DPH Home Visiting Information for Providers

Partnering to Support Your Patients Beyond the Office

The DPH Home Visiting Program is a no cost, voluntary service for high-risk moms and babies, supporting patients from pregnancy through the baby’s first birthday. Delivered by public health nurses and trained community health workers, DPH Home Visiting complements clinical care by extending support beyond the office.

DPH Home Visiting functions as an extension of your care team by:

• Serving as your eyes and ears between appointments
• Supporting high-risk moms and babies at no cost to patients or providers
• Providing post-visit updates and escalating urgent concerns 
• Reinforcing care plans, medication adherence, patient education, and appointment attendance 
• Promoting better health outcomes and quality of life for high-risk moms and babies

Together, we can foster healthier outcomes for Georgia’s moms and babies.

Who the Program Serves 

DPH Home Visiting supports pregnant and postpartum mothers and infants who may benefit from additional monitoring, education, or support during pregnancy or after birth. Patients do not need to be in crisis to qualify. Early referral is encouraged, though enrollment may occur at any point during pregnancy or postpartum.

Refer expectant or postpartum mothers with:

• Hypertension or gestational hypertension
• Preeclampsia
• Diabetes
• Multiple gestations
• Prior preterm delivery
• Preterm labor
• Chronic conditions or co-morbidities
• Prior second trimester pregnancy loss
• Prior fetal/neonatal death
• Pre-existing health conditions
• Substance use disorder
• Mental health condition
• Poor support system
• Difficulty complying with provider recommendations and/or follow-up (e.g., keeping appointments)
• Other medical conditions or concerns for poor outcomes

Refer infants with: 

• Recent NICU discharge
• Very low birth weight (VLBW) or low birth weight (LBW)
• <36 weeks gestation at delivery
• Positive maternal screening for substances at delivery
• Suspected or confirmed congenital syphilis or HIV infection
• Poor maternal support system or other environmental concerns

When and How to Refer

Providers are encouraged to refer high-risk moms and babies to the program when extra support or resources could help them. We strongly recommend you consider including the DPH Home Visiting Program Referral Form as part of the patient’s plan of care or discharge process.

Referrals are simple:

1. Complete the one-page DPH Home Visiting Referral Form
2. Submit via fax, scan, or electronic submission
3. The DPH Home Visiting team manages patient outreach, enrollment, and ongoing follow-up

This approach minimizes administrative burden while ensuring high-risk patients receive timely support.

DPH Home Visiting Referral Call to Action

Download A Referral Form  (PDF, 421.6 KB)

What DPH Home Visiting Provides

DPH Home Visiting delivers personalized, relationship-based support focused on patient needs. Services may include:

• Regular check-ins between provider visits
• Monitoring for maternal, postpartum, and infant warning signs
• Reinforcement of prescribed care plans and follow-up recommendations
• Patient education to support understanding and adherence 
• Connection to community-based resources when appropriate 

DPH Home Visitors work closely with providers and alert care teams when urgent concerns arise, supporting continuity and safety across care settings.

Monitoring and Service Components

Maternal (Pregnancy and Postpartum) 

Clinical assessment for pregnancy and postpartum complications include:

• Blood pressure assessment
• Fingerstick for blood glucose (if indicated)
• Weight
• Urine dipstick
• Fetal heart tones

Screening for pregnancy and postpartum warning signs and symptoms:

• Vaginal bleeding or fluid leaking during pregnancy
• Vaginal bleeding or discharge after pregnancy
• Severe headaches
• Severe abdominal pain
• Extreme swelling of hands or face
• Changes in vision
• Severe swelling, redness, or pain in the leg or arm
• Trouble breathing
• Chest pain or fast-beating heart
• Depression and anxiety

Infant (Nutrition and Development) 

Clinical assessment includes:

• Feeding
• Weight
• Head circumference
• Developmental screening

FAQs