Capacity Assessment and
Implementation Plan Instructions (Cohort 1)
State Fiscal Year 2013
Home Visiting Services Account
July 1, 2012 - June 30, 2013
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Table of Contents
I. Capacity Assessment and Implementation Plan Overview
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II. Grant Award Description
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A. Grant Award
B. Funding Period
III. Capacity Assessment and Implementation Plan Submission
A. Online Submission
B. Submission Deadline
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IV. Application Overview and Special Instructions
A. Overview
B. Special Instructions
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V. Technical Assistance
A. Instructional Webinar
B. Individual Technical Assistance
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I. Capacity Assessment and Implementation Plan Overview
The Home Visiting Services Account (HVSA) Implementation Hub supports grantees in implementing
services with fidelity in order to produce the outcomes promised by the evidence-based, research-based, or
promising practices home visiting model utilized by each respective grantee. Research shows that fidelity,
the “degree to which a program as implemented corresponds with the program as described,” is correlated with
better model-specific results and outcomes (Fixen, Naoom, Blase, Friedman & Wallace, 2005 National
Implementation Resource Network).
Thrive by Five Washington’s (Thrive) Implementation Hub supports programs in implementing services with
fidelity by providing technical assistance to build their capacity in core components that have been
demonstrated to improve fidelity—staff selection, training, coaching, facilitative administration (organizational
capacity development), and decision-support data systems (evaluation and continuous quality improvement) —
ultimately moving programs through stages of implementation for quality program development.
We have developed a Capacity Assessment and Implementation Plan to assess grantee programs’ capacity to
implement services with fidelity—focusing on the core components cited above.
Follow the instructions provided in this document to complete your Capacity Assessment and Implementation
Plan for your state fiscal year 2013 HVSA grant. The online Capacity Assessment and Implementation Plan can be
found here.
II. Grant Award Information
A. Grant Award
In December 2010, grantees in Cohort 1 of the Home Visiting Services Account received the following grant
awards for one year (December 15, 2010–December 14, 2011) with a commitment for a renewed investment
annually for up to an additional 4 years (5 years total) based on contract compliance, performance, and available
funds:
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Friends of Youth (Parents as Teachers): $100,000
Mason County Public Health Department (Nurse-Family Partnership): $100,000
Tacoma-Pierce County Health Department (Nurse-Family Partnership): $100,000
West Valley School District #208 (Parent-Child Home Program): $54,960
For the second year of funding, Thrive renewed the investment for a 6-month period (December 15, 2011–June
30, 2012) to align the Cohort 1 funding cycle with other funding cycles in HVSA. Upon completion of this
Capacity Assessment and Implementation Plan, Thrive will renew your grant for the next one-year period (July
1, 2012–June 30, 2013) at the level originally awarded (listed above).
B. Funding Period
The funding period for this grant award will be July 1, 2012 through June 30, 2013.
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III. Capacity Assessment and Implementation Plan Submission
A. Capacity Assessment and Implementation Plan Online Submission Instructions
HVSA grantees are required to complete a Capacity Assessments and Implementation Plan online.
The online Capacity Assessment and Implementation Plan can be found here.
Follow the instructions below to complete and submit your online assessment:
1. Registration—To register in the online system:
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Click on the link above. After clicking, you will be directed to a log-in page.
On the log-in page, click on “New Applicant.” You will be prompted to develop an email and
password.
Select an email and password. The system allows only one email address to be attached to a
particular submission. If several people will be using the log-in information to complete the Capacity
Assessment, be sure to choose a password that can be shared. Only one user from your organization
should be in the online Capacity Assessment at a given time.
NOTE: Upon completing your registration, you will receive an email in your inbox. The email will
include your password and the link to your application. Use this link to return to your online
application in all circumstances. Do not go in again through the link provided in the Baseline
Capacity Assessment and Implementation Plan Instructions. Forward this email to any additional
staff members who will be working on your application with you.
After registering, you will be directed to a screen that reads “Please Enter the Password.”
Enter the password for the Capacity Assessment and Implementation Plan: BCFY2012. Next, you will
be directed to the Tax ID # Page.
