basis. Visits include a thorough physical assessment of mom and baby, psychosocial assessment of family and environment, referral and follow up of identified needs and educational counseling. Each family visited will receive an educational item and/or digital thermometer when available. GCDHHS follows the Family Connects evidence-based model for implementation of the activity.

Pregnancy Care Management

The Pregnancy Care Management Program is a free care management service available to pregnant women enrolled in North Carolina Medicaid and to a limited number of low income, uninsured pregnant women.

Pregnancy Care Managers are registered nurses or social workers who will work with you and your prenatal care provider to ensure you receive the best possible care while you are pregnant and up to sixty days after you deliver your baby.

Eligibility criteria include:

  • History of a preterm birth < 37 weeks gestation

  • Chronic illness such as diabetes, hypertension, HIV

  • Homelessness, family violence

  • Substance use including smoking, alcohol and drug use during pregnancy

How are referrals made to the Pregnancy Care Management Program?

  • Completion of the Pregnancy Risk Screening form by OB providers also known as Pregnancy Medical Homes 

  •  Notification via ED or hospital use

  • Referrals from other community agencies (schools, DSS, WIC)

  • Self- referral

Services include:

  • Coordinating your care across all your providers

  • Helping you get the services you need, like medical care, transportation to appointments arranged, connection to food and housing resources

  • Referring you to other programs, like childbirth or breastfeeding education classes, Women, Infants and Children (WIC) nutrition program, and family planning

  • Answering your questions

  • Additional support during your pregnancy

Your pregnancy care manager will work closely with you and your prenatal provider to meet your needs during your pregnancy. If you have to go to the hospital during your pregnancy, a care manager will contact you after discharge to see how you are doing.

Pregnancy Care Managers can talk with you on the phone, meet with you at your prenatal appointments or meet you at your home or at a location that is convenient for you. Pregnancy Care Management services are provided at no cost.

Your prenatal provider can help you learn more about Pregnancy Care Management or call Lydia Monk at the local health department at 336-641-3700 for more information.

Our goal is to help you have a healthy pregnancy and a healthy baby.

Click here for more information.

Community Alternatives Program (CAP/C) for Disabled Children

Community Alternatives Program (CAP/C) for Disabled Children is a program designed to serve medically high risk children up to age 21 who would be institutionalized in a nursing facility or hospital without Medicaid payment for the home care available through CAP/C. Read our Community Alternatives Program Brochure for more information or phone 336-641-3660.

Community Health Response Program (CHRP)

provides health care in the homes of adults living in Guilford County. Home visits are made to evaluate an individual’s home environment and his/her general physical condition. Nurse and aide services are available on a sliding fee scale. See our Fee Schedule for details. Assistance is also provided in finding community resources to meet the individual’s health and personal needs. The Community Health Response Brochure has more details about this program.

Care Coordination for Children (CC4C)

To learn more, click  CC4C.

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