Enter your TAX ID#. If your Tax ID # is invalid, you will receive the following message: “The Tax ID
that you entered was not found in the IRS database. Please check your entry. If it is correct, click OK
to begin filling out your application form.” If your TAX ID # is valid, you will be moved forward into
the Capacity Assessment and Implementation Plan.
2. Completion—To complete your application:
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Provide the requested data in all sections of the Capacity Assessment data fields within the
specified word limits (denoted in the application). We encourage you to develop the narrative in a
Microsoft Word document and paste final responses to each question in the appropriate sections.
Upload all required attachments on the Budget and Attachment tab.
Users will be able to save their work as they proceed through each section of the Capacity
Assessment. You can exit and return to your saved application at any time using the link provided in
the autogenerated email.
3. Submission—To Submit your Assessment:
 After completing all required sections of the Capacity Assessment, proceed to the “Review My
Assessment” tab. This tab will indicate if there are any required fields that were not completed.
 If you have not completed required fields, return to those fields, complete them, and again review
your Capacity Assessment.
 When your assessment is eligible for submission, a “Submit” button will be available for viewing.
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Click on “Submit.” If your submission is successful, you will receive an email acknowledgment within
a few minutes.
B. Application Deadline
The Capacity Assessment and Implementation Plan is due by 5pm on July 6, 2012.
IV.Overview and Special Instructions
A. Overview
The Capacity Assessment and Implementation Plan consists of six sections. Each section contains a set of
questions or requested information for the grantee to provide.
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Grantee Information
Project Overview
Logic Model (Document Upload)
Implementation Capacity
Fidelity and Quality Assurance
Budget and Attachments (Document Upload)
B. Special Instructions
The section below provides additional special instructions that will help to inform your responses for the Logic
Model and Budget and Attachments sections of the assessment.
1. Logic Model
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Function of the Logic Model: The HVSA logic model is a roadmap demonstrating the relationship
between program resources, the implementation of home visiting services, and the results your
program is working to achieve. Development of a well-informed, appropriate logic model is critical
to successful program implementation, and to your Capacity Assessment and Implementation Plan
to the Home Visiting Services Account. The logic model is used to:
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Develop the Scope of Work for Grantees: The logic model supplied in your Capacity Assessment
will be used to develop the scope of work for your new state fiscal year 2013 HVSA grant
agreement.
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Maintain Implementation Focus: Home visiting programs rely on fidelity in implementation to
produce high-quality services. It can be tempting to drift from core model activities. The logic
model helps programs stay on track and resist those temptations to add or take away from the
core activities and fidelity requirements of the model utilized.
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Report on Program Performance: Your HVSA logic model will be used as a template for a
portion of HVSA quarterly and year-end reporting.
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Align Reporting for Grantees Implementing the Same Home Visiting Models: HVSA-funded
programs implementing the same home visiting model will use aligned logic models so that data
can be reported for multiple programs implementing the same model. There will be programspecific content populating some of the categories, but common activity categories, process
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outcomes (fidelity), and program indicators will be reported to the HVSA and used for
continuous quality improvement at the program level. There will also be targeted alignment of
outcomes across models so the impact of the portfolio can be demonstrated.
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Guide Continuous Quality Improvement Activities: The logic model provides a method for
charting program progress, allowing each grantee to track what is happening and what is not,
and where expectations are being met, not met, or exceeded. Through a continuous quality
improvement lens, both qualitative and quantitative findings will inform program development.
The technical assistance support from HVSA, which includes model-specific technical assistance,
will help you think through strategic adjustments to improve intended results.
Instructions for Completion of the Logic Model: You will submit an HVSA logic model in the “Logic
Model” section of the online assessment. The "Logic Model" section in the online assessment has
two required components: Step 1: Logic Model Upload and Step 2: Logic Model Data Fields.
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Step 1: Logic Model Upload: Download the logic model template from the online assessment,
complete it in accordance with instructions provided in the Capacity Assessment, and upload a
copy. Once you have completed the template, move to Step 2.
Step 2: Logic Model Data Fields: Enter the resources, activities, components, and outputs
provided in your template into the data fields in the online assessment.
The Logic Model template for Step 1: Logic Model Upload will look like the chart below. Use the
instructions that follow to complete your logic model template.
HVSA EBHV LOGIC MODEL
RESOURCES
ACTIVITIES
OUTPUTS
Provided outputs for each
relevant activity
Target Population:
Target Geographic
Area:
Staffing:
Home Visiting
Curriculum Used:
1: Activity
 1.1:
Component
 1.2:
Component
 1.3:
Component
 1.1: Output
 1.2: Output
 1.3: Output
FIDELITY
(PROCESS)
INDICATORS
PROGRAM
INDICATORS
(CONSTRUCTS)
OUTCOMES
(BENCHMARKS)
Do not
populate
Do not populate
Do not populate
Funding Sources:
Data System(s):
The logic model template consists of six categories: resources, activities, outputs, fidelity indicators,
program indicators, and outcomes. To complete the template for this assessment, you will need to
populate only the resources, activities, and outputs fields. You will be required to complete the fidelity
indicators, program indicators, and outcomes at a later time. Descriptions for each of these categories,
as well as specific instructions for populating the categories, are provided below.
Resources are the human, financial, organizational, and community inputs a program requires for
implementation. Resources include target population, target geographic area, staffing, home visiting
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curriculum, funding sources, and data systems. For each of the resources listed in the logic model
template, please provide the information specific to HVSA-supported services only. For example, for
staffing, only include the FTEs supported by the HVSA award (i.e., if your program has 8 FTEs and HVSA
will support 1 FTE, only include 1 FTE in your logic model).
Activities are the core the model activities required for fidelity that contribute to results. Populate your
logic model with up to eight activities you will implement in order to achieve outcomes. Be sure to
include any activity that is an enhancement to the model you are implementing. Example activities are
provided below:
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Hire Staff (In order to deliver services at the capacity proposed in the request)
Staff Trainings (Required national model and/or organization-specific trainings)
Recruitment (How will outreach be conducted)
Home visits (Brief description of services)
Groups (Topic areas of the groups)
Developmental Screenings (Brief description of screenings)
Supervision (Brief description)
Enhancement (Brief description of enhancements, i.e. Mental health consultant on staff, Father
component, Depression screening, etc.)
After identifying up to eight key activities for your logic model, list up to three components of each
activity. The components help to define the activity. For example, if your activity is training, three
related components might be: 1) initial model training for new staff; 2) ongoing model training for
existing home visiting staff; and 3) professional development training provided by the organization.
NOTE: Do not include data collection as an activity.
Outputs describe the dosage, frequency, and duration of the components. For each component of an
activity listed in the logic model, provide a corresponding output for HVSA-supported services. Outputs
should be as detailed as possible, and where appropriate, include quantifiable information. For example,
if your activity is “training,” and your first component is “initial model training for new staff,” the
corresponding output for the component could be “two home visitors will complete the one-time, fiveday model-required training by September 1, 2012.”
Fidelity Indicators are model-specific measures that are used to determine the degree to which your
program is implemented in correspondence with the program as described. These fields should not be
populated for the application; they will be completed at a later date.
Program Indicators are changes in the status or conditions of program participants. These fields should
not be populated for the application; they will be completed at a later date.
Outcomes are the specific changes and benefits you want to see as a result of program implementation.
These fields should not be populated for the application; they will be completed at a later date.
PLEASE SEE THE EXAMPLE LOGIC MODEL BELOW.
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Sample HVSA EBHV Logic Model
Lead Organization Name: Tathra Services
Home Visiting Model: XYZ Evidence-Based Home Visiting Program
Date (Month/Year): July 1, 2012
RESOURCES
ACTIVITIES
OUTPUTS
Provided outputs for each relevant
activity
Target Population:
Hispanic, pregnant
women under the age of
25, living in poverty
1.
Staff
1.1. Hire new staff
1.
Target Geographic Area:
Blue Harbor County,
Tathra Beach
2.
Training
2.1. New Staff will receive
initial model training
2.2. Ongoing required
model training
2.
Training
2.1. 2 newly hired staff will
attend 4 full days of
initial model training by
September 30, 2012
2.2. 1 Supervisor will attend 2
full days of required yearly
supervisor training by
September 30, 2012
3.
Outreach/Recruitment
3.1. Develop recruitment
plan
3.
Outreach/Recruitment
3.1. Supervisor and home
visiting team will create a
10 month
outreach/recruitment plan
by September 1, 2012 to
recruit 60 pregnant teen,
with the goal of enrolling
30 pregnant teens.
3.2. Supervisor and 1 home
visitor will conduct .5 hour
presentations to 3
organizations, each
month, for months, for a
total of 30 presentations
per year.
Staffing:
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Home Visitors: 3, .5
FTE Home Visitors
(1.5 FTE total)
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Supervisor: .20 FTE
Supervisor
Home Visiting
Curriculum Used:
XYZ EBHV Curriculum
Funding Sources:
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Coral Foundation
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P&J Block Grant
Data System(s)
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Efforts to Outcomes
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Agency Data
Collection System
3.2. Presentations to
alternative schools,
pediatrician’s offices,
nail salons, etc.
Staff
1.1. 2, .5 FTE home visitors will
be hired by 8/31/12
FIDELITY
(PROCESS)
INDICATORS
Do not populate
PROGRAM INDICATORS
(CONSTRUCTS)
Do not populate
OUTCOMES
(BENCHMARKS)
Do not populate
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4.
Home Visits
4.1. Provide home visits
to pregnant teens
using X,Y,Z Evidence
Based Home Visiting
curriculum
4.
Home Visits
4.1. 30 pregnant teens will
receive weekly, 1.5 hour
home visits for 2 years.
5.
Reflective Supervision
5.1. Supervisor will
conduct reflective
supervision with
home visitors.
5.
Reflective Supervision
5.1. 25, twice a month, 1 hour
each, reflective
supervision sessions will
be conducted for each
home visitor annually.
Enhancement:
Enhancement:
6.
6.
Mental Health Consultant
6.1. Mental Health
Consultant meets
with home visitors.
Mental Health Consultant
6.1. 12 monthly, 2 hour
consultations with each
home visitor.
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2. Budget and Attachments
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Budget: For the Capacity Assessment, each grantee is required to complete a budget. You will download the
budget template from the “Budget and Attachments” Tab, complete the template with your budget
information, and upload the completed template to the online assessment. The budget template is designed
to capture information on your total home visiting program budget, as well as the specific use of HVSA
funds. An excerpt from the template is below.
Provide information on your specific HVSA expenses in the “HVSA Funding” column and all other budgeted
program expenses in the “Other Program Funding” column. After entering budget information in both
columns, enter the total in the “Total Program Budget” column. Your “HVSA Funding” expenses should
constitute nor more than 85% of your “Total Program Budget” to remain in alignment with the 15% match
required of your HVSA Cohort.
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Attachments: You will be required t submit the following attachments as Microsoft Word or PDF Files in
the “Budget and Attachments” section of the assessment. Please upload the following attachments:
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Most recent IRS Form 990
Most recent audited financial statement
Organization’s current-year operating budget. For large, multi-service organizations, include only the
budget for the home visiting program.
List of current board members
V. Technical Assistance
Thrive will provide the following technical assistance opportunities to support you in completing their Capacity
Assessment and Implementation Plans:
A. Instructional Webinar: Thrive will hold a webinar on Monday, June 11 from 1:30-3:00pm to review the instructions
and expectations for the Capacity Assessment and Implementation Plan and to introduce grantees to the online
grantmaking system.
B. Individual Technical Assistance: Thrive will provide Individual Technical Assistance on Wednesday, June 20, 2012
from 10:30am-2:15pm to address any questions. Each applicant can schedule one optional, 45-minute technical
assistance phone appointment. Appointments can be scheduled by emailing Marcy Miller, Manager of Home
Visiting, at [email protected]. Appointments are only available on June 20, 2012 during the times listed
below:
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10:30am-11:15am
11:30am-12:15pm
12:30pm-1:15pm
1:30pm-2:15pm
If an extenuating circumstance will prevent you from participating in this meeting, please contact Marcy Miller
as soon as possible. Please email all questions you will pose in your TA appointment to Marcy Miller by close of
business on the June 18, 2012.
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